Diagnosis

Characteristics of Abdominal Pain

Typical Physical Findings, if Present

Cardiovascular

Stable ischemic heart disease

Chronic typical or atypical angina

Postprandial epigastric pain, abdominal angina

Acute coronary syndrome

Unstable angina (progressive, new onset, or new occurrence of rest angina)

Severe constant epigastric pain

Aortic dissection

Sharp or tearing, sudden onset radiating from substernal to intrascapular, might involve epigastric area

Loss of carotid or upper extremity pulses, stroke

Abdominal aortic aneurysm

Back, flank, abdominal pain (when the aneurysm ruptures)

Symptoms from local compression, hemodynamic instability, embolic phenomena affecting the lower limbs, pulsatile abdominal mass

Pulmonary

Bacterial pneumonia

Pleuritic pain with dyspnea

Pleural friction rub

Gastrointestinal

Abdominal abscess

Abdominal pain, focal tenderness, signs of peritonitis may be present

Fever, ileus, tenderness to palpation, reduced bowel sounds

Acute cholecystitis

Biliary colic, right hypochondriac pain, pain radiating to back or scapula

Murphy sign (+), tenderness to deep palpation, mass at the right hypochondriac region

Cholangitis

Acute or chronic RUQ pain

Fever, chills, jaundice, RUQ tenderness, +/- septic shock, +/-confusion

Acute pancreatitis

Epigastric pain, may be boring radiating to back

Epigastric tenderness

Acute pyelonephritis

Flank pain that may radiate to the groin

Costovertebral angle tenderness, chills, fever

Appendicitis

Periumbilical or epigastric pain that migrates to the RLQ

Rebound tenderness, rigidity, guarding, Rovsing sign, obturator sign, psoas sign, Dunphy sign

Diverticulitis

Sharp pain in LLQ

Rebound tenderness, rigidity, guarding

Intussusception

Pain is colicky, severe, and intermittent

RUQ sausage-shaped mass and RLQ emptiness (Dance sign), abdominal distension if obstruction is complete, currant jelly stools

Intestinal volvulus

Severe colicky abdominal pain

Abdominal distension, abdomen very tympanic to percussion, obstipation, rebound tenderness if peritoneal irritation

Intestinal perforation

Sharp, severe, sudden-onset epigastric pain

Rebound tenderness, rigidity, bowel sounds are usually absent in generalized peritonitis

Intestinal obstruction (eg, malignancy)

Crampy abdominal pain

Increased bowel sounds, tenderness, rigidity, guarding, fullness

Esophageal disease (eg, rupture, tear)

Substernal pain or pressure, sharp or dull

Nonspecific

Gastroesophageal reflux

Substernal and/or epigastric burning

Bad odor with breathing

Other Causes of Abdominal Pain That Should be Considered

Septic shock

Abdominal pain to deep palpation, signs of perforation and peritonitis

Fever, hypotension, tachycardia, altered mental status, petechiae, or purpura in disseminated intravascular coagulation

Testicular torsion

Sudden onset of severe testicular, inguinal, abdominal pain

Scrotal pain that does not resolve with elevation of the testicle, tender and high-riding testicle, horizontal lie of the testicle, absent cremasteric reflex

Ectopic pregnancy

Lower abdominal pain

Vaginal bleeding, pelvic pain, acute onset severe pain with tubal rupture followed by hemodynamic instability

Metabolic (eg, acute intermittent porphyria)

Severe, colicky, poorly localized abdominal pain

Signs and symptoms specific for the metabolic pathology (eg, skin lesions, urine discoloration, neurologic symptoms)

Lactic acidosis

Diffuse abdominal pain that cannot be easily localized

Nausea, vomiting, Kussmaul breathing, hypotension, oliguria, altered mental status

LLQ, left lower quadrant; RLQ, right lower quadrant; RUQ, right upper quadrant.