Approach to upper abdominal pain: Clinical sciences

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Introduction0:00–0:25

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

Acute management0:25–0:54

If the patient is unstable, start acute management before doing any diagnostic workup. This means you might need to stabilize their airway, provide supplemental oxygen, establish IV access and continuously monitor hemodynamics.
On the other hand, for stable patients, your first step is to obtain a focused history and physical exam or H and 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.

Focused H&P/Acute abdomen0:54–2:23

Next, you should quickly assess for any signs of an acute abdomen. In this case, ask for history of recent abdominal or GI procedures such as EGD colonoscopy or surgery as well as abdominal aortic aneurysm on physical exam.
Acute abdomen presents with signs of diffuse peritoneal inflammation, including diffuse tenderness, rebound, pain, rigidity and guarding also upright chest X ray or abdominal X ray series should be done to check for free air under the diaphragm which suggests perforation of the viscera.
Now, acute abdomen is also known as the surgical abdomen. Since emergency surgical intervention is required for most causes such as perforated viscous, abdominal sepsis or ruptured abdominal aortic aneurysm.
In this case, exploratory laparotomy is considered both diagnostic and therapeutic. So call for an emergent surgical consult while you continue resuscitation and the diagnostic workup.
Now, once you have ruled out an acute abdomen, the next step is to assess for other causes of upper 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.

Other causes in stable patients2:23–2:41

First, let's start with right upper quadrant pain, which is associated with biliary and liver conditions. If the patient reports right, upper quadrant pain, in addition to H and P, you should order labs like CBCC MP lipase and amylase.

RUQ/Biliary disease2:41–4:01

The classic presentation of biliary diseases is the acute onset of pain. After eating a fatty meal associated with nausea, vomiting and sometimes a fever, important risk factors to look out for are biologically female sex, obesity and age over 40.
The exam might reveal right upper quadrant tenderness with a positive Murphy sign. Labs might show leukocytosis with a left shift elevated LFT S and normal lipase and amylase.
Keep in mind that labs can be all normal, especially in biliary colic. Next, order an ultrasound to visualize the gallbladder.
The ultrasound usually shows signs of biliary disease, like sludge or stones in the gallbladder. Pericholecystic fluid, a thickened gallbladder wall and sometimes a dilated common bile duct.
If this is the case, you can make a diagnosis of biliary colic, acute cholecystitis, choledocholithiasis or acute cholangitis.
All right, let's move on to liver disease. These patients typically report nausea, vomiting and fever history might also reveal risk factors like substance use disorder, immunosuppression cancer or hypercoagulable state.

Liver Disease4:01–6:16

On exam, you might find right upper quadrant tenderness, hepatomegaly, jaundice or altered mental status. In extreme cases.
If you find leukocytosis with left shift, elevated LFT S with normal lipase and amylase on labs. The next step is to obtain a right upper quadrant ultrasound to rule out gallbladder pathology.
If there are no signs of biliary disease, order a CT scan, which will help you make a diagnosis. If you see a peripheral rim enhancing liver lesion in a patient with fever, then you can consider a liver abscess on the flip side.
If you see hepatomegaly and thrombosed hepatic veins, you can diagnose Budd Chiari syndrome. Finally, if imaging shows a thrombus in the portal vein, we're talking about portal vein, thrombosis.
Ok. Let's move on to another important cause of right upper quadrant pain, which is acute hepatitis, just like with other liver diseases.
These patients present with nausea, vomiting and fever. However, an important risk factor to look out for is recent travel as before a physical exam might reveal right, upper quadrant tenderness, hepatomegaly and jaundice.
While labs are usually normal, except for elevated LFT S including fractionated bilirubin. Keep in mind that fractionated bilirubin is different in diseases where the liver isn't working mainly leading to elevated indirect bilirubin.
Whereas diseases of the biliary system would mainly lead to elevated direct bilirubin. Now, if you see these findings, you should consider acute hepatitis next or viral hepatitis serology like IgM antibodies for hepatitis A or H BS antigen and anti HBC antibodies for hepatitis B.
Now that right upper quadrant is complete, let's move on to epigastric pain. Two main causes of epigastric pain are pancreatitis and gastroduodenal conditions.

Epigastric/Pancreatitis6:16–7:41

In addition to H and P order, labs like CBCC MP lipase and amylase. First up, patients with pancreatitis might report sudden onset of severe epigastric pain that radiates to the back associated with nausea, vomiting chills and general malaise.
Often they may have a history of recent heavy alcohol use. A physical exam might reveal epigastric or diffuse tenderness and mild to moderate abdominal distension with rebound and guarding.
Finally, labs might show leukocytosis, elevated LFT S lipase and amylase. So, if you see all these findings consider pancreatic causes of pain and order a right upper quadrant ultrasound or a CT scan to confirm the diagnosis.
Ultrasound might reveal signs of gallstone, pancreatitis like biliary stones or dilated common bile duct. On the other hand, CT might show an enlarged edematous pancreas with peri pancreatic inflammation and fluid together with H and P and labs.
Imaging helps you make a diagnosis of pancreatitis. Next, let's talk about gastric conditions which are a more common cause of epigastric pain on history.

Gastric causes7:41–9:09

Patients often describe a burning sensation after eating bloating, associated with nausea, vomiting and in severe cases, hematemesis.
Additionally, they might have some risk factors such as alcohol use disorder, chronic NSAID use or steroid use. Physical exam might show nonspecific signs like vague epigastric tenderness with a negative carnet sign.
This is when the patient is asked to tense their abdominal muscles, either by lifting their head or raising their legs while lying down and their abdominal pain decreases.
Indicating that the pain is due to an intraabdominal cause. If the pain increases, the cause is likely within the abdominal wall when it comes to labs, they're usually normal.
If you suspect gastric pathology, be sure to order an upright chest X ray or abdominal X ray series in order to rule out perforation before proceeding with an upper gi endoscopy.
If the X rays do not show free air under the diaphragm and the endoscopy shows erythema and edema of the gastroesophageal mucosa as well as mucosal erosion, ulceration and other inflammatory changes within the foregut.
You can diagnose gastric conditions like gastritis but also duodenitis as well as peptic ulcer disease and GERD. All right, let's move on to left upper quadrant pain which is mainly caused by diseases of the spleen.

LUQ/Spleen9:09–11:38

Laboratory. Work for these patients includes CBC and C MP on history.
Most patients describe it nonspecific symptoms like abdominal fullness, early satiety fatigue and referred pain to the shoulder.
Additionally, you might find risk factors like endocarditis or recent travel. Physical exam typically reveals abdominal distension with a palpable left, upper quadrant mass with mild or no tenderness.
Finally, labs might show leukocytosis as well as thrombocytopenia due to sequestration. Next, you should consider splenic causes of pain and order an abdominal ultrasound.
Now, ultrasound might show splenomegaly or focal lesions. If you are unable to visualize the entire spleen, you can order a CT which will help you make a diagnosis.
If you see an illdefined lesion with peripheral rim enhancement with or without septations, you can diagnose a splenic abscess.
On the other hand, imaging might show wedge shaped hypodense lesions which should make you think about splenic infarction.
Finally, if imaging shows a well defined round hyperdense lesion, think of splenic artery aneurysm, which is a surgical emergency.
All right, let's take a step back and talk about hematologic disorders that can cause left upper quadrant pain. These patients might also report early satiety, abdominal fullness and referred pain to the shoulder.
Additionally, they might report fatigue, weight loss or have a history of hematologic disorders like sickle cell anemia or lymphoma.
In this case, labs might show anemia, leukocytosis and mononucleosis or cytopenia and hematologic malignancy. If you see these findings consider hematologic disorders and get a blood smear.
Any abnormal white blood cell or red blood cells or the smear should point to a hematologic disorder. Lastly, here's a clinical pearl.
The hepatic flexure of the colon is in the right upper quadrant while the splenic flexure is in the left, upper quadrant.
So keep in mind that colon diseases can present with upper quadrant pain too and should be considered in your differential.
All right, 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 for patients without an acute abdomen.

Review11:38–12:18

Determine the location of the pain to narrow your differential diagnosis. Right, upper quadrant pain is often caused by hepatobiliary diseases like acute cholecystitis or acute hepatitis.
Well, epigastric pain can be indicative of pancreatitis, gastritis, peptic ulcer disease or GERD finally left. Upper quadrant pain is usually caused by splenic conditions such as splenic abscesses or infarction as well as hematologic disorders like sickle cell anemia or lymphoma.