General Considerations

Abdominal pain is the chief complaint in 5%-10% of patients presenting to emergency departments and one of the top 10 outpatient complaints. Accurate diagnosis can be difficult, because the array of possible problems associated with abdominal pain is wide. For this reason, a detailed history, thorough physical examination, and laboratory and radiologic evaluations are necessary.

Clinical Findings

History

Essentials of Diagnosis

• Determine acute versus chronic.
  
• Quality, location, and radiation of pain.
  
• Associated symptoms.

The history is one of the most important components in the evaluation of abdominal pain and can help direct the subsequent workup. The first priority is to determine whether the pain is acute or chronic. The sudden or severe onset of abdominal pain, particularly pain associated with hemodynamic changes, leads toward an emergent evaluation and intervention.

A thorough and accurate history requires effective communication skills on the part of the clinician. Physicians are more likely to collect the full history when implementing the “engage, empathize, educate, and enlist” method. Patients should be allowed to tell their story, which usually takes 1 or 2 minutes and often answers the questions regarding onset, intensity, location, and frequency of the problem that can help focus the physical examination.

Onset

It is important to determine onset of pain to help in determinig the cause of abdominal pain as well as the need for emergent referral. Abdominal pain can be categorized as acute, subacute, or chronic. Generally, 3 months of symptoms are considered chronic, while acute and subacute are more subjectively determined. Acute pain is often associated with problems causing peritoneal irritation as from appendicitis, or ruptured abdominal organ. Many of these problems require emergency management and consultation with a surgeon. In the family medicine office, many other issues present with a more gradual onset of abdominal pain and by abdominal pain that is chronic in nature (Table 30-1).

Quality of Pain

The patient’s description of the quality of the pain provides clues to the etiology of the problem. Pain can be sharp, stabbing, burning, dull, gnawing, colicky, crampy, gasey, focal, migrating, or radiating. A pressure-like description (“there’s an elephant sitting on me”) suggests cardiac ischemia. The more focal these symptoms are, the more helpful the location can be to determining the diagnosis.

Location

The location of the pain coupled with any radiation can be helpful. The abdomen can be separated into four quadrants: right upper (RUQ), left upper (LUQ), right lower (RLQ), and left lower (LLQ). Location can further be identified, including mid-epigastric or suprapubic. From the location of the pain, the differential of causes can be narrowed.. Several causes of abdominal pain have classic patterns of location and radiation even to areas outside the abdomen. For example, pain from the lower esophagus may be referred higher in the chest and is often confused with pain associated with cardiac conditions, such as an acute myocardial infarction.

Frequency/Timing

The frequency and pattern of the pain are particularly useful in identifying abdominal pain that is gradual in onset. Pain timing may be related to eating, defecation, body position, or movement. The type of meal which seems to cause pain gives more diagnostic clues. Peritoneal irritation is eased by lack of movement, while visceral pain tends to cause patient to keep moving to try to find a comfortable position. Many pains may peak and then be relieved by defecation. This finding is suggestive of colonic pathology.

Other Diagnostic Clues/Associated Symptoms

Physicians need to determine if other associated symptoms are present. Patient should be asked specifically about presence and quality of nausea, vomiting, diarrhea, or constipation. The presence of blood, melena, hematachezia, or mucus is important in assessing vomitous or bowel movements. Fever and chills suggest an infectious etiology. Feculent emesis is correlated with bowel obstruction. The presence of blood or melena in the stool requires further evaluation due to the possibility of gastrointestinal (GI) bleeding. Emotional stress can exacerbate functional bowel disease. However, it should not be used as a primary diagnostic discriminator between functional and organic disease because many organic diseases can be accentuated by emotional stress.

Past medical history can provide important clues to the etiology of abdominal pain. A history of previous episodes can help direct further evaluation. Previous abdominal surgery increases the risk for bowel obstruction secondary to adhesions, strangulation, or hernia. Patients with a history of cardiovascular disease are at greater risk for bowel infarction. A history of tobacco or alcohol use is associated with an increased incidence of gastroesophageal reflux disease (GERD) and peptic ulcer disease (PUD). Alcohol abuse is also a common cause of pancreatitis. Multiparity, obesity, and diabetes mellitus all increase the risk of gallbladder disease. Tubal ligation or a history of pelvic inflammatory disease (PID) indicates a greater risk for an ectopic pregnancy.

No medical history is complete without a medication history that also includes both over-the-counter drugs and herbal supplements. Aspirin and other platelet aggregation inhibitors, steroids and nonsteroidal anti-inflammatory drugs (NSAIDs), and antidepressants increase the risk of GI bleeding. Antibiotics can be associated with nausea, diarrhea, or both.

Advancing age can change the patient’s presentation and perception of abdominal pain. There is a 10%-20% reduction in intensity of pain per decade of age over 60 years. This fact should be considered when elderly patients present with only vague or mild abdominal pain. The elderly are significantly less likely to present with a classic symptom pattern for things like appendicitis or PUD.

Physical Examination

Essentials of Diagnosis

• Inspect, auscultate, palpate, and percuss abdomen.
  
• Assess for tenderness on palpation as well as rebound tenderness.
  
• Listen for infrequent bowel sounds

The history obtained dictates the focus of the abdominal examination. In addition to the abdominal examination, a pelvic examination is frequently indicated in female patients presenting with abdominal pain. An effective physical examination of the abdomen has many steps that flow intuitively. The physician should begin by positioning the patient supine with the knees slightly bent then proceed with the steps listed as follows:

Inspection

An inspection for distention, discoloration, scars, and striae should be conducted. Distention suggests ascites, obstruction, or other masses increasing the abdominal contents. Discoloration may include bruising as in the case of hemoperitoneum, found in the central portion of the abdomen, especially following abdominal trauma. The presence and location of scars help clarify and confirm the history previously obtained. Striae suggest rapid growth of the abdomen. Old striae tend to be white, whereas new striae or those related to endocrine abnormalities tend to be purplish or dark pink. In persons of color, this may appear to be a darkening of the skin. The abdomen should also be inspected when the patient is upright, as many hernias resolve when the patient is in a supine position.

Auscultation

Auscultation should be performed prior to palpation. The physician should listen for the quality of bowel sounds: normal, hypoactive, hyperactive, or high pitched. Hypoactive and hyperactive bowel sounds can both be present in the case of total or partial bowel obstruction, or ileus. It is also necessary to listen for bruits over the aorta, renal arteries, and femoral arteries when auscultating. Bruits may be suggestive of aneurysms in those areas. Palpating gently while auscultating decreases the likelihood of guarding, embellishment, or symptom magnification on the part of the patient.

Palpation

Palpation of the abdomen should be done in several steps, beginning with the lightest of touches away from the area of greatest pain and moving closer to the tender area as the examination progresses. There are several aspects to palpation, including consistency, tenderness, masses, and organ size. Consistency can range from soft to rigid; increased rigidity is indicative of an acute abdomen needing more emergent intervention.

Tenderness can be separated by location, radiation, and associated rebound or guarding. Murphy sign, sudden cessation of the patient’s inspiratory effort during deep palpation of the RUQ, is suggestive of acute cholecystitis. Pain stemming from visceral organs may appear to radiate secondary to other areas being innervated by the same nerve. For example, the pain caused by pancreatitis often radiates to the back. Kehr sign, abdominal pain radiating to the left shoulder, is indicative of splenic rupture, renal calculi, or ectopic pregnancy. Radiation of pain can also be caused by inflammation of surrounding tissues.

It is difficult to palpate the deep muscles of the abdomen, but the same effect can be obtained by examining pain with motion of muscles. For example, the iliopsoas muscle test can assess for inflammation within the psoas muscle or inflammation of overlying structures such as the appendix. The test is performed by having the patient lie supine, then lift the right leg while flexing at the hip. Resistance is applied to the leg. Pain with this maneuver is suggestive of appendicitis or retroperitoneal dissection.

Rebound tenderness indicates peritoneal irritation, which can come from perforation along the GI tract or from the non-GI sources such as a ruptured ovarian cyst or PID. When there is peritoneal irritation, the patient will often demonstrate guarding. Guarding can be voluntary or involuntary. Voluntary guarding can occur when the patient anticipates the pain. The “closed eye” sign has been shown to help differentiate the etiology of the pain. Patients whose pain has an organic etiology will keep their eyes open and watch as the examiner approaches the abdomen. Patients who close their eyes are more likely to have psychosocial factors contributing to their abdominal pain.

Involuntary guarding is caused by flexion of the abdominal wall muscle as the body attempts to protect the internal organs. This protective reflex can be used to differentiate visceral pain from abdominal wall or psychogenic pain, demonstrated with the Carnett test. Once the area of greatest tenderness is located, the patient then flexes the abdominal wall and the point is palpated again. Pain that is less severe with palpation of the flexed abdomen wall has a high probability of being visceral. Pain that remains the same or is worsened with this maneuver likely stems from the abdominal wall or from nonorganic causes.

Palpation of the abdomen of a ticklish patient can be difficult. Two approaches can help the physician palpate these patients more thoroughly. One method is to first use the stethoscope for light palpation and then curl the fingers past the edge of the stethoscope to create a less sensitive tough. In an alternative technique, the patient places his or her hands on the abdomen and the examiner palpates through the patient’s hands and just over the edge of the patient’s fingers. This permits deep palpation without contraction of the abdominal muscles from laughing.

In addition to feeling for tenderness with palpation, the physician should examine the abdomen for masses and organ size. Palpable masses include colon cancer masses, kidney abnormalities, non-GI tumors, aneurysms, or other organ abnormalities. Most are found on deep palpation. This palpation can be facilitated by having the patient in the supine position with the knees slightly bent, to allow for relaxation of the abdominal muscles. If a mass is palpated, it should be examined for location, size, shape, consistency, pulsations, mobility, and movement with respiration.

When palpating for organ size, the liver and spleen should be examined. Before trying to palpate the lower border of the liver or spleen, the examiner should ask the patient take a deep breath and then exhale while he or she palpates deeper. The normal liver span at the midclavicular line is 6-12 cm. The liver in men and taller individuals tends to be larger than that in women and shorter individuals. Additionally, the liver span in the midsternal line can be helpful. This span is normally 4-8 cm. Anything larger than 8 cm should be considered enlarged. The size of the liver may better be appreciated by percussing along the midclavicular line. The examiner should start in an area of tympany and progress to an area of dullness, both from above the liver and below the liver. The upper border generally sits at the fifth to seventh intercostal space. Inferior displacement is suggestive of emphysema or other pulmonary disease.

The spleen may not be palpable or just a tip of the spleen may be palpable. Both of these findings are normal. The actual span of the spleen can be determined by percussion. The area of dullness related to the spleen is generally from the sixth to the tenth rib. It should be percussed in the left midaxillary line.

Percussion

Percussion can be helpful to determine both the size of the organs and other information about the abdomen. Percussion over the liver or spleen should be slightly dull. A change in the character of the sound can indicate that the edge of the organ is reached. This can also be determined by the scratch test, a gentle form of percussion. It is performed by placing the stethoscope over the liver, gently scratching the surface of the skin beginning above the upper border of the liver and progressing down below the lower border of the liver. The quality of the sound changes as the examiner’s scratch travels from the lung field to the liver and then to the abdomen. These changes in sound help to identify the borders of the liver.

After the size of organs is determined, the rest of the abdomen can be examined for other abnormalities. Tympany should be present over the stomach bubble because of the air present. Tympany related to the stomach should be found in the area of the left lower border of the rib cage and left epigastrium. However, any increased tympany throughout the rest of the abdomen suggests dilation or perforation of the bowel. Dullness can be stationary, as with solid masses, or shifting as with mobile fluid. Shifting dullness is generally present with significant ascites.

Laboratory Findings

Essentials of Diagnosis

• CBC, electrolytes, BUN, creatinine, glucose for most patients.
  
• All women of childbearing age should have pregnancy test.
  
• Iron studies for adults older than 50 years.

There are many laboratory tests available to clarify diagnosis in patients with abdominal pain. Most patients should have basic testing to include complete blood cell count (CBC), electrolytes, blood urea nitrogen (BUN), creatinine, and glucose. Alkaline phosphatase and liver function tests can be helpful. Other tests should be ordered for specific concerns or locations of pain. The CBC in the acute setting can be misleading. A normal hemoglobin and hematocrit in the setting of acute rapid blood loss can be reassuring, but should be rechecked as patient is fluid-resuscitated. With increased fluid volume, anemia is often apparent. The presence of anemia, especially in those older than 50, should prompt iron studies including ferritin level. Older patients may present with vague abdominal pain in the setting of hypothyroidism, and so a thyroid-stimulating hormone level can be useful.

RUQ pain should be evaluated with bilirubin, liase, amypase, trypsin, and liver function tests. There are settings where hepatitis panels are useful as well. Amylase is elevated in most cases of pancreatitis, but also many other abdominal problems. Therefore, a lipase and trypsin level can help clarify diagnosis, as these tests are more specific for pancreatitis.

Abdominal pain associated with diarrhea may need stool studies depending on the timing and type of diarrhea present. The acute setting rarely needs laboratory testing except in the setting of severe dehydration, blood in stool, or the immunocompromised patient. Stool studies, including white blood cell count (WBC), hemoccult testing, ova and parasite, culture for enteric pathogens, and Clostridium difficile toxin level, can be done for chronic diarrhea or bloody diarrhea. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) should be checked if there is concern for inflammatory bowel disease, especially if WBCs are found in stool. Intermittent symptoms suggestive of celiac disease may warrant laboratory tests for antiendomysial antibody.

Some populations should have other tests done as well. Women of childbearing age should have pregnancy test done regardless of tubal ligation. Lower abdominal pain patients may need a urinalysis (U/A), although many intra-abdominal problems can cause changes in U/A that may appear similar to urinary tract infection. Other lower abdominal pain causes warrant vaginal cultures for gonorrhea and Chlamydia. Cardiac pain can cause abdominal complaints and necessitates its own set of laboratory studies. Generalized complaints may warrant further studies such as magnesium level, calcium level, or vitamin D panel.

Imaging Studies

Essentials of Diagnosis

• CT scan is test of choice for acute abdominal pain.
  
• U/S is test of choice for RUQ pain.
  
• Colonoscopy should be considered in abdominal pain in all patients older than 50.

Plain films of the abdomen can be a fast effective first test in the evaluation of the patient with abdominal pain, both acute and chronic. Upright and lateral decubitus films of the abdomen can show dilated small bowel loops (suggestive of obstruction), free air (perforated organ), mass (tumor or other obstructing cause), or stones (biliary or renal). Small bowel follow-through shows abnormalities of ileum such as ulcer or mass. Barium enema can be useful for evaluation of constipation. The advantages of plain radiographs include the speed of availability, low cost, and low radiation exposure. Despite these advantages, sometimes it is more useful to bypass this first step and start with more specific testing, especially in the setting of an acute abdomen.

Computerized tomography (CT) of the abdomen and pelvis is the test of choice for many acute (and some nonacute) causes of abdominal pain. Protocols for specific problems can limit radiation exposure and time of examinations while providing more accurate information. Spiral CT for either appendicitis or renal calculus has been shown to be fast, safe, effective, and cost efficient. Other problems well visualized by CT scan include diverticulitis, bowel obstruction, pancreatitis, abdominal aortic aneurysm, and pneumoperitoneum. Most soft tissue tumors are well visualized. Renal and biliary stones can be seen on CT scan, although many are not radio opaque and are more easily visualized with ultrasound.

Ultrasonography (US) is the test of choice for most RUQ pain. It is a low-cost, low-risk imaging technique. Ultrasound is the most reliable imaging of the biliary system and pelvic organs. Hernias can sometimes be identified with ultrasound. It is useful for pregnant patients because there is no radiation exposure or contrast material. Children may tolerate US better than CT scan for certain problems like appendicitis due to a shorter time and lesser need to remain completely still for the examination. Obesity limits the usefulness of this testing modality. US is very operator dependent in its accuracy.

In the setting of chronic pain, direct visualization of the internal structures of the GI tract is often needed. Upper endoscopy is used for evaluation of dyspepsia, ulcers, and other upper gastric abnormalities. This imaging modality allows for direct visualization of the mucosal as well as for biopsy of mucosa or lesions and treatment of bleeding sources. Colonoscopy or sigmoidoscopy is indicated for most patients older than 50 years or with other risk factors for cancer. Direct visualization of the mucosa of the colon can help in diagnosis of diverticular disease, cancer, diarrhea, and inflammatory bowel disease.

Other modalities are available for imaging of the abdomen, including magnetic resonance imaging (MRI). MRI is useful for further evaluation of lesions seen on other tests. There are many other imaging modalities for problems related to the urinary system as well. Further discussion of specific imaging is discussed in each section focused on problems.

General Considerations

The word dyspepsia was first used in the early 18th century to describe a person’s ill humor, indigestion, or disgruntlement. The modern family practitioner uses the term to describe a set of symptoms that can encompass several different diseases and the etiology associated with them. Chronic or recurrent discomfort centered in the upper abdomen is the description most commonly used by clinicians for dyspepsia. Dyspepsia can be associated with heartburn, belching, bloating, nausea, or vomiting. Common etiologies include PUD and GERD. Rare causes include gastric and pancreatic cancers.

Although dyspepsia is reported to affect 40% of the world’s adult population and accounts for 2%-3% of all visits to primary care providers, only about 10% of affected adults seek medical advice. Approximately 15%-25% of dyspepsia is caused by PUD and 5%-15% by GERD.

No specific etiology is found for approximately 50%-60% of patients who present with epigastric pain. When a patient has suffered at least 3 months of dyspepsia without a definitive structural or biochemical explanation, the clinical term applied is nonulcer dyspepsia or functional dyspepsia. Other etiologies that occur infrequently include gastric or esophageal cancer, biliary tract disease, gastroparesis, pancreatitis, carbohydrate malabsorption, medication-induced symptoms, non-GI diseases affecting the stomach (sarcoidosis, diabetes, and thyroid and parathyroid diseases), metabolic disturbances (hypercalcemia and hyperkalemia), hepatoma, intestinal parasites, and other cancers, particularly pancreatic cancer.

The history is often similar, whether the symptoms are from PUD, GERD, or nonulcer dyspepsia. Studies have shown that the symptoms and the degree of symptoms do not correlate with the findings on endoscopy.

The physical examination is also similar. There may be tenderness in the midepigastric area. Unless an ulcer has perforated, causing signs of peritonitis, the rest of the abdominal examination is unremarkable.

The treatment for dyspepsia depends on the etiology and will be discussed in the different sections on PUD, GERD, and nonulcer dyspepsia.

Peptic Ulcer Disease

General Considerations

The four major causes of ulcers include Helicobacter pylori–induced ulcers, NSAIDs, acid hypersecretory conditions, and idiopathic ulcers.

There is clear evidence to support the eradication of H pylori in patients who have documented ulcers. Over the past 20 years, the association of H pylori with peptic ulcers has decreased from 90% to as low as 15%-20% in some countries. This decrease is related to increased treatment of H pylori infections. H pylori infections have been commonly associated with low income, low educational levels, and overcrowded living conditions. African Americans and Hispanics have about a one-third higher rate of infection than white Americans. In the United States, 40% of all adults are infected with H pylori by the time they reach 50 years of age, compared with only 5% of all children aged 6-12 years. In developing countries, children are more commonly infected at a younger age and there is a higher incidence of infection throughout the entire population.

Pathogenesis

Infection with H pylori used to be the leading cause of peptic ulcers and use of NSAIDs was the second leading cause. Now NSAID use and idiopathic ulcers are the most common cause. In the United States, one in seven individuals uses NSAIDs. Of long-term NSAID users who undergo an upper endoscopy, 5%-20% are found to have an ulcer. Risk factors for developing an ulcer due to NSAID use are a personal history of ulcer, age older than 65 years, current steroid use, use of anticoagulants or a history of cardiovascular disease, and the impairment of another major organ. NSAIDs are prescribed to nearly 40% of all persons older than 65 years. Elderly patients who commence a course of treatment with NSAIDs have a 1%-8% chance of being hospitalized within the first year of therapy for GI complications caused by NSAIDs. Patients who are H pylori positive and who are taking NSAIDs have a higher risk of complications.

Prevention

Eradication of H pylori infection before starting a course of treatment with NSAIDs reduced the risk of developing an ulcer early in the treatment.

Clinical Findings

As with most cases of abdominal pain, the history obtained provides the majority of information used to focus the differential diagnosis. Factors pointing toward PUD include a gnawing pain with the sensation of hunger, a prior personal or family history of ulcers, tobacco use, and a report of melena.

The most accurate diagnostic test is esophagogastroduodenoscopy (EGD), which allows both visualization and biopsy of the ulcer as well as testing for H pylori. There is good evidence to support the “test and treat” approach to evaluate H pylori. The most cost-effective noninvasive test is the monoclonal stool antigen test. Breath urea testing is also noninvasive but more expensive and, in some studies, not as accurate. Currently, serology testing is used mainly for research or surveillance testing. Serology may also be indicated in an actively bleeding ulcer that complicates the performance of an EGD.

Complications

In the elderly (aged ≥80 years) who have ulcers, the incidence of complications is much higher in patients who are taking aspirin and are H pylori infected. A hypersecretory condition, such as Zollinger-Ellison syndrome, is suspected in patients who have multiple ulcers and is caused by a gastrin-producing tumor. The incidence of GI bleeding from the upper GI tract has decreased (possibly related to the increased treatment of H pylori), so the relative frequency of lower GI bleeding has increased.

Treatment

Treatment of PUD requires the initial eradication of H pylori if present, stopping or reducing the dose of NSAIDs, and treatment with an H2 blocker or a proton pump inhibitor (PPI). Many Food and Drug Administration (FDA)–approved treatment regimens exist to eradicate H pylori. They usually include two or three antibiotics plus a PPI or an H2 blocker for 10-14 days. Because antibiotic resistance changes and subsequently recommended treatment options change, it is necessary to refer to current guidelines either locally or from the Centers for Disease Control and Prevention (CDC). Treatment of the H pylori infection facilitates the healing of the ulcer and decreases the rate of recurrence in the first year from 75% to only 10%. Medical treatment of peptic ulcer has become very effective and surgical intervention needs to occur less frequently. When surgery is performed, it is more commonly done with a laparoscopic repair.

Gastroesophageal Reflux Disease

Clinical Findings

Heartburn is the single most common symptom of GERD. Ten percent of the US population experience heartburn at least once per day and almost 50% experience symptoms at least once per month. Other common symptoms include regurgitation, belching, and dysphagia. GERD can also be associated with multiple extraesophageal symptoms and conditions. Pulmonary conditions that can be caused by GERD include asthma, chronic bronchitis, aspiration pneumonia, sleep apnea, atelectasis, and interstitial pulmonary fibrosis. Ear, nose, and throat manifestations of GERD include chronic cough, sore throat, hoarseness, halitosis, enamel erosion, subglottic stenosis, vocal cord inflammation, granuloma, and, possibly, cancer. Noncardiac chest pain, chronic hiccups, and nausea are also associated with GERD.

Changes in body position tend to exacerbate the symptoms of GERD, particularly lying down or bending forward. Complications include Barrett esophagus, esophageal strictures, ulceration, hemorrhage, and, rarely, perforation. Of all patients who undergo an upper endoscopy for GERD, 8%-20% are found to have Barrett esophagus.

The esophagus has three mechanisms in place to try to prevent mucosal injury. The lower esophageal sphincter (LES) creates a barrier to acid reflux. Peristalsis, gravity, and saliva provide acid clearance mechanisms. The third defense mechanism is epithelial resistance.

Diagnosis is made using the medical history and treatment with H2 receptor antagonists, prokinetic agents, or PPIs. Symptomatic improvement following treatment can be indicative of GERD. Other methods to assist with the diagnosis include symptom questionnaires, catheter and wireless pH-metry, and impedance-pH monitoring. Upper endoscopy fails to reveal 36%-50% of all patients who have been diagnosed via esophageal pH monitoring. Patients who have typical symptoms and respond to PPIs do not need further evaluation. Endoscopy should always be performed if alarming symptoms are present such as bleeding, weight loss, or dysphagia, especially if the alarm symptoms occur in an elderly patient.

Treatment

Treatment of GERD involves lifestyle modification and medication. Lifestyle modifications that have the greatest impact in reducing symptoms of GERD and that also provide positive health benefits include cessation of smoking, moderation in the consumption of alcohol, weight loss in the case of overweight patients, and reduction in dietary fat intake. Certain foods that decrease LES pressure (chocolate), stimulate acid secretion (coffee, tea, and cola beverages), or produce symptoms by their acidity (orange or tomato juice) should be avoided. In addition, elevating the head of the bed by 6 in, avoiding bedtime snacks, and reducing meal size, particularly the evening meal, can all help ameliorate symptoms of GERD.