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Abdominal Pain
Abdominal pain that is not relieved with home remedies.
What is abdominal pain?
Abdominal pain is pain that you feel anywhere between your chest and groin. This is often referred to as the stomach region or belly.

What describes the abdominal pain?
  1. Abdominal pain in a child.

  2. Abdominal pain relieved with home remedies.

  3. Abdominal pain that is severe, constant, and not relieved with home remedies.

  4. Abdominal pain in an adult that is recurrent (usually in gallstones).

  5. Abdominal pain in an adult that is severe and horrible for the first time.

  6. Abdominal pain in a woman who is not pregnant.

  7. Abdominal pain in a woman who is pregnant.

    Physician medical emergency room
    Here are further guidelines.

    Physician surgeon medical emergency
    Here are further guidelines.

    How many causes of abdominal pain are there?
    At least 26.

    What are all causes of abdominal pain?
    1. Indigestion
    2. Constipation
    3. A stomach virus
    4. Menstrual cramps in women
    5. Irritable bowel syndrome (IBS)
    6. Crohn's disease or ulcerative colitis
    7. Food poisoning
    8. Food allergies
    9. Gas in the digestive tract
    10. Urinary tract infection
    11. Abdominal muscle strain or pull
    12. Hernia
    13. Gallstones
    14. Kidney stones
    15. Endometriosis in women
    16. Gastroesophageal reflux disease (GERD)
    17. Appendicitis
    18. Diverticulitis
    19. Abdominal aortic aneurysm (swelling in the belly’s main artery)
    20. Bowel blockage or obstruction
    21, Tumor or equivalent of the stomach, pancreas, liver, bile duct, gallbladder, or immune cells
    22. Ovarian cancer or cysts in women
    23. Pancreatitis (inflammation of the pancreas)
    24. Cholecystitis (inflammation of the gallbladder)
    25. Low blood flow to your intestines caused by a blocked blood vessel
    26. Ectopic pregnancy in women (when a fertilized egg grows outside the uterus, such as in a Fallopian tube)

    Differential Diagnosis

    The most common approach to the diagnosis of abdominal pain focuses on the location of the pain, with a separate grouping for causes of diffuse abdominal pain.

    Right Upper Quadrant

    •Biliary colic
    •Cholangitis
    •Cholecystitis
    •Fitz-Hugh-Curtis Syndrome
    •Hepatitis
    •Hepatic abscess
    •Hepatic congestion
    •Herpes zoster
    •Mesenteric ischemia
    •Perforated duodenal ulcer
    •Pneumonia (RLL)
    •Pulmonary embolism
    •Pyelonephritis/nephrolithiasis

    Left Upper Quadrant

    •Gastric ulcer
    •Gastritis
    •Herpes Zoster
    •Myocardial ischemia
    •Pancreatitis
    •Pneumonia (LLL)
    •Pulmonary embolism
    •Splenic rupture/distension
    •Pyelonephritis/nephrolithia

    Right Lower Quadrant

    •Aortic aneurysm
    •Appendicitis
    •Crohn disease
    •Diverticulitis
    •Ectopic pregnancy
    •Endometriosis
    •Epiploic appendagitis
    •Herpes zoster
    •Inguinal hernia
    •Ischemic colitis
    •Meckel diverticulum
    •Mittelschmerz
    •Ovarian cyst
    •Ovarian torsion
    •Pelvic inflammatory disease
    •Psoas abscess
    •Regional enteritis
    •Testicular torsion
    •Ureteral calculi

    Left Lower Quadrant

    •Aortic aneurysm
    •Diverticulitis
    •Ectopic pregnancy
    •Endometriosis
    •Epiploic appendagitis
    •Herpes zoster
    •Inguinal hernia
    •Ischemic colitis
    •Meckel diverticulum
    •Mittelschmerz
    •Ovarian cyst
    •Ovarian torsion
    •Pelvic inflammatory disease
    •Psoas abscess
    •Regional enteritis
    •Testicular torsion
    •Ureteral calculi

    Differential Diagnosis for diffuse abdominal pain

    •Aortic aneurysm
    •Aortic dissection
    •Appendicitis (early)
    •Bowel obstruction
    •Diabetic gastric paresis
    •Diabetic ketoacidosis
    •Familial Mediterranean Fever
    •Gastroenteritis
    •Heavy metal poisoning
    •Hereditary angioedema
    •Malaria
    •Mesenteric ischemia
    •Metabolic disorder
    •Narcotic withdrawal
    •Pancreatitis
    •Perforated bowel
    •Peritonitis
    •Sickle cell crisis
    •Volvulus

    What Symptoms of Abdominal Pain Are Cause for Concern?
    If your abdominal pain is severe or if it is accompanied by any of the following symptoms, contact your health care provider as soon as possible:

    Fever
    Inability to keep food down for several days
    Inability to pass stool, especially if you are also vomiting
    Painful or unusually frequent urination
    The abdomen is tender to the touch
    The pain is the result of an injury to the abdomen
    The pain lasts for several days
    These symptoms can be an indication of an internal problem that
    requires treatment as soon as possible.

    Seek immediate medical care for abdominal pain if you:

    Vomit blood
    Have bloody stools
    Have difficulty breathing
    Have pain occurring during pregnancy

    How Is the Cause of Abdominal Pain Determined?
    Because there are so many potential causes of abdominal pain, your health care provider will perform a thorough physical exam, discuss with you the type of symptoms you are experiencing, and ask you several questions about the pain you are feeling. These questions may include:

    What type of pain are you experiencing?
    Is the pain throughout your abdomen or is it confined to a particular area?
    Where in your abdomen does the pain seem to be located?
    What type of pain are you experiencing? Is it stabbing and severe?
    Is it a dull ache?
    When does the pain occur? Always? More often in the morning or at night? If the pain comes and goes, about how long does it last each time?
    How long have you had this pain?
    Does the pain also radiate into your lower back, shoulder, groin, or buttocks?
    Does any activity such as eating or lying on one side relieve the pain?
    Have you been injured recently?


    Abdominal pain in a woman who is not pregnant.
    Abdominal pain in a woman who is pregnant.

    Does it occur after eating certain types of foods or after drinking alcohol? During menstruation?
    Are you currently taking any medications or herbal supplements? Are you pregnant?
    Here are further guidelines.
    Once an initial evaluation has been completed, your health care provider may have you undergo some tests to help find the cause of your pain. These may include stool or urine tests, blood tests, barium swallows or enemas, an endoscopy, X-ray, ultrasound, or CT scan.

    Diagnostic Testing

    Diagnostic testing should be guided by the patient’s history and physical examination findings which can be used to initially narrow the differential diagnosis. Standard “abdominal labs” are listed below, but should be tailored to the patient’s presentation. Refer to the Common Laboratory Studies chapter for further information about each test.

    •Complete blood count
    •Electrolytes
    •Liver function tests
    •Lipase
    •Urine analysis


    •Beta- HCG (females only) In addition to these labs, further labs that can be helpful in particular presentations of abdominal pain include: troponin, coagulation studies including prothrombin time and partial thromboplastin time, lactate, C reactive protein, and gonococcal/chlamydia testing.

    What is the treatment?
    Treat the underlying cause.

    Treating abdominal pain depends on its cause. Treatments can range from medications for inflammation, GERD, or ulcers, to antibiotics for infections, to changes in personal behavior for abdominal pain caused by certain foods or beverages. In some cases, such as appendicitis and a hernia, surgery is necessary.

    Antibiotics: The abdomen is a frequent site of infection in the development of sepsis. Patients with abdominal pain who are found to be septic should receive early administration of antibiotics as part of their initial resuscitation. Antibiotics should also be given promptly to patients with peritonitis or a perforated viscus.

    Antiemetics: Abdominal pain is frequently associated with nausea and vomiting. Two commonly used drugs for nausea and vomiting in the emergency department are ondansetron and metoclopramide and they have been demonstrated to be roughly equivalent in efficacy. Ondansetron is given 4-8 milligrams orally or intravenously every 4 hours; metoclopramide is given 10 milligrams intravenously, sometimes with the addition of diphenhydramine to prevent extrapyramidal side effects.

    Analgesia: Patients presenting in significant abdominal discomfort and a history and physical suggesting a concerning diagnosis should be provided with immediate pain relief. Narcotic medication should not be withheld out of concern that the abdominal exam may become unreliable and the diagnosis therefore obscured. Fentanyl provides a nice option if a shorter acting agent is desired or if the blood pressure is tenuous.

    Specialty Consultation: Immediate surgical consultation should be obtained in patients whose presentation of abdominal pain involves hemodynamic instability and/or a rigid abdomen.

    Outpatient Follow-up: Approximately 25% of patients presenting to the emergency department with abdominal pain ultimately receive the diagnosis of “nonspecific abdominal pain,” and follow-up is an essential part of their disposition plan. Of these patients, 30-hour follow-up can yield a difference in diagnosis or treatment in up to 20%. In addition to expedited outpatient follow-up, many patients presenting with nonspecific abdominal pain may benefit from outpatient specialty follow-up for further, non-emergent testing.


    Pearls and Pitfalls

    •Monitor vital signs for impending hemodynamic collapse
    •Patients with a peritoneal examination warrant early surgical consult.
    •Elderly patients may present with very atypical symptoms but have high morbidity and mortality associated with the complaint of abdominal pain. CT is diagnostic of an urgent intra-abdominal condition in 50% of these patients.
    •Every female of childbearing age with abdominal pain must receive a pregnancy test.
    •Diffuse or upper abdominal pain should warrant thorough cardiac and pulmonary evaluation; diaphragmatic irritation can present as abdominal discomfort.
    •The most frequent causes of emergency department missed CT diagnoses are right upper quadrant pathology (only 15-20% of gallstones are radiopaque) and urinary tract infections.
    •Patients with significant intra-abdominal conditions tend to have exams that evolve over time. Frequent re-examinations will help with both diagnosis and early treatment.
    •Manage and treat pain when appropriate. •When in doubt, arrange close follow-up.

    Old sysyem

    It is important to consider which specialty to consult based on the likely diagnosis. For instance, a ruptured AAA will be managed by vascular surgery, a perforated viscus by general surgery, testicular torsion by urology, and a ruptured ectopic pregnancy by OB/GYN. Nonsurgical consultation such as gastroenterology for a GI bleed or the medical ICU for diabetic ketoacidosis may also be necessary.

    New System

    What should physician surgeon medical emergency know?
    You have to know everything of these entities.
    General surgery emergencies
    Thoracic surgery emergencies
    Colon and rectal surgery emergencies
    Obstetrics emergencies
    Gynecologic surgery emergencies
    Neurological surgery emergencies
    Ophthalmic surgery emergencies
    Oral and maxillofacial surgery emergencies
    Orthopaedic surgery emergencies
    Otolaryngology emergencies
    Pediatric surgery emergencies
    Plastic and maxillofacial surgery emergencies
    Urology emergencies
    Vascular Surgery Emergencies Here are further guidelines.

    What should physician surgeon elective surgery know?
    You have to know everything of these entities.
    General surgery elective surgeries
    Thoracic surgery elective surgeries
    Colon and rectal elective surgeries
    Obstetrics elective surgeries
    Gynecologic elective surgeries
    Neurological elective surgeries
    Ophthalmic elective surgeries
    Oral and maxillofacial elective surgeries
    Orthopaedic elective surgeries
    Otolaryngology elective surgeries
    Pediatric elective surgeries
    Plastic and maxillofacial elective surgeries
    Urology elective surgeries
    Vascular elective surgeries
    Here are further guidelines.
    These abilities are must in addition to be basically a physician with abilities of diagnosis and treatment in various healthcare settings.

    Why has training for emergency surgeon and emergency anesthetist been mentioned together?
    Emergency surgeon and emergency anesthetist services in an operating room are interdependent at a specific time duration and location.

    What medical emergency cases go to an emergency surgeon or emergency anesthetist in a hospital operating room?

    Out of 1,150 human medical emergencies, only 26 go to an emergency surgeon and/or an emergency anesthetist in operating room.

    What are examples of emergency cases that go to an emergency surgeon and/or emergency anesthetist in a hospital operating room?
    Acute airway obstruction
    Acute appendicitis
    Acute mesenteric ischemia
    Acute subdural hematoma
    Acute trauma
    Aortic dissection
    Bleeding ectopic pregnancy
    Bowel obstruction
    Cardiac tapenade
    Gastrointestinal perforation
    Incision wounds that need closure under general anesthesia.
    Internal bleeding
    Intestinal volvulus
    Limb ischemia
    Paraphimosis
    Peritonitis
    Pneumothorax
    Priapism
    Retained abortion
    Retinal detachment
    Ruptured aortic aneurysm
    Stercoral perforation
    Testicular torsion
    Traumatic fractures that need internal fixation under general anesthesia.
    Urinary retention not relieved by catheterization. Here are further guidelines.

    What should an emergency surgeon and emergency anesthetist know?
    An emergency surgeon and emergency anesthetist should know all types of human diagnosis and treatment in various healthcare settings. Then, he or she should be allowed to manage cases listed after proven expertise. Here are further guidelines.

Abdominal pain in a child.
Where to get help

•The emergency department of your nearest hospital
•Paediatrician
•Primary care physician

There are several questions that your pediatrician/Physician medical emergency room/Physician primary care may ask, so it can be quite helpful to gather the information ahead of time to help figure out what’s causing the pain.
• How long has the pain been present? Has it been days, weeks, or months?
• How bad is the pain? Does your child cry?
• Where is the pain? Around the belly button, or lower right belly?
• How long does the pain last? Does anything seem to make it better or worse?
• Any fever, vomiting, or diarrhea?
• Does the pain wake her up at night or interfere with activity?
• Does it happen only on preschool days, or a particular time of day?
• How is her appetite?
• Is it related to any specific food or drink such as milk products? Or is it better or worse after she eats?
• Is she potty trained? Does the pain occur only when she needs to poop?
• Does she poop every day? Is the stool hard or soft? Is it big or small? Is there any blood in the stool?
• Any recent social or family stress or change in environment?
• Any family history of stomach or intestinal diseases or issues? • Any recent travel or exposure to pets?

Crying, Age 3 and Younger

Crying related to normal development and behavior

Hungry cries
Upset cries
Pain cries
Crying related to a serious illness or injury
Crying and shaken baby syndrome
Crying related to medical conditions

Are you concerned about your child's crying? Review health risks that may make any symptom more serious.

How old ___ _____?
Less than 3 months
3 months to 3 years
4 years or older

Has your child had a head injury?
Yes
No

Okay. Let's go to Head Injury, Age 3 and Younger

Abdominal Pain, Age 11 and Younger

Symptoms to watch for during home treatment

Call your doctor if any of the following occur during home treatment: •Pain increases or localizes to one section of the abdomen.
•Other symptoms develop, such as diarrhea, nausea, vomiting, or fever. •The belly feels hard or looks very swollen.
•Symptoms become more severe or frequent.

You can help your doctor diagnose and treat your child's condition by being prepared to answer the following questions:
•Is your child vomiting? If so, describe how much, how often, and how long.
•Does your child have a fever?
•Has your child had an injury to the abdomen?
•How long has your child had the pain?
•What was your child doing when the pain started?
•Has your child had similar episodes of abdominal pain before? What were these episodes like? How were they treated?
•Is the pain constant, or does it come and go?
•Is the pain localized to one area or generalized over the whole belly?
•How severe is the pain? What has your child's activity level been?
•Can your child describe the pain? Is the pain cramping, a steady ache, or sharp and burning?
•What makes the pain better? What makes the pain worse?
•Does your child have other symptoms, such as nausea, urinary problems, constipation, or diarrhea?
•Has your child recently traveled outside of his or her native ______?
•Has your child drunk any untreated well, stream, or lake water?
•Does your child have any health risks?

Does your child have pain or cramping in the belly? Review health risks that may make any symptom more serious.
Yes
No

How old __ ____?
Less than 3 months
3 months to 11 years
12 years or older


Has your child had surgery on the chest or belly in the past 2 weeks?

Okay. Let's go to Postoperative Problems

Has your child swallowed or inhaled an object?
Yes
No

Okay. Let's go to Swallowed or Inhaled Objects


Does your child have symptoms of shock?
Yes
No

Shock is a life-threatening condition that may occur quickly after a sudden illness or injury.

Babies and young children often have several symptoms of shock. These include:
•Passing out (losing consciousness).
•Being very sleepy or hard to wake up.
•Not responding when being touched or talked to.
•Breathing much faster than usual.
•Acting confused. The child may not know where he or she is.

Where to get help

•The emergency department of your nearest hospital

Prevention

Abdominal pain in children can often be prevented.
•Abdominal pain in children is often caused by irregular bowel habits. Become familiar with your child's normal bowel patterns. Also, be aware of the size and consistency of your child's stools. This will help to determine whether constipation is a problem. For information on preventing constipation and establishing toilet training, see the topic Constipation, Age 11 and Younger.
•Try to make sure your child has regular eating habits. Overeating is a common cause of abdominal discomfort. Have your child eat slowly and stop when he or she feels full. For more information, see the topic Healthy Eating for Children.
•Swallowing air (aerophagia) can cause abdominal pain and a swollen abdomen. Your child may also have a lot of belching or flatus. Limit chewing gum and carbonated beverages to help prevent this. Many children swallow air when they are anxious or frightened.

Abdominal pain in a woman who is not pregnant.
Abdominal pain in a woman who is pregnant.
Life threatening causes of abdominal pain

•Generalised peritonitis with shock
•Acute bowel obstruction
•Ruptured abdominal aortic aneurysm
•Acute mesenteric infarction
•Toxic shock syndrome

Patients with abdominal pain are common in the ED, but you need a strategy for quickly identifying patients who are at high risk for life-threatening causes of pain, and you need to order testing and consultation that improves the accuracy of your clinical assessment.

• What are the 4 groups of patients with abdominal pain who are frequently misdiagnosed?

• Why do elderly patients with appendicitis often have little or no abdominal pain?

• In women of childbearing age, is there a realistic algorithm to distinguish gastroenteritis from appendicitis, ectopic pregnancy, and PID?

• What role should prior abdominal surgeries have in assessing abdominal pain?

• What are the 18 high-yield historical questions to ask patients who present with abdominal pain?

• Fever, high WBC, low blood pressure, tachycardia: how reliable are these in pointing to a cause for abdominal pain?

• Pain location, migration, tenderness, and guarding: what each one can (and can’t) tell you about what is going on.

• When pelvic and testicular exams are must-dos.

• What are the highest-yield lab tests? CBC? Lipase or amylase? CRP?

• When x-ray is all you need, and when CT is a must.

• Will opioids make diagnosis more difficult?

Abdominal pain in a woman who is pregnant.
What are more serious cases of abdominal pain during pregnancy?
1. Miscarriage
2. Placental abruption
3. Preeclampsia
4. Ectopic pregnancy
5. Preterm labor
6. Urinary Tract Infection (UTI)
7. Appendicitis
8. Gallstones

Many women have healthy pregnancies, but serious complications can develop that require immediate attention from your ob-gyn. Some red flags to watch out for include bleeding, severe pain, fever, and visual disturbances.

Miscarriage

When women experience abdominal pain in the first trimester, "you always have to be concerned about miscarriage," Dr. Duff says, because the unfortunate fact is that 15 to 20 percent of pregnancies end in miscarriage. Symptoms of miscarriage include bleeding and cramping that can be rhythmic or resemble menstrual cramps.

Placental abruption

Your placenta is the source of oxygen and nutrients for your baby. It usually implants high on the uterine wall and doesn't detach until after your baby is born. In rare cases (1 out of every 200 births), the placenta can separate from the uterine wall, a dangerous complication, which is most common in the third trimester. Dr. Duff describes the pain from a placental abruption as "severe, constant, progressively worsening lower abdomen pain." Your uterus may become rock hard (if you press on the abdomen, it won't indent) and you may also have dark, red blood that does not have clots. In some cases, a woman may go into labor when her placenta separates, in which case her ob-gyn will usually deliver the baby by emergency cesarean section. If the abruption is mild, a doctor may allow the pregnancy to continue or may induce labor and do a vaginal delivery. Women at risk for this condition include those who have a history of placental abruption, or who have high blood pressure, preeclampsia, and abdominal trauma.

Preeclampsia

According to the Preeclampsia Foundation of America, preeclampsia and other hypertensive disorders are experienced by 5 to 8 percent of all pregnant women. Preeclampsia can develop anytime after 20 weeks of pregnancy, which is one reason why your doctor checks your blood pressure at every appointment, and it is characterized by high blood pressure and protein in the urine. Because high blood pressure constricts the vessels in the uterus that supply the fetus with oxygen and nutrients, the baby's growth may be slowed. Preeclampsia also increases the risk of placental abruption, in which the placenta separates from the uterine wall before delivery. When preeclampsia is severe, it can be accompanied by pain in the upper right portion of your abdomen as well as nausea, headaches, swelling, and visual disturbances, such as flashing lights. It you suspect that you have preeclampsia, call your ob-gyn immediately.

Ectopic pregnancy

Ectopic or tubal pregnancies, in which the egg implants someplace other than the uterus, most often in the fallopian tube, occur in 1 in 50 pregnancies, according to the March of Dimes. In the unlikely event that you have an ectopic pregnancy, you may experience intense pain and bleeding between your 6th and 10th weeks of pregnancy, as the tube becomes distended. Women at increased risk for an ectopic pregnancy include those who have had an ectopic pregnancy in the past, or have had pelvic, abdominal, fallopian tube surgery, and those who have had endometriosis, a tubal ligation, an intrauterine device (IUD) in place at the time of conception, or a pelvic infection. An abnormally shaped uterus and the use of artificial reproductive techniques also seem to increase the risk.

Ectopic pregnancies cannot continue and require immediate treatment. If you had a positive pregnancy test but have not yet had your pregnancy confirmed by a medical exam, and you experience abdominal pain, you should be evaluated immediately by your ob-gyn, says Linda Chambliss, M.D., chief of obstetrics at St. Joseph's Hospital and Medical Center in Phoenix. Your ob-gyn or midwife can perform an ultrasound to confirm whether the egg has implanted in the uterus.

Preterm labor

If you're experiencing regular contractions before you're 37 weeks pregnant, and you have a persistent backache, you could be having preterm labor. Now is not the time to wait it out--call your ob-gyn right away. The contractions may or may not be accompanied by leaking vaginal fluid or blood or a decrease in fetal movement. Even experienced pros on their third pregnancy may not be able to tell if contractions are just Braxton Hicks or true preterm labor, Dr. Chambliss says, so she asks her patients to call anytime they feel contractions. You may end up being sent home because it's a false alarm (Dr. Chambliss says that up to 30 percent of the women who show up in her triage unit are), but it's better to be safe than sorry, especially in this case.

Urinary Tract Infection (UTI)

Up to 10 percent of expectant moms will get a urinary tract infection (UTI) at some point during their pregnancy, according to the March of Dimes. Typical symptoms include a sudden urge to urinate, pain or burning with urination, and bloody urination--but some patients with a UTI also experience abdominal pain, Dr. Chambliss says. "The concern with UTIs during pregnancy is that they can progress to an infection in your kidneys that will increase your risk of preterm labor," she adds. That's one reason why your ob-gyn tests your urine every visit, to check for the signs of bacteria that can lead to a UTI. The good news is that if a UTI is caught early it should be easy to treat with antibiotics.

Appendicitis

Appendicitis can be difficult to diagnose in pregnancy, says Dr. Duff, because "as the uterus enlarges, the appendix pulls up and can get up near the belly button or liver. That atypical presentation gives us a curve ball." And because a diagnosis can be delayed, it's one of the reasons a woman is at greater risk of dying from appendicitis during pregnancy. Although the usual hallmark of appendicitis is pain in the lower right quadrant of your abdomen, when you're pregnant you may feel it higher up. Other symptoms include lack of appetite, nausea, and vomiting.

Gallstones

Stones in the gallbladder are more common in women, especially if they are overweight, over the age of 35, or have a history of stones. The pain from gallstones (also called cholecystitis) is severe and focused in the upper right quadrant of your abdomen. In some cases, the pain may also radiate around to your back and under your right shoulder blade.
Here are further guidelines.

Last Updated: November 9, 2020