Abdominal Pain in Primary Care

Question 1

Organs in the right hypochondriac region?

Answer 1

Liver, gallbaldder, right kidney, small intestine

Question 2

Organs in the epigastric region?

Answer 2

Stomach, liver, pancreas, duodenum, spleen, adrenal gland

Question 3

Organs in left hypochondriac region?

Answer 3

Spleen, colon, left kidney, pancreas

Question 4

Organs in right lumbar region?

Answer 4

Gallbladder, liver, right colon

Question 5

Organs in umbilical region?

Answer 5

Umbilicus, parts of the small intestine, duodenum

Question 6

Organs in the left lumbar region?

Answer 6

Descending colon, sigmoid colon

Question 7

Organs in right iliac region?

Answer 7

Appendix, cecum

Question 8

Organs in hypogastric region?

Answer 8

Urinary bladder, sigmoid colon, female repro organs

Question 9

Organs in left iliac region?

Answer 9

Descending colon, sigmoid colon

Question 10

Right hypochondriac region pain differentials?

Answer 10

Lower lobe PNA, cholecystitis, cholangitis, hepatitis, abscess, pyelonephritis, nephrolithiasis, pancreatitis, duodenitis, duodenal ulcer, congestive hepatomegaly, small intestine obstruction

Question 11

Epigastric region pain differentials?

Answer 11

ACS, cholecystitis, cholangitis, pancreatitis, AAA, dissection, gastritis, early appendicitis, hernia

Question 12

Left hypochondriac region pain differentials?

Answer 12

ACS, MI, myocarditis, pericarditis, embolus, lower lobe PNA, pancreatitis, splenic infarction/rupture, gastritis, pyelonephritis, nephrolithiasis

Question 13

Right lumbar region pain differentials?

Answer 13

AAA, dissection, mesenteric ischemia, psoas abscess, colic pyelonephritis

Question 14

Umbilical region pain differentials?

Answer 14

AAA, dissection, early appendicitis, gastroenteritis, large/small intestinal obstruction

Question 15

Left lumbar region pain differentials?

Answer 15

AAA, dissection, mesenteric ischemia, psoas abscess, colic pyelonephritis

Question 16

Right iliac region pain differentials?

Answer 16

Appendicitis, intestinal obstruction, right diverticulitis, constipation, ulcerative colitis, Crohn’s disease, epididymo-orchitis, tessticular torsion, neprolithiasis, UTI, ectopic pregnancy, pelvic inflammatory dosease, endometriosis, hernia, psoas abscess

Question 17

Hypogastric region pain differentials?

Answer 17

Appendicitis, diverticulitis, constipation, ulcerative colitis, Crohn’s disease, UTI, urinary retention, cystitis, ectopic pregnancy, pelvic inflammatory disease, endometriosis, hernia, Mittelschmerz

Question 18

Left iliac region pain differentials?

Answer 18

Large/small intestinal obstruction, diverticulitis, constipation, ulcerative colitis, Crohn’s disease, epididymo-orchitis, tessticular torsion, neprolithiasis, UTI, ectopic pregnancy, pelvic inflammatory dosease, endometriosis, hernia, psoas abscess, perforated colon

Question 19

3 types of abdomina pain?

Answer 19

1. Visceral
2. Parietal
3. Referred

Question 20

What is visceral pain?

Answer 20

When noxious stimuli affect a viscus such as the stomach or intestines

Question 21

Describe visceral pain

Answer 21

Dull, poorly localized and felt in the middle

Pain from foregut: felt in epigastrium
Pain from midgut: felt in periumbilical
Pain from hindgut: felt in lower abdomen

Question 22

What is parietal pain?

Answer 22

Noxious stimuli of the parietal peritoneum

Question 23

Describe parietal pain

Answer 23

Sharp, intense, discrete, localized. Coughing or movement aggravates pain

Question 24

What is referred pain?

Answer 24

Felt in remote areas supplied by the same dermatome as the affected organ

Question 25

Timeframe for acute abdominal pain?

Answer 25

Pain lasting less than 7 days

Question 26

Important history questions to get description of pain?

Answer 26

Location and radiation
Temporal elements
Quality
Severity
Precipitants or palliation
Associated symptoms (other GI symptoms, GU symptoms, constitutional symptoms, cardiopulmonary symptoms, other)

Question 27

T/F: in the acute surgical abdomen, vomiting precedes pain

Answer 27

FALSE

In the acute surgical abdomen pain precedes voming, the reverse is typically true in medical conditions

Question 28

Common, less common, and rare possible diagnoses for any location in abdomen?

Answer 28

Question 29

Common, less common, and rare possible diagnoses in epigastric region?

Answer 29

Question 30

Common, less common, and rare possible diagnoses in LUQ region?

Answer 30

Question 31

Common, less common, and rare possible diagnoses in LLQ region?

Answer 31

Question 32

Common, less common, and rare possible diagnoses in periumbilical region?

Answer 32

Question 33

Common, less common, and rare possible diagnoses in RUQ region?

Answer 33

Question 34

Common, less common, and rare possible diagnoses in RLQ region?

Answer 34

Question 35

Common, less common, and rare possible diagnoses in suprapubic region?

Answer 35

Question 36

What are some possible causes of sudden onset abdominal pain?

Answer 36

Question 37

What type of abdominal pain warrants urgent evaluation?

Answer 37

Unstable vital signs

Signs of peritonitis on abdominal exam (eg, abdominal rigidity, rebound tenderness, and/or pain that worsens when the examiner lightly bumps the stretcher)

Concern that the abdominal pain is from a life-threatening condition (eg, acute bowel obstruction, acute mesenteric ischemia, perforation, acute myocardial infarction, ectopic pregnancy)

Question 38

Evaluation components for RUQ pain?

Answer 38

• Complete blood count with differential
• Electrolytes, blood urea nitrogen (BUN), creatinine, and glucose
• Aminotransferases, alkaline phosphatase, and bilirubin
• Lipase and/or amylase

Patients should also have an abdominal ultrasound to evaluate for hepatobiliary etiologies

Question 39

Evaluation components for epigastric pain?

Answer 39

• Complete blood count with differential
• Electrolytes, BUN, creatinine, and glucose
• Aminotransferases, alkaline phosphatase, and bilirubin
• Lipase and/or amylase

If there is concern for hepatobiliary pain, patients should have an abdominal ultrasound for evaluation

Question 40

Evaluation components for LUQ pain?

Answer 40

Left upper quadrant pain can be caused by splenic etiologies imaging with either ultrasound or computed tomography (CT) scan is recommended

Question 41

Evaluation components for lower abdominal pain?

Answer 41

• Pregnancy test
• CBC
• UA
• STI screening
• CMP
• CRP/ESR

Subacute right lower quadrant pain with diarrhea is the most characteristic presentation of ileal Crohn disease, although the presentation of inflammatory bowel disease (IBD) can be highly variable

Acute left lower quadrant pain with fever and elevated white blood cell count is suggestive of diverticulitis

Question 42

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Components of chronic abdominal pain evaluation?

Answer 42

• Complete blood count with differential
• Electrolytes, blood urea nitrogen (BUN), creatinine, and glucose
• Calcium
• Aminotransferases, alkaline phosphatase, and bilirubin
• Lipase and/or amylase
• Serum iron, total iron binding capacity, and ferritin
• Anti-tissue transglutaminase

Question 43

Answer 43

b. Correct

Systemic illnesses such as diverticulitis, mesenteric ischemia, and urinary retention are more common in older patients, whereas nonspecific abdominal pain is less common. Physical examination findings of guarding and rebound tenderness are less likely to be present in an older person with peritonitis. For these reasons, imaging has more utility in older patients and changes management in approximately two-thirds of cases. Because mesenteric ischemia is common and often presents with minimal examination findings, CT angiography should be considered in an older patient with a benign abdominal examination.

Question 44

Answer 44

c. Correct

Clinical diagnosis of diverticulitis is reasonable if risk factors for complicated diverticulitis are not present. These risk factors include more than five days of symptoms, signs of peritonitis or obstruction, rectal bleeding, multiple occurrences of diverticulitis, and immunocompromise. Rebound tenderness suggests peritonitis, which is a risk factor for complicated diverticulitis and warrants imaging with CT with intravenous contrast media.

Question 45

Differential diagnoses table for acute abdominal pain in all ages (flip to see)

Answer 45