Diagnosis of Acute Abdominal Pain

Peritonitis

HISTORY - Pain severe and generalized; prostration; fever/chills; movement worsens pain.

PHYSICAL EXAM - Fever; generalized abdominal tenderness with guarding, rigidity, and rebound tenderness; decreased bowel sounds; patient lies still; hypotension, tachycardia, pallor, and sweating may be present.
Perforation of viscus

HISTORY - Pain severe and generalized.

PHYSICAL EXAM - Signs of peritonitis
Bowel infarction

HISTORY - Patient is usually older than 50 years of age (unless arterial embolus is the causative factor). Pain is often diffuse and may not reach maximal intensity for hours; bloody diarrhea occasionally.

PHYSICAL EXAM - Hypotension, tachycardia, pallor, and sweating may be present; signs of peritonitis; abdominal distension.
Bowel obstruction

HISTORY - Nausea, vomiting, often a preceding history of constipation, abdominal distension; pain may wax and wane; history of abdominal surgery.

PHYSICAL EXAM - Abdominal distension with generalized tympanitic percussion; high pitched rushing bowel sounds early, decreased later; patient tosses and turns.
Rupture of an abdominal aortic aneurysm

HISTORY - Acute abdominal, low back, or flank pain.

PHYSICAL EXAM - Pulsatile abdominal mass; hypotension, tachycardia, and asymmetrical pulses may be present.
Myocardial infarction

HISTORY - Severe, epigastric discomfort most common in persons over age 50, women, and diabetics; occasional nausea and vomiting

PHYSICAL EXAM - Diphoresis; no abdominal tenderness
Appendicitis

HISTORY - Initially pain is epigastric/periumbilical. Often progresses to right lower quadrant. Onset gradual, progressing over hours.

PHYSICAL EXAM - Low-grade fever (less than 101°F); right lower quadrant tenderness on abdominal or rectal exam; bowel sounds variable; peritonitis if perforation occurs. Obturator/psoas tests are often positive. Rebound tenderness referred to right lower quadrant.
Hepatitis

HISTORY - Malaise, myalgia, nausea, and right upper quadrant pain.

PHYSICAL EXAM - Hepatic tenderness and enlargement. Jaundice may be present.
Diverticulitis

HISTORY - Pain in lower left quadrant; constipation; nausea, often vomiting; course lasts several days. 25% of patients may have minor rectal bleeding.

PHYSICAL EXAM - Fever; lower left quadrant tenderness and fullness or mass; occasional rectal mass and tenderness; decreased bowel sounds. Localized signs of peritonitis may be present.
Cholecystitis

HISTORY - Colicky pain in epigastrium or right upper quadrant, occasionally radiating to right scapula; colicky with nausea, vomiting, fever; sometimes chills, jaundice, dark urine, light-colored stools (obstruction of common duct); may be recurrent.

PHYSICAL EXAM - Fever; right upper quadrant tenderness with guarding, occasional rebound; decreased bowel sounds.
Pancreatitis

HISTORY - Upper abdominal pain, occasionally radiating to back; mild to severe; associated with nausea/ vomiting; history of alcoholism or gallstones; often recurrent; pain may be eased by sitting up or leaning forward.

PHYSICAL EXAM - Periumbilical tenderness; occasionally associated with hypotension, tachycardia, pallor, and sweating; bowel sounds decreased.
Salpingitis pelvic inflammatory disease (females)

HISTORY - Pain initially in lower quadrants but may be generalized; usually severe; fever/chills occasionally; dyspareunia; occasional vaginal discharge.

PHYSICAL EXAM - Fever; tenderness with guarding/rebound in lower quadrants; pain on lateral motion of cervix; adnexal tenderness; purulent discharge from cervix.
Ruptured ectopic pregnancy (females)

HISTORY - Last menstrual period more than 6 weeks previous; pain in one lower quadrant; acute onset and severe

PHYSICAL EXAM - Adnexal tenderness and mass; postural hypotension and tachycardia may be present.
Ureteral stone

HISTORY - May note a history of previous “kidney stone”; pain may begin in flank and radiate to groin; painful urination and blood in urine are frequently noted.

PHYSICAL EXAM - Often unremarkable; flank tenderness may be noted as well as decreased bowel sounds. Fever is noted if urinary tract infection occurs.
Reflux esophagitis

HISTORY - Burning, epigastric or substernal pain radiating up to jaws; worse when lying flat or bending over, particularly soon after meals; relieved by antacids or sitting upright.

PHYSICAL EXAM - Patient often obese; normal abdominal exam.
Peptic ulcer or (nonulcerative) dyspepsia

HISTORY - Burning or gnawing, localized episodic or recurrent epigastric pain appearing 1–4 hours after meals; may be made worse by alcohol, aspirin, steroids, or other anti-inflammatory medications; relieved by antacids or food.

PHYSICAL EXAM - Deep epigastric tenderness.
Ulcerative colitis

HISTORY - Rectal urgency; recurrent defecation of small amounts of semiformed stool; pain worsens just before bowel movements; blood in stools

PHYSICAL EXAM - Low-grade fever; tenderness over colon; rectal tenderness and commonly blood in stools; weight loss may be present.
Regional enteritis

HISTORY - Pain in right lower quadrant or periumbilical; usually in young persons; insidious onset; may be relieved by defecation; stools are often soft and unformed.

PHYSICAL EXAM - Low-grade fever; periumbilical or right quadrant tenderness or mass; weight loss may be present
Irritable bowel

HISTORY - Recurrent abdominal discomfort and/or change in bowel habits aggravated by anxiety; diarrhea often alternates with constipation; diarrhea and constipation may also be the predominant symptom.

PHYSICAL EXAM - No fever; minimal abdominal tenderness over the course of the large bowel or normal abdominal exam; rectal examination is normal and feces contain no blood.