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Abdominal Pain

Age, location, pregnancy status, and the vascular exam.

LearnQuick referenceClinical practice

Your objective: explain the approach, recognize important warning signs, then test your recall.

Abbreviations explained
ACS
Acute coronary syndrome
OMI
Occlusion myocardial infarction
ECG
Electrocardiogram
PE
Pulmonary embolism
POCUS
Point-of-care ultrasound
QTc
QT interval corrected for heart rate
LBBB
Left bundle branch block
RBBB
Right bundle branch block
hs-cTn
High-sensitivity cardiac troponin
CTA
Computed tomography angiography
ICU
Intensive care unit
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The jobAge, location, pregnancy status, and the vascular exam.

  1. hCG in every patient of childbearing potential.
  2. Killers first: AAA, mesenteric ischemia, ectopic, perforation, torsion.
  3. Localise by embryology and migration; then image (US for biliary/GYN, CT as the workhorse).
  4. Medical mimics last: DKA, inferior MI, basal pneumonia.

The ED goal is triage: exsanguinating and necrotizing causes first, then time-sensitive surgical causes, then medical mimics.

Localization follows embryology (epigastric=foregut, periumbilical=midgut, suprapubic=hindgut) — migration of pain is diagnostic gold.

Ruptured AAA Critical

Key: Age >60 + pain/hypotension/pulsatile mass — bedside US, straight to OR/vascular; do not wait for a perfect CT.

Mesenteric ischemia Critical

Key: Pain out of proportion, AFib or vasculopathy; lactate and WBC may be normal early — CTA is the test.

Ruptured ectopic pregnancy Critical

Key: Every patient of childbearing potential with abdominal pain gets a pregnancy test.

Perforated viscus Critical

Key: Sudden severe pain, rigid abdomen, free air (upright CXR or CT).

Ovarian / testicular torsion Critical

Key: Acute one-sided pain — Doppler US. Testicular salvage is highest if detorsion is within ~6 h, but operate on suspicion — do not wait out a clock.

Abdominal aortic / mesenteric dissection Critical

Key: Consider in the same breath as chest-dissection presentations.

DKA, inferior MI, basal pneumonia Emergent

Key: Medical mimics — check glucose, ECG, and lungs in every atypical story.

Appendicitis / cholecystitis / diverticulitis / obstruction Common

Key: Time-sensitive; score and image. Selected uncomplicated appendicitis may be antibiotics-first per protocol (CODA).

Tick what your patient has — the banner updates as you go.

Onset & migration

periumbilical → RLQ (appendicitis); sudden maximal (perforation, torsion, AAA)

Relationship to meals (biliary), defecation (colonic), vomiting first vs pain first (surgical vs medical)

Blood

hematemesis, melena, hematochezia; last menstrual period & pregnancy possibility

Vascular history

AFib, known AAA, atherosclerosis → ischemia

Immunosuppression and steroids blunt peritoneal signs

Peritoneal signs

rigidity, rebound, guarding

Murphy sign (cholecystitis), McBurney (appendicitis), Rovsing/psoas/obturator

Pulsatile mass + bruits; Cullen/Grey-Turner are late and uncommon (retroperitoneal blood)

Hernial orifices and genital exam in every male with scrotal/inguinal pain

Volume status

tachycardia, dry mucosa, capillary refill

Bedside

  • Urine hCG in all patients of childbearing potential
  • POCUS: AAA size, free fluid, gallbladder wall/stone, intrauterine pregnancy

Labs

  • CBC, CRP, electrolytes, glucose, lactate, lipase, LFTs, urinalysis
  • Type & screen when surgery is likely; quantitative β-hCG

Imaging

  • CT abdomen/pelvis with IV contrast = workhorse (appendicitis, diverticulitis, ischemia, AAA)
  • US first for biliary and gynecologic; MRI in pregnancy when US is inconclusive
Medication safety reminder

Use this as a first-pass prompt; verify all medications, doses, concentrations, contraindications, weight, pregnancy status, and local protocols before administration.

Check indication, allergy, route, renal/hepatic risk, interactions, monitoring, and local formulary.

Discharge

  • Benign exam, normal labs/imaging when indicated, reliable return precautions — reassess within 24–48 h if pain persists.

Admit / surgical consult

  • Appendicitis (early laparoscopic appy, or antibiotics-first per local protocol), cholecystitis, diverticulitis, obstruction without strangulation.

Emergency surgery / IR / ICU

  • Ruptured AAA, perforation, mesenteric ischemia, strangulated obstruction, torsion.

Use objective reassessment and the local pathway.

Before the next decision · reassess and hand over

Use these learning prompts with the presentation’s pathway. They are not discharge criteria.

  1. Reassess: compare symptoms, observations and examination with the initial assessment and response to treatment.
  2. Warning signs for Abdominal Pain:
    • Hypotension or syncope with abdominal pain
    • Pain out of proportion to exam findings
    • Rigid abdomen or positive peritoneal signs
    • GI bleeding with known AAA repair (aortoenteric fistula)
    • Acute scrotal pain — treat as torsion until proven otherwise
    • Immunosuppressed with mild findings (can decompensate fast)
  3. Reconsider: check unresolved findings and alternative explanations, including the pitfalls below.
  4. Escalate: communicate deterioration, uncertainty or needs beyond the current setting.
  5. Plan the transition: identify outstanding results, responsibility for follow-up, patient understanding and specific return advice.
Review this presentation’s disposition pathway →Practice a handover →

Clinical Pearls

  • hCG in every patient of childbearing potential — no exceptions for “no risk factors.”
  • Pain out of proportion with a quiet belly is mesenteric ischemia until CTA says otherwise.
  • Analgesia does not mask the surgical abdomen — treat pain and re-examine.
  • The elderly with a soft abdomen still perforate, infarct, and rupture AAAs — lower the CT threshold.

Pitfalls

  • Analgesia does not mask the diagnosis — treat the pain and re-examine (ACEP).
  • Normal lactate & WBC do not exclude early mesenteric ischemia.
  • Ectopic pregnancy happens with “no risk factors” and a negative exam — and with a history of tubal ligation.
  • Elderly with soft findings can have catastrophes — lower the threshold for CT.
  • Diaphragmatic irritation (basal pneumonia, inferior MI) presents as upper abdominal pain.
PRACTICE REFRESHER

Rapid recall

Test your first action and the dangerous diagnoses before revealing the answer.

01 · First move

Before you scroll, what needs to happen first?

02 · Immediate threats

Name at least two diagnoses that cannot wait.

PRIVATE TO THIS DEVICE

Your learning note

Capture a weak point, a teaching pearl, or a question to take to your next shift.

Review schedule starts when marked reviewed
Acute Pelvic Pain (Women)Scrotal Pain & SwellingNausea & VomitingGI BleedingDiarrhea

Selected guidance · source check 2026-09-07. These 1 source links support selected teaching points, not a complete review of this topic. Check population, setting and local protocol before applying a recommendation.

  • Rosen’s Emergency Medicine, 10th ed. (2023) — abdominal pain & surgical abdomen
  • Tintinalli’s Emergency Medicine, 9th ed.
  • WSES 2020 guidelines (appendicitis, diverticulitis); CODA trial (NEJM 2020) for antibiotics-first appendicitis
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