Assessing Abdominal Pain in Adults: A Rational, Cost-Effective, and Evidence-Based Strategy

Points and Pearls Excerpt

• Be wary of early diagnostic closure and misdiagnosis of abdominal pain; there are many abdominal and extra-abdominal mimics of dangerous etiologies.
• The elderly, the immunocompromised, women of childbearing age, and patients with prior abdominal surgeries are at a higher risk for misdiagnosis.
• The peritoneum becomes less sensitive with age, and peritonitis can be a late or absent finding.
• Elderly patients can present without fever, leukocytosis, or abdominal tenderness but still have surgical abdominal pathology.
• Consider diagnostic imaging in all geriatric patients presenting with abdominal pain.
• Do not forget the pelvic exam, testicular exam, and rectal exam as part of your physical examination, when appropriate.

Most Important References

• Gardner CS, Jaffe TA, Nelson RC. Impact of CT in elderly patients presenting to the emergency department with acute abdominal pain. Abdom Imaging. 2015;40(7):2877-2882. (Retrospective study; 464 patients aged ≥ 80 years)
• Kereshi B, Lee KS, Siewert B, et al. Clinical utility of magnetic resonance imaging in the evaluation of pregnant females with suspected acute appendicitis. Abdom Radiol (NY). 2018;43(6):1446-1455. (Retrospective study; 212 MRI examinations)
• Lewis KD, Takenaka KY, Luber SD. Acute abdominal pain in the bariatric surgery patient. Emerg Med Clin North Am. 2016;34(2):387-407. (Review)
• Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA. 1996;276(19):1589-1594. (Review)
• Magidson PD, Martinez JP. Abdominal pain in the geriatric patient. Emerg Med Clin North Am. 2016;34(3):559-574. (Review)
• Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. Int J Gen Med. 2012;5:789-797. (Review)
• Bass JB, Couperus KS, Pfaff JL, et al. A pair of testicular torsion medicolegal cases with caveats: the ball’s in your court. Clin Pract Cases Emerg Med. 2018;2(4):283-285. (Case studies; 2 patients)
• Kestler A, Kendall J. Emergency ultrasound in first-trimester pregnancy. In: Connolly J, Dean A, Hoffman B, et al, eds. Emergency Point-of-Care Ultrasound. 2nd edition. Oxford UK: John Wiley and Sons; 2017. (Textbook)