Abdominal Pain

Definition
Abdominal pain refers to the perceived location of pain not necessarily to its site of origin, which may be remote from the abdominal cavity. Acute pain requires rapid, often emergent assessment of likely causes (e.g., a perforated viscus) and equally rapid intervention. Subacute and chronic pain may reflect a wide range of disease processes, many anatomic, some functional, and generally allowing for a more leisurely diagnostic and therapeutic approach.

Epidemiology
Incidence o One of the most common presenting problems in emergency medicine o Accounts for ~10% of all emergency department visits o Half of healthy adults have abdominal pain on questioning. Age and sex o Dependent on cause of abdominal pain, for example: Acute cholecystitis is more common in women than in men. Ischemic colitis is more common in the elderly. o Can affect anyone at any time

Mechanism

Among the numerous mechanisms of abdominal pain are: o Pain originating in the abdomen Inflammation of the parietal peritoneum, for example: Release of acid into the peritoneum from a perforated duodenal ulcer Obstruction of a hollow viscus, for example:
o o o

Acute biliary obstruction by a gallstone Vascular disturbances, for example:

Embolism to the superior mesenteric artery with resultantintestinal ischemia

Injury to the abdominal wall, for example: Tear in the abdominal musculature from trauma Distension of visceral surfaces, for example:
o

Splenomegaly occurring rapidly in a patient with acute hemolysis Pain referred from extraabdominal sources Common sites include: o Thorax (for example, pleuritis) o Spine (for example, a herniated disc) o Pelvis (for example, epididymitis) Metabolic causes, for example:

Hyperlipidemia causing acute pancreatitis Neurologic/psychiatric causes, for example: Herpes zoster (shingles) Functional causes, for example: Stress, anxiety Toxic causes, for example:

Lead poisoning Still incompletely defined mechanisms, for example:

o

Familial Mediterranean fever

Symptoms & Signs

Signs and symptoms of abdominal pain reflect underlying pathophysiologic mechanism. Symptoms are best described by referring to quality, location, intensity, duration, and timing of the pain. Signs reflect the site of origin and, although critical to diagnosis, in many cases are nonspecific. Pain of abdominal origin

Inflammation of the parietal peritoneum o Quality: steady and aching o Location: directly over the inflamed area o Intensity: dependent on the type and amount of material to which the peritoneal surfaces are exposed in a given time period Sudden release into peritoneal cavity of a small quantity of sterile acid gastric juice causes

much more pain than the same amount of grossly contaminated neutral feces. Enzymatically active pancreatic juice causes more pain and inflammation than the same amount of sterile bile containing no potent enzymes. Blood and urine are often so bland they are detected only if contact with the peritoneum is sudden or massive. In bacterial contamination (e.g., pelvic inflammatory disease), pain is frequently of low intensity until bacterial multiplication has caused elaboration of irritating substances. o Rate at which irritating material is applied to the peritoneum is important. In perforated peptic ulcer, the clinical picture depends on the rapidity with which gastric juice enters the peritoneal cavity. o Pain is accentuated by pressure or changes in tension of the peritoneum. Produced by palpation or movement, such as coughing or sneezing Patient with peritonitis lies quietly in bed to avoid painful motion. Patient with colic may writhe incessantly. o Tonic reflex spasm of the abdominal musculature may be present. Localized to the involved body segment Intensity of spasm is dependent on the location and rate of development of the inflammatory process and the integrity of nervous system. Spasm over a perforated retrocecal appendix or a perforated ulcer into the lesser peritoneal sac may be minimal or absent because of the protective effect of overlying viscera. A slowly evolving process often greatly attenuates the degree of spasm. o There may be little or no detectable pain or spasm in obtunded, seriously ill, debilitated elderly or psychotic patients, even in catastrophic abdominal emergencies. Obstruction of hollow viscera o Classically described as intermittent or colicky Produces steady pain with occasional exacerbations

Not nearly as well localized as pain of parietal peritoneal inflammation Obstruction of the small intestine Colicky pain Usually periumbilical or supraumbilical Poorly localized As the intestine becomes progressively dilated with loss of muscular tone, pain may become steadier and less colicky. With superimposed strangulating obstruction, pain may spread to the lower lumbar region if there is traction on the root of the mesentery. Colonic obstruction

Colicky pain of lesser intensity than that of the small intestine Often located in infraumbilical area Lumbar radiation is common. Acute distention of the gallbladder (cholecystitis)

Steady rather than colicky pain; the term biliary colic is misleading. Usually felt in the right upper quadrant with radiation to the right posterior region of the thorax or the tip of right scapula o Acute distention of the common bile duct (typically from choledocholithiasis) Often felt in the epigastrium with radiation to the upper part of the lumbar region Differentiation between common bile duct pain and acute distention of the gallbladder may be impossible; in either condition, typical patterns of radiation are frequently absent. o Gradual dilatation of the biliary tree (e.g., carcinoma of head of pancreas) May cause no pain or only a mild aching sensation in the epigastrium or right upper quadrant o Acute inflammation of the biliary tree (acute cholangitis) Sharp, cutting, or gnawing right upper quadrant or epigastric pain, often radiating to the right shoulder or interscapular region of the back Usually accompanied by fever (89%) and jaundice (60%); called Charcots triad

In suppurative acute cholangitis, confusion and hypotension may be present as well as Charcots triad (making Reynoldss pentad). o Distention of the pancreatic ducts Pain is similar to that of distention of the common bile duct. Very frequently accentuated by recumbency and relieved by upright position o Obstruction of the urinary bladder Dull suprapubic pain, usually low in intensity Restlessness without specific complaint of pain may be the only sign of a distended bladder in an obtunded patient. o Acute obstruction of the intravesicular portion of ureter Severe suprapubic and flank pain that radiates to the penis, scrotum, or inner aspect of upper thigh o Obstruction of the ureteropelvic junction Pain in costovertebral angle o Obstruction of remainder of the ureter Flank pain that often extends into the same side of abdomen Vascular disturbances o Pain is not always sudden or catastrophic. o Embolism or thrombosis of the superior mesenteric artery or impending rupture of an abdominal aortic aneurysm Pain may be severe and diffuse (poorly localized). o Occlusion of the superior mesenteric artery

Pain may be mild, continuous, and diffuse for 2 or 3 days before vascular collapse or findings of peritoneal inflammation appear, or severe and diffuse. Early, insignificant discomfort is caused by hyperperistalsis rather than peritoneal inflammation. Absence of tenderness and rigidity in the presence of continuous, diffuse pain is characteristic of vascular disease. Rupturing abdominal aortic aneurysm Abdominal pain with radiation to the sacral region, flank, or genitalia

Pain may persist over several days before rupture and collapse occur. Abdominal wall pain o Usually constant and aching o Movement, prolonged standing, and pressure accentuate discomfort and muscle spasm. o Hematoma of rectus sheath Occurs most often in patients on anticoagulant therapy A mass may be present in the lower quadrants of abdomen. Simultaneous involvement of muscles in other parts of body usually differentiates myositis of the abdominal wall from an intraabdominal process.

Referred pain in abdominal diseases

Referred pain of thoracic origin

o

Frequently accompanied by splinting of the involved hemithorax with respiratory lag (i.e., defined as an asymmetric expansion of the lungs on inspiration; it can signify splinting of muscles related to intrapleural or intraabdominal pain or intrathoracic disease such as pneumothorax or massive atelectasis) and decrease in excursion, often more marked than that seen in intraabdominal disease o Diaphragmatic pleuritis from pneumonia or pulmonary infarction May cause pain in the right upper quadrant or supraclavicular area o Apparent abdominal muscle spasm caused by referred pain o When caused by referred pain, spasm diminishes during inspiration. o Spasm is present during both inspiration and expiration when pain is of abdominal origin. o Palpation over the area of referred pain in the abdomen rarely accentuates the pain; in some cases may relieve it. Referred pain from spine o Usually involves compression or irritation of nerve roots o Characteristically is intensified by certain motions (e.g., cough, sneeze, strain)

Associated with hyperesthesia over involved dermatomes Referred pain from the testicles or seminal vesicles
o

Dull aching pain Poorly localized o Generally accentuated by the slightest pressure on the testicles or seminal vesicles
o o

Metabolic abdominal crises May simulate almost any other type of intraabdominal disease In certain instances (e.g., hyperlipidemia), metabolic disease may be accompanied by an intraabdominal process such as pancreatitis. o Can lead to unnecessary laparotomy unless recognized C1 esterase deficiency associated with angioneurotic edema is often associated with severe abdominal pain. The abdominal attacks of familial Mediterranean fever range from dull, aching pain with distension to severe generalized pain with signs of peritonitis. Pain of porphyria and lead colic o Severe hyperperistalsis is a prominent feature. o Pain can be difficult to distinguish from that of intestinal obstruction. Uremia and diabetes o Nonspecific pain o Pain and tenderness frequently shift in location and intensity. o Diabetic acidosis may be precipitated by an abdominal crisis, such as acute appendicitis or intestinal obstruction. Failure of the pain to resolve when the diabetes is brought under control therefore necessitates a search for other underlying pathology. Black widow spider bites o Intense pain and rigidity of the abdominal muscles and back (the latter infrequently involved in intraabdominal disease)

Neurogenic causes

Abdominal pain may result from diseases that injure sensory nerves. o Nature of the pain Burning Usually limited to distribution of given peripheral nerve Normal stimuli such as touch or change in temperature may be experienced as pain. May be precipitated by gentle palpation Frequently present in patient at rest o Abdominal muscles are not rigid. o Respirations are not disturbed. o Distension of the abdomen is not common. o Demonstration of irregularly spaced cutaneous pain spots may be the only indication of old nerve lesion underlying causalgic pain. Pain arising from spinal nerves or roots
o o o o

in
o

Comes and goes suddenly Lancinating Not related to intake of food There is no distention of the abdomen or changes respirations. May be caused by:

Herpes zoster Impingement by arthritis Tumors Herniated nucleus pulposus Diabetes Syphilis o Severe muscle spasm is common, but is either relieved or not accentuated by abdominal palpation. o Pain is made worse by movement of the spine and is usually confined to a few dermatomes. o Hyperesthesia is very common. Functional causes

Conforms to none of above patterns Irritable bowel syndrome (IBS) Characterized by abdominal pain and altered bowel habits o Episodes of pain often brought on by stress. o Pain varies considerably in type and location. o Nausea and vomiting are rare.
o

Localized tenderness and muscle spasm are inconsistent or absent.

o

Differential Diagnosis
Two useful ways of approaching the diagnosis of abdominal pain are by mechanism and by location.

Differential diagnosis based on mechanism of pain See Table 14-1. Pain originating in the abdomen o Parietal peritoneal inflammation Bacterial contamination (e.g., perforated appendix, pelvic inflammatory disease) Chemical irritation (e.g., perforated ulcer, pancreatitis, mittelschmerz) o Mechanical obstruction of hollow viscera (e.g., blockage of the small or large intestine, biliary tree, or ureter) o Vascular disturbances Embolism or thrombosis Vascular rupture Pressure or torsional occlusion Sickle cell anemia o Abdominal wall Distortion or traction of the mesentery Trauma or infection of the abdominal muscles o Distention of visceral surfaces (e.g., hepatic or renal capsules) Pain referred from an extra-abdominal source o Thorax (e.g., myocardial or pulmonary infarction, pneumonia,pericarditis, esophageal disease) o Spine (e.g., radiculitis from arthritis, herpes zoster) o Genitalia (e.g., torsion of the testicle) Metabolic causes o Uremia o Diabetic ketoacidosis o Porphyria o Immunologic factors (C1 esterase inhibitor deficiency) Neurologic/psychiatric causes o Organic Tabes dorsalis Herpes zoster Causalgia and others o Functional

IBS: one of the most common causes of abdominal pain Toxic causes o Lead poisoning and others o Black widow spider bite Uncertain mechanisms o Narcotic withdrawal o Heat stroke

Differential diagnosis based on location of pain Right upper quadrant o Cholecystitis o Cholangitis o Pancreatitis o Pneumonia/empyema o Pleurisy/pleurodynia o Subdiaphragmatic abscess o Hepatitis o Budd-Chiari syndrome Right lower quadrant o Appendicitis o Salpingitis o Inguinal hernia o Ectopic pregnancy o Nephrolithiasis o Inflammatory bowel disease o Mesenteric lymphadenitis o Typhlitis Epigastric o Peptic ulcer disease o Gastritis o Gastroesophageal reflux disease o Pancreatitis o Myocardial infarction o Pericarditis o Ruptured aortic aneurysm o Esophagitis Periumbilical o Early appendicitis o Gastroenteritis o Bowel obstruction o Ruptured aortic aneurysm Left upper quadrant o Splenic infarct o Splenic rupture

Splenic abscess Gastritis o Gastric ulcer o Pancreatitis o Subdiaphragmatic abscess Left lower quadrant o Diverticulitis o Salpingitis o Inguinal hernia o Ectopic pregnancy o Nephrolithiasis o IBS o Inflammatory bowel disease Diffuse nonlocalized pain o Gastroenteritis o Mesenteric ischemia o Bowel obstruction o IBS o Peritonitis o Diabetes o Malaria o Familial Mediterranean fever o Metabolic diseases o Psychiatric diseases
o o

Diagnostic Approach
General considerations A diagnosis can almost always be achieved in patients with acute pain, unlike in patients with chronic pain. Definitive diagnosis cannot always be established on initial examination. o Except in an emergent situation, watchful waiting with repeated questioning and examination will often:

Elucidate the true nature of the illness Indicate the proper course of action Few abdominal conditions require abandonment of an orderly approach.

Only patients with exsanguinating intraabdominal hemorrhage (e.g., a ruptured aneurysm) must be rushed to the operating room immediately. This is relatively rare. Only a few minutes are required to assess critical nature of problem.
o

Eliminate all obstacles, obtain adequate venous access for fluid replacement, begin operation. Many have died while awaiting unnecessary examinations (e.g., electrocardiograms, abdominal films). There are no contraindications to operation when massive intraabdominal hemorrhage is present. o In most cases, GI hemorrhage can be managed more conservatively. IBS

One of the most common causes of abdominal pain o Must always be kept in mind o Diagnosis based on clinical criteria after exclusion of demonstrable structural abnormalities Diseases of the upper abdominal cavity, such as acute cholecystitis or perforated ulcer, are frequently associated with intrathoracic complications. o The possibility of intrathoracic disease must be considered in every patient with abdominal pain, especially if pain is in the upper part of abdomen. o Thoracic and abdominal diseases frequently coexist and may be difficult to differentiate. Patients with known biliary tract disease often have epigastric pain during myocardial infarction. Biliary colic may be referred to the precordium or left shoulder in patient who has suffered previously from angina pectoris. Patients with an inferior myocardial infarction often have abdominal symptoms; some have no abdominal or chest pain. Consider a metabolic origin whenever the cause of abdominal pain is obscure. o If prompt resolution of pain does not result from correction of metabolic abnormalities (e.g., DKA), suspect an underlying organic problem. Diagnosis of the cause of abdominal pain in the elderly can be difficult. o Coexistence of multiple chronic conditions and the use of multiple pharmaceutical agents may make the clinical picture unclear. o The physical examination may be benign even in the face of catastrophic illness.
o

History Far more valuable than any laboratory or radiographic examination o A reasonably accurate diagnosis can usually be made on the basis of history alone. o The chronological sequence of events is often more important than the location of pain. o Key points of information include: Location of the pain Radiation of the pain Exacerbating and ameliorating factors Associated symptoms (fevers, chills, weight loss or gain, nausea, diarrhea, constipation, blood in the stool, jaundice, change in color of urine or stool, change in diameter of stool) Family history of bowel disorders Alcohol intake Medication history o Drugs may be causative; e.g., NSAIDs may cause ulcer disease and gastritis. o Medications may suggest a diagnosis; e.g., an elderly patient taking antihypertensive and cholesterol-lowering drugs may have generalized atherosclerotic disease and be at risk for ischemic bowel disease. Accurate menstrual history in women Sexual history, contacts, risky behaviors, past sexually transmitted diseases o Remember to consider extra-abdominal sources of pain.

Physical examination There is no substitute for sufficient time spent in examination. Simple inspection of the patient (e.g., the facial expression, position in bed, and respiratory activity) may provide valuable clues to the severity of pain and urgency of the situation. Measurement of vital signs is the critical first step in examination. o Fever, hypotension, tachycardia, and tachypnea, alone or in combination, are signs requiring urgent attention and intervention. o Orthostatic changes may indicate hypovolemia and/or hemorrhage.

Examination of the skin and eyes for jaundice Auscultation and percussion of the chest Auscultation of the abdomen for bowel sounds Palpation of the abdomen for masses, tenderness, and peritoneal irritation Rectal examination and stool testing for occult blood Pelvic examination in a female, testicular and prostatic examination in a male The amount of information gleaned is directly proportional to gentleness and thoroughness of examiner. o Once a patient with peritoneal inflammation has been examined brusquely, accurate assessment by the next examiner becomes almost impossible. Eliciting rebound tenderness by sudden release of a deeply palpating hand in patient with suspected peritonitis is cruel and unnecessary. o Gentle percussion of abdomen (rebound tenderness on miniature scale) can be far more precise and localizing. o Asking the patient to cough will elicit true rebound tenderness without the need to place a hand on the abdomen. o Forceful demonstration of rebound tenderness will startle and induce protective spasm in nervous or worried patient in whom true rebound tenderness is not present. o A palpable gallbladder will be missed if palpation is so rough that voluntary muscle spasm becomes superimposed on involuntary muscular rigidity. Abdominal signs

May be minimal, but are still meaningful if accompanied by consistent symptoms o May be virtually or totally absent in cases of pelvic peritonitis Thus, a rectal and/or pelvic exam are critical components of the assessment. o Tenderness on pelvic or rectal examination in absence of other abdominal signs can be caused by operative indications such as:
o

Perforated appendicitis Diverticulitis Twisted ovarian cyst Auscultation

The presence, absence, and quality of bowel sounds may be misleading and often over-rated as a diagnostic tool. o A strangulating small intestinal obstruction or perforated appendicitis may occur in the presence of normal peristaltic sounds. o When proximal part of intestine above an obstruction becomes markedly distended and edematous, peristaltic sounds may lose characteristics of borborygmi and become weak or absent, even when peritonitis is not present. o Severe chemical peritonitis of sudden onset is usually associated with truly silent abdomen. Laboratory examinations (as indicated)
o

Laboratory Tests

May be of value, yet only infrequently establish a definitive diagnosis o Tests that should be ordered include: Complete blood count Blood chemistries including blood urea nitrogen, glucose, bilirubin, amylase, and lipase Urinalysis Radiologic studies (as indicated) o Plain and upright or lateral decubitus radiographs o Contrast enema o Ultrasonography o CT with contrast o Radioisotopic scans (HIDA) o Barium or water-soluble contrast study of upper GI tract Useful in rare instances when the diagnosis is elusive Avoid oral administration of barium sulfate if there is any question of possible obstruction of the colon. Diagnostic procedures o Upper and lower endoscopy o Endoscopic retrograde cholangiopancreatography (ERCP) o Laparoscopy
o

Urinalysis
o

Helps reveal the patients state of hydration

Helpful in assessing renal dysfunction, bleeding, or infection in the urinary tract, and the presence of diabetes/DKA Complete blood count o Leukocytosis
o

Never the single deciding factor for surgical intervention Count >20,000/L may be seen in perforation of a viscus, pancreatitis, acute cholecystitis, pelvic inflammatory disease, and intestinal infarction. Note that other coexisting conditions may also elevate the white blood cell count, e.g., steroid therapy, other inflammatory or infectious processes. A normal white blood cell count is not rare in perforation of abdominal viscera. o Anemia When combined with an accurate history, the presence of anemia may be very helpful in the diagnosis. o Iron deficiency anemia may indicate GI blood loss from an ulcer or intestinal lesion. o In a patient with a GI bleed, if the red cells are microcytic and hypochromic, blood loss is probably chronic; if not, the blood loss is likely more acute. Blood chemistries o Blood urea nitrogen (BUN), glucose, and liver function studies will assess renal function, diabetes, and underlying liver and biliary disease. o Serum amylase may be elevated in pancreatitis, a perforated ulcer, strangulating intestinal obstruction, and acute cholecystitis. Thus, an elevation of the amylase does not rule out the possibility of surgical disease. The amylase rises within 212 hours of the onset of acute pancreatitis. o Serum lipase Rises less acutely than the amylase, but stays elevated longer o -human chorionic gonadotrophin levels will be elevated in pregnancy. Blood and urine cultures should be obtained in patients with fever or unstable vital signs.

The elderly may not manifest fever despite infection, and the threshold for obtaining cultures should be low. HIV testing, if relevant
o

Imaging
If the diagnosis is in doubt, then imaging studies can provide important information. Plain and upright or lateral decubitus radiographs may be of particular value in cases of: o Intestinal obstruction (gas-filled bowel with cutoff at site of blockage) o Perforated viscus (free air in the abdomen) o Ischemic bowel disorders (thumbprinting of the bowel wall) o Gallstones (visible in about 1015% of cases) Barium or water-soluble contrast study of upper GI tract o May demonstrate partial intestinal obstruction that may elude diagnosis by other means o If there is any question of obstruction of colon, oral administration of barium sulfate should be avoided. Contrast enema may be diagnostic in suspected colonic obstruction (without perforation). Ultrasonography is useful in detecting:

Enlarged gallbladder or pancreas Gallstones o Enlarged ovary o Tubal pregnancy Nuclear scan with hepatobiliary iminodiacetic acid (HIDA ) o A functional assessment of gallbladder function o A positive test for acute cholecystitis is present when the dye enters the common bile duct but not the gallbladder. o Useful when cholecystitis is suspected but other imaging tests fail to demonstrate significant stone disease. CT scanning may demonstrate:
o o

An enlarged pancreas or other abdominal mass o Gallstones o Ruptured spleen o Thickened colonic or appendiceal wall and streaking of the mesocolon or mesoappendix characteristic of diverticulitis or appendicitis
o

Lymphadenopathy suggestive of a chronic neoplastic or inflammatory process o Vascular aneurysm

o

Diagnostic Procedures
Upper and lower endoscopy o Best method for detecting lesions within the lumen and mucosa of the GI tract Upper endoscopy will detect ulcer disease, gastritis and tumors, for example. Lower endoscopy (colonoscopy) will detect acute inflammatory bowel disease and tumors. ERCP

Excellent way to visualize diseases of the common bile duct and pancreas when other imaging techniques have failed. Laparoscopy o Especially helpful in diagnosing pelvic conditions, such as: Ovarian cysts Tubal pregnancies Salpingitis o Can also detect acute appendicitis Peritoneal lavage is used only in cases of trauma. o Has been replaced as diagnostic tool by ultrasound, CT, and laparoscopy Exploratory laparotomy o Less commonly needed with todays improved imaging techniques
o

Treatment Approach
The principles of managing the patient with acute abdominal pain are similar to those of any urgent clinical situation. As required by the circumstances, stabilize the patient. o IV access is almost always advisable. o Restoration of proper fluid and electrolyte balance should be carried out as quickly as tolerated. Ascertain if urgent surgical intervention is required. Provide pain relief. o Narcotics or analgesics should not be withheld until a definitive diagnosis or definitive plan is formulated. The correct diagnosis is almost never hidden by the use of adequate analgesia. Prescribe empiric antibiotic therapy if intraabdominal infection is suspected.

Specific Treatments
Symptom relief

Provide other symptomatic relief (e.g., antiemetics, antispasmodics). Definitive treatment is dependent on etiology of pain.

Pain control o Opioid analgesics (e.g., hydromorphone: 12 mg SC or IM; meperidine: 75100 mg IM) o Antacids or H2 receptor antagonists for burning pain caused by gastric acid (famotidine: 20 mg/50 mL IV; ranitidine: 50 mg) H2 receptor blockers tend to provide quicker relief than proton pump inhibitors. o Intravenous ketorolac (1530 mg) may be used for renal or biliary colic. Control of intractable emesis o Droperidol (2.5 mg IM) o Prochlorperazine (510 mg IM) o Promethazine (12.525 mg IM) o Trimethobenzamide (200 mg IM) o Any of these agents may cause mental status changes. Nasogastric tube with suction for suspected small-bowel obstruction

Empiric antibiotics Second-generation cephalosporins combined with metronidazole (unless local antibiotic resistance)

Cefotetan (13 g IV q12h) Cefoxitin (2 g q48h or 3 g q6h IV) o Metronidazole (loading dose: 15 mg/kg IV infusion over 1h; maintenance dose: 7.5 mg/kg IV infusion over 1h, q6h) The combination of metronidazole with a fluoroquinolone (e.g., levofloxacin 750 mg qd IV) is frequently used, with the addition ofampicillin 2g q6h IV) in severe, life-threatening disease. Alternatives: -lactam agents with lactamase antagonists
o o o o o

Ampicillin sulbactam (1.53 g q6h IV) Piperacillin/tazobactam (3.375 g q6h IV) Ticarcillin/clavulanate (200300 mg/kg per d IV)

Alternatives if patient recently took other antibiotics: carbapenem orcefepime o Imipenem (500 mg q6h to 1 g q8h IV) o Meropenem (1 g q8h IV) Antifungal agents may be necessary for immunocompromised patients.

Definitive treatment

Monitoring
Careful follow-up with frequent reexamination (by the same examiner, when possible) is recommended. Repeated studies may be necessary when a definitive diagnosis has not been made.

Dependent on etiology of pain

Complications
Complications are dependent on the etiology of the pain but can include: o Sepsis o Peritonitis o Ruptured viscus o Ischemic bowel o Intraabdominal hemorrhage o Intestinal obstruction o Urinary obstruction o Splenic infarction

Prognosis

Prognosis depends on:

o o o

Etiology Timely diagnosis Appropriate treatment

Prevention
Possible preventive measures depend on the underlying cause.

ICD-9-CM
789.00 Abdominal pain, unspecified site 789.0_ Abdominal pain, (anatomic site specified by fifth digit)

See Also

Abdominal Abscesses Abdominal Aortic Aneurysm Acute Appendicitis Acute Cholecystitis Acute Intestinal Obstruction Acute Pancreatitis

Internet Sites
Professionals o Homepage-Physicians American College of Gastroenterology Patients o Abdominal pain MedlinePlus o Abdominal Pain American College of Gastroenterology

Chronic Pancreatitis Gallstones Gastritis Irritable Bowel Syndrome Pelvic Inflammatory Disease Peptic Ulcer Disease Peritonitis

General Bibliography
Attard AR et al: Safety of early pain relief for acute abdominal pain. BMJ305:554, 1992 [PMID:1393034] Cervero F, Laird JM: Visceral pain. Lancet 353:2145, 1999 [PMID:10382712] Gatzen C et al: Management of acute abdominal pain: decision making in the accident and emergency department. J R Coll Surg Edinb 36:121, 1991 [PMID:2051408] Jones PF: Suspected acute appendicitis: trends in management over 30 years. Br J Surg 88:1570, 2001 [PMID:11736966] Marco CA et al: Abdominal pain in geriatric emergency patients: variables associated with adverse outcomes. Acad Emerg Med 5:1163, 1998 [PMID:9864129] Scott HJ, Rosin RD: The influence of diagnostic and therapeutic laparoscopy on patients presenting with an acute abdomen. J R Soc Med 86:699, 1993 [PMID:8308808] Tait IS, Ionescu MV, Cuschieri A: Do patients with acute abdominal pain wait unduly long for analgesia? J R Coll Surg Edinb 44:181, 1999 [PMID:10372490] Taourel P et al: Acute abdomen of unknown origin: impact of CT on diagnosis and management. Gastrointest Radiol 17:287, 1992 [PMID:1426841] Weyant MJ et al: Interpretation of computed tomography does not correlate with laboratory or pathologic findings in surgically confirmed acute appendicitis. Surgery 128:145, 2000 [PMID:10922984]

Yu J et al: Helical CT evaluation of acute right lower quadrant pain: part I, common mimics of appendicitis. AJR Am J Roentgenol 184:1136, 2005 [PMID:15788584] This topic is based on Harrisons Principles of Internal Medicine, 17th edition, chapter 14, Abdominal Pain by W Silen.

PEARLS
The workup of the patient with acute abdominal pain can be viewed as a 3-step process: o Patients who are hemodynamically unstable are at risk for having had a vascular catastrophe such as a ruptured aortic aneurysm and go immediately to surgery. o The 3 conditions that must be considered next are intestinal obstruction, peritonitis, and a ruptured ectopic pregnancy. Outcome is adversely influenced by delaying surgical intervention. o In a hemodynamically stable patient without obstruction, peritonitis, or a ruptured ectopic pregnancy, evaluation can be more deliberative and is based on the location of the pain. Severe pathology may be masked in immunosuppressed and elderly subjects because of a compromised inflammatory response. Signs and symptoms of peritonitis may be muted. Referred abdominal pain is often perceived to be near the surface of the body. Left upper quadrant pain in a patient with atrial fibrillation (or who for some other reason is at risk for thromboembolism) may indicate a splenic infarct.