Diagnostic approach to abdominal pain in adults

INTRODUCTION

Abdominal pain can be a challenging complaint for both primary care and specialist physicians because it is frequently a benign complaint, but it can also herald serious acute pathology. Abdominal pain is present on questioning of 75 percent of otherwise healthy adolescent students [1] and in about half of all adults [2]. The prevalence of abdominal pain is consistently high across diverse geographic regions and age groups, and it is frequently a result of the irritable bowel syndrome [1-5].

From the large population of patients with benign causes of abdominal pain, clinicians are responsible for trying to determine which patients can be safely observed or treated symptomatically and which require further investigation or specialist referral. This task is complicated by the fact that abdominal pain is often a nonspecific complaint that presents with other symptoms [6]. Thus, the overall sensitivity and specificity of the history and physical examination in diagnosing the different causes of abdominal pain is poor [7], particularly for benign conditions [8,9]. Fortunately, studies of the accuracy of history and physical examination for the more serious causes of abdominal pain (eg, acute appendicitis), alone or in combination with focused investigations, have yielded better results [10-12].

This topic reviews an approach to the triage and diagnosis of adults with acute or chronic nontraumatic abdominal pain. A more complete differential diagnosis of abdominal pain and its pathophysiology is discussed separately. (See "Differential diagnosis of abdominal pain in adults".)

TRIAGE AND DISPOSITION

Acute abdominal pain frequently requires urgent investigation and management. Such patients require assessment of their airway, breathing, and circulation, followed by appropriate resuscitation. Many patients will require analgesics, which can be administered judiciously without compromising physical assessment of peritoneal signs [13-19].

Patients with suspected surgical abdomens must be transferred to an acute care facility where urgent surgical consultation and management are available. Patients requiring resuscitation or parenteral analgesia should also be transferred to an acute care facility where more appropriate nursing care and laboratory and radiology facilities are available. Patients with less acute illnesses may require consultation or referral for further management following a more detailed history and initial assessment, as described below.