History

• Pain:
  • Nature of onset of pain
  • Time of onset and duration of pain
  • Location of pain initially and at presentation
  • Extra-abdominal radiations
  • Quality of pain (sharp, dull, crampy)
  • Aggravating or alleviating factors
  • Relation of associated finding to pain onset
  • Previous episodes
• Anorexia
• Nausea
• Vomiting (bilious, coffee-ground emesis)
• Malaise
• Fainting or syncope
• Cough, dyspnea, or respiratory symptoms
• Change in stool characteristics (eg, melena)
• Hematuria
• Changes in bowel or urinary habits
• History of trauma or visceral obstruction
• Gynecologic and obstetric history
• Postoperative (eg, cause ileus)
• Family history (eg, familial aortic aneurysm)
• Alcohol use and quantity
• Medications (eg, aspirin and NSAIDs)

Physical Exam

• Vital signs
• Abdominal:
  • Scars
  • Distended abdomen
  • Abnormal bowel sounds:
    • High-pitched rushes with bowel obstruction
    • Absence of sound with ileus or peritonitis
  • Pulsatile abdominal mass
  • Rebound tenderness, guarding, rigidity, and cough test for peritoneal irritation (eg, appendicitis, peritonitis)
  • Rovsing sign, suggestive of appendicitis:
    • Palpation of left lower quadrant causes pain in right lower quadrant (RLQ)
  • Psoas sign suggests appendicitis (on right):
    • Pain on extension of thigh
  • Obturator sign suggests pelvic appendicitis (on the right only):
    • Pain on rotation of the flexed thigh, especially internal rotation
  • Lloyd’s sign: CVA percussion tenderness indicative of pyelonephritis, renal colic, or perinephric abscess
  • McBurney point tenderness associated with appendicitis:
    • Palpation in RLQ 2/3 distance between umbilicus and right anterior superior iliac crest causes pain
  • Murphy sign, suggestive of cholecystitis:
    • Pause in inspiration while examiner is palpating under liver
  • Carnett sign indicates abdominal wall pain:
    • Pain when a supine patient tenses the abdominal wall by lifting the head and shoulders
  • Tender or discolored hernia site
  • Rectal and pelvic examination:
    • Tenderness with pelvic peritoneal irritation
    • Cervical motion tenderness
    • Adnexal masses
    • Rectal mass or tenderness
    • Guaiac positive stool
• Genitourinary:
  • Flank pain
  • Dysuria
  • Costovertebral angle tenderness
  • Suprapubic tenderness
  • Tender adnexal mass on pelvis
  • Testicular pain:
    • May be referred from renal or appendiceal pathology
• Referred pain:
  • Kehr sign (diaphragmatic irritation due to blood or other irritants) causes shoulder pain
• Extremities:
  • Pulse deficit or unequal femoral pulses
• Skin:
  • Jaundice
  • Liver disease (caput medusa)
  • Hemorrhage:
    • Grey Turner sign of flank ecchymosis
    • Cullen sign is ecchymotic area round the umbilicus.
  • Herpes zoster
  • Cellulitis
  • Rash (Henoch–Schönlein purpura)
  • Murphy sign, suggestive of cholecystitis:
    • Pause in inspiration while examiner is palpating under liver
  • Tender or discolored hernia site

Lab

• Lab values are rarely diagnostic
• CBC
• Serum electrolytes, creatinine, and glucose
• ESR
• Procalcitonin
• LFTs
• Lactic acid
• Serum lipase:
  • More sensitive and specific than amylase for pancreatitis
• Urinalysis
• Stool analysis and culture:
  • Clostridium difficile titers in patients with diarrhea taking antibiotics
• Pregnancy testing

Imaging

• ECG:
  • Consider if risk factors for coronary artery disease are present
• Abdominal radiograph: Supine and upright
  • CT is superior for suspected visceral perforation and bowel obstruction
• Upright CXR:
  • Pneumoperitoneum
  • Intrathoracic disease causing referred abdominal pain
• Departmental US and Point-of-Care US (POCUS):
  • Biliary abnormalities
  • Hydronephrosis
  • Intraperitoneal fluid
  • Aortic aneurysm
  • Intussusception
• US (Doppler ultrasonography):
  • Volvulus and malrotation
  • Testicular and ovarian torsion
  • Hepatitis, cirrhosis, and portal vein thrombosis
• Abdominal CT:
  • Spiral CT without contrast:
    • Renal colic
    • Retroperitoneal hemorrhage
  • CT with IV contrast only:
    • Vascular rupture suspected in a stable patient (eg, acute abdominal aortic aneurysm [AAA], aortic dissection)
    • Ischemic bowel
    • Pancreatitis
    • Appendicitis
  • CT with IV and oral contrast:
    • History of inflammatory bowel disease
    • Thin patients (low BMI)
    • Diverticulitis
  • CT angiography:
    • Mesenteric ischemia
    • AAA
• IVP:
  • CT has replaced the use of IV urography in detection of ureteral stones
• Barium enema:
  • Intussusception
  • Treatment and confirmation of intussusception is with air contrast enema
• MRI:
  • If concerns for radiation exposure or nephrotoxicity
  • Contraindicated in patients with metallic implants
  • Consider in pregnant patients and OB-Gyn pathology

Pregnancy Considerations

Ultrasonography and MRI should be preferred to prevent exposure of ionizing radiation to the fetus

Pediatric Considerations

• Under 2 yr:
  • Hirschsprung disease
  • Incarcerated hernia
  • Intussusception
  • Volvulus
  • Foreign body ingestion
• 2–5 yr:
  • Appendicitis
  • Incarcerated hernia
  • Meckel diverticulitis
  • Sickle cell crisis
  • Henoch–Schönlein purpura
  • Constipation

Admission Criteria

• Surgical intervention
• Peritoneal signs
• Patient unable to keep down fluids
• Lack of pain control
• Medical cause necessitating in-house treatment (MI, DKA)
• IV antibiotics needed

Discharge Criteria

No surgical or severe medical etiology found in patient who is able to keep fluid down, has good pain control, and is able to follow detailed discharge instructions

Advised to develop and implement a standardized follow-up protocol (can be in primary care or by telehealth) to monitor progress and adherence to discharge instructions