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Acute abdominal pain is the chief complaint in about 5% of ED visits
Most patients are discharged after ED evaluation
Only about 10% require urgent surgery
Causes of Acute Abdominal Pain Stratified by Age 8500 patients, 200 EDs in 17 countries over a 10-year period . [ Gallagher EJ, in Emergency Medicine , Tintinalli JE, p 490] 13% 13% Other 4% <0.1% Gynecologic <0.1% 2% Vascular <0.1% 3% Hernia <0.1% 4% Cancer <0.1% 6% Diverticular disease 2% 7% Pancreatitis 2% 12% Bowel obstruction 32% 15% Appendicitis 40% 16% Nonspecific abdominal pain (NSAP) 6% 21% Biliary Tract Disease <50 Years 50 Years FINAL DIAGNOSIS
Causes of Acute Abdominal Pain Stratified by Age
In all large series of acute abdominal pain in adults, the largest groups are (in order):
Nonspecific abdominal pain (NSAP)
Biliary disease (usually cholecystitis)
This accounts for 75% of cases
In older patients, biliary disease is most common:
A 60 year old woman with Type II diabetes mellitus, hypertension, coronary artery disease, chronic renal insufficiency, two prior myocardial infarctions, Marfan’s syndrome, who is a smoker and drinker for >40 years, presents to the ED on Monday night with abdominal pain, fever, nausea, vomiting, vaginal bleeding, bloody diarrhea, and syncope. On exam, she is lethargic, tachypneic, hypotensive, with a barely palpable pulse. Her abdomen is distended and rigid. She’s deaf and mute.
A 34 year old woman in her 34 th week of gestation presents with vague constant right-sided abdominal pain for about 12 hours. The pain seems to be located more in the RUQ than anywhere else. She feels some mild nausea, but otherwise has no complaint. On exam, her vital signs are normal, and her abdomen is gravid with some tenderness in the right lateral mid-abdomen, and right upper quadrant.
A 22 year old woman presents to the ED complaining of severe lower abdominal pain. The pain began the day before presentation, and was crampy and intermittent, but she was awakened today at 4 am with severe pain which is constant, and lightheadedness. On exam, her vital signs are: pulse 130 and thready, BP 80/60, RR 28, T 37, O 2 sat 94%. She has lower abdominal tenderness.
Clear visualization of IUP excludes ectopic pregnancy except for the rare heterotopic pregnancy : historically 0.3/10000 but now overall incidence 1.25/10000 (.3/10000 up to 2.5-6.25/10000 in PID, and 33/10000 in reproductive technology and 100/10000 in IVF patients
If an IUP is not seen, it is correlated with the discriminatory zone (DZ) of the quantitative HCG
DZ = the threshold level above which a normal IUP should be seen on US
An 85 year old man with HTN, Type II diabetes mellitus, CAD, history of MI x 2, CHF with an ejection fraction of 20%, paroxysmal atrial fibrillation (not on warfarin), stroke x 2, presents with severe constant diffuse abdominal pain which began 1 hour ago after dinner. He had a normal bowel movement today and had a good appetite at dinner. On exam, the patient is crying out in distress and writhing around on the stretcher. His vital signs are: pulse 110, BP 150/100, RR 24, T 37, O 2 sat 92%. His abdomen is not distended, there are no bowel sounds, and the abdomen is non-tender throughout.