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Unformatted text preview: Evaluation of Acute Abdominal Pain in Adults SARAH L. CARTWRIGHT, MD, and MARK P. KNUDSON, MD, MSPH Wake Forest University School of Medicine, Winston-Salem, North Carolina A bdominal pain is a common pre- sentation in the outpatient setting and is challenging to diagnose. Abdominal pain is the present- ing complaint in 1.5 percent of office-based visits 1 and in 5 percent of emergency depart- ment visits. 2 Although most abdominal pain is benign, as many as 10 percent of patients in the emergency department setting and a lesser percentage in the outpatient setting have a severe or life-threatening cause or require surgery. 2 Therefore, a thorough and logical approach to the diagnosis of abdomi- nal pain is necessary. Differential Diagnosis When evaluating a patient with acute abdominal pain, the physician should focus on common conditions that cause abdomi- nal pain as well as on more serious condi- tions. The location of pain should drive the evaluation (Table 1) . For some diagnoses, such as appendicitis, the location of pain has a very strong predictive value. A final diagnosis is not usually made at the first outpatient visit; therefore, it is critical to begin the evaluation by ruling out serious disease (e.g., vascular diseases such as aor- tic dissection and mesenteric ischemia) and surgical conditions (e.g., appendicitis, cho- lecystitis). Physicians should also consider conditions of the abdominal wall, such as muscle strain or herpes zoster, because these are often misdiagnosed. History and Physical Examination Although location of abdominal pain guides the initial evaluation, associated signs and symptoms are predictive of certain causes of abdominal pain (Table 2 3-6 ) and can help narrow the differential diagnosis. HISTORY When possible, the history should be obtained from a nonsedated patient. 7 The initial differ- ential diagnosis can be determined by a delin- eation of the pain’s location, radiation, and movement (e.g., appendicitis-associated pain usually moves from the periumbilical area to the right lower quadrant of the abdomen). After the location is identified, the physician should obtain general information about onset, duration, severity, and quality of pain and about exacerbating and remitting factors. 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-predictive value for appendicitis)....
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