As with other system based complaints, we need to consider the many possible factors that may be at play regarding abdominal complaints. The most common abdominal complaint is pain, which can have several pathological causes. First lets review the systems that can be involved in the complaint of abdominal pain:
Gastrointestinal system: This one is rather obvious. Obstructions in the flow of fecal matter through the GI tract causes distension, which presents as dull, poorly localized pain. The appendiceal lumen, if obstructed, can become inflamed, ischemic, and necrotic in the condition known as appendicitis. In this case we get referred pain to the umbilicus, that gradually migrates to the RLQ. Diverticulitis and IBS commonly present with LLQ cramping and bloating, that is typically relieved with a bowel movement. Gastritis can present with diffuse or localized pain, bloating, and diarrhea. The key feature of pain located in the GI is that it is typically dull in character and represents distension and inflammation of the intestinal lumen.
Reproductive system: Sharp, constant RLQ or LLQ pain in women of child bearing age may represent ectopic pregnancy. Diffuse pelvic pain with foul vaginal discharge may represent PID. Testicular or ovarian torsion can present with constant aching pain in the pubic region that may radiate to the RLQ or LLQ.
Genitourinary system: Urinary tract and kidney infections can present with hypogastric/pelvic pain, that may be colicky in nature and worsen with urination. Kidney stones often present with flank pain that may radiate into the pubic region, that worsens with urination.
Cardiovascular system: Aching pain in the umbilical region that may become sharp over time, and radiates to the sacrum, indicates a potential AAA. Epigastric pain that is described as burning or aching can indicate PUD, GERD, or MI. Pain that is dull and diffuse may indicate mesenteric ischemia.
Other:Epigastric pain that is sharp or “boring” and felt through to the back can indicate pancreatitis. RUQ pain that is sharp, follows a fatty meal, and worsens with palpation may indicate cholecystitis. RUQ pain with visible or palpable mass, and evidence of jaundice suggests hepatitis. Diffuse pain that is described as sharp and presents with rebound tenderness suggests peritonitis.
As you can see there are several systems contained in the relatively compact abdominal cavity. This makes a thorough history and physical essential. In addition to NOPQRST-ASPN, there are specific questions we want to ask:
Has there been any changes to bowel or bladder habits?
Any blood noted in the urine or stool?
When was the last bowel movement?
Is the patient on any narcotic pain medication, routine tylenol, or NSAIDs?
In the elderly, when was their last colonoscopy?
Has there been any changes in the patient's appetite?
When performing a physical assessment, we want to assess all 4 quadrants for tenderness, asymmetry, rigidity, distension, palpable masses, or guarding. In the event that the pain is located above the umbilicus, we should perform a 12-lead to rule out a cardiac cause. Pay special attention to the patient's blood pressure and heart rate as many serious abdominal conditions can produce bleeding and shock. We on alert for anyone whose shock index is approaching 1.0. IV cannulation is recommended i the event that a fluid bolus or medications may be needed.
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