Character of pain
Colicky pain waxes and wanes. It usually occurs secondary to hyperperistalsis of smooth muscle against a mechanical site of obstruction (e.g., small-bowel obstruction, renal stone).
An important exception is biliary colic, in which pain tends to be constant.
Pain that is sharp, severe, persistent, and steadily increases in intensity over time suggests an infectious or inflammatory process (e.g., appendicitis).
Location of pain
Pain caused by inflammation of specific organs may be localized [e.g., right-upper-quadrant (RUQ) pain caused by acute cholecystitis].
Careful attention must be given to the radiation of pain. The pain of renal colic, for example, may begin in the patient’s back or flank and radiate to the ipsilateral groin, whereas the pain of a ruptured aortic aneurysm or pancreatitis may radiate to the patient’s back.
Alleviating and aggravating factors
Patients with diffuse peritonitis describe worsening of pain with movement (i.e., parietal pain); the pain is ameliorated by lying still.
Patients with intestinal obstruction have visceral pain and usually experience a transient relief from symptoms after vomiting.
Associated symptoms of Acute Abdominal Pain
Nausea and vomiting frequently accompany abdominal pain and may hint at its etiology. Vomiting that occurs after the onset of pain may suggest appendicitis, whereas vomiting before the onset of pain is more consistent with the diagnosis of gastroenteritis or food poisoning. The sequence as well as the character of the emesis should be documented. Bilious emesis suggests a process distal to the duodenum. Hemetemesis may suggest a peptic ulcer or gastritis.
Fever or chills suggests an inflammatory or an infectious process, or both.
Anorexia is present in the vast majority of patients with acute peritonitis.
B. Past medical history, surgical history, and organ-system review
Pathologic medical conditions may precipitate intra-abdominal pathology.
Patients with peripheral vascular disease or coronary artery disease may have abdominal vascular disease (e.g., AAA or mesenteric ischemia).
Patients with a history of cancer may present with bowel obstruction from recurrence.
Major medical problems are important to recognize early in the patient and may call for urgent surgical exploration.
A thorough medical history and organ-system review must be carried out to exclude various extra-abdominal causes of abdominal pain.
Diabetic patients or patients with known coronary artery disease or peripheral vascular disease who present with vague epigastric symptoms may have myocardial ischemia as the cause of the abdominal symptoms.
Right-lower-lobe pneumonia may present as RUQ pain in association with cough and fever.
A thorough menstrual history must be obtained in women.
Pelvic inflammatory disease (PID) typically occurs early in the cycle and may be associated with a vaginal discharge.
Ectopic pregnancy must be considered in every woman of child-bearing age with lower abdominal pain, especially if accompanied by a history of amenorrhea.
Ovarian cysts can cause sudden pain by enlarging, rupturing, or causing ovarian torsion. The timing in relation to the menstrual cycle is crucial. A ruptured follicular cyst pain occurs at midcycle (i.e., mittelschmerz), whereas the pain of a ruptured corpus luteum cyst develops around the time of menses.
Abdominal pain that occurs monthly suggests endometriosis.
Previous abdominal surgery in a patient with colicky abdominal pain may suggest intestinal obstruction secondary to adhesions, incarceration of an incisional hernia, or recurrence or malignancy. These are generally accompanied by nausea and vomiting.