Approach to periumbilical and lower abdominal pain: Clinical sciences

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A 24-year-old woman presents to the emergency department with sudden-onset, sharp right lower quadrant abdominal pain that began approximately 3 hours ago, shortly after lifting weights at the gym. Her last menstrual period was 4 weeks ago. She has no dysuria, hematuria, urinary frequency, or urgency. Her vital signs are within normal limits. The patient appears comfortable. On abdominal examination, the abdomen is soft and nondistended with moderate tenderness in the right lower quadrant, without rebound or guarding. There is no costovertebral angle or suprapubic tenderness. Laboratory evaluation, including CBC, CRP, and urinalysis are within normal limits, and a urine pregnancy test is negative. Which of the following is the most appropriate next step in the evaluation?  

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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. 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. 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.

Sources

  1. "The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis" Diseases of the Colon & Rectum (2020)
  2. "Management of acute appendicitis in adults: A practice management guideline from the Eastern Association for the Surgery of Trauma" Journal of Trauma and Acute Care Surgery (2019)
  3. "American Association for the Surgery of Trauma emergency general surgery guideline summaries 2018: acute appendicitis, acute cholecystitis, acute diverticulitis, acute pancreatitis, and small bowel obstructionAcute cholecystitis management guidelines summaryAcute colonic diverticulitis management guidelines summaryIntestinal obstruction due to adhesions guideline summaryAcute pancreatitis management guidelines summary" Trauma Surgery & Acute Care Open (2019)
  4. "Evaluation and management of small-bowel obstruction" Journal of Trauma and Acute Care Surgery (2012)
  5. "EGS. The American Association for the Surgery of Trauma. " AAST (2020)