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Evaluation and management of acute abdominal

pain in the emergency department
International Journal of General Medicine downloaded from https://www.dovepress.com/ on 04-Aug-2023

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International Journal of General Medicine
24 September 2012
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Christopher R Macaluso Abstract: Evaluation of the emergency department patient with acute abdominal pain is
Robert M McNamara sometimes difficult. Various factors can obscure the presentation, delaying or preventing the
Department of Emergency Medicine,
correct diagnosis, with subsequent adverse patient outcomes. Clinicians must consider multiple
Temple University School of Medicine, diagnoses, especially those life-threatening conditions that require timely intervention to limit
For personal use only.

Philadelphia, PA, USA morbidity and mortality. This article will review general information on abdominal pain and
discuss the clinical approach by review of the history and the physical examination. Additionally,
this article will discuss the approach to unstable patients with abdominal pain.
Keywords: acute abdomen, emergency medicine, peritonitis

Introduction
Abdominal pain is the most common reason for a visit to the emergency department
(ED), accounting for 8 million (7%) of the 119 million ED visits in 2006.1 Obviously,
anyone practicing emergency medicine (EM) must be skilled in the assessment of
abdominal pain. Although a common presentation, abdominal pain must be approached
in a serious manner, as it is often a symptom of serious disease and misdiagnosis may
occur. Abdominal pain is the presenting issue in a high percentage of medicolegal actions
against both general and pediatric EM physicians.2,3 The modern physician should
be humbled by the fact that, despite diagnostic and therapeutic advances (computed
tomography [CT], ultrasonography, and laparoscopy), the misdiagnosis rate of the most
common surgical emergency, acute appendicitis, has changed little over time.4

History
The clinician should try to obtain as complete a history as possible as this is gener-
ally the cornerstone of an accurate diagnosis. The history should include a complete
description of the patient’s pain and associated symptoms. Medical, surgical, and social
history should also be sought as this may provide important information.

Assessment of the patient’s pain

Correspondence: Christopher R
Macaluso The classic PQRST mnemonic for a complete pain history is as follows:
Department of Emergency Medicine, P3 – Positional, palliating, and provoking factors
Temple University School of Medicine,
10th Floor Jones Hall, 1316 West Q – Quality
Ontario St, Philadelphia, PA 19140, USA R3 – Region, radiation, referral
Tel +1 215 707 7550
Email Christopher.Macaluso@tuhs.
S – Severity
temple.edu T3 – Temporal factors (time and mode of onset, progression, previous episodes)

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 Macaluso and McNamara Dovepress

This mnemonic will help to ensure a thorough history, an acute onset. For example, only 47% of elderly patients
but rigidly following the above sequence does not allow for with a proven perforated ulcer report the acute onset of pain.8
a smooth patient interview, so the authors prefer to ask the Likewise, volvulus, particularly of the sigmoid colon, can
patient where they feel the pain (location), what kind of pain present with a gradual onset of pain.9 Serious vascular issues
it is (character), when and how it began (onset), how bad it is such as mesenteric ischemia may present with a gradual onset
(intensity), and where else they feel it, what makes it worse of pain. Conversely, one would expect a gradual onset in the
or better, how it has changed over time, and whether they setting of an infectious or inflammatory process. Pain that
have ever had it before. awakens the patient from sleep should be considered serious
until proven otherwise.10 The time of onset establishes the
Location duration of the pain and allows the physician to interpret the
Embryology determines where a patient will “feel” visceral current findings in relation to the expected temporal progres-
pain, which is generally perceived in the midline because sion of the various causes of abdominal pain.
afferent impulses from visceral organs are poorly localized.
Visceral nociceptors can be stimulated by distention, Intensity
stretch, vigorous contraction, and ischemia. Pain from Pain that is severe should heighten the concern for a seri-
foregut structures, which include the stomach, pancreas, ous underlying cause; however, descriptions of milder pain
liver, biliary system, and the proximal duodenum, will be cannot be relied on to exclude serious illness, especially in
typically localized to the epigastric region. The rest of the older patients who may under-report symptoms.
small bowel and the proximal third of the colon including the
appendix are midgut structures, and visceral pain associated Patterns of radiation and referral of pain
with these organs is perceived in the periumbilical region. The neural pathways give rise to predictable patterns of
Hindgut structures such as the bladder, and distal two-thirds referred pain and radiation. Kehr’s sign is a classic example
of the colon, as well as pelvic genitourinary organs usually where diaphragmatic irritation, usually from free intraperito-
cause pain in the suprapubic region. Pain is usually reported neal blood, causes shoulder pain.11 Any other inflammatory
in the back for retroperitoneal structures such as the aorta process or organ contiguous to the diaphragm can also cause
and kidneys.5,6 referred shoulder pain. Another well described example is
ipsilateral scapula pain caused by biliary disease. Radiation
Character may also reflect progression of disease such as with contin-
Clinicians should seek to distinguish between the dull, ued aortic dissection, or ongoing passage of a ureteral stone.
poorly localized, aching, or gnawing pain generated While considering referred pain, it is important to remember
by viscerally innervated organs, compared with the that deep musculoskeletal structures (especially of the back)
characteristically “sharp”, more defined and localized are innervated by visceral sensory fibers with similar qualities
somatic pain caused by irritation of the parietal peritoneum to those arising from intra-abdominal organs. These fibers
or other somatically innervated structures. Somatic pain is converge in the spinal cord, giving rise to “scleratomes”:
transmitted via the spinal nerves from the parietal peritoneum regions of referral in the abdomen and flanks. Thus, in cases
or mesodermal structures of the abdominal wall. Noxious where a patient’s perceived location of symptoms appears to
stimuli to the parietal peritoneum may be inflammatory or be completely unrevealing on physical exam, a careful assess-
chemical in nature (eg, blood, infected peritoneal fluid, and ment of musculoskeletal structures should be made.12
gastric contents).5,7
Duration and progression
Onset Persistent worsening pain is worrisome, while pain that is
Acute-onset pain, especially if severe, should prompt imme- improving is typically favorable. Serious causes of abdominal
diate concern about a potential intra-abdominal catastrophe. pain generally present early in their course; however, delays
The foremost consideration would be a vascular emergency in presentation can occur, especially in the elderly. Certain
such as a ruptured abdominal aortic aneurysm (AAA) or patterns of progression can be diagnostic, such as the migra-
aortic dissection. Other considerations for pain of acute onset tion of pain in appendicitis where the initial distention of the
include a perforated ulcer, volvulus, mesenteric ischemia, and appendix causes a periumbilical visceral pain that shifts to
torsion; however, these conditions may also occur without the right lower quadrant once the inflammatory process is

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 Dovepress Evaluation and management of acute abdominal pain in the ED

detected by the somatic sensors of the parietal peritoneum. Vomiting

Although labeled “colic,” gallbladder pain is generally Vomiting may occur in almost any abdominal disease.
not paroxysmal, and it almost never lasts less than 1 hour, Pain generally precedes vomiting in surgical conditions,
with an average of 5–16 hours’ duration, and ranging up to with the important exception of esophageal rupture from
24 hours.13 Small bowel obstruction typically progresses forceful emesis.10,17 It is usually present in small bowel
from an intermittent (“colicky”) pain to more constant pain obstruction, unless the obstruction is partial or the patient is
when distention occurs. One would only expect somatic pain presenting early in the course. Many other serious entities
(arising from transmural ischemia or perforation contigu- including large bowel obstruction frequently present without
ous to the parietal peritoneum) late in the course of a bowel vomiting. The nature of the vomiting may be diagnostically
obstruction. helpful. With small bowel obstruction, one anticipates a pro-
gression from gastric contents to bilious to feculent emesis
Provocative and palliating factors as the duration of the illness increases. Frequent nonproduc-
The clinician needs to ask what, if anything, makes the pain tive retching can point to gastric volvulus,18 while repetitive
worse and what improves the pain. It is important to estab- nonbilious vomiting may indicate gastric outlet obstruction.
lish whether jarring motions such as coughing or walking The presence of blood or bile should be noted. Bilious vomit-
exacerbate the pain, suggesting peritoneal irritation.14 Patients ing in an infant is always considered a harbinger of serious
with peritonitis often remark on increased pain with jolts or abdominal illness such as intestinal malrotation.19 Blood or
bumps in the road. A recommended interview sequence coffee ground emeses are usually caused by gastric diseases
would be “how did you get here today? Tell me about the or complications of liver disease. Massive hematemesis in a
ambulance/car ride.” With upper abdominal pain one should patient with a prior abdominal aortic aneurysm repair may
specifically ask whether it is pleuritic as this may signify chest be due to aorto-enteric fistula.20 The key feature of vomiting
disease. Peptic ulcer disease may be exacerbated (gastric) or from more benign causes such as viral or food-borne illness
relieved (duodenal) by eating. Mesenteric ischemia may is that it is self-limited.
be precipitated by eating, as can the pain of intermittently
symptomatic gallstones, often associated with fatty meals. Bowel symptoms
The patient should be questioned about any self treatments, While diarrhea is a frequent accompaniment of more benign
particularly analgesics and antacids, and the response to abdominal conditions, its presence alone should never rule
these measures. out serious disease. For example, diarrhea is common with
mesenteric ischemia and is frequently reported in conditions
Previous episodes such as appendicitis.15,21 In one series of 1000 ED patients pre-
Recurrent episodes generally point to a medical cause, with senting with abdominal pain, 18% presented with diarrhea.
the exceptions of mesenteric ischemia (intestinal angina), No patient aged less than 40 with diarrhea and continuous
gallstones, or partial bowel obstruction. pain was found to have a surgical cause for their symptoms.22
Conversely, diarrhea can be reported in up to one-fifth of
Assessment of the associated symptoms patients with colonic obstruction.23 Diarrhea also occurs in
Gastrointestinal and urinary symptoms are the primary focus; early small bowel obstruction as the reflexively hyperactive
however, it is important to ask about fever and cardiopul- bowel distal to the obstruction clears itself, and with partial
monary symptoms. Associated symptoms should be placed obstruction, diarrhea may be ongoing. Absence of flatus is
in the clinical context, including the patient’s age and the a more reliable sign than constipation in bowel obstruction,
current point in the course of the illness. since the bowel clears gas more rapidly than fluid. Bloody
stool in the presence of significant abdominal pain should
Anorexia raise the suspicion for mucosal compromise from ischemia.
With appendicitis, most physicians expect the patient to Melena suggests an upper source of bleeding, while frank
report anorexia. However, pooling of the literature indicates blood can indicate a lower source or a massive upper bleed
that, while this is a discriminatory symptom, it is only pres- with rapid transit time. The urge to defecate in a patient with
ent in 68% of patients with appendicitis.15 The report of this acute abdominal pain has been described as a harbinger of
symptom decreases to 20%–44% in elderly patients with serious disease including a ruptured aneurysm in the older
appendicitis.16 patient or ruptured ectopic pregnancy in the young.24

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Other symptoms concern given the variety of potentially lethal underlying

Many genitourinary tract diseases can present with abdominal causes. On the other hand, especially in the elderly, the clini-
pain. Conversely, any inflammatory process contiguous to cian must not be misled by the well appearing patient who
the genitourinary tract (including appendicitis, cholecystitis, may still have serious underlying disease.26 The clinician
pancreatitis, or any inflammatory process involving bowel) should take note of the patient’s position, spontaneous
may result in both pyuria and dysuria. This can lead to misdiag- movements, respiratory pattern, and facial expression.
nosis of both gastrointestinal and genitourinary conditions. In
men, testicular torsion may present as abdominal pain, nausea, Vital signs
and vomiting. In women, the enlarging uterus of pregnancy can Vital sign abnormalities should alert the clinician to a seri-
itself cause discomfort and displace abdominal organs in such a ous cause of the abdominal pain. However, the presence of
way as to further complicate the diagnosis of many abdominal normal vital signs does not exclude a serious diagnosis. While
conditions, especially appendicitis. For these reasons, a men- fever certainly points to an infectious cause or complication,
strual (where applicable), sexual, and genitourinary history it is frequently absent with infectious causes of abdominal
should be obtained in most patients with abdominal pain. The pain. For example, fever is absent in over 30% of patients
report of normal, regular menses should not preclude consid- with appendicitis and in the majority of those with acute
eration of current pregnancy.25 Cardiopulmonary symptoms cholecystitis.15,27 Tachypnea may be a nonspecific finding, but
such as cough and dyspnea can point to a nonabdominal cause it should prompt consideration of chest disease or metabolic
of abdominal pain. Syncope may indicate disease originating acidosis from entities such as ischemic bowel or diabetic
in the chest (pulmonary embolism, dissection) or abdomen ketoacidosis.
(acute aortic aneurysm, ectopic pregnancy).
The abdominal examination
Past medical and surgical history, The emergency physician should know the key elements
current medications of the abdominal examination while understanding their
A history of prior abdominal surgery can rule out a con- limitations. In particular, all techniques for the detection of
dition or raise the suspicion for a complication such as peritonitis will yield both false-negative and false-positive
obstruction from adhesions. Many medical conditions cause results.
acute abdominal pain, including diabetic ketoacidosis,
hypercalcemia, Addison’s disease, and sickle cell crisis. Inspection, auscultation, and percussion
Other less common metabolic causes of acute abdominal Inspection is important for the detection of surgical scars,
pain include uremia, lead poisoning, methanol intoxication, skin changes including signs of herpes zoster, liver disease
hereditary angioedema, and porphyria. The patient’s cur- (caput medusa), and hemorrhage (Grey Turner’s sign of
rent medications should be reviewed with attention to those flank ecchymoses with a retroperitoneal source, Cullen’s
affecting the integrity of the gastric mucosa (steroids and sign of a bluish umbilicus with intraperitoneal bleeding).11
nonsteroidal anti-inflammatory drugs), immunosuppressive With distention, percussion will allow the differentiation
agents (impair host defenses and the generation of an inflam- between large bowel obstruction (drum-like tympany) and
matory response), and any that can impair nociception advanced ascites (shifting dullness). Auscultation is of very
(narcotics may also be a cause of pain due to constipation). limited diagnostic utility, and prolonged listening for bowel
sounds is an ineffective use of time, although it may reveal
Social history high pitched sounds in early small bowel obstruction or the
The patient’s use of drugs and alcohol may have important diag- silence encountered with ileus or late in the course of any
nostic implications. Cocaine use may cause intestinal as well abdominal catastrophe. Bruits have been described with
as cardiac ischemia. Gastrointestinal complications of alcohol aortic, renal, or mesenteric stenosis, but are rarely appreciated
abuse are extensive and well known. Direct questions regarding in a busy ED.28
domestic violence may reveal a traumatic source of pain.
Palpation
Physical examination The ED abdominal exam is directed primarily to the
The general appearance of the patient is noted first. An “ill localization of tenderness, the identification of peritonitis,
appearing” patient with abdominal pain is always of great and the detection of certain enlargements such as the

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 Dovepress Evaluation and management of acute abdominal pain in the ED

abdominal aorta. Various strategies have been advocated to identification of cholecystitis.27,33,34 The use of indirect tests
improve the palpation phase of the examination, including such as the “cough test,” where one looks for signs of pain
progression from nonpainful areas to the location of pain. such as flinching, grimacing, or moving the hands to the
It may be useful to palpate the abdomen of anxious or less abdomen upon coughing has a similar sensitivity but with a
cooperative children with the stethoscope to define areas of specificity of 79%.35 In children, indirect tests would include
tenderness.29 Meyerowitz30 advocates following up the initial the “heel drop jarring” test (child rises on toes and drops
examination with a secondary palpation with a stethoscope weight on heels) or asking the child to jump up and down
while telling the patient one is listening in order to uncover while looking for signs of abdominal pain.29,36
exaggerated symptoms. It is preferable to have the patient flex Guarding is defined as increased abdominal wall muscular
the knees and hips to allow for relaxation of the abdominal tone and is only of significance as an involuntary reflex when it
musculature (see below discussion of guarding). reflects a physiological attempt to minimize movement of the
Localized tenderness is generally a reliable guide to the intraperitoneal structures. In contrast, “voluntary guarding”
underlying cause of the pain. More generalized tenderness can be induced by any person with conscious control of their
presents a greater diagnostic challenge. Unless the patient abdominal wall musculature and is frequently seen in com-
has had an appendectomy, the authors recommend, given its pletely normal patients with apprehension about the abdomi-
frequency as a serious cause of abdominal pain, continued nal exam. Rigidity is the extreme example of true guarding.
consideration of appendicitis in any patient with right lower To identify true guarding, the examiner gently assesses muscle
quadrant tenderness. Despite the known issues with diagnos- tone through the respiratory cycle, preferably with the knees
ing appendicitis in the elderly, virtually all of them will have and hips flexed to further relax the abdomen. With “voluntary
right lower quadrant tenderness.8 If tolerated by the patient, guarding,” the tone will decrease with inspiration, while with
palpation or percussion may include assessment of the liver true guarding, the examiner will be able to detect continued
and spleen size and a search for pulsatile or other masses abdominal wall tension throughout the respiratory cycle.
and an assessment of the quality of femoral pulses. A tender Guarding and rigidity may be lacking in the elderly because
pulsatile and expansile mass is the key distinguishing feature of laxity of the abdominal wall musculature. Disturbingly,
of an acute abdominal aortic aneurysm, although this and only 21% of patients over the age of 70 with a perforated
most other masses are much more accurately diagnosed ulcer presented with epigastric rigidity.8
with the aid of a bedside ultrasound machine, if available.31
The femoral pulses may be unequal with aortic dissection.32 The rectal examination
Inspection and palpation of the patient while they are stand- The diagnostic value of a rectal examination in the evaluation
ing may reveal the presence of hernias undetected in the of acute abdominal pain is limited; however, it may be of
supine position. use in detecting intestinal ischemia, late intussusception, or
colon cancer. The routine performance of a rectal examina-
Tests for peritoneal irritation tion in suspected appendicitis is not supported by the avail-
Determining the presence or absence of peritonitis is a pri- able literature.37 It is recommended that, as a general rule,
mary objective of the abdominal examination; unfortunately, one should not perform this examination in children as it
the methods for detecting it are often inaccurate. Traditional adds little to the diagnostic process at the cost of significant
rebound testing is performed by gentle depression of the discomfort.38 On the other hand, the exam’s utility is likely
abdominal wall for approximately 15–30 seconds with sudden to increase with the patient’s age, and one study found that
release. The patient is asked whether the pain was greater with within 1 year nearly 11% of patients over the age of 50 diag-
downward pressure or with release. Despite limitations, the nosed with nonspecific abdominal pain in an ED were found
test was one of the most useful in a meta-analysis of articles to have cancer, principally of the colon.33 The use of the
investigating the diagnosis of appendicitis in children.29 Cope’s rectal examination in other age groups should be targeted
Early Diagnosis of the Acute Abdomen recommends against to diagnoses in which it may yield important information.37
this test because it is unnecessarily painful. The authors sug-
gest gentle percussion as more accurate and humane.28 When Special abdominal examination
subject to study, traditional rebound testing has a sensitivity techniques
for the presence of peritonitis near 80%, yet its specificity is There are a number of examination techniques that may be useful
only 40%–50% and it is entirely nondiscriminatory in the to the emergency physician in helping to establish a diagnosis.

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Some of these tests have not been well studied, but docu- Murphy’s sign
mentation of their presence or absence on the chart will Murphy described cessation of inspiration in cholecystitis
indicate a consideration of a specific disease process such when the examiner curled their fingers below the anterior
as appendicitis. right costal margin from above the patient.45 Now most com-
monly performed from the patient’s side, inspiratory arrest
Carnett’s sign while deeply palpating the right upper quadrant is the most
Abdominal wall tenderness can be caused by trauma, and reliable clinical indicator of cholecystitis, although it only
with increasing numbers of patients on therapeutic anti- has a sensitivity of 65%.27
coagulation, abdominal wall hematoma. The following
technique, described by Carnett in 1926, may confirm the The psoas sign
abdominal wall as the source of the patient’s pain. The point The psoas sign is provoked by having the supine patient
of maximal pain is identified, and this is palpated with the lift the thigh against hand resistance, or with the patient
abdomen wall relaxed and then tensed through the perfor- laying on their contralateral side and the hip joint passively
mance of a half sit-up with the arms crossed. Increased pain extended. Increased pain suggests irritation of the psoas
with the wall tensed is a positive sign of abdominal wall muscle by an inflammatory process contiguous to the muscle.
pathology, a decrease in pain is considered a negative test. When positive on the right, this is a classic sign suggestive
When prospectively applied in 120 patients, the test was of appendicitis. Other inflammatory conditions involving the
positive in 24, with only one having an intra-abdominal retroperitoneum, including pyelonephritis, pancreatitis, and
pathologic condition.39 Others have found it less accurate but psoas abscess, will also elicit this sign.
still useful.40 This test should not be routinely applied but is
considered when there is a supportive history and absence The obturator sign
of indicators of other illness.41 The obturator sign is elicited with the patient supine and the
examiner supporting the patient’s lower extremity with the
Cough test hip and knee both flexed to 90 degrees. The sign is positive
Originally described by Rostovzev in 1909, this test seeks if passive internal and external rotation of the hip causes
evidence of peritoneal irritation by having the patient cough.42 reproduction of pain, and suggests the presence of an inflam-
Jeddy and colleagues43 described a positive test as a cough matory process adjacent to the muscle deep in lateral walls of
causing a sharp, localized pain. They applied this prospec- the pelvis. Potential diagnoses include a pelvic appendicitis
tively to patients with right lower quadrant pain and found (on the right only), sigmoid diverticulitis, pelvic inflamma-
it to have near perfect sensitivity with a specificity of 95% tory disease, or ectopic pregnancy.
for the detection of appendicitis or peritonitis (one patient
with perforated diverticulitis). Bennett and colleagues 35 The Rovsing sign
consider signs of pain on coughing such as flinching, gri- The Rovsing sign is a classic test used in the diagnosis
macing, or moving of hands to the abdomen as a positive of appendicitis. It is a form of indirect rebound testing in
test and reported a sensitivity of 78% with a specificity of which the examiner applies pressure in the left lower quad-
79% for the detection of peritonitis in a prospective study of rant, remote from the usual area of appendiceal pain and
150 consecutive patients with abdominal pain. tenderness. The test is positive if the patient reports rebound
pain in the right lower quadrant when the examiner releases
Closed eyes sign pressure.15 In limited studies, the psoas, obturator, and Rovs-
Based on the assumption that the patient with an acute ing signs demonstrate a low sensitivity (15%–35%) but a rela-
abdominal condition will carefully watch the examiner’s tively high specificity (85%–95%) for appendicitis.15,29,46
hands to avoid unnecessary pain, this test is considered an
indicator of nonorganic cause of abdominal pain. The test Other examination elements
is considered positive if the patient keeps their eyes closed Careful examination of adjacent areas is a key part of the
when abdominal tenderness is elicited. In a prospective study assessment of the patient with abdominal pain. In addition to
of 158 patients, Gray and colleagues44 found that 79% of the skin inspection, the back should be assessed for tenderness at
28 patients who closed their eyes did not have identifiable the costovertebral angle, spinous processes, and paraspinal
organic pathology. regions. Because virtually any chest disease can present

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 Dovepress Evaluation and management of acute abdominal pain in the ED

with abdominal pain, particular attention should be paid to the bowel lumen or peritoneal space in bowel obstruction
the cardiopulmonary examination. The groin, including the or other intestinal catastrophes. Bedside ultrasonography is
femoral triangle, is assessed for hernias. The male patient an extremely useful diagnostic adjunct in such patients. In
must be inspected for testicular pathology including torsion the older patient, hypotension should prompt an immediate
and infection. In females with lower abdominal pain a pelvic search for an abdominal aortic aneurysm, immediately fol-
examination is almost always necessary. The pelvic examina- lowed by sonographic evaluation of the inferior vena cava
tion presents an opportunity to assess the pelvic peritoneum for intravascular volume status, and sonography of the heart,
directly for signs of inflammation through the assessment of pleural, and peritoneal spaces to exclude massive effusions
cervical motion tenderness. If Fitzhugh-Curtis syndrome is or evidence of massive pulmonary embolus. Bedside
a consideration, a pelvic examination may be indicated with echocardiography will also identify severe global myocardial
upper abdominal pain.7 depression as a cardiogenic cause of shock. In the younger
patient, a large amount of free fluid detected by ultrasound
Analgesia and the abdominal examination in an unstable patient is most commonly due to rupture of
The emergency physician should not hesitate to administer an ectopic pregnancy, spleen, or hemorrhagic ovarian cyst.
adequate analgesic medication to the patient with acute An immediate urine pregnancy test will be the first step in
abdominal pain. When studied, the administration of narcotic distinguishing these.
analgesics does not obscure the diagnosis or interfere with The proper place for the unstable patient with an acute
the treatment of the patient. The United States Agency for abdominal aortic aneurysm is the operating room or, in some
Healthcare Research and Quality issues reports regarding centers, the interventional suite for emergency aortic stent
making health care safer and recommended this practice placement. Attempts to obtain CT imaging, may cause fatal
after a review of the literature.47 Previously, Cope’s Early delays in definitive treatment. With a high clinical index
Diagnosis of the Acute Abdomen admonished the physician of suspicion (if possible, supported by emergency bedside
for administering morphine, but this stance has been reversed ultrasonography), most patients sent directly to surgery
in more recent editions.47,48 Thomas and colleagues49 authored will be found to have an acute AAA, and nearly all others
a prospective study where the administration of up to 15 mg will have an alternative diagnosis that still needs operative
of morphine did not affect diagnostic accuracy in patients intervention.50
with acute abdominal pain. They further recommended its
use in that it fulfills the physician’s “imperative to relieve Diagnostic studies and disposition
suffering.” Appropriate diagnostic testing is covered in the respective
chapters for specific entities; however, it must be emphasized
Approach to the unstable patient that there are significant limitations of imaging and labora-
On occasion, a patient with acute abdominal pain will present tory studies in the evaluation of acute abdominal pain and all
in extremis. The ill-appearing patient with abdominal pain diagnostic tests have a false-negative rate. If the history and
requires immediate attention. This is particularly so in the physical examination leads to a high pre-test probability of
elderly, as the overall mortality rate for all older patients a disease, a negative test cannot exclude the diagnosis. For
with acute abdominal pain ranges from 11%–14%, and example, the total leukocyte count can be normal in the face
those presenting in an unstable fashion have an even poorer of serious infection such as appendicitis or cholecystitis.29,51
prognosis.26 CT is frequently used in evaluation of the patient with
The usual sequence of resuscitation is applied to the abdominal pain. Clinicians are enamored with the recent
unstable abdominal pain patient with airway control achieved advances in the technology that have allowed for improved
as necessary. Hypotension requires the parallel process of image resolution and shorter acquisition times along with
treatment and an early assessment for life threatening condi- coronal and three-dimensional reconstruction. However, it
tions requiring emergent surgical intervention. Hypotension remains an imperfect test for conditions such as appendicitis
from blood and fluid loss from the gastrointestinal tract is and may add little to the clinical assessment.52,53
usually apparent from the history coupled with a digital Plain abdominal radiographs are of limited utility in
rectal examination. If this evidence is lacking in the patient the evaluation of acute abdominal pain.54 Although they
with abdominal pain, there needs to be early consideration may be helpful (free intraperitoneal air, calcified aortic
of third spacing, which can cause enormous fluid shifts into aneurysm, air fluid levels in obstruction) other diagnostic

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 Macaluso and McNamara Dovepress

studies are almost always indicated or perform better as the 13. Silen W. Cholecystitis and other causes of acute pain in the right upper
quadrant of the abdomen. In: Cope’s Early Diagnosis of the Acute
initial testing. If plain radiographs are utilized, the limitations Abdomen. New York: Oxford; 2010:131–140.
must be appreciated. For example, a standard upright film 14. Giamberardino MA, De Laurentis S, Affaitati G, et al. Modulation of
will not demonstrate free air in up to 40% of patients with pain and hyperalgesia from the urinary tract by algogenic conditions
of the reproductive organs in women. Neurosci Lett. 2001;304(1–2):
a perforated ulcer.55 61–64.
The oft repeated axiom of “treat the patient, not the test” 15. Wagner JM, McKinney WP, Carpenter JL. Does this patient have
appendicitis? JAMA. 1996;2786:1589–1594.
certainly applies in the patient with acute abdominal pain. 16. Kraemer M, Franke C, Ohmann C, et al. Acute appendicitis in late
An unexpected negative test result should prompt a reas- adulthood: incidence, presentation, and outcome. Results of a pro-
sessment of the patient and consideration for observation spective multicenter acute abdominal pain study and a review for the
literature. Arch Surg. 2000;3835:470–481.
and repeat examination for disease progression. Whenever 17. Brewer RJ, Golden GT, Hitch DC, et al. Abdominal pain: an analysis
the diagnosis is in question, serial examination as an inpa- of 1,000 consecutive cases in a university hospital emergency room.
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