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FM Learner
105 Topics*
Allergy*
Dehydration*
Epistaxis*
Fatigue*
Immigrants*
Loss of Consciousness*
Loss of Weight*
Pain*
Palliative*
Periodic Screening*
Red Eye*
Renal Failure*
Sexual Assault*
Shortness of Breath*
Smoking Cessation*
Travel Medicine*
Trauma*
♥
ACLS*
Acute Coronary Syndrome
Anemia*
Iron-Deficiency Anemia
B12 Deficiency Anemia
Atrial Fibrillation*
Chest Pain*
DVT*
EKG
Heart Failure*
Hyperlipidemia*
Hypertension*
INR
Ischemic Heart Disease*
Pulmonary Embolism
Derm*
Acne
Fungal Disease
Genital Ulcers
Lacerations*
Leg edema
Psoriasis
Rosacea
Urticaria/Angioedema
GI
Abdominal Pain*
Abnormal Liver Tests
Anorectal pathology
Biliary disease
Celiac
Diarrhea*
Dyspepsia*
GI Bleed*
Hepatitis*
Inflammatory Bowel Disease
Irritable Bowel Syndrome
NAFLD/NASH
Endo
Osteoporosis*
Diabetes*
Diabetic Ulcer
DKA/HHS
Hyperkalemia
Hyponatremia
Obesity*
Thyroid*
Thyroid Nodule
ID*
Antibiotic Classes
Cellulitis
Dysuria* / UTI*
Earache* / AOM
Fever*
Immunization*
Meningitis*
Pharyngitis
Pneumonia*
Rhinosinusitis
STIs*
URTI*
MSK
Fibromyalgia
Fractures*
Gout
Joint Disorder*
Knee Pain
Neck Pain*
Low-back Pain*
Nocturnal Leg Symptoms
Polymyalgia Rheumatica
Rheumatoid Arthritis
Shoulder Pain
Neuro
Bell's Palsy
Concussion / mTBI
Dementia*
Dizziness*
Tremor
Seizures*
Stroke*
Parkinsonism*
Headache*
OBGYN
Vaginitis*
Vaginal Bleeding*
Urinary Incontinence
Pregnancy Termination
Pregnancy*
Postpartum Complications
Polycystic Ovarian Syndrome
Nipple Discharge
Menopause*
Infertility*
Hypertensive Disorders of Pregnancy
Contraception*
Breast Lump*
Peds
NRP
Pediatric Fractures
Petechiae/Purpura
Pediatric UTI
Pediatric Urology
Pediatric Shock
Pediatric Fever
PALS
Newborn*
Neonatal Jaundice
In Children*
Well-baby Care*
Food protein-induced proctocolitis
Failure to Thrive
Infantile Colic
Hip Pain
Febrile Seizure
Enuresis
Encopresis
Croup*
Ψ
ADHD
Anxiety*
Bipolar
Depression* / Suicide*
Eating Disorders*
Insomnia*
Personality Disorder*
Poisoning*
Schizophrenia*
Somatization*
Substance Use*
Alcohol Use and Withdrawal
Opioid Use
Resp
Hemoptysis
Cough*
COPD*
Asthma*
Uro
Interstitial Cystitis
Hematuria
Nephrolithiasis
Prostate*
Sex*
Other
Bedside Ultrasound
Central Line
Chest Tube
Intraosseous Line
Intubation
Lumbar Puncture
Medical Marijuana
Medical Education
Medical Assistance in Dying
Procedural Sedation
SAMPs
SOOs
Urine dipstick
FM Learner
105 Topics*
Allergy*
Dehydration*
Epistaxis*
Fatigue*
Immigrants*
Loss of Consciousness*
Loss of Weight*
Pain*
Palliative*
Periodic Screening*
Red Eye*
Renal Failure*
Sexual Assault*
Shortness of Breath*
Smoking Cessation*
Travel Medicine*
Trauma*
♥
ACLS*
Acute Coronary Syndrome
Anemia*
Iron-Deficiency Anemia
B12 Deficiency Anemia
Atrial Fibrillation*
Chest Pain*
DVT*
EKG
Heart Failure*
Hyperlipidemia*
Hypertension*
INR
Ischemic Heart Disease*
Pulmonary Embolism
Derm*
Acne
Fungal Disease
Genital Ulcers
Lacerations*
Leg edema
Psoriasis
Rosacea
Urticaria/Angioedema
GI
Abdominal Pain*
Abnormal Liver Tests
Anorectal pathology
Biliary disease
Celiac
Diarrhea*
Dyspepsia*
GI Bleed*
Hepatitis*
Inflammatory Bowel Disease
Irritable Bowel Syndrome
NAFLD/NASH
Endo
Osteoporosis*
Diabetes*
Diabetic Ulcer
DKA/HHS
Hyperkalemia
Hyponatremia
Obesity*
Thyroid*
Thyroid Nodule
ID*
Antibiotic Classes
Cellulitis
Dysuria* / UTI*
Earache* / AOM
Fever*
Immunization*
Meningitis*
Pharyngitis
Pneumonia*
Rhinosinusitis
STIs*
URTI*
MSK
Fibromyalgia
Fractures*
Gout
Joint Disorder*
Knee Pain
Neck Pain*
Low-back Pain*
Nocturnal Leg Symptoms
Polymyalgia Rheumatica
Rheumatoid Arthritis
Shoulder Pain
Neuro
Bell's Palsy
Concussion / mTBI
Dementia*
Dizziness*
Tremor
Seizures*
Stroke*
Parkinsonism*
Headache*
OBGYN
Vaginitis*
Vaginal Bleeding*
Urinary Incontinence
Pregnancy Termination
Pregnancy*
Postpartum Complications
Polycystic Ovarian Syndrome
Nipple Discharge
Menopause*
Infertility*
Hypertensive Disorders of Pregnancy
Contraception*
Breast Lump*
Peds
NRP
Pediatric Fractures
Petechiae/Purpura
Pediatric UTI
Pediatric Urology
Pediatric Shock
Pediatric Fever
PALS
Newborn*
Neonatal Jaundice
In Children*
Well-baby Care*
Food protein-induced proctocolitis
Failure to Thrive
Infantile Colic
Hip Pain
Febrile Seizure
Enuresis
Encopresis
Croup*
Ψ
ADHD
Anxiety*
Bipolar
Depression* / Suicide*
Eating Disorders*
Insomnia*
Personality Disorder*
Poisoning*
Schizophrenia*
Somatization*
Substance Use*
Alcohol Use and Withdrawal
Opioid Use
Resp
Hemoptysis
Cough*
COPD*
Asthma*
Uro
Interstitial Cystitis
Hematuria
Nephrolithiasis
Prostate*
Sex*
Other
Bedside Ultrasound
Central Line
Chest Tube
Intraosseous Line
Intubation
Lumbar Puncture
Medical Marijuana
Medical Education
Medical Assistance in Dying
Procedural Sedation
SAMPs
SOOs
Urine dipstick
More
105 Topics*
Allergy*
Dehydration*
Epistaxis*
Fatigue*
Immigrants*
Loss of Consciousness*
Loss of Weight*
Pain*
Palliative*
Periodic Screening*
Red Eye*
Renal Failure*
Sexual Assault*
Shortness of Breath*
Smoking Cessation*
Travel Medicine*
Trauma*
♥
ACLS*
Acute Coronary Syndrome
Anemia*
Iron-Deficiency Anemia
B12 Deficiency Anemia
Atrial Fibrillation*
Chest Pain*
DVT*
EKG
Heart Failure*
Hyperlipidemia*
Hypertension*
INR
Ischemic Heart Disease*
Pulmonary Embolism
Derm*
Acne
Fungal Disease
Genital Ulcers
Lacerations*
Leg edema
Psoriasis
Rosacea
Urticaria/Angioedema
GI
Abdominal Pain*
Abnormal Liver Tests
Anorectal pathology
Biliary disease
Celiac
Diarrhea*
Dyspepsia*
GI Bleed*
Hepatitis*
Inflammatory Bowel Disease
Irritable Bowel Syndrome
NAFLD/NASH
Endo
Osteoporosis*
Diabetes*
Diabetic Ulcer
DKA/HHS
Hyperkalemia
Hyponatremia
Obesity*
Thyroid*
Thyroid Nodule
ID*
Antibiotic Classes
Cellulitis
Dysuria* / UTI*
Earache* / AOM
Fever*
Immunization*
Meningitis*
Pharyngitis
Pneumonia*
Rhinosinusitis
STIs*
URTI*
MSK
Fibromyalgia
Fractures*
Gout
Joint Disorder*
Knee Pain
Neck Pain*
Low-back Pain*
Nocturnal Leg Symptoms
Polymyalgia Rheumatica
Rheumatoid Arthritis
Shoulder Pain
Neuro
Bell's Palsy
Concussion / mTBI
Dementia*
Dizziness*
Tremor
Seizures*
Stroke*
Parkinsonism*
Headache*
OBGYN
Vaginitis*
Vaginal Bleeding*
Urinary Incontinence
Pregnancy Termination
Pregnancy*
Postpartum Complications
Polycystic Ovarian Syndrome
Nipple Discharge
Menopause*
Infertility*
Hypertensive Disorders of Pregnancy
Contraception*
Breast Lump*
Peds
NRP
Pediatric Fractures
Petechiae/Purpura
Pediatric UTI
Pediatric Urology
Pediatric Shock
Pediatric Fever
PALS
Newborn*
Neonatal Jaundice
In Children*
Well-baby Care*
Food protein-induced proctocolitis
Failure to Thrive
Infantile Colic
Hip Pain
Febrile Seizure
Enuresis
Encopresis
Croup*
Ψ
ADHD
Anxiety*
Bipolar
Depression* / Suicide*
Eating Disorders*
Insomnia*
Personality Disorder*
Poisoning*
Schizophrenia*
Somatization*
Substance Use*
Alcohol Use and Withdrawal
Opioid Use
Resp
Hemoptysis
Cough*
COPD*
Asthma*
Uro
Interstitial Cystitis
Hematuria
Nephrolithiasis
Prostate*
Sex*
Other
Bedside Ultrasound
Central Line
Chest Tube
Intraosseous Line
Intubation
Lumbar Puncture
Medical Marijuana
Medical Education
Medical Assistance in Dying
Procedural Sedation
SAMPs
SOOs
Urine dipstick
Abdominal Pain
Given a patient with abdominal pain, paying particular attention to its location and chronicity:
Distinguish between acute and chronic pain.
Generate a complete differential diagnosis (ddx).
Investigate in an appropriate and timely fashion.
In a patient with diagnosed abdominal pain (e.g., gastroesophageal reflux disease, peptic ulcer disease, ulcerative colitis, Crohn’s disease), manage specific pathology appropriately (e.g., with medication, lifestyle modifications).
In a woman with abdominal pain:
Always rule out
pregnancy
if she is of reproductive age.
Suspect
gynecologic
etiology for abdominal pain.
Do a
pelvic
examination, if appropriate.
In a patient with acute abdominal pain, differentiate between a
surgical
and a non-surgical abdomen.
In specific patient groups (e.g., children, pregnant women, the elderly), include group-specific surgical causes of acute abdominal pain in the ddx.
Given a patient with a life-threatening cause of acute abdominal pain (e.g., a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy):
Recognize the life-threatening situation.
Make the diagnosis.
Stabilize the patient.
Promptly refer the patient for definitive treatment.
In a patient with chronic or recurrent abdominal pain:
Ensure adequate follow-up to monitor new or changing symptoms or signs.
Manage symptomatically with medication and lifestyle modification (e.g., for
irritable bowel syndrome
).
Always consider
cancer
in a patient at risk.
Given a patient with a diagnosis of
inflammatory bowel disease
(IBD) recognize an
extra
intestinal manifestation.
DDx Abdominal Pain
Cardiovascular:
ACS
, pericarditis
Aortic dissection, mesenteric ischemia, sickle cell crisis
Pulmonary:
Pneumonia
, embolus
Biliary
:
Cholecystitis, cholelithiasis, cholangitis
Gastric:
Esophagitis, gastritis,
peptic ulcer
, small-bowel mass or obstruction
Colonic:
Appendicitis
, colitis,
diverticulitis
,
IBD
, bowel obstruction, peritonitis,
celiac disease
Hepatic:
Hepatitis
, abscess, mass
Pancreatic:
Pancreatitis
, mass
Renal:
Cystitis
, nephrolithiasis, pyelonephritis
Splenic:
Abscess
Gynecologic:
Ectopic pregnancy
, ovarian mass, ovarian torsion,
PID
, fibroids, endometriosis, ovulatory pain, ruptured ovarian cyst
Abdominal wall:
Herpes zoster, muscle strain, hernia
Metabolic:
Uremia,
DKA
, porphyria, adrenal insufficiency, narcotic withdrawal, heavy metal poisoning
Psych:
IBS
History
Acute vs. Chronic
Fever, stools (diarrhea, bloody), vomiting (bilious, bloody)
Malignancy (early satiety, weight loss, night sweats, changes in stools)
Alcohol, smoking, drugs
NSAIDs
Past surgeries (obstruction)
Females (pregnancy)
Vaginal bleeding/discharge, LMP
Physical Exam
Vitals
Chest/Lung
Abdo
Pelvic/Genital exam
Rectal exam
Investigations
Labs (eg. CBC, ALT/AST, amylase/lipase, lytes (glucose, creat), UA, bhCG)
Ultrasound
X-ray (CXR, AXR)
Endoscopy/Colonoscopy
ERCP
Urea breath test
Choice of imaging
Ultrasound (gallbladder, gyne) if
RUQ/suprapubic
Otherwise
,
CT
Consider IV contrast for RLQ, non-localized (r/o appendicitis)
Consider Oral + IV contrast LLQ (r/o sigmoid diverticulitis)
X-ray limited use
Free air (if upright)
Perforation
Calcifications
10% of gallstones, 90% of kidney stones, and 5% appendicoliths
Multiple dilated loops of the bowel and air-fluid levels
Bowel obstruction or paralytic ileus
Women
Do NOT Miss Dx in Acute Pelvic Pain in Women
Life-threatening
Ectopic pregnancy
Appendicitis
Ruptured ovarian cyst
Fertility-threatening
PID
Ovarian Torsion
Children
Red Flags
Fever (after onset of vomiting or pain)
Bilious vomiting
Bloody diarrhea
Absent bowel sounds
Voluntary guarding
Rigidity
Rebound tenderness
** Do not forget
testis
**
Differential diagnosis based on age group
<1yo
Common: Colic, constipation, GERD,
food protein allergy
Urgent: Acute gastroenteritis, malrotation without volvulus, pyloric stenosis
Emergent: Trauma (abuse), midgut volvulus, NEC, omphalitis, incarcerated hernia, intussusception
1-5yo
Common: UTI, constipation
Urgent: Acute gastroenteritis,
HSP
, pneumonia, Meckel diverticulum
Emergent: Trauma,
appendicitis
, asthma
5-12yo
Common: UTI, constipation, functional
Urgent: Acute gastroenteritis,
IBD
, HSP, pneumonia
Emergent: Trauma, appendicitis,
gonadal torsion
,
DKA
, asthma
>12yo
Urgent: Gastroenteritis, IBD, pneumonia, hepatitis, pancreatitis, nephrolithiasis, PID
Emergent: Trauma, appendicitis, gonadal torsion,
ectopic pregnancy
, DKA, asthma
Investigation in children with abdominal pain
Consider urinalysis, CBC, pregnancy test, ESR/CRP
Consider ultrasound prior to proceeding with abdominal CT
Elderly
More likely complicated by coexistent disease, medications
May present later in course of illness and nonspecific symptoms
Physical examination can be misleadingly benign
Increase risk of cholecystitis, pancreatitis, diverticulitis, obstructions (adhesions, malignancy)
Do not miss AAA, mesenteric ischemia
References:
Pediatric Health Med Ther. 2017.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5774593/
AAFP 2016. Acute Abdominal Pain in Children.
https://www.aafp.org/afp/2016/0515/p830.html
AAFP 2015. Diagnostic Imaging of Acute Abdominal Pain in Adults.
https://www.aafp.org/afp/2015/0401/p452.html
AAFP 2008. Evaluation of Acute Abdominal Pain in Adults.
http://www.aafp.org/afp/2008/0401/p971.html
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