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Vanderbilt Core Clinical Curriculum

Abdominal Pain

A variety of important acute and chronic diseases cause abdominal pain. Many of these diseases pose serious threats to patients. Patients with the chief complaint of abdominal pain represent one of the 25 required clinical experiences.

Required Skills/Procedures:

1. Perform situation-appropriate (problem-focused or complete) history and physical examinations
2. Interpret clinical information to formulate a prioritized differential diagnosis
3. Guide the creation of a patient-specific management plan

Appropriate Setting: Inpatient and Outpatient

Expected level of Responsibility: Direct supervision with real patients

Learning Topics during encounters with a patient with ABDOMINAL PAIN can include:

Medical Knowledge Learning Topics related to ABDOMINAL PAIN

1. Principal types of pathophysiologic mechanisms of abdominal pain (i.e., obstruction, peritoneal irritation, vascular insufficiency, abnormal motility, mucosal irritation, metabolic aberrations, nerve injury, referred pain, psychopathology)
2. Relative likelihood of common causes of abdominal pain according to the quadrant in which the pain is located and the elements of the history important in distinguishing among etiologies
3. Symptoms and signs indicative of an acute abdomen
4. Indications and limitations of principal diagnostic studies necessary to differentiate among common causes of abdominal pain

Diagnostic Evaluation Learning Topics related to ABDOMINAL PAIN

1. Age-appropriate medical history that differentiates among etiologies of disease, including:

  • characterization of a patient’s abdominal pain: location, severity, character, pattern, radiation
  • temporal sequence: onset, frequency, duration, progression
  • associated symptoms: nausea, vomiting, fever, chills, anorexia, weight change, cough, dysphagia, dysuria, altered bowel function (diarrhea, constipation, obstipation, hematochezia, melena)
  • exacerbating and remitting factors: position, food, activity, medications
  • pertinent medical history: prior surgery, other illness (attn. to diabetes, cardiovascular disease, immunosuppression), menstrual cycle
  • medications: prescription and supplements (attn. to anticoagulation, steroids)
  • family history

2. Physical examination that establishes the diagnosis and severity of disease including:

  • correct order and technique for examining the abdomen
  • adequate rectal and pelvic exam (under supervision)
  • identification of relevant scars, abnormal bowel sounds, and signs of peritoneal inflammation

3. Maneuvers utilized in evaluating acute abdominal pain (Examples include: iliopsoas sign, Rovsing’s sign, obturator sign, Murphy’s sign, cough tenderness, heel tap, cervical motion tenderness)

4. Successful examination of special populations, including infants and children, pregnant women, patients with altered neurologic status, and post-operative patients.

5. Differential Diagnosis of the most important and likely causes of a patient’s abdominal pain, recognizing specific history and physical exam findings that distinguish between potential causes

6. Diagnostic and laboratory tests necessary to determine the cause of a patient’s abdominal pain, including consideration of costs and test performance characteristics as well as patient preferences. (Examples include: CBC, BMP, liver enzymes, amylase and lipase, lactate, hepatitis serology, fecal leukocytes, stool culture, stool guaiac, stool fat, CT scan, abdominal/pelvic ultrasound, FAST u/s, radionuclide scan of hepatobiliary system, MRCP,ERCP, upper endoscopy, sigmoidoscopy, colonoscopy, barium studies, angiography, paracentesis)

7. Indications for the use of certain procedures in the evaluation and management of a patient with abdominal pain, including:

  • nasogastric tube
  • peripheral intravenous catheter
  • venipuncture
  • insertion of Foley catheter

8. Appropriate composition of admission orders as part of the initial assessment and care of patients with acute abdominal pain.

9. Explanation of the results of the evaluation to the patient, taking into consideration the patient’s knowledge about his/her condition.

Management Plan Learning Topics related to ABDOMINAL PAIN

1. Relative urgency of treating various causes of abdominal pain

2. Surgical management of abdominal pain including:

  • the indications for operative intervention
  • the key elements of informed consent
  • the maintenance of other organ systems during the physiologic stress of the peri-operative period, including measures for prophylaxis against complications
  • the resuscitation of patients with acute abdominal process

3. Medical management of various diagnosis presenting with abdominal pain, including the indications and side effects of various treatment modalities (including antibiotic therapy)

4. Communication of the diagnosis, treatment plan, and prognosis of the disease to patients and their families in a caring and compassionate manner, reflecting an understanding of the emotional impact of disease and its potential effect on lifestyle (work performance, sexual functioning, etc.)

5. Patient education about their treatment plan, including counseling related to preventive measures

6. Referral for psychological support if indicated, including the management of chronic abdominal pain

7. Follow-up planning

Potential Differential Diagnosis Topics Include:

Gastroduodenal

  • GERD
  • Gastritis
  • Peptic ulcer disease
  • Gastroparesis
  • Pyloric stenosis (pediatrics)

Biliary

  • Gallstone disease
    • biliary colic
    • cholecystitis
    • cholangitis
  • Acalculous cholecystitis
  • Hepatitis
  • Hepatic abscess
  • Pancreatitis

Small Bowel

  • Small bowel obstruction
    • complete vs partial
    • adhesions
    • hernia
    • tumor
    • malrotation (pediatrics)
  • Irritable bowel syndrome
  • Gastroenteritis
  • Enterocolitis
    • opportunistic infections
  • Ileus
  • Inflammatory bowel disease
  • Meckel’s diverticulitis
  • Intussusception
  • Necrotizing enterocolitis (pediatrics)

Large Bowel

  • Appendicitis
  • Constipation
  • Hirschsprung’s (pediatrics)
  • Diverticulitis
  • Pseudomembranous colitis
  • Typhlitis
  • Large bowel obstruction
    • adhesions
    • hernia
    • tumor
    • volvulus

Spleen

  • Rupture
  • Infarct

Vascular

  • AAA rupture
  • Other aneurysmal diseases (splenic artery)
  • Mesenteric ischemia
    • acute vs chronic

Urinary Tract

  • Urolithiasis
  • Pyelonephritis

Pelvic

  • PID
  • Tubo-ovarian abscess
  • Ovarian cyst
  • Ovarian torsion
  • Endometriosis
  • Ectopic pregnancy
  • Intrauterine pregnancy

Genital

  • Testicular torsion
  • Epididymitis

Abdominal wall

  • Hernia

Extra-Abdominal

  • MI
  • Pneumonia
  • DKA
  • Sickle cell crisis
  • Herpes Zoster

Trauma
(see Trauma VC3 page for additional topics)