Severe abdominal pain Differential diagnosis

• Abdominal Aortic Aneurysm rupture
• Other abdominal arterial aneurysms (i.e., iliac or renal)
• Aortic dissection
• Renal colic
• Biliary colic
• Musculoskeletal back pain
• Pancreatitis
• Cholecystitis
• Bowel obstruction
• Perforated viscus
• Mesenteric ischemia
• GI hemorrhage
• Aortic thromboembolism
• Myocardial infarction
• Addisonian crisis
• Sepsis
• Spinal cord compression

• Abdominal epilepsy or abdominal migraine
• Boerhaave syndrome
• Adrenal crisis
• Early appendicitis
• Constipation +/− fecal impaction
• Diabetic ketoacidosis
• Diverticulitis
• Dysmenorrhea
• Ectopic pregnancy
• Esophagitis
• Endometriosis
• Fitz-Hugh-Curtis syndrome
• Gastroenteritis
• Hepatitis
• Incarcerated hernia
• Infectious gastroenteritis
• Inflammatory bowel disease
• Irritable bowel syndrome
• Ischemic bowel
• Meckel diverticulitis
• Neoplasm
• Ovarian torsion
• Ovarian cysts (hemorrhagic)
• Pelvic inflammatory disease
• Peptic ulcer disease
• Renal/ureteral calcul
• Renal Infarction
• Sickle cell crisis
• Spider bite (Black widow)
• Splenic infarction
• Spontaneous abortion
• Testicular torsion
• Tubo-ovarian abscess
• UTI
• Volvulus
• Referred pain:
  • Myocardial infarction
  • Pneumonia
• Abdominal wall pain:
  • Abdominal wall hematoma or infection
  • Black widow spider bite
  • Herpes zoster

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
  • HSP
  • Constipation

• Peritoneal irritants:
  • Gastric juice, fecal material, pus, blood, bile, pancreatic enzymes
• Visceral obstruction:
  • Small and large intestines, gallbladder, ureters and kidneys, visceral ischemia, intestinal, renal, splenic
• Visceral inflammation:
  • Appendicitis, inflammatory bowel disorders, cholecystitis, hepatitis, peptic ulcer disease, pancreatitis, pelvic inflammatory disease, pyelonephritis
• Abdominal wall pain
• Referred pain: (e.g., intrathoracic disease)

• 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
• Anorexia
• Nausea
• Vomiting (bilious, coffee-ground emesis)
• Malaise
• Fainting or syncope
• Cough, dyspnea, or respiratory symptoms
• Change in stool characteristics (e.g., melena)
• Hematuria
• Changes in bowel or urinary habits
• History of trauma or visceral obstruction
• Gynecologic and obstetric history
• Postoperative (e.g., cause ileus)
• Family history (e.g., familial aortic aneurysm)
• Alcohol use and quantity
• Medications: (e.g., aspirin and NSAIDs)

ED TREATMENT/PROCEDURES

Nasogastric tube decompression and bowel rest

IV fluids and electrolyte repletion

Antiemetics are important for comfort.

Narcotics or analgesics should not be withheld.

Send for blood type and cross-match for unstable patient

Surgical consultation based on suspected etiology

MEDICATION

Fentanyl: 1-2 µg/kg IV qh

Morphine sulfate: 0.1 mg/kg IV q4h PRN

Ondansetron: 4 mg IV

Prochlorperazine: 0.13 mg/kg IV/PO/IM q6h PRN nausea; 25 mg PR q6h in adults

Promethazine: 25-50 mg/kg IM/PO/PR

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

The patient should return with any warning signs:

• Vomiting
• Blood or dark/black material in vomit or stools
• Yellow skin or in the whites of the eyes
• No improvement or worsening of pain within 8-12 hr
• Shaking chills, or a fever >100.4°F (38°C)

PEARLS AND PITFALLS

• Elderly patients are more likely to present with atypical presentations and life threatening etiologies requiring admission.
• Do not consider constipation if stool is absent in the rectal vault.
• Etiology requiring surgical intervention is less likely when vomiting precedes the onset of pain.