History and physical examination in adults with abdominal pain - UpToDate, 2013
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History and physical examination in adults with abdominal pain - UpToDate, 2013

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History and physical examination in adults with abdominal pain - UpToDate, 2013

History and physical examination in adults with abdominal pain - UpToDate, 2013

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History and physical examination in adults with abdominal pain - UpToDate, 2013 History and physical examination in adults with abdominal pain - UpToDate, 2013 Document Transcript

  • History and physical examination in adults with abdominal pain Authors Mary B Fishman, MD Mark D Aronson, MD Section Editor Robert H Fletcher, MD, MSc Deputy Editor Fenny H Lin, MD All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Apr 2013. | This topic last updated: mar 5, 2012. INTRODUCTION — Abdominal pain can be a challenging complaint for both primary care and specialist physicians because it is frequently a benign complaint, but can also herald serious acute pathology. Abdominal pain is present on questioning of 75 percent of otherwise healthy adolescent students [1] and in about half of all adults [2]. The history and physical examination are central to narrowing the differential diagnosis of abdominal pain and guiding the evaluation. Detailed aspects of the history and physical examination in adults with abdominal pain will be reviewed here. The differential diagnosis of abdominal pain, including the neurologic basis for abdominal pain, and a diagnostic approach to adults with abdominal pain, including a more directed history and physical examination, are discussed separately. (See "Differential diagnosis of abdominal pain in adults" and "Diagnostic approach to abdominal pain in adults".) HISTORY — The history is the most important clue to the source of abdominal pain. Thepainmay be categorizedbyitsunderlyingmechanism:    Visceral pain is usually dull and aching in character, although it can be colicky; it is often poorly localized. It arises from distention or spasm of a hollow organ such as the discomfort experienced early in intestinal obstruction or cholecystitis. Parietal pain is sharp and very well localized. It arises from peritoneal irritation such as the pain of acute appendicitis with spread of inflammation to the parietal peritoneum. Referred pain is aching and perceived to be near the surface of the body. In addition, pain should be characterized according to location, chronology, severity, aggravating and alleviating factors, and associated symptoms.  The location of abdominal pain helps narrow the differential diagnosis. As examples, pain due to acute cholecystitis or hepatitis tends to occur in the right upper quadrant. Appendicitis often produces pain in the periumbilical area and right lower quadrant, diverticulitis usually gives rise to lower abdominal pain in the midline or left lower quadrant, and esophagitis and peptic ulcer disease usually cause discomfort substernally in the upper abdomen area. Pain radiation is also
  •       important: the pain of pancreatitis classically bores to the back, while renal colic radiates to the groin. (See "Diagnosis and acute management of suspected nephrolithiasis in adults".) The onset, frequency, and duration of the pain are helpful features. The pain of pancreatitis is typically gradual and steady, while rupture of a viscus with resultant peritonitis begins suddenly and is maximal from the onset. The quality of the pain includes determining whether the pain is burning or gnawing, as is typical of gastroesophageal reflux and peptic ulcer, or colicky, as in the cramping pain of gastroenteritis or intestinal obstruction. The severity of the pain generally is related to the severity of the disorder, especially if acute in onset. As an example, the pain of biliary or renal colic or mesenteric infarction is of high intensity, while the pain of gastroenteritis is less marked. However, this distinction is often difficult for the physician to evaluate, since it is subjective and dependent upon the patient's personality and previous pain experiences. In addition, age and general health may affect the patient's clinical presentation. A patient taking corticosteroids may have significant masking of pain, and the elderly often present with less intense pain. It is helpful to ask a patient to compare this pain with previous painful experiences, grading on a 1 to 10 scale. It is important to ask the patient for factors that can aggravate or alleviate the pain. The pain of mesenteric ischemia usually starts within one hour of eating, while the pain of peptic ulcer disease is relieved by eating and recurs several hours after a meal when the stomach is empty. The pain of pancreatitis is classically relieved by sitting up and leaning forward. Peritonitis often causes patients to lie motionless on their backs because any motion causes pain. Obtaining a history of pain occurring in relationship to eating lactose or gluten containing foods may be helpful in identifying lactose intolerance or celiac disease. Symptoms that occur in relation to abdominal pain may give important information. Weight loss may occur in association with malignancy, nausea and vomiting with bowel obstruction, and change in bowel habits with a colonic lesion. Women should be asked whether they engage in sexual activity, the number of sexual partners, whether any sexual partners are new, and whether any sexual partners are experiencing symptoms suggestive of a sexually transmitted infection. (See "Screeningforsexuallytransmittedinfections".) Premenopausal women should be asked about their menstrual history (last menstrual period, last normal menstrual period, previous menstrual period, cycle length) and use of contraception. Pregnancy should be excluded in all women of childbearing age with abdominal pain. (See "Initial prenatal assessment and patient education".) PHYSICAL EXAMINATION — A complete physical examination for a patient with abdominal pain should emphasize the vital signs and the abdominal, rectal, pelvic, and genitourinary regions. Traditional teaching has recommended to not administer narcotic analgesics during the initial evaluation because they may interfere with physical findings and lead to misdiagnosis. However, a systematic review of patients with acute abdominal pain undergoing evaluation in the emergency department setting has found that opiate administration may alter physical findings but does not cause management errors [3]. If necessary, it is reasonable to treat the patient's pain while the assessment proceeds.
  • General examination — The general appearance and level of comfort or discomfort should be noted. Inspection of the abdomen should include attention to the position assumed by the patient when in pain; strict immobility is typical of a patient with peritonitis, while patients with biliary or renal colic writhe in agony. Vital signs should include measurement of orthostatic changes in blood pressure and heart rate. Obstruction, peritonitis, and bowel infarction can cause large amounts of third spacing of fluid and intravascular volume depletion or overt shock. The presence of fever may be significant, but its absence, especially in the elderly, debilitated, or immunosuppressed, does not rule out serious illness. The eyes should be examined for scleral icterus and the skin for jaundice. The lungs need to be examined for signs of consolidation and the heart for murmurs and rubs. (See "Auscultation of cardiac murmurs" and "Auscultation of heart sounds".) Abdominal examination — Auscultation of the abdomen may be helpful in the evaluation of abdominal pain. A complete lack of bowel sounds is found in advanced peritonitis or adynamic ileus. Abnormally active, high-pitched bowel sounds are a feature of early bowel obstruction, while a friction rub in the appropriate area might be heard in a patient with a splenic infarct or hepatic metastasis. Gentle percussion is useful to identify acute peritonitis. This is preferred to deep palpation and testing for rebound tenderness, since it is much less traumatic for patients. Similarly, if testing for rebound tenderness is performed, the examination can begin gently before the release of pressure and need only proceed to deeper palpation before release, if rebound symptoms are not elicited with superficial palpation and release. Percussion is also used to identify ascites, liver span, and bladder and splenic enlargement. Tympany signifies a distended bowel, while dullness may signify a mass. Shifting dullness is a reliable and fairly accurate sign for the detection of ascites. There is good interobserver agreement among clinicians in calling a particular percussion sound resonant, dull, or hyperresonant; agreement is not as good for percussing organ size [4]. Palpation must be performed gently and while the patient is distracted, particularly if psychogenic pain is suspected. It is best to begin examining the quadrant of the abdomen where the patient is experiencing the least pain. Muscular rigidity or "guarding" is an important and early sign of peritoneal inflammation; it can be unilateral in a patient with a focal inflammatory mass such as a diverticular abscess or diffuse as in peritonitis. Guarding is typically absent with deeper sources of pain such as renal colic and pancreatitis. However, it may be difficult to determine if abdominal tenderness is deep (implicating disease of visceral organs) or superficial. Palpation also may detect enlarged organs or masses. Rectal and pelvic examination — A rectal is generally required in all patients with acute abdominal pain, and a pelvic examination is generally required in all women with acute lower abdominal pain. Fecal impaction might be the explanation for signs and symptoms of obstruction in the elderly, while tenderness on rectal examination may be the only abnormal finding in a patient with retrocecal appendicitis. Stool for occult blood should also be obtained. The pelvic examination is critical for determining whether abdominal pain is due to pelvic inflammatory disease, an adnexal mass or cyst, uterine pathology, or an ectopic pregnancy. (See "The gynecologic history and pelvic examination".) View slide
  • Other findings — The patient should be examined for signs of nerve and muscle wall injury and hernia. Pain in a dermatomal distribution and hyperesthesia are both signs of nerve involvement as in herpes zoster or nerve root impingement. Abdominal wall pathology may be found by palpation or by noting exacerbation of the pain when using the abdominal wall muscles (eg, sitting up). SUMMARY    The history and physical examination are central to narrowing the differential diagnosis of abdominal pain and guiding the evaluation. (See 'Introduction' above.) Pain should be characterized according to location, chronology, severity, aggravating and alleviating factors, and associated symptoms. Pregnancy should be excluded in all women of childbearing age with abdominal pain. (See 'History' above.) A complete physical examination should emphasize vital signs, the abdominal, rectal, pelvic, and genitourinary regions. Opioids may be given as necessary while the assessment proceeds. A rectal examination is generally required in all patients with acute abdominal pain, and a pelvic examination is generally required in all women with acute lower abdominal pain. (See 'PhysicalExamination' above.) Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. 2. 3. 4. Hyams JS, Burke G, Davis PM, et al. Abdominal pain and irritable bowel syndrome in adolescents: a community-based study. J Pediatr 1996; 129:220. Heading RC. Prevalence of upper gastrointestinal symptoms in the general population: a systematic review. Scand J GastroenterolSuppl 1999; 231:3. Ranji SR, Goldman LE, Simel DL, Shojania KG. Do opiates affect the clinical evaluation of patients with acute abdominal pain? JAMA 2006; 296:1764. McGee SR. Percussion and physical diagnosis: separating myth from science. DisMon 1995; 41:641. View slide