Acute abdominal pain — the emergency department approach

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Target exams

Red flags

• The woman of the reproductive age with the abdominal pain has an ectopic pregnancy until the beta-hCG excludes it — the test is non-negotiable before any imaging with the radiation
• The elderly patient with the abdominal pain and the haemodynamic instability has a ruptured abdominal aortic aneurysm until proven otherwise — the bedside ultrasound and the surgical call precede the CT
• The pain out of all proportion to the examination, with the minimal tenderness but the severe distress, is the mesenteric ischaemia — the lactate is raised and the CT angiography is time-critical
• The colicky pain with the patient writhing around the bed is the obstructed hollow viscus (the ureter, the gallbladder, the bowel); the constant pain with the patient lying still is the peritonitis or the ischaemia — the bedside behaviour is the discriminator
• The burning epigastric pain relieved by food or antacid is the peptic ulcer disease; the burning pain radiating to the back with the hypotension is the perforation or the pancreatitis
• The immunocompromised or the neutropenic patient with the right-lower-quadrant pain has the neutropenic enterocolitis (the typhlitis) until proven otherwise — the CT is the test, the broad-spectrum antibiotics are the treatment
• The rigid, board-like abdomen with the guarding and the rebound is the peritonitis from a perforation — the erect CXR for the free air, the fluid resuscitation and the urgent surgery
• The sudden-onset severe epigastric or tearing pain may be the myocardial infarction, the aortic dissection or the ruptured AAA — the ECG and the bedside ultrasound are part of every abdominal pain workup