Approach to abdominal pain in non-pregnant patients in the emergency department

ED: emergency department; IV: intravenous; CBC: complete blood count; LFTs: liver function tests; IVC: inferior vena cava; CXR: chest radiograph; ECG: electrocardiogram; AAA: abdominal aortic aneurysm; CT: computed tomography; ICU: intensive care unit; ACS: acute coronary syndrome; PUD: peptic ulcer disease; UTI: urinary tract infection; PID: pelvic inflammatory disease; RUQ: right upper quadrant; TAH-BSO: total abdominal hysterectomy with bilateral salpingo-oophorectomy; HIV: human immunodeficiency virus.

* Peritoneal signs include rigidity, involuntary muscle guarding, severe or rebound tenderness, and pain with coughing or shaking stretcher.

¶ Stress-dose glucocorticoids (eg, hydrocortisone) should be administered if adrenal insufficiency is suspected (eg, chronic glucocorticoid therapy, history of primary adrenal insufficiency).

Δ For example, pain that resolves with reduction of incarcerated hernia.

◊ Concerning signs, symptoms, and history for acute vascular process include pain out of proportion to exam, sudden onset of pain, associated syncope, new onset or prior history of atrial fibrillation, and prior history of atherosclerotic vascular disease or hypertension.

§ Signs and symptoms suggesting obstruction include vomiting, increased belching, obstipation, and abdominal distension.

¥ Signs and symptoms of UTI include dysuria, urinary urgency/frequency, and pyuria. Signs and symptoms of cervicitis/PID include lower abdominal pain, abnormal uterine bleeding, vaginal discharge, cervical motion and/or adnexal tenderness, and vaginal/endocervical discharge.

‡ Either point-of-care or radiology-performed depending on available equipment and expertise with specific study.

† Signs and symptoms suggesting a gynecologic cause include sudden onset of maximal intensity of pain, lower abdominal/pelvic location of pain, associated vaginal discharge or bleeding, and adnexal or cervical motion tenderness.

** High-risk features include previous bariatric surgery, active malignancy, taking glucocorticoids or immunosuppressives, organ transplant recipient, sickle cell disease, HIV. Refer to related UpToDate content for further discussion.