Abdominal Pain

Last Updated: 8/22/2023

#Abdominal Pain


  • Onset: *** sudden vs gradual
  • Location: *** 
  • Duration/Timing: *** constant, intermittent, post-prandial
  • Character: *** sharp, dull, crampy, burning
  • Radiation: *** to R/L shoulder, groin
  • Severity: ***
  • Better/Worse: *** eating, drinking, positional
  • Associated Symptoms: *** fever, n/v, diarrhea, GI bleed, constipation, weight loss, jaundice, urinary sxs
  • Medications: *** abx, NSAIDs, steroids
  • Notable PMH: *** gallstones, pancreatitis, other GI dxs, previous abd surgeries, substance use
  • Sexual History: *** LMP, pregnancy, prior STIs
  • Red Flags: *** severe pain, intractable vomiting, evidence of shock, rigidity, peritonitis, out-of-proportion to exam, distention

Differential By System:

  • Gastrointestinal - PUD, gastritis, appendicitis, diverticulitis, IBD, gallstones, pancreatitis, hepatitis, ischemic bowel disease
  • Gynecological - ectopic pregnancy, ovarian cysts, PID, endometriosis, Mittelschmerz
  • Urological - UTI, nephrolithiasis, pyelonephritis
  • Musculoskeletal - strain, hernia
  • Vascular - AAA, mesenteric ischemia
  • Other - DKA, porphyria, sickle cell crisis

Differential By Location: 

  • RUQ - cholecystitis/cholangitis, biliary colic, hepatitis, PUD
  • RLQ - appendicitis, colitis, ectopic pregnancy, torsion
  • LUQ - splenic rupture, splenic infarct, PUD
  • LLQ - diverticulitis, colitis, ectopic pregnancy, torsion, 
  • Epigastric - pancreatitis, dissection, GERD, PUD, hiatal hernia
  • Extra-Abdominal - MI, PE, PNA, pleural effusion, chest wall pain, radiculopathy, VZV, UTI/pyelo, nephrolithiasis, menstrual pain, endometriosis, PID


  • Labs: CBC, CMP, lipase/amylase, U/A, b-HCG, trop, EKG; consider BCx, lactate, coags, CRP/ESR, H. Pylori breath test, stool studies 
  • Imaging: CXR/KUB for obstruction, perforation, stones; RUQUS for gallstones, liver dx; Renal US for hydronephrosis, stones; CTAP for nuclear etiology including appendicitis, deverticulitis, pancreatitis; MRI Abdomen to characterize soft tissue (liver lesions, soft tissue masses
  • Refer for EGD for upper abdominal pain, reflux, suspected upper GI bleed with IDA
  • Heating pads, tylenol, antacids, PPI; avoid NSAIDs
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If You Remember Nothing Else

A thorough history and physical examination are the cornerstones of diagnosis. The character, location, and timing of the pain, associated symptoms, and aggravating or alleviating factors can often direct you to the most likely causes. It's essential to be systematic and rule out life-threatening conditions such as AAA, bowel perforation, and myocardial infarction, especially in high-risk populations. Basic investigations like CBC, LFTs, lipase, and imaging can be guided by your differential, but don't chase zebras before ruling out the horses. In women, always consider pelvic pathologies like ectopic pregnancy or PID. Remember that 'red flag' symptoms like weight loss, anemia, or GI bleeding warrant further workup.

Clinical Pearls

Pain Characteristics and Location:

  • Location and character of pain will often guide the diagnosis.
  • Colicky pain is often seen in obstruction cases (gallstones, kidney stones, bowel obstruction) while a constant, dull ache might suggest inflammation.
  • Pain that radiates to the back might suggest pancreatic pathology, whereas pain radiating to the right shoulder may indicate gallbladder disease.
  • Pain that worsens on eating might suggest gastric ulcer or pancreatitis while pain that gets better with eating might suggest duodenal ulcer.

Medications and Their Effects:

  • NSAIDs can cause gastritis or peptic ulcers
  • Steroids can lead to peptic ulcers
  • Opioids and iron supplements can cause constipation
  • Antibiotics can lead to Clostridium difficile infection

Specific Populations and Symptoms:

  • Elderly patients and immunocompromised patients may present with more subtle symptoms, even in severe conditions like appendicitis or perforated ulcers. Always maintain a high index of suspicion in these populations.
  • Unexplained iron deficiency anemia in a postmenopausal woman or a man should prompt a search for a gastrointestinal cause, including malignancy.

The Abdominal Exam:

  • Acute Abdomen - severe tenderness, rigidity (involuntary guarding), rebound tenderness.
  • Voluntary guarding - when a patient tenses their abdominal muscles in response to the approach or touch of the examiner. It's a conscious, or at least semi-conscious, act often driven by the anticipation of pain. You may notice that muscle tension eases when the patient is distracted or reassured.
  • Involuntary guarding or Rigidity - an unconscious reflex contraction of the abdominal wall muscles that occurs in response to inflammation of the parietal peritoneum. Unlike voluntary guarding, this muscle contraction does not ease with distraction or reassurance and may remain constant.
  • Rebound tenderness - the abrupt “release” movement can cause the organs and the inflamed peritoneum to briefly shift and rub against each other. The underlying mechanism is thought to be due to irritation of the parietal peritoneum, which is sensitive to pain, stretch, and temperature (unlike the visceral peritoneum, which is only sensitive to stretch and pressure).
  • Murphy's Sign - pain on palpation of the right upper quadrant during inspiration is suggestive of cholecystitis
  • McBurney's Point Tenderness - Pain when pressure is applied and then quickly released in the right lower quadrant, approximately 2 inches from the anterior superior iliac spine on a straight line drawn to the umbilicus is suggestive of appendicitis
  • Rovsing's Sign - pain in the right lower quadrant during palpation of the left lower quadrant is suggestive of appendicitis.
  • Psoas Sign - pain when the patient's right thigh is passively extended or when the patient actively flexes at the hip is suggestive of retrocecal appendicitis
  • Obturator Sign - pain when the hip and knee are flexed and the leg is rotated internally and externally is suggestive of pelvic appendicitis
  • Kehr's Sign - left shoulder pain referred from a splenic injury
  • Cullen Sign - periumbilical bruising that can be suggestive of hemoperitoneum or acute pancreatitis with hemmorrhage
  • Grey Turner Sign - bruising on the flanks that can be suggestive of retroperitoneal bleed or acute pancreatitis

Trials and Literature

  • Evaluation of Acute Abdominal Pain in Adults - AAFP