James S Newman, M.D.
The University of Texas Medical
“All who have had much experience of
the group of cases known generally as
the acute abdomen will probably agree
that in that condition early diagnosis is
Types of abdominal pain
• Colicky pain - caused by distention of a
hollow viscus, such as bowel.
• Somatic pain - caused by inflammation
of the parietal peritoneum.
• Visceral pain - caused by inflammation
of the visceral peritoneum and capsule
of solid organs.
Quadrant View of the
• Inflammation of the gall bladder caused by duct
obstruction with a gall stone.
• Pain is usually steady for an hour or more after onset
and made worse by eating.
• If there is significant inflammation associated with the
cholecystitis, there may be local peritoneal pain
• Pain may be referred to the scapular area and
accompanies nausea, vomiting, and fever without
• Diagnosed with ultrasound.
• Caused by obstruction of the biliary tract
leading to bacterial overgrowth in the gall
• Marked by Charcot’s Triad - RUQ pain,
jaundice and fever.
• Diagnosed by ultrasound.
• Is an emergency and must be treated with IV
• May require decompression via endoscopic
or surgical means.
• Caused by inflammation of the liver by
viruses, alcohol or certain drugs.
• Marked by tender, enlarged liver with
malaise, fever and jaundice.
• Diagnosed by history and laboratory
evaluation - liver function tests and viral
• Treatment depends on etiology of disease.
• Most commonly caused by alcoholism (50%) and gall
stones (30%) obstructing the common bile duct.
• Constant mid-epigastric visceral pain usually
occurring after a heavy meal or alcoholic binge.
• Pain may radiate to the back (50%) and is
accompanied by nausea, vomiting and anorexia.
• Diagnosed by amylase and lipase. Imaging by CT
scan may be desirable in some cases.
Peptic Ulcer Disease
• Caused by increased gastric acid production or decreased
• Increased gastric acid production may be caused by
alcoholism or gastrin producing tumor (Zollinger-Ellison
• Decreased mucosal protection may be caused by overuse
of NSAID’s or by infection with Helicobacter pylori.
• Pain is visceral and may become somatic if perforation
occurs. There may be radiation to the back.
• Diagnosed by H. pylori antigen in the serum, abdominal x-
rays detect free air if there is perforation, UGI and
• Treatment consists of Omeprazole 20mg, Amoxicillin 1gm,
Dissecting Abdominal Aortic
• Caused by tearing of the layers of the
abdominal aorta secondary to atherosclerotic
• Pain of dissection is described as an
excruciating tearing sensation often referred
to the midline back.
• May be accompanied by hypotension,
pulsatile abdominal mass and diaphoresis.
• Diagnosed by abdominal ultrasound
• Is a surgical emergency!
• Diverticula form in weakened areas of the colonic
wall and may become impacted with feces leadingt to
infection and possible perforation.
• Pain is described as cramping, steady visceral pain.
• May be accompanied by change in bowel habits,
fever, nausea, vomiting and anorexia.
• May have leukocytosis on CBC.
• Diagnosed by CT scan - swollen edematous bowel
wall. *Must avoid colonoscopy and barium enema in
the acute setting to avoid perforation*
• Pain caused by distention of cyst lining and
may hemorrhage into the pelvic cavity.
• Pain is described as constant achy pain in the
lower quadrants and may radiate to the groin
• Diagnosed by ultrasound
• Also consider ovarian torsion, pelvic
inflammatory disease and ectopic pregnancy.
• Pelvic etiologies must be considered in any
female patient presenting with signs of an
• Caused by obstruction of the appendiceal
lumen usually by a fecalith.
• Pain starts as periumbilical and migrates to
the RLQ (McBurney’s Point)
• Is accompanied by nausea, vomiting and
anorexia. May have fever - especially if
• Diagnosed by ultrasound or CT scan.
• Treatment is surgical and is an emergency if
General Abdominal Pain
• Some causes of abdominal pain are
generalized and not restricted to any
• Caused by inflammation of the
gastrointestinal tract by microorganisms,
radiation and other irritants.
• Described as diffuse crampy abdominal pain.
• Often accompanied by diarrhea, nausea,
vomiting, dehydration and fever.
• Diagnosis is by history and stool cultures if
• Caused by neoplastic growth in the ascending,
transverse, descending or sigmoid colon. Increased
incidence in high fat, low fiber diets, positive family
history and history of inflammatory bowel disease.
• Pain is colicky and is similar to that caused by large
bowel obstruction, especially left-sided lesions.
• Associated with change in bowel habits, heme
positive stool and weight loss.
• Diagnosed by colonoscopy, flexible sigmoidoscopy
and barium enema.
• Rectal exam should also be performed as 10% of
cancers are palpable on rectal exam.
• Caused by obstruction of the bowel lumen by mass,
hernia entrapment, volvulus, intussusception and
rotation around scar adhesions.
• Pain is colicky in nature.
• Accompanied by vomiting - especially if the
obstruction is proximal.
• May be accompanied by watery diarrhea - evacuation
of distal intestinal contents.
• Diagnosed by abdominal x-rays looking for distended
loops of bowel and air-fluid levels.
• Caused by obstruction of the upper urinary tract
by a stone that is induced by dehydration,
infection, hypercalcemia and other metabolic
• Pain is described as colicky and located
anywhere from the flank to the groin.
• Diagnosed by intravenous pyelogram, ultrasound
or CT scan.
• Should also consider pyelonephritis, cystitis and
• Onset of pain, location, quality, severity,
radiation, associated symptoms.
• Past medical and surgical history,
medications and menstrual history -
possibility of pregnancy.
• Description of emesis and stool - color,
consistency, amount, presence of
mucous and blood.
• Vital signs to evaluate for signs of infection,
dehydration, shock, instability.
• Inspect visually for distention, scars,jaundice, signs of
hernias or masses.
• Auscultate - high pitched bowel sounds may indicate
early obstruction. No bowel sounds indicate ileus.
Increased bowel sounds may be associated with
• Palpate and Percuss - for tenderness, masses,
pulsation, hernias, guarding, CVA tenderness, liver
and spleen size, ascites and hyperresonance.
• Pelvic exam in women
• CBC with Diff, urinalysis, electrolytes.
• Liver function tests, amylase/lipase.
• CXR for free air under the diaphragm or lower
• Supine and upright abdominal x-rays.
• Ultrasound, CT scan, IVP, barium enema,
UGI, endoscopy and colonoscopy when
• Pregnancy test in all reproductive-aged
• Must decide whether to admit and observe,
discharge or operate.
• Keep NPO until diagnosis has been
• IV fluids for maintaining correct fluid balance
• Nasogastric tube for gastric decompression,
vomiting or bleeding.
• Foley catheter to ensure adequate hydration
and urine output.
• Pain medications as indicated.
• The Virtual Hospital - www.vh.org
• The Mont Reid Surgical Handbook,
Berry et al.
• Surgical Recall, Blackbourne.
• Special Thanks to Matt Davis, MSIII and
Angela Hewlett, MSIII for their tireless
efforts and assistance.