Q&A: Diagnosis and Investigation of Severe Acute Abdominal Pain

Abdominal pain can be a challenging complaint for both primary care and specialist clinicians because it is frequently a benign complaint, but it can also herald serious acute pathology. Clinicians are responsible for trying to determine which patients can be safely observed or treated symptomatically and which require further investigation or specialist referral. This task is complicated by the fact that abdominal pain is often a nonspecific complaint that presents with other symptoms.

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In this article:
Evaluation and diagnostic approach to acute abdominal pain
MCQ exam: clinical scenario
MCQ exam: answer
MCQ exam: explanation

Evaluation and diagnostic approach to acute abdominal pain

Abdominal pain is a common problem. Most patients have a benign and/or self-limited etiology, and the initial goal of evaluation is to identify those patients with a serious etiology that may require urgent intervention. A history and focused physical examination will lead to a differential diagnosis of abdominal pain, which will then inform further evaluation with laboratory evaluation and/or imaging.

The diagnostic approach to acute abdominal pain will depend on whether or not the pain is localized. The location of abdominal pain helps narrow the differential diagnosis as different pain syndromes typically have characteristic locations. Some patients with acute abdominal pain will need urgent or emergency evaluation.

MCQ exam: clinical scenario

A 60 year old patient presents with three days onset of severe abdominal pain radiating to the back. On physical examination, a pulsatile mass in the periumbilical region is found. The patient is hemodynamically stable.

The next appropriate step would be:

a) Oral cholecystogram
b). Intravenous urogram
c) Endoscopy
d) CT scan of the abdomen
e) Serum amylase
f) Ultrasound of the abdomen

MCQ exam: answer

The correct answer is D.

MCQ exam: explanation

When patients have the classic triad of pain, hypotension, and a pulsatile abdominal mass, the diagnosis of ruptured Abdominal Aortic Aneurysm(AAA) is straightforward and is usually made rapidly. However, many patients do not present classically, and misdiagnosis of ruptured AAAs, which leads to a delay in definitive surgical therapy, is very common. Patients who are misdiagnosed are usually hemodynamically stable on presentation but are at risk for sudden and catastrophic deterioration. Because patients with ruptured AAAs usually have abdominal, back, or flank pain, with or without hypotension, common misdiagnoses are other disease processes causing these symptoms.

The sudden onset of pain often leads to the clinical suspicion of renal colic. Abdominal pain and tenderness may suggest pancreatitis, intestinal ischemia, or other intraabdominal disorders. The diagnosis of musculoskeletal back pain is especially dangerous because such patients are often discharged from the Emergency Department.

Reference(s)
1). UpToDate: Evaluation of the adult with abdominal pain. Available online: https://www.uptodate.com/contents/evaluation-of-the-adult-with-abdominal-pain