Approach to periumbilical and lower abdominal pain: Clinical sciences

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Introduction0:00–0:29

Abdominal pain is a symptom of many conditions, which can range from benign to serious ones that require surgical intervention.
Based on the affected region of the abdomen, abdominal pain can be classified into right upper quadrant, left upper quadrant, right lower quadrant, and left lower quadrant.
It can also be epigastric or periumbilical. The first step in evaluating a patient with abdominal pain is to assess their ABCDE to determine if they are stable or unstable.

Unstable patient: Acute management0:29–1:12

If the patient is unstable, start acute management before doing any diagnostic workup. This means that you might need to stabilize their airway, provide supplemental oxygen, establish IV access, and continuously monitor hemodynamics.
Here’s a high yield fact! If an unstable patient presents with abdominal pain, be sure to rule out life-threatening conditions like acute mesenteric ischemia and perforated viscus, as well as abdominal aortic aneurysm.On the other hand, for stable patients, your first step is to obtain a focused history and physical exam, or H&P for short.

Stable patient: Acute abdomen1:12–2:44

On history, you should characterize the pain based on its location, severity, and chronicity, and determine aggravating and alleviating factors as well as other associated symptoms.
Next, you should quickly assess for any signs of an acute abdomen. In this case, history may reveal recent abdominal or GI procedures such as EGD, colonoscopy, or surgery; as well as abdominal or GI cancer.
In some cases, the patient will have a history of abdominal aortic aneurysm. On physical exam, you’ll usually find severe distension with rigidity, diffuse tenderness, rebound, and guarding.Because an acute abdomen is a surgical emergency, you need to call the surgical team right away.
You should also get bedside imaging, including an abdominal x-ray that may show free air or small or large bowel obstruction; and an abdominal ultrasound, which may show abnormality of the aorta and free fluid.
Depending on your suspicion for underlying cause, the surgery team may take the patient for a possible exploratory laparotomy.
In this case, exploratory laparotomy is considered both diagnostic and therapeutic. The intervention might reveal threatening conditions like abdominal sepsis, perforated viscus, ruptured abdominal aortic aneurysm, and even acute bowel infarction and necrosis.
Now, once you have ruled out an acute abdomen, the next step is to assess for other causes of abdominal pain. The location of pain on history and physical examination can be your best initial guide to narrow your differential diagnoses based on your clinical suspicion.Let’s start with the causes of periumbilical abdominal pain, which include small bowel obstruction and infectious gastritis or enterocolitis.

Stable patient: Other causes2:44–3:06

Periumbilical Pain - SBO3:06–4:57

First, obtain a focused history and physical exam. Small bowel obstruction is one of those “not to miss” causes of periumbilical abdominal pain.
These patients typically report crampy pain that is often associated with nausea, bilious vomiting, oral intolerance, and bowel changes like constipation and the more severe obstipation, where the person can’t pass gas or stool at all.
Additionally, you might find some risk factors like elderly patients, patients with a history of abdominopelvic surgery, inflammatory bowel disease, or a hernia.
On exam, you might find abdominal distension with diffuse tenderness, hypertympanic sounds on percussion, and hyperactive bowel sounds on auscultation.
In addition, remember to look for surgical scars and periumbilical or groin hernias during your exam! Then, you should order labs like CBC and CMP, which are usually normal but sometimes you might find leukocytosis, as well as signs of dehydration from vomiting, such as electrolyte abnormalities like hypernatremia.
All these findings should make you consider small bowel obstruction, so your next step is to order a CT scan of the abdomen and pelvis with oral contrast.
Imaging typically shows dilated loops of the bowel with a transition point and distal collapsed bowel, as well as air-fluid levels.
Additionally, you might see signs of the cause of the obstruction like the target sign of intussusception, most often in children; or portions of the small bowel within an umbilical hernia.
So, if you see any of these on imaging, you can help you make a diagnosis of small bowel obstruction. Another common cause of periumbilical abdominal pain is infectious gastritis or enterocolitis.

Infectious gastritis/enterocolitis4:57–5:44

Patients often report sudden onset of crampy pain, nausea, vomiting, diarrhea, and fever after ingesting raw or spoiled foods.
Others might report sick contacts with similar symptoms, recent travel, or antibiotic use. On a physical exam, you can expect to find a soft abdomen with mild tenderness on an otherwise healthy looking individual.
If you see these findings in combination, you can diagnose infectious gastritis or enterocolitis. Remember this is a clinical diagnosis, and often does not warrant additional diagnostic tests.Next up, let’s talk about right lower quadrant pain which is often caused by acute appendicitis.

RLQ: acute appendicitis5:44–6:57

Patients may report an acute onset of periumbilical abdominal pain that migrated to the RLQ with associated nausea, vomiting, fever, chills, and anorexia.
The exam might reveal tenderness at McBurney point with localized rebound and guarding. Be sure to check for the Rovsing sign, psoas sign, or obturator sign as well.
Once again, you want to obtain labs like CBC and CMP. CBC will likely show mild leukocytosis with left shift while CMP will be normal.
Okay, with these findings you should consider appendicitis and order a CT scan of the abdomen and pelvis with oral contrast.
CT scan typically shows a dilated appendix with thickened wall, periappendiceal fat stranding with trace amounts of fluid.
In some cases, you might see a phlegmon, or a ball of inflammation, and an appendicolith. These findings confirm the diagnosis of appendicitis.Alright, let’s move on to the left lower quadrant pain which can be caused by diverticulitis.

LLQ: Diverticulitis6:57–7:57

Start with focused history and physical. Patients with diverticulitis often report constant pain in any part of the colon, but most commonly in the LLQ with fever, chills, and bowel changes like constipation or diarrhea.
You might find localized tenderness with rebound and guarding with mild to moderate distension on the exam. Then, you’ll need to order labs like CBC and CMP, which usually show mild leukocytosis with a left shift.
If you suspect diverticulitis, order a CT scan of the abdomen and pelvis with oral contrast, which can show diverticula with colonic wall thickening and fat stranding, extraluminal gas/fluid, and in some cases an abscess.
If you see these findings, the diagnosis of diverticulitis is confirmed.Finally, if the pain is localized to the groin or the abdominal wall, you should suspect a hernia.

Abdominal wall pain: Hernia7:57–9:45

Patients often describe a growing bulge with heaviness or discomfort around it. They might associate the bulge with heavy lifting with a pop sensation, and worsening of the discomfort with standing or straining.
Be sure to ask about prior surgeries as hernias can occur around old incision sites. Hernias can be mildly or sometimes even severely tender, but try to reduce the hernia contents to palpate for the fascial edge as long as the patient can tolerate it.
On exam, you must assess if the hernia is reducible, incarcerated, or strangulated. Patients with a reducible hernia will have a bulge that protrudes on cough or Valsalva.
On the other hand, the contents of an incarcerated hernia become trapped and can’t be reduced. Lastly, a strangulated hernia is a complication of incarceration where the blood flow to the trapped bowel is cut off, leading to bowel ischemia.
Remember to look for overlying inflammatory skin changes like redness during your exam, which should make you concerned for strangulated hernia and needs emergent surgical consult!
Lab tests are often normal, while patients with an incarcerated or strangulated hernia may develop lactic acidosis from bowel ischemia.
Now, most of the time, a hernia can be diagnosed clinically. But if a thorough exam is not feasible due to body habitus or you’re concerned about an incarcerated or strangulated hernia, you can order a CT scan of the abdomen and pelvis to visualize the hernia and its contents to help you confirm your diagnosis.Lastly, if history and physical exam haven’t revealed any gastrointestinal cause of the abdominal pain, you should consider other possible causes as alternative diagnoses.

Alternative diagnoses9:45–10:20

Some common conditions to consider include UTI and kidney stones, as well as urinary retention. In biologically female patients, think about pelvic inflammatory disease, ectopic pregnancy, ovarian torsion, and ovarian cyst rupture.
On the flip side, if the patient is biologically male, consider testicular torsion as the cause of lower abdominal pain.Alright, as a quick recap… When assessing a patient with abdominal pain, first look for signs and symptoms of an acute abdomen which will require an emergent surgical evaluation.

Review10:20–11:18

For patients without an acute abdomen, determine the location of the pain to narrow your differential diagnosis. Periumbilical abdominal pain generally involves small bowel obstruction or infectious enterocolitis.
On the other hand, acute appendicitis can present as right lower quadrant pain, while diverticulitis presents most commonly on the left.
For nonspecific lower abdominal pain, look for hernias if it is localized to the abdominal wall or the groin. Finally, if there’s no gastrointestinal cause of abdominal pain, you should consider other causes as alternative diagnoses, such as UTI, kidney stones, urinary retention, pelvic inflammatory disease, ectopic pregnancy, ovarian torsion, ovarian cyst rupture, and testicular torsion.
Approach to periumbilical and lower abdominal pain | Osmosis