Assessing Acute Abdominal Pain: A Team Physician's Challenge

Roy T. Bergman, MD

Emergencies Series
Editor: Warren B. Howe, MD

In Brief: The etiology of abdominal pain is diverse, but, for immediate purposes, the team physician must simply focus on whether the process requires surgical intervention. An effective history includes a detailed description of the pain and its onset, and an accounting of associated symptoms and events. Pain from a serious condition typically arises suddenly and is continuous, progressively worse, and long lasting; begins during inactivity; and is not near the umbilicus. Portions of the physical exam that require physical contact should begin farthest away from the site of maximal pain. Auscultation should precede palpation to avoid alteration of peristalsis.

The definitive diagnosis of abdominal pain presents a formidable challenge even in the best of circumstances. It is especially challenging, though, for team physicians, who often have limited access to ancillary tests and specialists.

Actually, a dual challenge faces the treating physician when an athlete reports abdominal pain. First, the complaint must be evaluated and a working diagnosis established. Second, a decision must be made about returning the patient to training and competition (figure 1: not shown).

This article is offered to help the team physician in this decision-making process. It is not intended to be a primer on the ideal way to evaluate and manage patients who have abdominal pain in the traditional medical setting.

Valuable Historical Information

Keep in mind that abdominal pain can be the major complaint of patients with serious surgical disease but is also a symptom in conditions as minor as precompetition anxiety (table 1). The critical distinction, then, is not between acute and nonacute pain, but between surgical and nonsurgical conditions. Also remember that athletes often tolerate pain better and seek medical attention later than nonathletes. Consequently, every complaint of abdominal pain must be taken seriously.

Table 1. Common Causes of Acute Abdominal Pain

Gastrointestinal Tract Appendicitis, acute* Meckel's diverticulitis* Perforated bowel* Perforated peptic ulcer* Small and large bowel obstruction* Strangulated hernia* Diverticulitis Gastritis Gastroenteritis Inflammatory bowel disease Mesenteric lymphadenitis Liver, Spleen, and Biliary Tract Cholangitis, acute* Cholecystitis, acute* Hepatic abscess* Ruptured hepatic tumor* Ruptured spleen* Biliary colic Hepatitis, acute Splenic infarct Peritoneum Intra-abdominal abscess* Primary peritonitis Tuberculous peritonitis Pancreas Pancreatitis, acute Urinary Tract Cystitis, acute Pyelonephritis, acute Renal infarct Ureteral or renal colic Female Reproductive System Ruptured ectopic pregnancy* Ruptured ovarian follicular cyst* Twisted ovarian tumor* Dysmenorrhea Endometriosis Salpingitis, acute Vascular System Ischemic colitis, acute* Mesenteric thrombosis* Ruptured arterial aneurysm* Retroperitoneum Retroperitoneal hemorrhage Miscellaneous Precompetition anxiety Trauma

*Condition often requires urgent surgery.

The history and physical will provide the needed diagnostic clues. To maximize the value of the exam, personally interview the patient and perform the physical examination.

A great deal of valuable information can be obtained by observing the patient during all phases of the encounter. Note especially the patient's general appearance, the capacity to answer questions, any obvious pain or discomfort, and the ability to change positions (table 2). Based on personal experience, the athlete who doesn't look or act ill probably isn't.

Table 2. Differentiating Common Nonmusculoskeletal Sources of Abdominal Pain
Condition	Typical Signs and Symptoms
Appendicitis, acute	Constant pain, progressively more severe; begins in periumbilical region, moves to right lower quadrant; nausea, vomiting, and anorexia follow pain; low-grade fever; patient appears ill
Cholecystitis, acute	Constant pain in right upper quadrant, onset often postprandial; nausea and vomiting; tenderness in right upper quadrant and right shoulder; splinting on right side
Perforated peptic ulcer	Sudden onset of pain in midepigastrium that spreads and is aggravated by movement; patient appears acutely ill and is reluctant to move; rigid abdomen; grunting respiration; bowel sounds absent
Ectopic pregnancy	Pain sudden, severe, and persistent, generally following a missed or abnormal period, typically epigastric; often associated with hypotension and tachycardia
Ovarian cyst	Pain constant with sharp, sudden onset; usually in ipsilateral hypogastrium; may have nausea and vomiting following the pain
Pelvic inflammatory disease	Pain at end of or shortly after normal menstrual period; bilateral lower quadrant pain aggravated by cervical manipulation; anorexia, nausea, and vomiting rare; possible cervical discharge; fever
Urinary calculus	Pain location changes with movement of stone, may radiate to testicle, groin of involved side; pain very severe; patient cannot get comfortable

The history of abdominal pain is a critical element in the evaluation. Note the following:

Mode of onset, progression, character, and severity of pain. Pain that is sudden in onset, severe or explosive, progressive, continuous, and lasts more than 6 hours generally indicates surgical etiology. Pain that is gradual in onset, mild to moderate in intensity, intermittent, recurrent, or resolves partially or completely in less than 6 hours favors a nonsurgical diagnosis.

Pain arising in a hollow, tubular structure, such as the ureter, intestine, biliary radicles, or fallopian tubes, may be continuous or intermittent. The severity of such pain is inversely proportional to the diameter of the tubular structure involved.

Activity during which pain was first noted. Persistent pain that awakens the patient or begins during relative inactivity suggests a surgical resolution. Pain that occurs during or closely following strenuous activity—or after eating—favors a nonsurgical diagnosis.

Initial location of pain and any shift. In general, the farther from the umbilicus the pain localizes, the greater the chance that a surgical condition exists. Pain arising from foregut derivatives (stomach, duodenum, biliary tract, and pancreas) or the spleen presents in the epigastrium. Pain arising from midgut derivatives (jejunum, ileum, proximal third of the colon, and appendix) presents in the periumbilical area. Pain arising from the embryonic hindgut (distal two-thirds of the colon), internal reproductive organs (ovaries, fallopian tubes, uterus, seminal vesicles, and prostate), and the urinary bladder presents in the hypogastrium.

A shift in pain occurs when the original inflammation extends to the parietal peritoneum. For example, appendicitis initially causes pain in the periumbilical area. Then, after 4 to 6 hours, the inflammation extends to the regional peritoneal surface and is perceived in the right lower quadrant.

Associated symptoms and their temporal relationship to the pain. Many abdominal conditions that cause pain also give rise to vomiting, nausea, anorexia, fever, chills, constipation, and diarrhea. In surgical conditions, pain may be followed by nausea, vomiting, and anorexia. In nonsurgical conditions nausea, vomiting, and anorexia typically precede pain. Additionally, clinical experience has shown that vomiting in the obese patient is an ominous symptom and virtually always suggests serious abnormalities.

Anorexia is uncommon in athletes, especially in obese individuals, and is therefore always a significant symptom in such patients. Fever is a common finding in patients who have abdominal pain; however, fever and chills is rarely seen in surgical processes. This combination suggests infection in the urinary tract, respiratory system, etc.

Constipation may accompany any abdominal condition that causes an illness. Obstipation—nonpassage of both stool and gas—however, always suggests a surgical problem. Diarrhea, especially with cramps, indicates gastroenteritis and other nonsurgical conditions like inflammatory bowel disease.

What aggravates the pain. Always ask first about which activities aggravate the pain. (One can generally assume that the opposite will ease the pain.) If the patient hears questions about what eases the pain, he or she may perceive it as minimizing the problem and become defensive.

Coughing, sneezing, rapid movements, and walking, especially down stairs, can cause peritoneal irritation. Musculoskeletal pain is often relieved by changing position. A bowel movement often eases the pain of gastroenteritis, but the pain may promptly recur.

Menstrual history and reproductive status. Many athletes are sexually active, and among sexually active people, women experience abdominal pain twice as often as men of the same age. Men who do experience abdominal pain, however, have a higher incidence of surgical disease. This disparity is generally because of the painful conditions affecting the female genitourinary tracts—nonsurgical (pelvic inflammatory disease, endometriosis, dysmenorrhea, and urinary tract infection) and surgical (torsion of ovary and ectopic pregnancy). In men, seminal vesiculitis, prostatitis, and urethritis can cause lower abdominal pain.

Pain that is severe, sudden in onset, and follows an abnormal menstrual period might stem from an ectopic pregnancy. Pain that is noted shortly after a normal menstrual period, is bilateral, and is accompanied by a fever and abdominal pain—but not nausea and vomiting—favors pelvic inflammatory disease.

Medications and supplements. Aspirin and other nonsteroidal anti-inflammatory drugs, erythromycin, potassium, and salt tablets commonly cause gastric irritation and abdominal pain.

Previous episodes, family history of similar problems, peers with the same symptoms, food intolerance, allergies, sudden changes in training or diet, and travel to regions with endemic disease. These all favor a nonsurgical diagnosis.

Physical Exam Pointers

The physical examination consists of vital signs, inspection, auscultation, light touch, palpation, percussion, and rectovaginal exam. Some keys to the physical exam are:

• Before beginning, tell the patient what will transpire—and why. Assure the patient that any test that causes pain or discomfort will be discontinued.
• Auscultation should precede other modalities that involve physical contact. This will prevent alteration of peristalsis by physical stimulation.
• All portions of the exam that involve contact with the abdomen (auscultation, light touch, palpation, and percussion) should begin in the area farthest from the site of maximal pain.
• Steps that involve physical contact should be done with the patient relaxing the muscles as much as possible. Then repeat with the patient tensing the abdominal muscles (voluntary guarding). If the pain from a given maneuver increases with guarding, the source of the pain is in the abdominal wall. If pain is lessened by guarding, the source is visceral.
• If the patient seems to be overreacting to palpation, or if guarding does not seem genuine, ask the patient questions and have him or her answer during palpation. It's difficult to talk and voluntarily guard at the same time. If the pain is real, the patient will stop talking during guarding.
• Avoid gross tests for rebound tenderness, which require pressure and quick release. They are not precise and are very uncomfortable. Light percussion is just as informative.
• Any pain elicited in the obese patient is significant. The panniculus acts as a damper to pressure.

Vital signs. Note pulse rate and rhythm, blood pressure, temperature, respiratory rate, and the characteristics of the respiratory cycle. Painful abdominal conditions frequently are reflected in the vital signs as tachycardia, tachypnea, elevated temperature, and, in conditions that involve the upper abdomen (inflammatory diseases) or the lower lobes of the lung, respiration that is rapid, shallow, painful (grunting), or splinted. Hypotension can result from gastrointestinal bleeding, dehydration, vagal stimulation, etc.

Inspection. Note any abdominal asymmetry, distension, bulges, scars, or splinting of the chest or abdomen during respiration. Short, grunting respirations can indicate basilar pneumonias or upper-abdominal inflammatory conditions.

Auscultation. Use either the bell or diaphragm and minimal pressure. Auscultate in all four quadrants, and be patient—it may take 2 to 3 minutes in each area to adequately evaluate the nature and character of peristalsis. Hyperperistalsis with rushes, cramps, and diarrhea suggests gastroenteritis. Hypoperistalsis or a silent abdomen favors serious surgical conditions.

Light touch. Gently stroke the abdomen. Underlying peritoneal irritation causes light touch to be perceived as dysesthesia, or a disagreeable sensation, and suggests a surgical process.

Palpation. This procedure should be gentle; applying slow pressure is essential. Palpate for hernias (epigastric, umbilical, incisional, inguinal, femoral, and spigelian) and areas of maximal tenderness. A rigid abdomen indicates a surgical condition.

If the response to palpation seems exaggerated, repeat auscultation using the diaphragm and more pressure. If the responses have been exaggerated, this maneuver can distract the patient and allow deeper palpation than when done with the hand alone.

Percussion. Gentle percussion can detect tympany dullness (ascites) and can isolate the area of maximal discomfort as accurately as the more gross tests of rebound tenderness do.

Rectal exam. Once privacy is ensured, examining the rectum is especially important if the patient has hypogastric pain. The rectal exam can reveal diffuse tenderness or localized bulges or tenderness associated with abscesses, appendicitis, seminal vesiculitis, or prostatitis. Note the character of the stool; mucoid or jellylike stool often indicates inflammatory bowel disease.

Pelvic exam. Parametrial bulges, masses, and induration favor surgical diagnoses. Exquisite pain with cervical manipulation, with fever, and without lateralizing signs suggests pelvic inflammatory disease, especially if the patient also has a cervical discharge.

How Serious?

When the history and physical are completed, one of three determinations is possible:

(1) The patient probably requires surgery, competition is precluded, and the patient is referred for tests, consultation, and definitive treatment.

(2) The patient probably has a nonsurgical condition that may allow competition if the condition is not too severe and if he or she responds to any required symptomatic or specific treatment.

(3) The results are equivocal. If so, reevaluate the patient in 2 to 3 hours. If the patient is better, he or she can continue training or competing. If the patient is unchanged or worse, competition is precluded and the patient is referred as necessary for tests and possible treatment.

Dr Bergman is a general surgeon in private practice in Lansing, Michigan, a fellow of the American College of Surgeons, and an editorial board member of The Physician and Sportsmedicine. Dr Howe is a team physician at Western Washington University in Bellingham, Washington, and an editorial board member of The Physician and Sportsmedicine. Address correspondence to Roy T. Bergman, MD, 405 W Greenlawn, Suite 235, Lansing, MI 48910.

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