I. Pertinent History:

  1. Menstrual history if patient is female of childbearing age
  2. Location of pain
  1. Diffuse: ischemia, strangulation
  2. Midepigatric: stomach, duodenum, liver, biliary
  3. Periumbilical: appendix, ureters, testes, ovaries
  4. Lower abdomen: lower ureter, colon, bladder, uterus
  1. Sudden onset: Consider perforated ulcer, ruptured abdominal aortic aneurysm, ruptured ectopic pregnancy
  2. Associated sx to ask about: vomiting, hematemesis, hematuria, diarrhea, obstipation, cough
  3. Known history of peptic ulcer disease, gallstones, abdominal surgery, AAA, coronary disease, arrhythmias (consider risk of arterial emboli in patients with atrial fibrillation)
  4. Alcohol use

II. Differential Dx:

  1. Intra-abdominal :
  1. Hollow viscera-Esophagitis, gastritis, PUD, cholecystitis, small bowel obstruction/infarction, inflammatory bowel dissease, appendicitis, colonic obstruction, pseudo-obstruction ("Ogilvie's syndrome"), diverticulitis, enteritis, malabsorption
  2. Solid organ-Acute hepatitis, pancreatitis, splenic infarct, pyelonephritis, subacute bacterial peritonitis
  3. Pelvic-Pelvic inflammatory disease, ectopic pregnancy
  4. Vascular-Ruptured AAA, aortic dissection, mesenteric Ischemia
  1. Extra-abdominal :
  1. Diabetic ketoacitosis
  2. Acute adrenal insufficiency (Addisonian Crisis)
  3. Acute porphyria
  4. Lower lobe pneumonia
  5. Pulmonary embolus
  6. Pneumothorax
  7. Sickle cell crisis

IV. Physical exam:

  1. Vitals, lungs, pelvic
  2. Abdomen
  1. Inspection-Distention, ecchymoses, caput medusae, surgical scars
  2. Percussion-Tympany, shifting. dullness, fluid wave, loss of liver dullness
  3. Palpation-Guarding, rebound, CVA tenderness, Murphy's sign, psoas sign, obturator sign
  4. Auscultation-Bowel sounds
  1. Rectal exam for tenderness, mass, occult blood

V. Workup

  1. CBC, lytes, glucose, creatinine, LFT's, lipase, amylase
  2. Consider CXR if Hx/Px suggests lower lobe pneumonia
  3. As indicated: ultrasound, CT (quite sensitive/specific for appendicitis), Ba enema/sm. bowel series, paracentesis, intravenous pyelography, endoscopy, angio, HIDA, Beta-hCG, ABG, U/A, cervical cultures

VI. Management:

  1. Prompt surgery likely indicated if there is significant suspicion for: Acute ppendicitis, strangulated hernia, GI tract perforation, Meckel's diverticulitis, Boerhaave's syndrome, acute cholecystitis, hepatic abscess, ruptured spleen, ruptured ectopic pregnancy, ruptured ovarian cyst, or ruptured AAA
  2. If none of the above, consider:
  1. Surgical consult
  2. NPO status
  3. NG tube (if obstruction suspected)
  4. Electrolyte/fluid management as appropriate
  5. Opioid analgesia as needed (contrary to popular belief, did not affect diagnostic accuracy in one randomized trial, see J. Am. Coll. Surg. 196:18, 2003--JW)
  6. Serial exams to clarify diagnosis
  1. Neostygmine 2mg IV x 1 may help hasten resolution of colonic pseudo-obstruction (NEJM 341:137, 1999--JW)
  2. In a study in 128 pts with partial small-bowel obstruction felt to be due to adhesions from prior surgery, randomized to conservative care vs. conservative care + (MgO, simethicone, and lactobacillus), incidence of not requiring surgery was sig. higher in the active-tx group (91% vs.76%) (CMAJ 173:1165, 2005--JW)