What are some common types of abdominal pain that send patients to the ED?
A lot of people come in with diarrhea, abdominal cramping, and vomiting. These diffuse, non-specific symptoms are more likely due to an infectious cause such as a bacteria or a virus – and often the treatment is supportive, to help you with your symptoms. You contrast that with someone who comes in with localized abdominal pain – “I have pain in my right lower quadrant.” That makes me think of a serious intra-abdominal process going on, like appendicitis.
However, diffuse abdominal pain can still definitely be something serious. In an overall well-appearing patient, it can come down to their age and risk factors. If I have a 20-year-old with nausea, vomiting, or diffuse abdominal pain, and if their vital signs are normal and their abdominal exam is reassuring, I am less likely to get a CT scan on them. But if a 90-year-old comes in with abdominal pain – the same symptoms as the 20-year-old – they are much more likely to get imaging. We know from the literature that abdominal pain in elderly patients carries higher risks than it does in younger patients. Due to this, most elderly patients who present to the ED are going to receive imaging.
Now, if that younger person with those symptoms has a history of something significant like a bowel resection or colon cancer, they’ll also likely get a scan.
What are some questions you would ask a patient with abdominal pain?
There’s a mnemonic you’re taught in the first year of med school for developing a patient history, called OLD CARTS. Essentially, it’s “When did your pain start? What’s the location of your pain? What's the duration? What's the character of your pain? Is it stabbing, aching, or burning? What makes it worse? What makes it better? Does it go anywhere else? What’s your pain level, zero to 10?”
For example, if someone says, “The pain started by my belly button, then migrated to my right lower quadrant, and it gets worse when I move,” that tells me to suspect appendicitis potentially.
In cases of non-specific abdominal pain, I take it that part of the ED’s job is to rule out bad things that could be causing the problem.
In emergency medicine, the goal is to determine that you don't have emergent conditions that require immediate intervention or hospital admission. I need to make sure your abdominal pain isn't appendicitis, a localized intra-abdominal infection, a bowel obstruction, or ischemia caused by you not getting enough blood supply. People want to know what’s causing their symptoms, but the tests we have allow us to rule out serious causes. In the ED, we can’t miss the big stuff, and that's how I think of every single patient that walks in the door.
Once you’ve ruled out more serious problems, do you sometimes advise patients to get further testing?
Yes. A lot of times, we see patients come in with epigastric pain – pain in the upper-middle part of the abdomen, underneath the breastbone. That can be from an ulcer or inflammation in the stomach. To diagnose those, they may have further testing by their primary care physician or even need to get an endoscopy, where a thin tube with a camera is used to visualize the ulcer or stomach inflammation, and sometimes they’ll need a biopsy. All of these are done in the outpatient setting.
What do you say to a patient when you’re about to discharge them?
We spend a lot of time on what we call return precautions – counseling patients on things to look for and when to come back to us. I might say, “I haven't found anything today, but that doesn't always mean that nothing's going on. That means it could be too early to see something. So if you start having fever, or if this pain gets worse or moves and your pain reliever isn’t cutting it, I need you to come back.”
The vast majority of patients who come to an ED with abdominal pain are treated and discharged. What are some common reasons that some of these patients might be admitted to the hospital for further treatment?
Typically it's appendicitis. Also, it’s patients with a bowel blockage, often caused by adhesions if you’ve had surgery in the past. They can compress the intestines and cause a blockage. Sometimes it’s inflammation of the gallbladder.
What would your advice be to someone who isn’t sure their abdominal pain is worth a visit to the ED?
This is always a challenging question. There isn’t an all-encompassing list of “come in for this but not this,” which makes this difficult. When in doubt always get evaluated by a clinical professional. When you come to the ED I have the chance to get your history and perform a physical exam. Based off this we can determine if labs and imaging are indicated, but this is challenging to do without an evaluation.
