Review of Clinical Signs

Series Editor: Bernard Karnath, MD

Acute Abdominal Pain

Bernard Karnath, MD
William Mileski, MD

bdominal pain is the most common cause of

A hospital admission in the United States.1 It

accounts for 5% to 10% of all emergency de-
partment visits.2 In 35% to 40% of all hospital
admissions for abdominal pain, the pain is nonspecific.3
In some cases, surgical intervention may be required.
ACUTE ABDOMINAL PAIN

Key Historical Data

Age of patient
Symptoms suggesting the need for surgical correction Time of pain onset
include a pain duration of less than 48 hours and pain Location of pain
followed by vomiting. Similarly suggestive signs include Character of pain
rebound tenderness and involuntary guarding on phys- Radiation of pain
ical examination.3
This article describes the signs and symptoms of
common causes of acute abdominal pain. The epidemi-
ology of acute abdominal pain is discussed, as are neces- ing of nausea and vomiting and of changes in bowel
sary elements of history taking and physical exam- habits should be determined, as should menstrual his-
ination. tory in female patients.

EPIDEMIOLOGY Age
Gastroenteritis is the most common cause of ab- The age of the patient is crucial; the differential diag-
dominal pain not requiring surgery,2 whereas appen- nosis of abdominal pain in a child is quite different
dicitis is the most common cause for which surgery is from that in an elderly patient. There are, of course,
necessary.3 In patients age 60 years or older, biliary dis- common conditions that cause acute abdominal pain
ease and intestinal obstruction are the most common in most age groups (eg, acute appendicitis).3,5 Intestinal
causes of acute abdominal pain that is surgically cor- obstruction and incarcerated hernias can similarly
rectable. In contrast, in patients younger than 60 years, occur in persons of all ages. However, intussusception is
acute appendicitis is the most common surgically cor- the most likely cause of intestinal obstruction in chil-
rectable cause, accounting for approximately 25% of dren,5 whereas adhesions are the more likely cause in
cases.4 In children, acute appendicitis is the leading adults.2 In elderly patients, pain from a myocardial
cause of acute abdominal pain; it accounts for 32% of infarction can be referred to the upper abdomen.2
children with acute abdominal pain admitted to the
hospital.5 Common causes of acute abdominal pain are Time of Onset
listed in Table 1. Pain that is sudden in onset or awakens the patient
from sleep suggests a perforated viscus.6 Knowing the
PATIENT HISTORY timing of associated nausea and vomiting is essential to
The term acute abdomen implies the sudden on- narrowing the diagnostic possibilities.1 Pain usually
set of abdominal pain for which a surgically cor-
rectable cause is likely. Besides the age of the patient,
key elements of patient history include time of pain Dr. Karnath is an Assistant Professor of Internal Medicine and Dr. Mileski
onset, location and character of the pain, and pattern is Chief of Trauma Services and Co-Director of Emergency Medicine,
of pain radiation. Additionally, the presence and tim- University of Texas Medical Branch, Galveston, TX.

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 Karnath & Mileski : Acute Abdominal Pain : pp. 45 50

Table 1. Common Causes of Acute Abdominal Pain

Upper abdominal pain

Acute cholecystitis
Acute pancreatitis
Perforated ulcer
Midabdominal pain Epigastric
RUQ LUQ
Intestinal obstruction
Mesenteric ischemia Umbilical
RLQ LLQ
Lower abdominal pain Hypogastric
or
Acute appendicitis suprapubic

Sigmoid diverticulitis
Gynecologic causes A B
Urologic causes Figure 1. Abdominal sections. (A) The 4 abdominal quadrants.
(B) The epigastric, umbilical, and suprapubic (hypogastric)
regions. LLQ = left lower quadrant; LUQ = left upper quadrant;
RLQ = right lower quadrant; RUQ = right upper quadrant.
precedes vomiting when abdominal pain is from surgi-
cally correctable causes, whereas the reverse is true for
medical conditions such as gastroenteritis. dull pain in the periumbilical region and progresses to a
sharp, severe pain in the right lower quadrant.
Location
The abdomen is divided into 4 quadrants, which are PHYSICAL EXAMINATION
further divided (with some overlap) into the epigastric, Inspection
periumbilical, and suprapubic regions (Figure 1).1 Right The physical examination of patients with acute ab-
upper quadrant pain is often reported by patients with dominal pain should begin with general observation.7 A
duodenal ulcers, acute pancreatitis, acute cholecystitis, patient writhing in agony likely has colicky abdominal
and acute hepatitis. Left upper quadrant pain is report- pain caused by ureteral lithiasis. On the other hand, a
ed frequently by patients with gastritis, gastric ulcer, patient lying very still is more likely to have peritonitis,
acute pancreatitis, and splenic infarct or rupture. Right and a patient who is leaning forward to relieve the pain
lower quadrant pain is typically reported by patients with may have pancreatitis. The examiner should also inspect
acute appendicitis, and left lower quadrant pain by pa- the abdominal wall for surgical scars and evidence of
tients with diverticulitis. Gynecologic and urologic caus- trauma, distention, masses, and hernias. The abdominal
es of acute abdominal pain can also present with lower wall is a commonly overlooked source of abdominal
quadrant abdominal pain. pain. Other parts of the body also should be inspected.
For example, the eyes should be inspected for evidence of
Character scleral icterus, which may indicate hepatobiliary disease.
The term character implies all the features of the
pain and usually can be determined by asking the Auscultation
patient to describe the quality of the pain. The pain is Auscultation of the abdomen is useful in assessing
most often described as being sharp or dull and may peristalsis. Bowel sounds are widely transmitted through-
also be described as being cramping (ie, colicky). Col- out the abdomen. Therefore, it is not necessary to listen
icky pain is defined as a rhythmic pain resulting from in all 4 quadrants. It is recommended, however, that aus-
intermittent spasms.7 Colicky abdominal pain is most cultation should last at least 1 minute. Bowel sounds are
commonly associated with biliary disease, nephrolithia- typically high pitched, so the diaphragm of the stetho-
sis, and intestinal obstruction.1 Pain that begins as a dull, scope should be used.
poorly localized ache and progresses to a constant, well- Bowel sounds are classified as normal, hyperactive, or
localized sharp pain indicates a surgically correctable hypoactive.8 Hypoactive bowel sounds are associated
cause. A classic example is the pain of acute appendici- with ileus, intestinal obstruction, and peritonitis. Intes-
tis, in which the pain initially begins as a poorly defined tinal obstruction can produce hyperactive bowel sounds,

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 Karnath & Mileski : Acute Abdominal Pain : pp. 45 50

which are high-pitched tinkling sounds occurring at

brief intervals; they are very audible. Auscultation should
precede percussion and palpation.

Percussion
The technique of percussion is performed by firmly
pressing the index finger of one hand on the abdominal
wall while striking the abdominal wall with the other
index finger. The percussion note that is heard may be
described as dull, resonant, or hyperresonant. Percussion
over the liver will generate a dull note, whereas percus-
sion over the gastric region will generate a hyperresonant
note because of the usual presence of a gastric air bub-
ble. The technique of percussion also can be used to
determine liver span. Percussion has likewise been advo- Figure 2. Illustration of how Murphys sign is elicited.
cated as a more humane method of eliciting signs of
peritonitis.9
Generalized percussion is a useful method for detect- upper abdomen include acute cholecystitis, acute pan-
ing the presence of ascites or intestinal obstruction in a creatitis, and perforated ulcers. Pain usually overlaps
distended abdomen. In the setting of ascites, a dull per- the left and right upper quadrants.
cussion note would be generated; in the setting of in- Acute cholecystitis. Cholecystitis results from bile stasis
testinal obstruction, a hyperresonant note would be secondary to obstruction of the cystic duct. Cholelithiasis
heard. If ascites is suspected, then a test for shifting dull- and cholecystitis are considered diseases of adulthood.
ness can be performed. Because ascites typically sinks Women are more likely to develop cholelithiasis than are
with gravity, percussion of the flanks generates a dull men.11 Although acute cholecystitis is an acute inflamma-
note and percussion of the periumbilical region gener- tory process, bacterial infection is not a cause in approxi-
ates a resonant note in a supine patient. The test for mately half of cases.11 When bacterial invasion does oc-
shifting dullness involves having the patient shift to a lat- cur, ascending cholangitis can result. Charcots triad of
eral decubitus position and then performing percussion right upper quadrant abdominal pain, fever, and jaun-
again; the area of resonance should shift upward. dice is common in patients with ascending cholangitis.11
In patients with cholecystitis, Murphys sign can be elicit-
Palpation ed by having the patient take a deep breath while the
Before palpating the abdomen, the examiner should right subcostal area is palpated (Figure 2).11 Abrupt cessa-
ask the patient to point directly to the area that hurts tion of inspiration secondary to pain is considered a posi-
most and then avoid palpating that area until absolutely tive Murphys sign.
necessary. Palpation may be difficult in a patient who has Acute pancreatitis. Pancreatitis results from autodiges-
guarding, defined by spasms of the abdominal muscles.1 tion of pancreatic tissue by proteolytic enzymes released
Guarding can be voluntary or involuntary. Voluntary into the pancreatic parenchyma. Initially, the pancreas
guarding occurs when there is conscious elimination of becomes edematous. In more severe cases of hemorrhag-
muscle spasms, and involuntary guarding is reported ic pancreatitis, there is parenchymal necrosis and hemor-
when the spasm response cannot be eliminated, which rhage. Retroperitoneal dissection of blood can result in
usually indicates diffuse peritonitis. Rebound tenderness bluish discoloration of the flanks (ie, Turners sign) or of
is elicited by pressing the abdominal wall deeply with the the periumbilical region (ie, Cullens sign).11
fingers and then suddenly releasing the pressure.1 Pain Biliary pancreatitis secondary to cholelithiasis is most
on this abrupt release of steady pressure is known as commonly encountered in women age 50 years and
Blumbergs sign and indicates the presence of peritoni- older in a community hospital setting, whereas alco-
tis. Asking the patient to cough is another method of holic pancreatitis is most commonly seen in men age
eliciting signs of peritonitis.10 30 to 45 years in an urban hospital setting.11 Patients
most commonly report epigastric pain, nausea, and
SPECIFIC DISORDERS vomiting; the pain is constant and boring in nature.
Upper Abdominal Pain Bowel sounds are decreased, and there is lack of rigidity
Common causes of acute abdominal pain in the or rebound tenderness.

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 Karnath & Mileski : Acute Abdominal Pain : pp. 45 50

Figure 3. Radiograph of a patient with a perforated peptic

ulcer showing free air under both diaphragms.
Figure 4. Abdominal radiograph showing dilated loops of
small intestine indicative of an obstruction.
Perforated peptic ulcer. Patients with perforated
peptic ulcers commonly experience sudden onset of
severe epigastric pain, which becomes generalized after less severe abdominal pain. Vomiting is a late feature
a few hours to involve the entire abdomen.6,7 Perforated and may be feculent. The differential diagnosis of ob-
peptic ulcers have a perioperative mortality rate of struction of the small intestine includes strangulated
23%.4 Observation typically reveals a patient lying quiet- hernia, volvulus, mesenteric thrombus, and gallstone
ly and breathing shallowly. The abdomen is rigid and ileus. An abdominal radiograph of a distal obstruction
board-like. Guarding is maximal at the site of perfora- of the small intestine will show a dilated loop (Figure 4).
tion. Upright chest radiography is the most appropriate Obstruction of the large intestine often has an insidi-
study for the detection of free intraperitoneal air, an ous onset. Pain is less severe than in the small intestine,
indication of a perforated viscus (Figure 3).6,7 and vomiting is infrequent. Distention of the abdomen
is common. The main causes of obstruction of the large
Midabdominal Pain intestine leading to midabdominal pain are cancer of
Common causes of midabdominal pain include in- the colon, diverticulitis, and volvulus. Change in bowel
testinal obstruction, mesenteric ischemia, and early habits, weight loss, abdominal pain, and rectal bleeding
appendicitis. The pain of early appendicitis eventually are highly suggestive of colon cancer. Diverticulitis,
migrates to the right lower quadrant and so will not be which will be discussed more fully as a cause of lower
discussed here. abdominal pain, presents as a fixed and tender left
Intestinal obstruction. Intestinal obstruction can be lower quadrant mass. Sigmoid volvulus is the most com-
either mechanical or nonmechanical.12 Mechanical mon type of colonic volvulus; symptoms begin gradually
obstruction results from gallstones, adhesions, hernias, and include cramping abdominal pain, followed by
volvulus, intussusception, or tumors, whereas nonme- obstipation.
chanical obstruction results from intestinal infarction or Mesenteric ischemia. Mesenteric ischemia presents
occurs after surgery as a paralytic ileus. Obstruction high with acute diffuse midabdominal pain, vomiting, de-
in the small intestine results in severe abdominal pain in creased bowel sounds, and distention resulting from
the epigastric or umbilical region with bilious vomiting. intestinal obstruction. The abdominal pain of acute
Distention of the abdomen is not an early feature. Ob- mesenteric ischemia is out of proportion to physical
struction located lower in the small intestine results in examination findings.2 Abdominal distention is a late

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 Karnath & Mileski : Acute Abdominal Pain : pp. 45 50

Figure 6. Illustration of how the obturator sign is typically

elicited.

region to the right lower quadrant in a region known

as McBurneys point, which is located two thirds of the
distance along a line drawn from the umbilicus to the
right anterior superior iliac spine.14 The pain is re-
lieved somewhat when patients assume a right lateral
decubitus position with slight hip flexion.
Abdominal tenderness is the most likely physical find-
ing. Voluntary guarding in the right lower quadrant is
common. Rovsings sign can be elicited by palpating
B deeply in the left iliac area and observing for referred
Figure 5. Illustration of how the psoas sign is typically elicit- pain in the right iliac fossa. When present, the psoas and
ed. (A) Standard method. (B) Alternate method. obturator signs also are helpful in establishing a diagno-
sis of appendicitis.13 The psoas sign is pain elicited by
extending the right hip while the patient is in the left lat-
sign indicative of gangrene. Signs of peritoneal irrita- eral decubitus position (Figure 5A).13 Alternatively, while
tion also indicate gangrene. in the supine position, the patient can lift the right thigh
against the examiners hand, which is placed above the
Lower Abdominal Pain knee (Figure 5B).13 The obturator sign is pain elicited by
Common causes of lower abdominal pain include flexing the patients right thigh at the hip with the knee
sigmoid diverticulitis, acute appendicitis, and gyneco- flexed and then internally rotating the hip (Figure 6).13
logic and urologic causes. Diverticulitis typically pre- Right-sided rectal tenderness may also be elicited on
sents as left lower quadrant pain, and appendicitis typi- rectal examination of patients with acute appendicitis.
cally presents as right lower quadrant pain.
Diverticulitis. Diverticulitis is an acute inflammation Other Causes of Abdominal Pain
of a colonic diverticulum, which is a small saclike out- Abdominal aortic aneurysm. Rupture of an abdomi-
pouching of the mucosa through the colonic muscle. nal aortic aneurysm most commonly produces symp-
Diverticulitis typically presents as left lower quadrant toms of abdominal pain and backache; hypotension is
pain. The pain is usually described as a cramping sen- also typically present. There is a 71% perioperative
sation. There may be associated fever. mortality rate associated with rupture of these aneur-
Appendicitis. The peak incidence of appendicitis ysms.4 Physical examination of the abdomen must be
occurs in the second decade of life.13 The differential performed to detect a pulsatile mass.
diagnosis is broad, and errors in diagnosis are com- Nephrolithiasis. Ureteral colic accounts for approxi-
mon. The diagnostic error rate can reach 23% in men mately 4% of patients who develop acute abdominal
and 42% in women.13 Patients who are seen within the pain.3,4 Colicky pain begins in the upper lumbar region
first few hours of pain onset report poorly defined con- and radiates laterally around the abdomen to the
stant pain in the periumbilical region. As the disease inguinal region. The patient is often writhing in pain.
progresses, the pain shifts from the periumbilical Findings of a normal appetite, short duration of pain,

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 Karnath & Mileski : Acute Abdominal Pain : pp. 45 50

Table 2. Signs in Patients with Acute Abdominal Pain

Sign Description Clinical Correlation

Guarding Spasms of the abdominal muscle Peritonitis (ruptured viscus)
Voluntary Conscious elimination of spasms possible
Involuntary Conscious elimination of spasms not possible
Blumbergs sign Elicited by pressing the abdominal wall deeply and then Peritonitis (ruptured viscus)
(rebound tenderness) suddenly releasing and observing for pain
Murphys sign Elicited by having the patient take a deep breath while Cholecystitis
the right subcostal area is palpated and observing for
abrupt cessation of inspiration because of pain
Turners sign Retroperitoneal dissection of blood resulting in bluish Pancreatitis
discoloration of the flanks
Cullens sign Retroperitoneal dissection of blood resulting in bluish Pancreatitis
discoloration of the periumbilical region
Psoas sign Elicited by extending the right hip while the patient is in Appendicitis
the left lateral decubitus position and observing for pain
Obturator sign Elicited by flexing the patients right thigh at the hip with Appendicitis
the knee flexed and then internally rotating the hip and
observing for pain
Rovsings sign Elicited by palpating deeply in the left iliac area and Appendicitis
observing for referred pain in the right iliac fossa

lumbar tenderness, and hematuria are highly sugges- 4. Irvin TT. Abdominal pain: a surgical audit of 1190 emer-
tive of acute ureteral colic.15 gency admissions. Br J Surg 1989;76:11215.
5. Bell R. Diagnosing the causes of abdominal pain in chil-
SUMMARY dren. Practitioner 1996;240:598601, 602.
6. al-Musawi D, Thompson J. The important signs in acute
In most cases, taking a careful history and perform-
abdominal pain. Practitioner 2000:244:3124, 3168, 320.
ing a thorough physical examination can elicit the exact
7. Murtagh J. Acute abdominal pain: a diagnostic approach.
cause of acute abdominal pain. For abdominal pain cor- Aust Fam Physician 1994;23:35861, 36474.
rectable by surgery, symptoms generally include a pain 8. Interpreting abnormal abdominal sounds. Nursing 2000;
duration of less than 48 hours and pain followed by 30:28.
vomiting. Pertinent signs include involuntary guarding 9. Silen W. Copes early diagnosis of the acute abdomen.
and rebound tenderness on physical examination. Cer- 20th ed. New York: Oxford University Press; 2000.
tain specific clinical signs (Table 2) detected on physical 10. Bennett DH, Tambeur LJ, Campbell WB. Use of cough-
examination can aid in narrowing the differential possi- ing test to diagnose peritonitis. BMJ 1994;308:1336.
bilities. HP 11. Moscati RM. Cholelithiasis, cholecystitis, and pancreati-
tis. Emerg Med Clin North Am 1996;14:71937.
12. Sheridan JL. Obstructions of the intestinal tract. Nurs
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