Approach to the patient with
acute abdominal pain
Asisst. Prof. Dr.Özlem Tanrıöver
Yeditepe University
Medical Faculty
Department of Family Medicine
Abdominal Anatomy
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Four quadrants:
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Right Upper Quadrant
Right Lower Quadrant
Left Upper Quadrant
Left Lower Quadrant
Three central areas:
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Epigastric
Periumbilical
Suprapubic
Abdominal Anatomy
Right upper quadrant
Liver, Head of Pancreas,
Kidney and Lung
Right lower quadrant
Appendix, Ureter, Bladder,
Colon, Gonads
Left upper quadrant
Heart, Spleen, Body of
pancreas, Kidney, Stomach,
Lung
Left lower quadrant
Ureter, bladder, colon, gonads
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The History and Physical in Perspective
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70% of diagnoses can be made based on
history alone.
90% of diagnoses can be made based on
history and physical exam.
Expensive tests often confirm what is found
during the history and physical.
Types of Abdominal Pain
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Pain from Hollow Viscera
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crampy/paroxismal
often poorly localized
related to peristalsis
patient writhing on exam table
Pain from Peritoneal Irritation
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steady/constant
often localized
patient lies still with knees up
Key Historical Points - Bowel and Bladder
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Nausea, Vomitting, Diarrhea, Constipation
Frank Blood, "Coffee Grounds" Emesis,
Black Stools
Urinary Frequency, Urgency, Discomfort
Key Historical Points - Reproductive
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Sexual Activity, Contraception, Last
Menstrual Period
Always Consider Pregnancy in Reproductive
Age Women
Have a Low Threshold for Pregnancy Testing
Gastrointestinal Review of Systems
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Trouble swallowing
Heartburn
Loss of appetite
Nausea
Change in bowel habits
Blood in stool
Dark tarry stools
Constipation
Diarrhea
Abdominal pain
Jaundice
Fever or chills
Ask the following questions:
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Where is the pain?
Has the pain changed its location since it
started?
Do you feel the pain in any part of your
body?
How long have you had the pain?
Have you had recurrent episodes of
abdominal pain?
Ask the following questions:
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Did the pain start suddenly?
Can you describe the pain? Is it sharp, burning,
cramping?
Is the pain continuous?
What makes it worse, or better?
Is the pain associated with nausea, vomiting,
sweating, constipation, diarrhea, bloody stools,
abdominal distention, fever, chills, eating?
If the patient is a woman;
When was your last period?
Abdominal Pain
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Location
Other symptoms
Character
Factors that
aggravate or
alleviate
Timing
Environment
Severity
Common causes of acute abdominal
pain
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Peptic Ulcer Disease
Cancer of Stomach
Pancreas, Colon
Biliary Colic
Acute Cholecystitis
Acute Appendicitis
Acute Diverticulitis
Intestinal Obstruction
Mesenteric Ischemia
Irritable Bowel Syndrome
Inflammatory Bowel Dis.
Hepatitis
Gastroenteritis
Peptic Ulcer Disease or Dispepsia
Ulcer begins in lining
of stomach or duodenum.
 Helicobacter pylori
infection is often present.
 Dyspepsia more
common ages 20- 29,
gastric ulcer in those
over 50 and duodenal
ulcer ages 30 – 60.
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Peptic Ulcer Disease or Dispepsia
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Pain is epigastric and may
radiate to the back.
Variable, gnawing, burning,
boring, aching or hungerlike.
Timing is intermittent.
Duodenal ulcer
more likely nocturnal.
Food and antacids may relieve
duodenal ulcer pain.
Accompaning symptoms
include nausea, vomiting,
belching, bloating, heartburn
and weight loss.
Pancreatitis
Inflammation of the
pancreatic tissue often
due to gallstones or
alcohol abuse.
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Pain is epigastric and
may radiate to the back.
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Pain onset is acute and
pain is steady.
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Pain may be worse when
supine and relieved with
leaning forward.
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Associated with nausea,
vomiting, abdominal
distention and fever.
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Biliary Colic and Acute Cholecystitis
Due to obstruction of the
cystic duct or common bile
duct by a gallstone.
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Pain is epigastric or right
upper quadrant and may
radiate to the right scapula
or shoulder.
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The pain is steady and
aching.
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Biliary colic may start
suddenly and subside then
recur whereas cholecystitis
is more steady.
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Associated with anorexia,
nausea, vomiting and
fever.
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Classic Presentations –
Acute Cholecystitis
Localized or diffuse RUQ pain
Radiation to right scapula
Vomitting and constipation
Low grade fever
Acute Diverticulitis
Inflammation of a
colonic saclike mucosal
Outpouching through the colonic
muscle.
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Pain is in the left
lower quadrant.
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The pain may begin
as cramps then
become steady.
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It is associate with
fever, constipation and
sometimes, brief diarrhea.
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Acute Appendicitis
Acute distention or
obstruction of the appendix.
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Pain often begins as poorly
localized periumbilical pain
followed by right lower quadrant
pain.
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Becomes more steady and
severe with time.
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Pain is worse with
movement or cough.
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Pain is associated with
anorexia, nausea, and
possibly vomiting which
typically follow the onset of
pain.
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Classic Presentations - Acute
Appendicitis
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Diffuse periumbilical pain and anorexia early
Pain localizes to RLQ as peritonitis develops
Low grade fever, nausea and vomitting may
not be present
Xrays and other tests are often negative
Psoas Sign
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This is a test for appendicitis.
Place your hand above the patient's right
knee.
Ask the patient to flex the right hip
against resistance.
Increased abdominal pain indicates a
positive psoas sign.
Obturator Sign
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This is a test for appendicitis.
Raise the patient's right leg with the knee
flexed.
Rotate the leg internally at the hip.
Increased abdominal pain indicates a
positive obturator sign
Rovsing's Sign
Tenderness felt in the RLQ when
palpation is performed on the left is
called Rovsing’s sign and suggests
appendicitis.
Classic Presentations - Acute Renal
Colic
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Severe flank pain
Radiation to groin
Vomitting and urinary
symptoms
Blood in the urine
Inflammatory Bowel Disease
Ulcerative Colitis
Inflammation of colon
 Soft bloody stools
 Insidious onset
 Associated with crampy lower or
generalized abdominal pain, anorexia,
weakness and fever
 Often begins in young people
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Inflammatory Bowel Disease
Crohn’s Disease
Chronic inflammation of the bowel wall,
typically involving the terminal ileum and/or
proximal colon
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Stools loose but not as bloody
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Insidious onset
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Associated with crampy periumbilical or right
lower quadrant pain with anorexia, low fever
and/or weight loss.
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Perianal or perirectal abcesses and fistulas
common
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May begin in youth or later.
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Physical Examination
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Pelvic
Genital
Rectal exam on every patient
with severe abdominal pain
Laboratory Evaluation
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CBC, Urine Analysis, Electrolytes
Urine and serum pregnancy test in all
women of reproductive age with lower
abdominal pain
Liver Function Tests , amylase/lipase on
all with upper abdominal pain
Radiographic Evaluation
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Plain radiograph
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upright and supine abdomen and chest x-ray
Ultrasound on patients with biliary and
pelvic symptoms
CT Abdomen and Pelvis
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evaluates vasculature, inflammation and solid
organs
The differential
diagnosis
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Acute Cholecystitis
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cystic duct obstructed, RUQ pain ? R scapula
LFTS, amylase
Acute Appendicitis
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anorexia, N/V and vague periumbilical pain
6-8 hrs pain migrates to RLQ, fever
Progresses to localized peritoneal irritation
CT useful in diagnosis
The differential
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Pancreatits
Acute Diverticulitis
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most commonly in sigmoid colon
symptoms related to inflammation or obstruction
CT useful early to r/o absess, Endoscopy
contraindicated ? wait 4-6 wks
Rx bowel rest, IV abx, surgery for failures
Pregnancy
appendicitis, cholecystitis, pyelonephritis,
adnexal problems (ovarian torsion, ovarian cyst rupture)
appendicitis 7/1000 pregnancies
3% fetal loss with surgery, but 20% with perforated appendix
Summary
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Obtain detailed history
Careful exam
Consider patient circumstances (diabetes,
age, previous ab surgery)
Early thorough work-up (labs/x-rays)
Frequent evaluation of progression
Rebound Tenderness
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This is a test for peritoneal irritation.
Warn the patient what you are about to
do.
Press deeply on the abdomen with your
hand.
After a moment, quickly release pressure.
If it hurts more when you release, the
patient has rebound tenderness
Psoas Sign




This is a test for appendicitis.
Place your hand above the patient's right
knee.
Ask the patient to flex the right hip
against resistance.
Increased abdominal pain indicates a
positive psoas sign.
Obturator Sign




This is a test for appendicitis.
Raise the patient's right leg with the knee
flexed.
Rotate the leg internally at the hip.
Increased abdominal pain indicates a
positive obturator sign
Rovsing's Sign
Tenderness felt in the RLQ when
palpation is performed on the left is
called Rovsing’s sign and suggests
appendicitis.