This document provides guidance on evaluating and diagnosing abdominal pain. It emphasizes the importance of thorough history taking and examination. Key vital signs and pain scores should be assessed. Analgesics can be given early without delaying diagnosis. Stability must be reassessed after interventions. Specific considerations are provided for different age groups and gender. Common patterns associated with various diagnoses are outlined. Four case studies are presented highlighting errors in diagnosis, including appendicitis mistaken for wall abscess, hernia nerve entrapment, testicular torsion, and opioid overdose masked by vague complaints. The takeaway is to be diligent and persistent until reaching a diagnosis.

1. Avoiding Errors in diagnosing
Abdominal Pain
- Dr Varun Patel

2. • Its 3am in your night shift, and a nurse tells
you that a patient is waiting in traige with
Abdominal pain persistent since 8hrs today...
What would run through your mind?

3. You couldn’t have thought of a better time to come?

4. Extensive Diagnostic Spectrum

5. Key Points in Evaluating Abdominal Pain
• Thorough History Taking & Examination – Half
the Errors are eliminated.
• Vital Parameters to be checked –
1. Blood pressure
2. Blood Sugar
3. Temperature
4. Oxygen Saturation
5. Pain Score

6. Be very specific in History Taking

7. Manage the Pain First (RCEM Standards)

8. Use Pain Ladder

9. Pain & Examination
• Breaking the Myth : “ Do not give Analgesia to
patients with Acute abdomen as it obscures
the Diagnosis ”
• As per Cochrane Review – Trials suggested no
delay in Diagnosis by providing early
Analgesics to patients with Abdominal Pain.

10. Assess for Stability
• Not all Patients with Abdominal Pain should
be managed in Triage Area!!
• All Unstable Patients should be reevaluated
every 30mins and also after every Medical
Intervention that you do.

11. Abdominal Pain - Reproductive Age Group
• For Females – Think of a Gynaecological or
Obstetric Cause!
Always do a Urine Pregnancy Test. (Especially if
taken for Imaging)
Famous Saying – “A Female in Reproductive age with
abdominal pain should be considered Pregnant until and
unless proven otherwise.”
• For both Males & Females –
- Take an Elaborate Sexual History
- Do a complete Genito-Urinary Examination

12. Abdominal Pain – Elderly Age Group
• May have Vague and Atypical Symptoms
• Fever is not a reliable Marker & WBCs have low
predictive value for Surgical disease.
• If Diagnosis is in Doubt – Liberal Imaging /
Admission / Observation Policy is strongly
advocated.
Diagnostic Key steps:
• Do a Digital Rectal Examination for all Elderly
Patients (A very valuable tool which is often
ignored)

13. No one can be this Happy before a PR Examination!

14. Abdominal Pain – Diagnostic Hints

15. Abdominal Pain + Shock:
• Aortic Dissection
• Abdominal Sepsis
• Leaking Abdominal Aortic Aneurysm (AAA)
• Myocardial Ischemia
• Ruptured Ectopic Pregnancy
• Hemorrhagic Pancreatitis
• Hollow Viscus Perforation

16. Abdominal Pain Out of Proportion to
Clinical findings:
• Ureteric Colic
• Mesenteric Ischemia
• Leaking Abdominal Aortic Aneurysm
• Diabetic Ketoacidosis

17. Abdominal Pain + Atrial Fibrillation
• Always rule out Mesenteric Ischemia.

18. Abdominal Pain + Radiation to Back
• Acute Cholecystitis
• Ascending Cholangitis
• Acute Pancreatitis
• Aortic Aneurysm
• Duodenal Ulcer

19. Abdominal Pain + Distention
• Acute Bowel Obstruction
• Ascitis
• Cancer
• Pregnancy!

20. Abdominal Pain irradiating to Shoulder tip
(Due to irritation of Diaphragm)
• Acute Cholecystitis
• Acute Pancreatitis
• Ectopic Pregnancy
• Bowel Perforation
• Aortic Aneurysm

21. Abdominal Pain Undiagnosed even
after CT Scan?

22. Think about Medical Causes of
Abdominal Pain:
• Diabetic Ketoacidosis
• Myocardial Infarction
• Pericarditis
• Lower Lobar
Pneumonia
• Pulmonary Embolism
• Addisonian Crisis
• Acute Intermittent
Porphyria
• Opioid
Overdose/Withdrawal
• Lead Poisoning
• Herpes Zoster
• Nerve Root
Compression
• Sickle Cell Crisis
• Acute Leukemia

23. Think Think Think!!
Let’s discuss a few cases with difficulty/errors in
Diagnosing Abdominal Pain

24. Case 1 - Appendicitis, Oh wait, is it?
• 30yr old male came to ED with history of Severe
Right Iliac Fossa pain (Pain Score- 8/10) gradually
increasing since last 8hrs. There was no history of
Fever, Vomiting, Constipation, Loose stools. On
examination – Patient had Tenderness over Right
Iliac Fossa, Guarding present but abdomen was
soft.
• Patient had a relief in pain to 3/10 after IV Opioid
administration.
• ALVORADO score was less than 6.
• Labs- WBCs – 9900, CRP – 10, Urea & Electrolytes
were within Normal Limits.

25. • USG Abdomen – Probe Tenderness in Right
Iliac fossa, Improperly Visualized Appendix
due to excessive Bowel Gas
• Provisional CT report – No Abnormality
detected
Any ideas about the Diagnosis?

26. Abdominal Wall Abscess due to
Pseudomonas Aeruginosa
Note: This was Diagnosed after
Surgeon went looking for this in CT
Scan and then a Biopsy was taken

27. Case 2 -Left Iliac Fossa – A Forgotten Quadrant
• A 42yr old male came to Emergency Dept with History
of Severe Left Iliac Fossa Pain irradiating to groin since
2 hrs. He has a history of similar episodes of Pain
multiple times in the past. The pain has never gone
away since it started a few months back. Today it
became worst and hence patient had to visit the ED.
• His pain used to be normal in mornings and worsened
during the day while working. It worsened severely
while Jogging.
• In his previous files, he has been seen by General
Surgeon, Orthopedician and a Gastroenterologist for
this pain multiple times.
• He had been taking multiple medications to manage
pain including Muscle relaxants for a few weeks now.

28. • On Examination – Abdomen was soft and non tender.
There was an old scar noted (Operated for Inguinal
Hernia few months back)
• All Lab investigations (including CBC, CRP, Electrolytes,
Creatinine, HsTroponin I, Urine Routine) , ECG, 2D
ECHO and Imaging including CT Abdomen+Pelvis with
Contrast, Renal Artery Doppler and Scrotal Doppler
were Normal. (Last done only a few days back)
• The Patient was also referred to Pain Management
Specialist recently and is using various non-allopathic
measures to control the pain.
Any ideas about the Diagnosis?

29. Ilio-Hypogastric Nerve Entrapment
(Caused by Inguinal Hernia Surgery)

30. Case 3 -Abdominal Pain – Finding the Origin
• A 16yr old boy came to ED at 3am with history of
Severe Right Flank pain irradiating to anterior abdomen
since 1 hour (Pain score – 10/10). There was a history
of Vomiting 2 times since onset of pain. There was no
history of Fever, Hematuria, Oliguria, Syncope,
Constipation, Loose Stools.
• On Examination – Abdomen was soft and non-tender.
There were no obvious scars noted on the abdomen.
• Lab Investigations (CBC, Electrolytes, Creatinine) were
within normal limits.

31. • Patient’s Pain was relieved after giving IV
Opioids. Due to unavailability of Imaging
during night time, it wasn’t done. In view of
Clinical improvement, the patient was sent
home.
• After 6 hrs, patient revisited ED with similar
complaints. This time Surgical reference was
given.
Any ideas about Diagnosis?

32. Testicular Torsion (Delayed Diagnosis
lead to Necrosis of Right Testicle)
Note- Always do a complete Genito-
Urinary examination in patients of
Reproductive Age group

33. Case 4- Patients Always Lie

34. • A 24yr old male came with History of Severe
generalized abdominal pain (Pain score- 9/10)
with history of 1 episode of Vomiting,
sweating and Acute confusion. There was no
history of Fever, Loose Stools, Abdominal
Trauma, Illicit Drug use, Syncope, chest pain.
• On Examination – Abdomen was Soft and
Non-Tender. There was no Guarding, Rigidity
or Rebound Tenderness
• Lab Investigations (CBC, Electrolytes, CRP,
Creatinine, Random Blood Sugar, Urine
Routine) were all within normal limits.

35. • CT Scan of the Brain & Abdomen were normal.
• Serial ECGs, HsTroponin I and 2D ECHO was
normal.
• Patient was admitted for Pain Management.
• Within 2 hrs of admission, patient suddenly
desaturated with no significant findings on
examination and Chest Xray. ABG showed
Type 2 Respiratory Failure with Respiratory
Acidosis. Blood Sugar was 222mg/dl. Blood
Pressure was 90/60mmHg. Patient had to be
Intubated soon in ICU.
• Any Ideas about the Diagnosis?

36. Opioid Overdose (Excess Afim intake)
Note: Patient was diagnosed when
Toxicology Screen was done after
admission to ICU in view of
Hypoventilation

37. Take Home – Be Diligent and Persistent
till you achieve a Diagnosis