Unexplained abdominal pain is one of the most common complaints presenting to every emergency, urgent care, or primary care setting. Often, the work up does not reveal a particular source for one’s abdominal pain. Consequently, this triggers further testing and/or consultation. This subsequently requires the patient to monitor their symptoms with close provider follow up. This can be with either their primary care provider or a specialist, such as a gastroenterologist or surgeon. Unexplained abdominal pain can be a frustrating issue for patients, so careful education must occur during each visit. A team approach allows for a better understanding of your patient’s condition and gives appropriate resources to manage their condition.
Take a good history
One of my former colleagues would always stress that a clinician needs to first, take a good history and physical to better understand their patient’s concerns. A good history gives the provider an idea of whether the patient’s pain is Acute or Chronic. Acute pain is something that happens within a few days. Chronic pain may be felt for weeks to months. Don’t be fooled because some patients with chronic abdominal pain may come into your facility with an acute exacerbation of their chronic problem. In fact, the patient’s chronic pain can make identifying an acute problem very difficult.
A good history should provide the information needed to hone in on your diagnosis. Important questions to ask your patient include the location, radiation, and severity of their pain. These three questions can narrow down your differential diagnosis. Likewise, other points such as chronology, associated symptoms, pattern, and aggravating and alleviating factors are helpful. Combined, these points will expand or limit your diagnosis. The more you ask, the more you will understand!
After good active listening, a thorough physical exam should be performed. Stay tuned for another blog related to a focused abdominal physical exam. A good exam will formulate an initial work-up and determine the next steps. Creating a differential diagnosis can be challenging. The list of conditions that cause abdominal or pelvic pain is long and arduous, and complicated by age, sex, and other risk factors. Patients who have emergent signs and symptoms should be evaluated in the appropriate setting. The capacity of your facility to performs tests should also be considered. Basic labs such as CBC, electrolytes, ridney and liver function, and Urinalysis may help make a prompt diagnosis. Don’t forget pregnancy testing in women of childbearing age. The exam is the most important part of the patient encounter after the history!
Choose the Correct Test
Imaging may be needed if lab work doesn’t point you in the right direction. Choosing an imaging study should be fine-tuned to the differential diagnosis. Ultrasound and CT imaging are common tests with specific uses. Ultrasound is ideal for any biliary or female pelvic symptoms. Bowel or solid organ pathology should be evaluated by a CT scan with oral and IV contrast. Non-contrast CT studies should be limited to diagnosis suspected kidney stones. Recent data from the American College of Radiology suggests that the renal impact of contrast media is not as great as it once was thought to be. Imaging is a great initial step in diagnosing unexplained abdominal pain, but may not yield a diagnosis. There are many benign diagnoses that can cause abdominal pain with normal initial lab work and imaging.
Referrals can cause confusion
The patient should be given clear guidance when the workup does not reveal an acute process or immediate need for surgical intervention. This discussion should address other possible causes of their pain. Often times, abdominal pain can result from emotional or psychiatric conditions. Unexplained abdominal pain remains one of the most common discharge diagnoses in emergency medicine. It is certainly a challenge for outpatient practices. Subsequent referral to specialists and/or further testing is likely needed. These referrals can be exhaustive and may not present clear findings. Too many referrals can cloud the picture and add confusion. Gastroenterologists can perform a range of procedures including endoscopic gastroduodenoscopy (EGD) and colonoscopy. Unfortunately, these can also result in nonspecific findings. Surgical consultation can also yield mixed results, and often lead to a referral back to gastroenterology.
Your patient should be counseled to seek further medical attention if their abdominal pain worsens. This can create a vicious cycle, but is a necessary discussion to have. Reassurance goes a long way! A good provider should remain unbiased and be open to the needs of their patients. Classic warning signs for patients to look out for include fever, anorexia, or gastrointestinal bleeding. Therefore, a good discussion and team approach with your patient can help you identify when chronic pain is presenting with an acute component.
Have you experienced difficulty managing abdominal pain in the acute or outpatient setting? If so, we can help. Check out the Provider Practice Essentials Clinical Toolkit!