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Evaluation of Acute Abdominal Pain in Adults
Evaluation of Acute Abdominal Pain in Adults
in Adults
Sarah L. Cartwright, MD, and Mark P. Knudson, MD, MSPH
Wake Forest University School of Medicine, Winston-Salem, North Carolina
Acute abdominal pain can represent a spectrum of conditions from benign and self-limited
disease to surgical emergencies. Evaluating abdominal pain requires an approach that relies
on the likelihood of disease, patient history, physical examination, laboratory tests, and imag-
ing studies. The location of pain is a useful starting point and will guide further evaluation.
For example, right lower quadrant pain strongly suggests appendicitis. Certain elements of
the history and physical examination are helpful (e.g., constipation and abdominal distension
strongly suggest bowel obstruction), whereas others are of little value (e.g., anorexia has little
predictive value for appendicitis). The American College of Radiology has recommended dif-
ferent imaging studies for assessing abdominal pain based on pain location. Ultrasonography
is recommended to assess right upper quadrant pain, and computed tomography is recom-
mended for right and left lower quadrant pain. It is also important to consider special popula-
tions such as women, who are at risk of genitourinary disease, which may cause abdominal
pain; and the elderly, who may present with atypical symptoms of a disease. (Am Fam Physi-
cian. 2008;77(7):971-978. Copyright © 2008 American Academy of Family Physicians.)
A
bdominal pain is a common pre- disease (e.g., vascular diseases such as aor-
sentation in the outpatient setting tic dissection and mesenteric ischemia) and
and is challenging to diagnose. surgical conditions (e.g., appendicitis, cho-
Abdominal pain is the present- lecystitis). Physicians should also consider
ing complaint in 1.5 percent of office-based conditions of the abdominal wall, such as
visits1 and in 5 percent of emergency depart- muscle strain or herpes zoster, because these
ment visits.2 Although most abdominal pain are often misdiagnosed.
is benign, as many as 10 percent of patients
in the emergency department setting and a History and Physical Examination
lesser percentage in the outpatient setting Although location of abdominal pain guides
have a severe or life-threatening cause or the initial evaluation, associated signs and
require surgery.2 Therefore, a thorough and symptoms are predictive of certain causes
logical approach to the diagnosis of abdomi- of abdominal pain (Table 2 3-6) and can help
nal pain is necessary. narrow the differential diagnosis.
When evaluating a patient with acute When possible, the history should be obtained
abdominal pain, the physician should focus from a nonsedated patient.7 The initial differ-
on common conditions that cause abdomi- ential diagnosis can be determined by a delin-
nal pain as well as on more serious condi- eation of the pain’s location, radiation, and
tions. The location of pain should drive the movement (e.g., appendicitis-associated pain
evaluation (Table 1). For some diagnoses, usually moves from the periumbilical area
such as appendicitis, the location of pain has to the right lower quadrant of the abdomen).
a very strong predictive value. After the location is identified, the physician
A final diagnosis is not usually made at the should obtain general information about
first outpatient visit; therefore, it is critical onset, duration, severity, and quality of pain
to begin the evaluation by ruling out serious and about exacerbating and remitting factors.
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Acute Abdominal Pain
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Evidence
Clinical recommendations rating References
A normal white blood cell count does not rule out appendicitis. C 12
Simultaneous amylase and lipase measurements are recommended in patients with epigastric pain. C 13
Ultrasonography is the imaging study of choice for evaluating patients with acute right upper quadrant C 14
abdominal pain.
Computed tomography is the imaging study of choice for evaluating patients with acute right lower C 15, 16
quadrant or left lower quadrant abdominal pain.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 896 or http://
www.aafp.org/afpsort.xml.
972 American Family Physician www.aafp.org/afp Volume 77, Number 7 ◆ April 1, 2008
Acute Abdominal Pain
Symptoms in patients with abdominal abdominal pain because they could suggest
pain that are suggestive of surgical or emer- pneumonia or cardiac ischemia.
gent conditions include fever, protracted There are several specialized maneu-
vomiting, syncope or presyncope, and evi- vers that evaluate for signs associated with
dence of gastrointestinal blood loss. causes of abdominal pain. When present,
some signs are highly predictive of certain
PHYSICAL EXAMINATION diseases. These include Carnett’s sign
The patient’s general appearance and vital (i.e., increased pain when a supine patient
signs can help narrow the differential diag- tenses the abdominal wall by lifting the head
nosis. Patients with peritonitis tend to lie and shoulders off the examination table) in
very still, whereas those with renal colic patients with abdominal wall pain9 ; Murphy’s
seem unable to stay still. Fever suggests sign in patients with cholecystitis5 (although
infection; however, its absence does not rule it is only present in 65 percent of adults with
it out, especially in patients who are older cholecystitis and is particularly unreliable in
or immunocompromised. Tachycardia and older patients10); and the psoas sign in patients
orthostatic hypotension suggest hypovole- with appendicitis.3 Other signs such as rigid-
mia. The location of pain guides the remain- ity and rebound tenderness are nonspecific.
der of the physical examination. Physicians Rectal and pelvic examinations are rec-
should pay close attention to the cardiac and ommended in patients with lower abdomi-
lung examinations in patients with upper nal and pelvic pain. A rectal examination
Finding LR+ LR– Finding present Finding absent Finding present Finding absent
Appendicitis3
Right lower quadrant pain 8.4 0.2 31 1 74 6
Migration of pain from the 3.6 0.4 16 2 54 13
periumbilical area to the right
lower quadrant of the abdomen
Fever 3.2 0.4 14 2 51 12
Psoas sign 3.2 0.88 14 4 52 23
Rebound tenderness 2.03 0.54 10 3 40 15
Rigidity 1.59 0.88 9 5 38 23
Anorexia 1.1 0.9 5 5 26 23
Bowel obstruction4
Constipation 8.8 0.6 32 3 75 16
Abdominal distention 5.7 0.4 23 2 66 12
Pain decreases after vomiting 4.5 0.8 19 4 60 21
Colic 2.8 0.8 13 4 48 21
Previous abdominal surgery 2.7 0.4 12 2 47 12
Cholecystitis5
Murphy’s sign 5.0 0.4 21 2 62 12
Right upper quadrant pain 2.5 0.3 11 2 45 9
Fever 1.8 0.8 8 4 37 21
Jaundice6 1.0 1.0 5 5 25 25
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Acute Abdominal Pain
may reveal fecal impaction, a palpable mass, the differential diagnosis and to determine
or occult blood in the stool. Tenderness whether certain imaging studies are appro-
and fullness on the right side of the rectum priate. Testing for chlamydia and gonorrhea
suggest a retrocecal appendix. A pelvic exam- is recommended for women at risk of sexu-
ination may reveal vaginal discharge, which ally transmitted infections.
can indicate vaginitis. The presence of cervi-
IMAGING STUDIES
cal motion tenderness and peritoneal signs
increase the likelihood of ectopic pregnancy11 Recommendations for initial imaging stud-
or other gynecologic complications, such as ies are based on the location of abdominal
salpingitis or a tubo-ovarian abscess. pain (Table 3 14-16). Ultrasonography is rec-
ommended when a patient presents with
Diagnostic Testing right upper quadrant pain.14 Radionuclide
LABORATORY TESTS imaging is slightly better than ultrasonog-
Appropriate diagnostic testing varies based raphy for detecting acute cholecystitis but
on the clinical situation. A complete blood is more expensive, takes longer to perform,
count is appropriate if infection or blood and cannot assess diagnoses outside of the
loss is suspected. One study of patients 15 to biliary tract.
83 years of age with suspected appendicitis Computed tomography (CT) with intra-
found that a white blood cell count greater venous contrast media is recommended
than 10,000 per mm3 (10 × 109 per L) was for evaluating adults with acute right lower
77 percent sensitive and 63 percent specific quadrant pain; CT with oral and intravenous
for the diagnosis (LR+ = 2.1, LR– = 0.37).12 contrast media is recommended for patients
Thus, nearly one in four patients with appen- with left lower quadrant pain.15,16 Sigmoid
dicitis does not have an elevated white blood diverticulitis is the most common cause of
cell count. left lower quadrant pain in adults, and CT
In patients with epigastric pain, simulta- has a reported sensitivity of 79 to 99 percent
neous amylase and lipase measurements are for detecting the condition.15 CT is better
recommended because an elevated lipase than ultrasonography for diagnosing appen-
level with a normal amylase level is not likely dicitis and can detect extracolonic causes of
to be caused by pancreatitis.13 Liver chem- abdominal pain.
istries are important in patients with right Left upper quadrant pain is caused by
upper quadrant pain. A urinalysis should be a variety of clinical conditions; therefore,
obtained in patients with hematuria, dys- imaging recommendations are not clear-cut.
uria, or flank pain. A urine pregnancy test If the patient’s history and physical exami-
should be performed in women of childbear- nation suggest esophageal or gastric pathol-
ing age who have abdominal pain to narrow ogy, endoscopy (or an upper gastrointestinal
series) is recommended. In other patients
with left upper quadrant pain, CT is useful
Table 3. Recommended Imaging Studies Based because it provides imaging of the pancreas,
on Location of Abdominal Pain spleen, kidneys, intestines, and vasculature.
In general, CT is highly effective at identify-
Location of pain Imaging ing patients with nonspecific abdominal pain
Right upper quadrant14 Ultrasonography who need urgent intervention (LR+ = 9.20,
Left upper quadrant CT LR– = 0.09).17
Right lower quadrant15 CT with IV contrast media Plain radiography of the abdomen is often
Left lower quadrant16 CT with oral and IV contrast media more readily obtainable and less expensive
Suprapubic Ultrasonography than ultrasonography or CT and can be
helpful in several circumstances. An upright
CT = computed tomography; IV = intravenous. radiograph of the chest or abdomen can
Information from references 14 through 16. detect free air under the diaphragm, which
indicates a perforation of the gastrointestinal
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Acute Abdominal Pain
Low risk (stable vital signs, High risk (unstable vital signs,
limited comorbidities) significant comorbidities)
Positive Negative
Consider urinary tract Consider sepsis, perforated
infection or diverticulitis viscus, or ischemic bowel
Perform pelvic transvaginal Consider a genitourinary
ultrasonography to evaluate cause of pain
for ectopic pregnancy or other General work-up Perform computed tomography
pregnancy-related complications for abdominal pain and consider hospitalization
General work-up
for abdominal pain
tract. Abnormal calcifications also can be ultrasonography is also helpful for diagnos-
seen on a plain radiograph; this includes ing other gynecologic pathology, such as
10 percent of gallstones, 90 percent of kidney fibroids, ovarian masses, ovarian torsions,
stones, and appendicoliths in 5 percent of and tubo-ovarian abscesses.
patients with appendicitis.18 Plain radiogra-
phy of the abdomen may help diagnose bowel Special Populations
obstruction with multiple dilated loops of There are certain populations in which the
the bowel and air-fluid levels, although simi- spectrum of disease is significantly different
lar findings may occur with paralytic ileus. than the majority of patients. Extra attention
Women of childbearing age present a spe- is warranted when evaluating special popu-
cific challenge when making decisions about lations, such as women and older persons,
diagnostic imaging. Gynecologic causes of with abdominal pain (Figure 1).
abdominal pain are more common in these Abdominal pain in women may be related
women, and radiation exposure should be to pathology in the pelvic organs. Ovarian
avoided if pregnancy is likely. Therefore, cysts, uterine fibroids, tubo-ovarian abscesses,
abdominal or transvaginal ultrasonography and endometriosis are common
is generally recommended for evaluating left causes of lower abdominal pain
Occult urinary tract infec-
lower quadrant pain in women of childbear- in women. In women of repro-
tion, perforated viscus, and
ing age16 and in pregnant patients with right ductive age, special attention to
ischemic bowel disease are
lower quadrant abdominal pain.15 pregnancy, including ectopic
commonly missed or diag-
If ectopic pregnancy is suspected, trans pregnancy, and loss of preg-
nosed late in older patients.
vaginal ultrasonography should be per- nancy is critical in forming an
formed. The sensitivity of transvaginal appropriate differential diagno-
ultrasonography for detecting ectopic sis. The possibility of pregnancy modifies the
pregnancy is 95 percent in a patient with a likelihood of disease and significantly changes
positive pregnancy test (human chorionic the diagnostic approach (e.g., avoidance of
gonadotropin level greater than 25 mIU per radiation exposure in diagnostic testing).
mL [25 IU per L]) and any abnormal ultra- Older patients with abdominal pain pres-
sound finding, whereas a negative pregnancy ent a particular diagnostic challenge. Disease
test and normal ultrasound findings virtually frequency and severity may be exaggerated
exclude ectopic pregnancy.19 Transvaginal in this population (e.g., a higher incidence
April 1, 2008 ◆ Volume 77, Number 7 www.aafp.org/afp American Family Physician 975
Acute Abdominal Pain
Patient history
Physical examination
CT
Figure 2. Algorithm for the evaluation of right upper quadrant abdominal pain. (CT = com-
puted tomography).
of diverticular disease or sepsis in those with populations. In low-risk patients, the pain
urinary tract infection). Presentation may location guides the initial differential diag-
differ in older patients, and poor patient nosis. Several areas of the abdomen deserve
recall or a reduction in symptom severity special attention because the clearest evi-
may cause misdiagnosis. There are several dence for a consistent work-up is in these
diseases that should be considered in all older areas.
patients with abdominal pain because of the For right upper quadrant pain, the his-
increased incidence and high risk of morbid- tory focuses on differentiating pulmonary,
ity and mortality in these patients. Occult urinary, and hepatobiliary pain (Figure 2).
urinary tract infection, perforated viscus, If urinary tract infection or nephrolithia-
and ischemic bowel disease are potentially sis is suspected, urinalysis is appropriate.
fatal conditions commonly missed or diag- Patients with colic, fever, steatorrhea, or
nosed late in older patients. a positive Murphy’s sign should receive
ultrasonography.
Approach to Patients The evaluation of right lower quadrant
A stepwise approach to abdominal pain pain is guided by the patient’s history (Fig-
requires identification of specific high-risk ure 3). Patients with symptoms (e.g., fever,
976 American Family Physician www.aafp.org/afp Volume 77, Number 7 ◆ April 1, 2008
Acute Abdominal Pain
Evaluation of Right Lower
Quadrant Abdominal Pain
April 1, 2008 ◆ Volume 77, Number 7 www.aafp.org/afp American Family Physician 977
Acute Abdominal Pain
7. Tamayo-Sarver JH, Dawson NV, Cydulka RK, Wigton RS, Radiology ACR Appropriateness Criteria. Right upper
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History and physical examination to estimate the risk 17. Gerhardt RT, Nelson BK, Keenan S, Kernan L, MacK-
of ectopic pregnancy: validation of a clinical prediction ersie A, Lane MS. Derivation of a clinical guideline
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978 American Family Physician www.aafp.org/afp Volume 77, Number 7 ◆ April 1, 2008