This document provides guidance on evaluating and managing patients presenting with abdominal pain. It lists common differential diagnoses for abdominal pain and immediate life-threatening causes that must be recognized. It recommends asking about the pain's location, quality, severity and other details. For testing, it suggests abdominal x-rays, ultrasound, CT scans and labs depending on the situation. The document provides examples of imaging findings and discusses dispositions such as surgical consultation, serial evaluation or discharge depending on the case.

5. “Tell me more about your pain….”
Location
Quality
Severity
Onset
Duration
Modifying factors
Change over time

6. Differential Diagnosis
• Appendicitis
• Biliary colic, cholecystitis,
cholangitis
• Bowel obstruction
• Diverticulitis
• Ectopic pregnancy
• Gastroenteritis
• Intussuception
• Mesenteric Ischemia
• Ovarian torsion
• Pancreatitis
• Pelvic Inflammatory
Disease (PID)
• Perforated peptic ulcer
• Ruptured or leaking
abdominal aortic
aneurysm (AAA)
• Testicular torsion
• Ureteral colic
• Volvulus

7. Immediate Life-Threatening
Causes of Abdominal Pain
These must be recognized from the primary survey :
Ruptured abdominal aortic aneurism (AAA)
Rupture of the spleen or liver
Ruptured ectopic pregnancy
Bowel infarction
Perforated viscus
Acute myocardial infarction (MI)

24. What kind of tests should you order?
 Depends what you are looking
for!
 Abdominal series
 3 views: upright chest, flat view of
abdomen, upright view of abdomen
 Limited utility: restrict use to
patients with suspected obstruction
or free air
 Ultrasound
 Good for diagnosing AAA but not
ruptured AAA
 Good for pelvic pathology
 CT abdomen/pelvis
 Noncontrast for free air, renal colic,
ruptured AAA, (bowel obstruction)
 Contrast study for abscess,
infection, inflammation, unknown
cause
 MRI
 Most often used when unable to
obtain CT due to contrast issue
 Labs
 CBC: “What’s the white count?”
 Chemistries
 Liver function tests, Lipase
 Coagulation studies
 Urinalysis, urine culture
 GC/Chlamydia swabs
 Lactate

25. Plain Films: Small bowel obstruction

26. Cecal Volvulus and Sigmoid Volvulus

27. Pneumoperitoneum

29. Ultrasound: Cholecystitis

32. Ovarian Torsion…

34. Ultrasound showing 7.5 cm AAA with intraluminal clot

35. CT of Rupturing AAA:

39. Patient with Herpes Zoster (“Shingles”) of the abdomen

41. Pearls, Pitfalls and Myths
• Do not restrict the diagnosis solely by the
location of the pain.
• Consider appendicitis in all patients with
abdominal pain and an appendix,
especially in patients with the presumed
diagnosis of gastroenteritis, PID or UTI.
• Do not use the presence or absence of
fever to distinguish between surgical and
medical causes of abdominal pain.
• The WBC count is of little clinical value in
the patient with possible appendicitis.
• Any woman with childbearing potential
and abdominal pain has an ectopic
pregnancy until her pregnancy test comes
back negative.
• Pain medications reduce pain and suffering
without compromising diagnostic
accuracy.
• An elderly patient with
abdominal pain has a high
likelihood of surgical disease.
• Obtain an ECG in elderly
patients and those with cardiac
risk factors presenting with
abdominal pain.
• A patient with appendicitis by
history and physical
examination does not need a CT
scan to confirm the diagnosis;
they need an operation.
• The use of abdominal
ultrasound or CT may help
evaluate patients over the age of
50 with unexplained abdominal
or flank pain for the presence of
AAA.

42. Disposition
 Non-specific abdominal pain
No source is identified
Vital signs are normal
Non specific abdominal exam, no evidence of peritonitis
or severe pain
Patient improves during ED visit
Patient able to take fluids
Have patient return to ED in 12-24 hours for re-
examination if not better or if they develop new
symptoms

50. Disposition
• Surgical consultation
• Serial evaluation
• Discharge

67. (‫م‬ ‫ويرزقه‬ ‫مخرجا‬ ‫له‬ ‫يجعل‬ ‫هللا‬ ‫يتق‬ ‫ومن‬‫ن‬
‫اليحتسب‬ ‫حيث‬)‫العظيم‬ ‫هللا‬ ‫صدق‬
AND WHOSOEVER FEARS ALLAH AND KEEPS
HIS DUTY TO HIM , GOD WILL MAKE A WAY
FOR HIM TO GET OUT (from ever difficulty).
AND WILL PROVIDE ( HIM l HER ) FROM
(SOURCES ) HE l SHE NEVER COULD
IMAGINE.
( THE NOBLE QURAN )