[6-24-2017: I have updated Reference 1 and added Reference 3. For any patient with abdominal pain, the Gastrointestinal Section of the American College of Radiology list of appropriateness criteria [Full Text PDF] can be used as a checklist to be sure that you have at least considered common causes of abdominal pain. And finally, I have added all the figures from Reference 2, Evaluation of Acute Abdominal Pain In Adults at the start of this post]
All the figures and tables that follow are from Reference 2:
Abdominal pain is a frequent cause of visits to the emergency departments, doctors offices, and urgent care centers.
When patients present to the emergency department for evaluation of abdominal pain, they are divided into three groups. One third of the patients have appendicitis and one third of the patients have no diagnosis established for their abdominal pain. And the final third have other serious diagnoses such as acute cholecystitis, small bowel obstruction, acute pancreatitis, kidney stone, perforated peptic ulcer, diverticulitis, cancer, or a gynecologic problem (see Important Note (1) below) .
The large number of possible causes of abdominal pain means that there are a large number of possible laboratory and imaging tests that we could order. To decide which tests to order, we evaluate the nature of the pain (constant or intermitent) and we ask where in or on the abdomen is the pain located.
Then we ask how long has the pain been present and what, if anything makes it better or worse. These questions allow us to generate a list of the most likely causes of the pain and then to decide which tests, if any, are needed. (2)
We divide the location of the abdominal pain into the following causes [for a more complete list of possible causes in each location please see Table 1 p 972 in reference (2)]:
A. Generalized abdominal pain—the abdoman hurts all over, there is no specific area that hurts. Any of the causes of abdominal pain that are on the list of localized abdominal pain can cause this [see Important Note (2) below].
B. Epigastric pain—pain located in the area between the end of the breast bone and above the umbilicus (the belly button). Possible causes of pain in this area include stomach or duodenal ulcers, gastritis, esophagitis, acute pancreatitis (inflammation of the pancreas), heart attack, aortic dissection, mesenteric ischemia (inadequate blood flowing to the intestines, and other causes
C. Right upper quadrant pain—pain located above the umbilicus and to the right of the epigastrium. Possible causes include cholelithiasis (gallstones), acute cholecystitis (inflammation of the gallbladder), pneumonia, pulmonary embolus (blood clot in the lung), nephrolithiasis (kidney stone), acute pyelonephritis (acute kidney infection), and other causes.
D. Left upper quadrant pain—pain located above the umbilicus and to the left of the epigastrium. Possible causes include the same as those that cause right upper quadrant pain except gallbladder disease. Gallstone pain (cholelithiasis) and gallbladder inflamation (acute cholechstitis) don’t cause pain in the left upper quadrant.
E. Periumbilical pain—pain located in the area around the umbilicus. Possible causes include early appendicitis, small bowel obstruction, peptic ulcer disease (stomach or duodenal ulcers), esophagitis, gastritis, aortic dissection, and mesenteric ischemia.
F. Right lower quadrant pain—pain located below and to the right of the umbilicus. Possible causes include appendicitis, Crohn’s disease, gynecologic problems (see Important Note below), nephrolithiasis (kidney stone), acute pyelonephritis (acute kidney infection), and other causes above.
G. Suprapubic pain—pain located just above the middle of the pelvic bone in the bladder area. Possible causes include include appendicitis, inflammatory bowel disease (ulcerative colitis or Crohn’s disease), cystitis (bladder infection), nephrolithiasis (kidney stone), acute pyelonephritis (acute kidney infection), gynecologic problems (see Important Note below), and others.
H. Left lower quadrant pain: inflammatory bowel disease (ulcerative colitis or Crohn’s disease of the colon), diverticulitis (inflammation of diverticuli which are colonic outpouchings), and gynecologic problems (see Important Note below).
I. Other causes of abdominal pain—these can cause pain that is generalized or in one part of the abdomen. Possible causes include inguinal hernia, abdominal wall hernia, abdominal muscle wall pain, herpes zoster, heavy metal poisoning (eg, lead or mercury), and porphyria.
Important Note: In any woman of reproductive age (between 10 years and 55 years old) it is critical to consider that abdominal pain of any nature and in any location could be due to a complication of pregnancy, specifically due to an ectopic pregnancy. An undiagnosed ectopic pregnancy can lead to death. Therefore every patient between those ages with abdominal pain should have serious consideration of a serum pregnancy test. And, if the serum pregnancy test is positive, then a transvaginal ultrasound is indicated.
Tomorrow, I’ll go over the laboratory and imaging diagnosis of abdominal pain.
(1)Acute Abdominal Pain and Fever or Suspected Abdominal Abscess [Full Text PDF]. American College of Radiology Appropriateness Criteria. Date of origin: 1996. Last review date 2012.
(2) Evaluation of Acute Abdominal Pain In Adults. American Family Physician, 2008.
(3) Complete List of American College of Radiology [Imaging] Appropriateness Criteria. Full Text PDF] [Updated on 6-24-2017]
