AssessmentsAbdominal pain: Clinical practice
USMLE® Step 1 style questions USMLE
USMLE® Step 2 style questions USMLE
A 13-year-old boy is brought to the emergency department for evaluation of testicular pain and swelling. The patient was running when he felt sudden onset groin pain. Since then, he experienced severe scrotal pain with associated nausea and vomiting. He has had similar episodes of pain over the past two months that have all self-resolved without intervention. He has no significant past medical history and has received all age-appropriate vaccinations. Temperature is 37.0°C (98.6°F), pulse is 94/min, respirations are 21/min, and blood pressure is 141/80 mmHg. Physical examination demonstrates an uncomfortable adolescent male in significant pain. Examination demonstrates an edematous and erythematous right scrotum. Stroking of the right inner thigh does not result in elevation of the right testis. The pain is worsened with elevation of the scrotum, and the scrotum does not transilluminate. Which of the following is the best next step in management?
Content Reviewers:Rishi Desai, MD, MPH
Abdominal pain is a very common complaint, and the differential diagnosis is wide, ranging from benign to life-threatening conditions.
Life-threatening conditions include a ruptured abdominal aortic aneurysm, mesenteric ischemia, perforation anywhere along the gastrointestinal tract, acute bowel obstruction, acute pancreatitis, peritonitis, ectopic pregnancy, ovarian torsion, and myocardial infarction.
There are three main types of abdominal pain: visceral, parietal, and referred pain.
Visceral pain happens when the nerves that run through the walls of an organ get stretched. The pain isn't usually well localized and feels like a dull ache or cramp.
Hollow organs cause an intermittent colicky type of pain, whereas solid organs cause a more constant pain.
Parietal pain is sharp and can be localized by pointing to a specific spot.
Finally, there’s referred pain which is when the brain mistakenly identifies pain as coming from one region like the shoulder when it’s actually coming from a different region like the diaphragm.
Abdominal pain, can often be separated into the abdominal area that’s involved.
Epigastric pain that’s associated with bloating, abdominal fullness, heartburn, or nausea is called dyspepsia, and it’s generally due to gastroesophageal reflux disease, gastritis, pancreatitis, or peptic ulcer disease - meaning an ulcer of the stomach or duodenum.
Left upper quadrant pain can overlap with the causes of epigastric pain, such as pancreatitis which causes pain that radiates to the back, but may also be due to the spleen.
Acute pain with fever and an elevated white blood cell count suggests appendicitis.
There’s also mesenteric ischemia, which is when blood flow to the small intestines is interrupted, typically due to arterial or venous thromboembolism, and may cause severe pain and bloody stools, as well as progressive low blood pressure, rapid heart rate, and ultimately shock.
Some conditions cause diffuse abdominal pain that can’t be localized.
A surgical emergency is an abdominal aortic aneurysm that has ruptured. This can cause pain that radiates to the back, and a pulsating sensation in the abdomen.
The mnemonic OPQRST can be used to help with history taking - especially regarding pain. O stands for onset, whether it was acute, gradual, or an ongoing chronic problem.
P stands for provocation and palliation, so whether any movement, pressure, rest, or other factors make the pain better or worse.
Q stands for quality, whether the pain is sharp, dull, crushing, or burning. It also relates to the pattern, like intermittent, constant, or throbbing.
R stands for region and radiation, meaning the location, or where the pain is on the body, and whether it radiates or extends to any other areas.
S stands for severity, which can be quantified with a score on a scale of 0 to 10 - 0 being no pain and 10 being the worst possible pain.
And finally, T stands for time, so how long the condition has been going on and if it has changed over time.
Associated symptoms can also help narrow the diagnosis. Common ones are nausea, vomiting, constipation, diarrhea, and changes in stool like the presence of blood or mucus, a foul smell, or changes in stool caliber.
In females, it’s important to always rule out the possibility of pregnancy. Then, we should ask for genitourinary symptoms, such as dysuria, frequency, and hematuria - which can occur with a urinary tract infection or kidney stones.
Constitutional symptoms like fevers, chills, fatigue, and weight loss, would raise concern for an infection, malignancy, or systemic illness like inflammatory bowel disease.
And epigastric pain associated with cardiac risk factors or other symptoms like chest pain, cough, dyspnea, orthopnea, and exertional dyspnea suggest a pulmonary or cardiac cause.
To evaluate abdominal pain, the first step is inspection.
First, there’s the person’s general appearance and how they’re positioned given their pain. For example, if they’re perfectly still in bed with knees bent that’s concerning for peritonitis. Other features include how a person is breathing, signs of abdominal distention, and scars from past surgeries.
Next is auscultation to hear bowel sounds. Normally there are two to twelve medium-pitched gurgles per minute.