Key Feature 7c: In a patient with chronic or recurrent abdominal pain: Always consider cancer in a patient at risk. 
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

In a previous post I wrote something that I thing is important to elaborate on with regards to chronic or recurrent abdominal pain: "Sometimes serious diseases first present in a benign way, and only the passage of time and development of more serious symptoms or signs will provide information that declares them." In particular this is as true for the presentation of cancer as any other etiology. Cancer can be a master of presenting subacutely, often only causing problems because it's grown large enough to have consequences due to the space or the energy it consumes (ex: constipation from a bowel obstruction caused by a growth or weight loss secondary to increased energy needs of a growing mass). In the 13 year old female who I wrote the source post about, cancer would be utterly unlikely, but in those patients who are older or who have a family history that increases their risk, this would be something to always keep in the back of your mind. 

My general approach to avoid missing a cancer when patients present with symptoms that could be caused by a cancer (but for which my pretest probability is still fairly low):

1. Inquire about constitutional symptoms (unintentional weight loss, fevers/chills/night sweats, fatigue/general malaise [though the latter can also simply point to severity of any disease process and not just malignancy]) 
2. Ensure they are up to date with any screening per local guidelines

The Canadian Task Force on Preventative Health Care provides a multitude of guidelines to support screening efforts. Here are their recommendations for colorectal cancer screening:

1. We recommend screening adults aged 50 to 74 for CRC with FOBT (either gFOBT or FIT) every two years OR flexible sigmoidoscopy every 10 years.
2. Adults are at high risk and may need to be screened earlier of more frequently if they have at least one of the following:
   1. Previous CRC or adenomatous polyps (ex: tubular or villous)
   2. Inflammatory bowel disease (ex: ulcerative colitis or Crohn’s disease)
   3. Signs or symptoms of CRC (ex: blood in the stool)
   4. History of CRC in one or more first-degree relatives
   5. Adults with hereditary syndromes predisposing to CRC (ex: familial adenomatous polyposis or Lynch syndrome)

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Assess and manage surgical disease including referral to surgical specialties as needed

Key Feature 6a: Given a patient with a life-threatening cause of acute abdominal pain (ex: a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy): Recognize the life-threatening situation. 
Skill: Selectivity
Phase: Diagnosis

Key Feature 6b: Given a patient with a life-threatening cause of acute abdominal pain (ex: a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy): Make the diagnosis
Skill: Clinical Reasoning
Phase: Diagnosis

Key Feature 6c: Given a patient with a life-threatening cause of acute abdominal pain (ex: a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy): Stabilize the patient
Skill: Selectivity, Clinical Reasoning
Phase: Treatment

Key Feature 6d: Given a patient with a life-threatening cause of acute abdominal pain (ex: a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy): Promptly refer the patient for definitive treatment. 
Skill: Selectivity
Phase: Diagnosis, Referral

I have not had the unfortunate experience of ever encountering a patient with an acutely life-threatening cause of abdominal pain. In fact, over the duration of my residency and my only occasional training in critical care/emergency, I may never encounter this. So I don't want to cop out on this, but I also don't want to delve into detail that will probably never be too clinically relevant for me. What I do want to know is what I would need to do to help try to save a patient's life if I am the physician who encounters a patient with an acutely life-threatening cause of abdominal pain. Here is what I feel I need to know to manage such a situation:

1. Recognize the life-threatening situation: With an acutely life-threatening cause of abdominal pain, the patient will likely either present with a complaint of acute abdominal pain, or else they may present in a decompensated state as a consequence of the underlying etiology (ex: the patient may be unconscious secondary to hypotension resulting from a massive bleed into the abdomen from a ruptured AAA or ectopic pregnancy). For patients who may be less able to localise or communicate their symptoms, the physical examination would be expected to reveal a peritonitic abdomen.
2. Make the diagnosis: In a patient with a life-threatening cause of abdominal pain, I need to make the call. Now I think it is certainly important to have an understanding of the different signs and symptoms associated with different etiologies for what could be going on, but rather than focus on this, I think it is more important to recognise that in this situation, a working DDx is more important than an accurate Dx. If a patient develops peritonitis from a perforated organ, of course knowing which organ was perforated, say, will only improve successful resuscitation. But regardless, in order to react urgently, we need to move on to stabilising the patient and saving their life, which is not amenable to a detailed workup if the etiology for the life-threatening abdominal pain is not overtly clear. So to me, this key feature is really about having a working DDx that takes into account patient risk factors (ex: in the elderly man with cardiac risk factors this must include the possibility of a ruptured AAA, and in the female of reproductive age this must include the possibility of a ruptured ectopic pregnancy). 
3. Stabilize the patient: ABCs. Although I won't outline the steps of the ABC emergency response algorithm here, this is the time to call them into action. In the setting of life-threatening causes of abdominal pain, there may very well be a bleed in the abdomen, and so circulation may be compromised and resuscitation efforts may centre around this. In the setting of acute abdominal pain and signs of hypovolemia (see two posts back for signs to look for), the patient should be suspected of having a bleed in their abdomen. As resuscitation efforts are underway, as part of this process, ordering investigations to determine the cause, severity, and consequences of the presentation should help refine the working DDx.
4. Promptly refer the patient for definitive treatment: In the setting of an acutely life-threatening cause of abdominal pain, making an urgent referral to the most appropriate surgeon is critical. The working DDx comes into play here. If suspicion of a ruptured AAA is at the top of the differential, an urgent consult to vascular surgery would be in order. If one is most suspicious of a ruptured ectopic pregnancy or another urgent gynecological cause, an urgent consult to an obstetrician-gynaecologist would be indicated. And if the cause of the life-threatening abdominal insult is undifferentiated, or if there aren't any more specialised surgeons available at the centre you are working, then an urgent consult to general surgery would be warranted.

Key Feature 7a: In a patient with chronic or recurrent abdominal pain: Ensure adequate follow-up to monitor new or changing symptoms or signs.
Skill: Clinical reasoning
Phase: Follow-up

Key Feature 7b: In a patient with chronic or recurrent abdominal pain: Manage symptomatically with medication and lifestyle modification (ex: for irritable bowel syndrome). 
Skill: Clinical reasoning, Communication
Phase: Treatment

Let's return one more time to the case of the 13 year old female who presented to the office with abdominal pain. In my assessment of her pain I applied a broad differential diagnosis to thinking about what could be going on: She described a recurrent pattern of this pain over the past month or so, maybe once a week, but this new episode started this same morning, so I had to keep both chronic and acute causes on my differential. I also needed to keep the differential for pediatric abdominal pain at the forefront, given differences in incidence and prevalence of diseases in pediatric compared to adult populations. This patient was otherwise well, but if she had been previously diagnosed with a chronic disease that can manifest with abdominal pain, I would've needed to consider an exacerbation of that disease as a possible contributor to the pain as well. As a female who was now postmenarchal, I needed to consider the possibility of gynecological causes of pain, including the possibility of pregnancy. Given the details of the account her pain story, and her localisation of pain in her abdomen as generalised rather than localised to the lower abdominal area, my suspicion for gynecological etiologies, and pregnancy in particular, was low. Given this diminutive pretest probability, and the fact that she appeared well on general physical examination, I deferred performing a pelvic exam. As I clinically worked through my differential, finding facts on history and exam to make my suspicion of different etiologies more or less pronounced, I arrived at my working diagnosis, which was constipation.*

Now constipation in and of itself is not a diagnosis, but rather a symptom, and it is important to address the underlying reason(s) for this. Given this patient's history and physical exam, my working diagnosis was functional constipation rather than constipation secondary to an organic etiology. The management for this centres on patient education and recommendations for behavioural and specific dietary interventions, and so we chatted and came to a shared understanding of lifestyle modifications that could be realistically adopted by this patient. No investigations needed to be ordered, at least not yet. In the setting of constipation that is seemingly functional and without alarm features, lifestyle changes are the first-line intervention. But this also means that as a clinician I must arrange followup to assess whether or not the intervention was successful, and to further intervene and possibly investigate if indicated. According to the UpToDate article ​Constipation in infants and children: Evaluation (2017), "Organic causes are responsible for fewer than 5 percent of children with constipation." Given her clinical assessment, this patient was unlikely to be in that 5%, but not definitively so. With any disease presentation, it is important to keep the possible worrisome diagnoses it could represent in your mind, to be able to counsel patient on associated symptoms to watch for. Sometimes serious diseases first present in a benign way, and only the passage of time and development of more serious symptoms or signs will provide information that declares them.

My general approach to the closing any patient encounter, including followup recommendations, is as follows: 

1. Impression: I explain my impression to the patient, aka what I think is going on to account for their concern(s). If I have enough information to reach a diagnostic conclusion then I explain what the diagnosis is by first soliciting what they know about the diagnosis and providing a tailored explanation to fill gaps (hopefully avoiding or at least explaining medical jargon along the way). I find asking if patients have any questions about the diagnosis is a great way to get a sense of how much or little they want to know about it etc.
2. Investigations: If I think more investigations are warranted in order to make a diagnosis or look for more information regarding severity or consequences, I explain what I think would be helpful and obtain consent if they are on board.
3. Management: After discussing what the situation at hand is, and perhaps what other information we may need to make conclusions, I work with patients to come up with a plan to address concerns. I present therapeutic options (including the possibility for behavioural/psychological, medical, and surgical intervention depending on the problem at hand), and I discuss the option to not do anything, or at least do anything yet, and what the natural history of the disease is so that patients may be fully informed should they opt not to take up any interventions. (Usually they do, as they usually come to the doctor to "fix" a problem, but other times, patients may learn that their concern does not have significant ramifications, and this by itself may provide reassurance that resolves the "problem" in and of itself.) After an informed discussion regarding benefits, risks and how to mitigate them if possible, and logistics of treatment options, we formulate a plan of action in moving forward. 
4. Follow-up: With an agreed upon plan, I suggest when I think the next follow-up appointment ought to be, depending on a multitude of factors (ex: time that it would take to see a benefit from an intervention or the risk of complications and the need to reassess). I also advise patients for what reasons they should call or return to clinic sooner (or go to an Emergency Department if urgent), typically for worsening or new concerning symptoms that would warrant intervention.
5. Resources: Before sending patients out the door I like to ensure I have a plan written down for patients, and possibly accompanied by resources such as a pamphlet to understand their disease or a crisis helpline to call if in distress, etc. 

For the patient with constipation, I explained that her presentation was in keeping with a diagnosis of functional constipation. I asked what she knew about this and explained what it means (not a default diagnosis, but actually having criteria that she met). I explained that it was a clinical diagnosis, which was great because it meant we wouldn't have to wait for the results of any investigations before starting treatment. I presented that the most evidence-based treatment for this diagnosis is lifestyle modifications, specifically by increasing physical activity and consumption of dietary fibre and water. We discussed what she thought she could do to get more physical activity and what sorts of foods she could see herself eating to increase the fibre intake. I gave her a number for how many grams of fibre in a day to shoot for, to help her get a sense of just how much fibre is recommended**, and explained what the expected benefits (decreased constipation), risks and how to mitigate them  (increasing fibre quickly can cause bloating, so I recommended she go up gradually in her daily consumption of fibre), and logistics (taking time to think about packing her lunch differently for school, for example) of these lifestyle interventions would be. If these changes were to be effective, we would likely see a benefit in 2 weeks or so, so we planned for follow up then. I also warned her that if she develops worsening or new symptoms not to hesitate to make an appointment sooner. (There was nothing I was seriously worried about in her case to provide more specific anticipatory advice.) I then provided a handout on Constipation in Children as published by UpToDate and said that I looked forward to seeing how she would be doing at the follow-up appointment :)

*You may be thinking, but what about irritable bowel syndrome?? Let's explore that a little bit. Like functional constipation, irritable bowel syndrome is also a functional disease in that there is no organic findings of disease on physical exam or investigations. (The best way I've heard someone explain functional disease is to use a headache for analogy. We can see evidence of a headache on physical exam, nor are there any tests we can use to prove that it is there, but we certainly experience the pain as real regardless. It is not just "in one's head.") Sometimes patient's may seem to  have what could be considered functional constipation and irritable bowel syndrome, at least if they have the IBC-C (for constipation) subtype. But the diagnostic criteria are different, and patients will fall into one or the other. This is has important ramifications, as labelling a patient with a particular diagnosis sticks to their medical chart like superglue, and more importantly it affects their understanding of their body and what they need to do to keep it functioning. So what are the diagnostic criteria for functional constipation and irritable bowel syndrome?

Rome IV criteria for functional constipation

1. Two or more of:
   1. Straining during more than 25% of defecations
   2. Lumpy or hard stools (Bristol Stool Scale Form 1-2, see the graphic picture below) in more than 25% of defecations
   3. Sensation of incomplete evacuation for more than 25% of defecations
   4. Sensation of anorectal obstruction/blockage for more than 25% of defecations
   5. Manual maneuvers to facilitate more than 25% of defecations (ex: digital evacuations, support of the pelvic floor)
   6. Fewer than 3 spontaneous bowel mvmts per week
2. Loose stools are rarely present without the use of laxatives
3. There are insufficient criteria for IBS

Rome IV criteria for irritable bowel syndrome

1. Recurrent abdominal pain, on average, at least one day per week in the last three months, associated with two or more of the following criteria:
   1. Related to defecation
   2. Associated with a change in stool frequency
   3. Associated with a change in stool form (appearance)

This is already quite a long post, but as a functional disorder the first-line treatment for IBS, like functional constipation, also includes dietary changes, but first-line for IBS is specifically adopting a  low FODMAPs diet. The Canadian Digestive Health Foundation has this resource you patients can use to understand what this entails.

**A general rule of thumb: For children 2 years and older, take the age and add 5-10 for the number of grams of daily fibre to incorporate in the diet. For example, a 13 year old patient would be advised to consume between 18-23 g of fibre daily. Once people reach adulthood, the rule of thumb is to aim for 20-35 g per day. 

Key Feature 3c: In a woman with abdominal pain: Do a pelvic examination, if appropriate.
Skill: Clinical Reasoning
Phase: Physical, Diagnosis

​In my last blog post I described my encounter with a 27 year old female patient presenting with abdominal pain. The cause of her pain was ultimately felt to be a combination of a flare-up of ulcerative colitis along with secondary acute opioid withdrawal. But during my first assessment of her, and with pain that she localised to her right lower quadrant, I had to consider that there was a gynecological etiology contributing to her pain. (As a female of childbearing age, this would be indicated regardless, but on top of that, she had significant risk factors including past history of a ruptured ovarian cyst and pelvic inflammatory disease.) A pelvic examination was warranted as part of this patient's workup, and my findings were reassuring in that there were no specific signs of gynecological pathology on exam. 

My approach to a general pelvic examination is as follows: 

1. Explain: Explain what the exam entails and ask if they have any questions. Obtain consent. Document this.
2. Chaperone: Ask the patient if they would like to have a chaperone present and document if this was declined.
3. Gather supplies: If a am doing a speculum exam +/- a Pap smear, this means having all of those supplies ready. 
4. Personal protection: Put on a pair of gloves.
5. Position and drape the patient: For this exam I position the patient in dorsal lithotomy position with a drape overlying the unclothed pelvis.
6. Inspection: Inspect the external pelvic area for any abnormalities (ex: rash or ulceration)
7. Palpation: Bimanual examination
   1. Vagina: Separating the labia with the thumb and index finger of my left hand, I insert the index and middle finger of my right hand facing laterally, and rotate 90º upwards. I feel for any masses or irregularities of the vaginal walls, I feel the cervix and take note of its position, consistency, and whether the cervical os is open or closed, and gently clasping it between my two fingers I palpate for cervical motion tenderness, a sign that would raise the suspicion for pelvic inflammatory disease. I then palpate for tenderness or abnormalities of the fornices.
   2. Uterus: I then move on to assess the uterus. To do this, I place my left hand approximately 4cm above the pubic symphysis, I place the index and middle fingers of my right hand in the posterior fornix, and then I push up on the cervix with my right hand while simultaneously pushing down on the abdomen with my left hand in the direction of my right hand. Now with the uterus between my two hands I can assess by palpation:
      1. Position (anteverted or retroverted)
      2. Size (a normal nonpregnant uterus is about the size of an orange)
      3. Shape (feeling for any irregularities, which could suggest the presence of fibroids)
      4. Surface (smooth vs nodular)
      5. Tenderness (this assessment is not comfortable  per se, but it should not otherwise cause pain)
   3. Adnexa: I then move on to the last component of the bimanual exam, which is to assess the adnexa on each side of the uterus. On each side, I place the fingers of my right hand into that lateral fornix, with the fingers of my left hand pushing into the iliac fossa on the same side, and I direct the force of my fingers toward one another, noting for any masses or tenderness. After finishing this last part of the bimanual exam, as I remove my right fingers from the vagina, I take a look to see if there is any blood or discharge on my glove.
8. +/- Speculum exam: *​In the setting of right lower quadrant pain without any focal genitourinary symptoms, performing a speculum exam is not indicated. This is my approach to performing a speculum exam when indicated.* Separate the labia and gently insert the lubricated speculum sideways (with blades closed and angled down and back), then rotate the speculum 90 degrees once fully inserted, open the blades to find an optimal view of the view of the cervix, and fix the blades there. Inspect the cervical os and note any discharge or cervical masses or lesions. At this point is when swabs and a Pap smear would be obtained. Now I inspect the vaginal mucosa as I remove the speculum, reversing the steps of insertion.

The end!

Abdominal Pain

Key Feature 2: In a patient with diagnosed abdominal pain (ex: gastroesophageal reflux disease, peptic ulcer disease, ulcerative colitis, Crohn’s disease), manage specific pathology appropriately (ex: with. medication, lifestyle modifications). 
Skill: Clinical Reasoning
Phase: Treatment

Key Feature 8: Given a patient with a diagnosis of inflammatory bowel disease (IBD) recognize an extra intestinal manifestation. 
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

Chronic Disease

Key Feature 1: In a patient with a diagnosed chronic disease who presents with acute symptoms, diagnose:

1. Acute complications of the chronic disease (ex: diabetic ketoacidosis).
   
2. Acute exacerbations of the disease (ex: asthma exacerbation, acute arthritis).
   
3. A new, unrelated condition.

Skill: Clinical Reasoning
Phase: Diagnosis

​When I was on rotation on the Family Practice Teaching Service at St Paul's Hospital I was managing a 27 year old female inpatient admitted with abdominal pain NYD (not yet diagnosed). Her past medical history was significant for ulcerative colitis, intravenous drug use now on opioid agonist therapy, pelvic inflammatory disease, and a ruptured ovarian cyst. Prior to the onset of the pain that brought her into the emergency department, she had not been taking any medications for the ulcerative colitis (the disease had been in remission) and she was on opioid agonist therapy to help manage her opioid use disorder. When she presented to the ED with acute abdominal pain she did not have a clear etiology to blame, and she was certainly unwell, so she was admitted to our service so we could manage her pain and figure out what was going on to resolve the underlying issue. After a couple of days into her admission and many investigations later, the team surmised that her pain was likely secondary to a flare up of the ulcerative colitis compounded with the pain of acute opioid withdrawal - the opioid agonist therapy she was taking was in the form of ingested slow-release oral morphine, which was likely not getting absorbed in her gut given its disposition. She was started back up on her antiinflammatory medication, her pain was temporarily managed with hydromorphone, and soon she was feeling back to her baseline. 

The list of possible aetiologies for abdominal pain is - as I've highlighted in previous blog posts - extensive. I will outline here the general management of selected aetiologies of abdominal pain that I must be  familiar with as a family doctor.

My information was gathered from Bugs & Drugs and the following UpToDate articles:

• Medical management of gastroesophageal reflux disease in adults
• Antiulcer medications: Mechanism of action, pharmacology, and side effects
• Peptic ulcer disease: Management
• Treatment regimens for Helicobacter pylori
• Management of mild to moderate ulcerative colitis in adults
• Management of severe ulcerative colitis in adults
• Overview of the medical management of mild (low risk) Crohn disease in adults 
• Overview of the medical management of severe or refractory Crohn disease in adults

Overview of the management of gastroesophageal reflux disease (GERD)
For uncomplicated GERD without alarm features*

1. Lifestyle/dietary modifications
   1. Weight loss: if overweight or recent weight gain
   2. Positional interventions: Elevation of the head of the bed if symptoms occur at night or if there are laryngeal symptoms (ex: cough, hoarseness, throat clearing). In the same vein, not eating 2-3 hours before bedtime or laying down after eating would be advisable.
   3. Dietary modifications: To selectively eliminate individualised triggers. Common triggers include fatty foods, caffeine, chocolate, spicy food, carbonated beverages, and peppermint. Alcohol can also be a trigger. Patients need not eliminate anything that is not a trigger for them, but these are common culprits to counsel about that may be worth a trial of elimination. 
2. Acid-suppressing medication
   1. Antacid therapy: With only intermittent episodes of bothersome heartburn occurring less than once weekly, starting with an over-the-counter antacid medication is a good first-line strategy
   2. H2RA therapy: If there are recurrent episodes happening no more than about once weekly, then a low-dose histamine 2 receptor antagonist (H2RA), taken only as needed, would suffice. My go to H2RA is ranitidine, which can be prescribed or purchased over-the-counter. And if there is an extra occasional episode of heartburn, perhaps because of a dietary indiscretion, then supplementing with an additional dose of over-the-counter antacid therapy would be totally appropriate. If the pain is not alleviated with a low-dose of H2RA used as needed, then stepping up to taking it regularly two times daily for a minimum of 2 weeks is warranted.
   3. PPI therapy: If the symptoms of heartburn continue to occur despite this continuous treatment, then it is time to discontinue the H2RA and initiate a once-daily proton pump inhibitor (PPI), starting at a low dose, and increasing this if the pain is still not controlled. Alternatively, if the patient first presented complaining of heartburning happening at least twice weekly from the get-go, starting a once-daily PPI at a low-dose without first trying antacids or an H2RA is warranted. My go-to PPI for GERD is omeprazole. The increase in the dose of the PPI, if needed, should be gradual, occurring after a 2 to 4 week interval at the trialed dose. Then, once the discomfort is controlled, the treatment (be it the H2RA or the PPI) should be continued at the first effective dose for at least 8 weeks. 
   4. Gastroenterology referral: Patients who fail to respond to once-daily PPI therapy are considered to have refractory GERD and should be referred to a gastroenterologist for further evaluation. They should also be referred to a gastroenterologist if they exhibit any alarm features* as part of their presentation. 
   5. Trial of cessation: If symptoms resolve completely with acid-suppressing medication, after a minimum of 8 weeks on this therapy, a trial of cessation is in order (unless there is another complicating factor to their acid reflux such as known esophagitis or Barrett's esophagus). If, after stopping the acid-suppressing therapy, the symptoms of acid reflux recur within three months, then the patient may need to be on the medication indefinitely. If it's been more than 3 months since stopping when the symptoms recur, then simply repeated a course of the above approach would be warranted.

*If any of the following alarm features are present, a referral to a gastroenterologist is indicated:

1. New onset epigastric discomfort in patients ≥60 years
2. Dysphagia or odynophagia
3. Anorexia, persistent vomiting, or unexplained weight loss
4. Evidence of gastrointestinal bleeding (hematemesis, melena, hematochezia, or occult blood in stool) or iron deficiency anaemia
5. Gastrointestinal cancer in a first-degree relative

Overview of the management of peptic ulcer disease (PUD)
The patient will have already been seen by a gastroenterologist, as endoscopy would've been done to detect the presence of ulceration. Although this means the gastroenterologist almost certainly will have developed a treatment plan for the patient to follow, it is important for family doctors to understand what needs to be done so they can ensure patient compliance.

1. Stop NSAID use: The patient should abstain from taking any NSAIDs. Avoiding tobacco is also recommended.
2. H. pylori eradication: If the patient was diagnosed as being infected with H. pylori, current standard of therapy specific to this part of the world, unless there are patient-specific reasons for prescribing an alternative regimen, is concomitant quadruple therapy for 2 weeks. This consists of a PPI twice daily, along with 3 antibiotics once daily: amoxicillin 1 g twice daily, clarithromycin 500 mg twice daily, and metronidazole 500 mg twice daily.
3. PPI therapy: The patient will need to be on daily PPI therapy for a total of 12 weeks, regardless of whether or not it was used as part of an H. pylori eradication regimen 
4. Test for cure: After 12 weeks of treatment and resolution of symptoms, if the patient was treated for H. pylori, a test for cure is warranted. This can be in the form of a urea breath test, fecal antigen test, or upper endoscopy. PPI therapy must be stopped at least 2 weeks before testing as the acid suppression reduces H. pylori bacterial load and so makes the testing for H. pylori less sensitive. If eradication was successful, awesome! No more treatment is indicated. But if eradication was not successful, a second alternative antibiotic regimen should be tried, and patient compliance with the antibiotic regimen should be assessed. If the second eradication regimen fails, gastroenterology followup should definitely be arranged if not already being done so as to get samples of the organism to determine its microbial sensitivity. 
5. Possible indefinite acid suppression: There may be some individuals who will have risk factors that may warrant ongoing acid-suppressing treatment.  These may include having a peptic ulcer that cannot be attributed to H. pylori infection or NSAID use, having a "giant" ulcer (>2 cm), or having comorbidities that warrant continued PPI use, among others. 

Overview of the management of inflammatory bowel disease [IBD] (ulcerative colitis [UC] or Crohn's disease [CD])
As with patients diagnosed with PUD, patients diagnosed with IBD will be seen and likely will continue to be seen by a gastroenterologist. It is important for family doctors to understand the management of IBD because they will be actively involved in helping patients manage the disease as well as their overall health, which can be impacted in numerous ways by IBD.

1. Vaccinations: Patients who have IBD are more immunocompromised, and the antiinflammatory medication needed to treat the disease compounds this. It is important to ensure patients are up to date on their vaccinations, of which more are indicated after being diagnosed with IBD. I list this management item first simply because patients are at increased risk of contracting infection once they start antiinflammatory medications, so this should be one of the first interventions that is addressed.
2. Antiinflammatory therapy: First line medication therapy will depend on severity and location, and patients with inflammatory bowel disease will almost certainly have a gastroenterologist whom they follow up with to manage treatment. The mainstay of therapy will be antiinflammatory medications. Common first-line ones include 5-aminosalicylic acid, budesonide, or sulfasalazine, among others. Corticosteroids and big guns like cyclosporine may be needed for refractory and severe symptoms (these medications being more potent but also with more negative side effects). And there are also newer and often highly effective but expensive monoclonal antibody therapies that may be used.
3. Management of complications: Patients with severe enough disease may need to be referred to the emergency department for more urgent management, hospital admission, and possibly even surgery. They may have a secondary gastrointestinal infection warranting antibiotics, they may be hypovolemic from having significant bloody diarrhea, and they made need intravenous strength medications. 
4. Management of extraintestinal manifestations: UC and CD have extraintestinal manifestations involving a number of other body systems, most commonly affecting the skin*, the eyes, or even the lungs. They will need to have management of all of these comorbidities, along with the underlying disease process (as treated with antiinflammatory medications).
5. Monitoring overall health: Routine monitoring of global health status is indicated in these patients, and there is lots to think of. In children and adolescents who are diagnosed with inflammatory bowel disease in particular, monitoring growth and nutritional status are major priorities, as the bowel disease wrecks havoc in the gut that leads to decreased absorption of nutrients, compounded by bouts of sickness that can lead to inability to ingest as many nutrients, along with increased expenditure of nutrients secondary to the inflammation and greater cell turnover. Because of this excess degree of inflammation, risk of bowel cancer is elevated in patients with IBD, and in particular UC, so it is also important to ensure that patients are being screened for colorectal cancer in keeping with recommendations.
6. Patient-centred care: With my family doctor hat on here specifically, it is important to also monitor how patients are coping with management of their disease. There is such variability in how active or quiescent inflammatory bowel disease may be, and it tends to have a relapsing-remitting course, so it is important to inquire as to how patients are coping. If patients are better able to cope, they will likely also have better health outcomes, promoting a positive feedback loop. The negative corollary is also likely true.

*Interestingly, the patient I was managing who had ulcerative colitis had an outbreak of lesions on her arms and legs, which she said started only a few days before she went in to the ED with abdominal pain. The two common types of extraintestinal  skin manifestations associated with IBD are erythema nodosum and pyoderma gangrenosum. According to the UpToDate article, Dermatologic and ocular manifestations of inflammatory bowel disease, "Erythema nodosum typically appears as raised, tender, red or violet subcutaneous nodules on the extensor surfaces of extremities. As erythema nodosum usually parallels intestinal disease activity, treatment is directed at the underlying IBD. If skin nodules precede any bowel symptoms or occur during quiescent phases of IBD, therapy with other medications, including prednisone, may be required." I looked up pictures of erythema nodosum, and the lesions the patient had certainly fit the look, along with the fact that they were nodular and tender to palpation, and were located on the extensor surfaces of her arms and legs. How interesting that they erupted at the same time or possibly right before the concomitant flare-up in her bowel disease! 

In summary, this has been another long but not even very detailed post that provides an overview of  important elements in the management of common and occasionally serious causes of abdominal pain.

Key Feature 1c: Given a patient with abdominal pain, paying particular attention to its location and chronicity: Investigate in an appropriate and timely fashion. 
Skill: Clinical Reasoning, Selectivity
Phase: Investigation

In a couple of weeks I will be starting my rotation in the pediatric emergency department at the BC Children's Hospital and I am pretty well guaranteed to encounter a pediatric patient presenting with abdominal pain. A few months later, I'll be on my emergency medicine rotation at St Paul's Hospital and I am also certainly going to need to work up a patient presenting with abdominal pain there too. About a year after this, I will be an independent physician practicing in the community, and I will be fully responsible for knowing what to do if a patient walks into my office complaining of abdominal pain, be it acute or chronic, focal or generalised, in a pediatric or elderly patient, who is otherwise healthy or with multiple comorbidities. So no better time than now to have an approach to my workup of abdominal pain.

Per the differential diagnosis to acute, chronic, and pediatric abdominal pain (see previous blog post), here is my (UpToDate) approach to ordering investigations to working up the causes and consequences of abdominal pain. The UpToDate articles that have informed this approach are "Evaluation of the adult with abdominal pain in the emergency department," "Evaluation of the adult with abdominal pain," "Emergent evaluation of the child with acute abdominal pain," and "Chronic abdominal pain in children and adolescents: Approach to the evaluation."

Acute Abdominal Pain

• First-line labs to consider ordering:
  1. Beta-human chorionic gonadotropin (B-hCG)
  2. Capillary blood glucose (CBG) 
  3. Complete blood count, electrolytes, creatinine, urea, glucose +/- arterial blood gas (ABG)
  4. Lipase and liver function tests (ALT +/- AST, ALP +/- GGT, bilirubin)
  5. Urine dipstick

• First-line imaging to consider ordering: 
  1. Abdominal X-ray (AXR) (may be helpful to look for bowel obstruction, bowel perforation, or a radiopaque foreign body) 
  2. Ultrasound of the abdominal +/- pelvis (imaging of choice in pregnancy, or if AAA or gallbladder disease suspected, and can be useful for detecting free fluid/blood, hydronephrosis, pancreatitis, and venous thrombosis)
  3. CT (the study of choice in the evaluation of undifferentiated abdominal pain)

A note on investigations in general in the setting of acute abdominal pain: If a patient is otherwise healthy, investigations should only be ordered to confirm a clinically suspected diagnosis or to investigate for abdominal pain of unclear etiology. The threshold for ordering a broader range of tests should be lower for immunosuppressed patients and those with significant comorbidities (ex: diabetes, cancer, HIV, cirrhosis), as well as elderly patients who are unable to provide a comprehensive history (ex: if they are nonverbal or have an altered mental status).

Chronic Abdominal Pain
The natural history of chronic abdominal pain usually indicates there is less acutely worrisome pathology that in turn can be worked up in less of a shotgun approach

• ​​​Right upper quadrant pain
  1. First-line labs: CBC with differential (CBCd), electrolytes, Cr, urea, glucose, ALT +/- AST, ALP +/- GGT, bilirubin, lipase
  2. First-line imaging: Abdominal ultrasound
• Epigastric pain
  1. Same investigations as for right upper quadrant pain +/- abdominal ultrasound depending on your suspicion of hepatobiliary etiology
• Left upper quadrant pain
  1. Same investigations as for epigastric pain but also include an ultrasound or CT scan of the abdomen to assess for spleen pathology

A note on upper abdominal pain, no matter the region: Also consider the need to obtain an ECG and troponin level if the patient has cardiac risk factors or symptoms concerning for angina (ex: dyspnea, symptoms that occur with physical exertion), or a CXR or CT scan if there are symptoms (ex: dyspnea, cough) or signs on physical examination suggestive of pleural or pulmonary pathology.

• Lower abdominal pain
  1. First-line labs to consider ordering: 
     1. B-hCG
     2. CBCd
     3. Urine dipstick
  2. Imaging: Not necessarily indicated, but consider DDx
• Diffuse abdominal pain
  1. First-line labs: B-hCG (women of childbearing age), electrolytes (calculate anion gap), creatinine, urea, glucose, calcium, CBCd, lipase. Also check ALT, ALP, and bilirubin in older adult or immunosuppressed patients who may present atypically
  2. Imaging: Not necessarily indicated, but consider DDx
• For chronic abdominal pain in which preliminary workup has not yielded any useful findings, consider ordering the following labs: CBCd, electrolytes, Cr, urea, glucose, calcium, ALT, ALP, bilirubin, lipase, fecal calprotectin (sensitive for intestinal inflammation), anti-TTG + IgA

Pediatric Abdominal Pain
A repeated note on investigations in general in the setting of acute abdominal pain: If a patient is otherwise healthy, investigations should only be ordered to confirm a clinically suspected diagnosis or to investigate for abdominal pain of unclear etiology. The threshold for ordering a broader range of tests should be lower for immunosuppressed patients and those with significant comorbidities.

1. First-line labs to consider in acute abdominal pain: 
   1. Beta-human chorionic gonadotropin (B-hCG)
   2. Capillary blood glucose (CBG) 
   3. Complete blood count, electrolytes, creatinine, urea, glucose +/- ABG
   4. Lipase and liver function tests (ALT, ALP, bilirubin)
   5. Urine dipstick
   6. Rapid strep antigen testing or bacterial throat culture for GAS (if assoc pharyngeal findings)
2. First-line imaging to consider in acute abdominal pain include: AXR, US, and CT abdomen (Imaging is indicated if clinical picture suspicious for trauma, peritonitis, obstruction, mass, distention, or focal tenderness/pain. If clinical picture highly suspicious for acute appendicitis, consult surgeon first.)
3. For chronic abdominal pain consider the following investigations: CBCd, electrolytes, glucose, creatinine, ALT, ALP, bilirubin, lipase, calcium, albumin, total protein, anti-TTG + IgA, fecal calprotectin, c-reactive protein (CRP), stool for culture + sensitivity, clostridium difficile antigen, ova + parasites (x 3), H pylori stool or breath test

There is so much to know about when and when not to order specific tests, far more than I've included here, and this doesn't even include how to interpret them! But this is a place to start, to capture the most worrisome and most common causes of abdominal pain.

Key Feature 3b: In a woman with abdominal pain: Suspect gynecologic etiology for abdominal pain. 
Skill: Clinical Reasoning
Phase: Hypothesis generation

In the 13 year old female per the last two posts, I suspected gynecologic etiology for her abdominal pain as my ddx for paediatric (and nonpediatric) abdominal pain is inclusive of this possibility.

My generic gynecological history-taking mnemonic is (one of those silly mnemonics that for whatever reason just sticks): MC HAMMER 

M - Menarche/last menstrual period/menopause
C - Cycle (regularity and length of time [number of days of entire cycle and subset of days having flow])
H - Hemorrhage (qty of flow and any intermittent spotting)
A - Aches associated with menstruation (dysmenorrhea)
M - Motherhood (GTPALM history, at what age the events occurred, if there were any associated complications, be it in the labour, delivery, or abortion as relevant)
M - Mishaps/miscarriages (usually this is obtained during my "motherhood" questioning, but there have been times where I've been happy to have a dedicated mnemonic letter for this as it gets me to think twice about explicitly asking about abortions, be they spontaneous or induced, and there has been a time I can remember when asking again deliberately prompted a patient to clarify that she indeed had had an abortion)
E - Evading pregnancy (use of contraception or fertility difficulties)
R - Risk factors (if pregnancy is being considered or not actively being prevented, such as folic acid supplementation, substance use, achieving or maintaining a healthy weight and lifestyle)

I gathered clinical information on the possibility of a gynaecological etiology in my 13 year old female patient by asking if she had reached menarche (yes), when the first date of her last menstrual period was (a few days before Christmas), if her cycles were typically regular (yes) and if there had been any alteration in this pattern recently (no). I asked her if she had any recent abnormal vaginal bleeding in terms of the pattern or quantity (no), and if she has had cramping associated with menstruation (not really), or any other pattern of pelvic/abdominal cramping (no). I asked if she is on or has ever been started on any sort of contraception (no), and opportunistically if she was considering that she might want to be prescribed contraception (not yet). 

I then went on to obtain a sexual history using the 5 Ps (as I have adapted, for my own purposes, the original format as advocated by the CDC). 

**Always start with a statement regarding confidentiality, particularly when taking a sexual history from adolescents, and the reasons why I am about to ask these sexual health questions.**

P - Practices (when was the last time that the patient was sexually active, and if they say "never," clarify that this includes oral-genital activity and not just penetrative intercourse)
P - Partners (how many partners has the patient had in the past month or year, and have they been males, females, or both?)*
P - Protection (does the patient use protection and if not, why not, or if yes, what and how often) (opportunity to ask if they have any questions about protection)
P - Past STI history (have they ever been diagnosed +/- treated for an STI, and if not, have they ever been tested and would they like to be at this time?)
P- Pregnancy prevention (are they using contraception, and if not, are they trying to conceive and would they be concerned if conception occurred? [prenatal counselling may be indicated]) (opportunity to ask if they have any questions about contraception)

Obtaining my sexual history with this patient revealed that she had never been sexually active (at all), and that she didn't feel she needed to explore methods of protection or contraception at this visit. I made sure to tell her that she can always return to the clinic at any time to discuss anything regarding sexual health, and told her about my favourite website she could explore for general sexual health information.

*Disclaimer: When I originally adapted the 5Ps for my own sexual history taking in medical school, appreciation of the gender spectrum as more than binary was lacking. Exploring the sexual and gender identities of their previous partners may or may not be indicated.

This patient had no pertinent positives on gynecological and sexual history. If there were any pertinent positives suggesting gynecological or STI-related pathology, relevant investigations may have included: B hCG to rule out pregnancy, STI testing, and an ultrasound of the pelvis.

Key Feature 3a: In a woman with abdominal pain: Always rule out pregnancy if she is of reproductive age. 
Skill: Clinical Reasoning
Phase: Hypothesis generation, Investigation

In assessing the 13 year old female who presented to clinic today concerned about abdominal pain, with my trusted pediatric ddx and its generalised inclusion of gynaecological causes in pubertal children, I was indeed prompted to first ask if she has had her first period (she had been having them for "awhile"), and then to obtain some pertinent gynaecological and sexual health history information, including when her last menstrual period was, if she has been sexually active yet, and if she has any symptoms in keeping with a sexually transmitted infection. She denied being sexually active yet, without any symptoms suggestive of an STI (ex: genital discharge or pruritus), and with consistently regular cycles that were free of dysmenorrhea. Because she characterised her pain as mild, along with the fact that she clinically appeared well without signs suggestive of genitourinary pathology, and because I had increased suspicion of nongenitourinary aetiologies for her pain, I trusted her, without any beta hCG backup. This is also taking into consideration the reliability of this patient and her family: that they were concerned enough to bring her to see her family doctor on the same day her self-reportedly minor pain started probably meant I could trust she would return for medical attention if her symptoms were not improving. Going from practically zero to instead a low pretest probability of GU related pathology would prompt me to screen her in my clinic for urine beta hCG, which is an extremely sensitive test for pregnancy (UpToDate, 2017). If I was in a position in which I was ordering bloodwork to investigate the possibility of other diagnoses, I would instead throw in a serum beta hCG (as long as the expected time to get the bloodwork was quick, such as in a hospital or emergency department setting), and I would certainly do this if I had a higher than low pretest probability of possible pregnancy. 

A note on sexual history taking in adolescents (and probably applicable to any demographic in general): A sexual history taken with other people present, be it parents, friends, or partners, may be as inconsequential as not taking a sexual history at all. It takes a total of probably 30 seconds to get the parent or whoever else out of the room, and although you may just get the same response, the privacy, along with a statement regarding confidentiality, increases the sensitivity in gathering important pieces of clinical information. Even if you think it is unlikely that a young adolescent has been sexually active yet, if you're a family doctor, you'll likely recognize this as an opportunity to broach the subject of contraception and practicing safe(r) sexual activity.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient's cultural and gender contexts, will be able to...

• Describe how the presentation and management of disease in children differs from adults
• Assess and manage atypical presentations of common medical conditions in the elderly
• Diagnose the common acute and non-acute disease entities requiring surgical treatment

Key Feature 1b: Given a patient with abdominal pain, paying particular attention to its location and chronicity: Generate a complete differential diagnosis (ddx).
Skill: Clinical reasoning
Phase: Hypothesis generation, Diagnosis

Key Feature 4: In a patient with acute abdominal pain, differentiate between a surgical and a non-surgical abdomen. 
Skill: Clinical reasoning, Selectivity
Phase: Physical, Diagnosis

Key Feature 5: In specific patient groups (ex: children, pregnant women, the elderly), include group-specific surgical causes of acute abdominal pain in the ddx. 
Skill: Clinical Reasoning, Selectivity
Phase: Hypothesis generation, Diagnosis

A 13 year old female presented to clinic with her mother today concerned about acute abdominal pain. She localised the pain as being midline in the lower abdomen. What is my ddx?

Like my previous post regarding the categorisation of acute vs chronic abdominal pain, sometimes (oftentimes) we encounter patients who challenge our clinical ability to categorise symptoms. Certainly this is true with pediatric patients, as their report of symptoms, if they are even old enough to verbally report symptoms, can be challenging to decode. Their inexperience with the pain of a headache may be entirely new, and perhaps associating feeling sick with feeling sick to their stomach, they may point to their tummy when you ask them where there pain is. Or maybe some kiddos actually feel sick to their stomach when they have a headache. The possibilities are endless, and without a reliable way to confidently know where pain or other manifestations of disease is originating from on history, as treating physicians we need to maintain a healthy dose of suspicion in searching for the culprit(s). As their own demographic, children also present with different probabilities of disease, and when it comes to abdominal pain, this is as true as any other undifferentiated symptom. 

My abbreviated ddx for pediatric abdominal pain (informed by the LMCC learning objectives) depending on the area to which the pain is localised (if they are old enough to be able to localise and communicate this information) is as follows:

• Epigastric pain
  • Gastroesophageal reflux disease
  • Peptic ulcer disease
  • Biliary tract disease
  • Pancreatitis
• Lower abdominal pain
  • Appendicitis
  • Mesenteric adenitis
  • Inguinal hernia (incarcerated)
  • Inflammatory bowel disease
  • Gastroenteritis
  • Constipation
  • Gynaecological causes in pubertal children
  • Urinary tract  infection
• Generalised pain
  • Peritoneal inflammation
  • Bowel (infantile colic, obstruction)
  • Malabsorption
  • Inflammatory bowel disease
• Flank pain
  • Nephrolithiasis
  • Pyelonephritis
• Functional abdominal pain

Of course, this list is not exhaustive, but it does prompt me to consider some of the most common diagnoses in pediatric patients, as well as important ones not to miss, including the ones that require urgent or emergent surgery. And when I encountered that 13 year old female in clinic today who was able to reliably tell me that she was having midline lower abdominal pain, I was able to use this ddx to inform my clinical data collection, my springboard to  collect pertinent negatives to arrive at a working diagnosis (which for this patient was constipation). I don't know that I was correct in reaching this conclusion, or that it was the only thing contributing to the pain, but my attending concurred with this conclusion, and it helped me look for the absence of findings suggesting a worrisome not-to-miss condition. If I cannot feel confident about localisation in a pediatric patient, then I can simply broaden my ddx to include all common and worrisome pediatric diagnoses. And if that still is unsatisfactory, I can consider the more extensive ddx I have for adult abdominal pain (which is still relatively abbreviated, but does take into consideration most bodily systems that may be sources of pain).

For completeness, here is my ddx for acute abdominal pain (adult patient, also informed by the LMCC objectives):

• Upper abdominal pain
  • Acute hepatitis, hepatic abscess
  • Biliary tract disease
  • Gastroesophageal reflux disease
  • Peptic ulcer disease, gastritis
  • Pancreatitis
  • Splenic infarct, splenic abscess
  • Referred cardiothoracic pain
  • Musculoskeletal pain
• Lower abdominal pain
  • Appendicitis
  • Mesenteric adenitis
  • Diverticulitis
  • Incarcerated hernia
  • Inflammatory bowel disease
  • Bowel obstruction
  • Renal colic
  • Urinary tract infection
  • Ectopic pregnancy
  • Pelvic inflammatory disease
  • Ovarian (torsion, ruptured ovarian cyst)
• Diffuse pain
  • Generalised peritonitis
  • Ruptured abdominal aortic aneurysm
  • Ischemic bowel disease
  • Gastroenteritis
  • Irritable bowel syndrome

And my ddx for chronic abdominal pain (adult patient, also informed by the LMCC objectives):

• Upper abdominal pain
  • Hepatic disease
  • Biliary disease
  • Ulcer and nonulcer dyspepsia (ex: heartburn)
  • Gastric cancer
  • Pancreatic disease
  • Referred cardiothoracic pain
• Lower abdominal pain
  • Bowel disease
    • Inflammatory bowel disease
    • Diverticular disease
    • Irritable bowel syndrome
  • Genitourinary disease
    • Pelvic inflammatory disease
    • Benign or malignant tumours
    • Endometriosis
    • Urinary tract disease

To elaborate a bit further on inclusion of surgical causes of acute abdominal pain, it is important to know which diagnoses require surgical referral, be it after a bit of a workup to confirm the diagnosis, or more urgent or emergently if the patient is seriously unwell or with signs of peritonitis*. In the pediatric patient, for example, this could mean first doing an ultrasound** to rule out appendicitis if you think it is possible but not highly likely as the cause of the abdominal pain, or it could mean ordering imaging concurrently as you urgently consult general surgery if you think an acute appendicitis is in fact likely to be the underlying etiology for the pain. For any case in which a patient is presenting with peritonitis and a broad working differential for acute abdominal pain, a consult to general surgery is indicated. If the working differential is more focused, given the clinical presentation and patient-specific risk factors, then the surgeon to consult will depend on suspected etiology and local specialist accessibility, and may warrant consultation with general surgery, gynaecology, urology, cardiac surgery, vascular surgery, or otolaryngology. Of course, consultation with a nonsurgical medical specialist may also be warranted given the working diagnosis, such as a gastroenterologist, nephrologist, or infectious disease specialist, among others. The timing of when to involve such specialists must be driven by the urgency of the situation in combination with the working differential, be it to provide diagnostic clarity when there is confusion or to administer therapy that is not in the general practitioner's scope of practice.

*In a patient presenting with acute abdominal pain, it is particularly important to examine the patient's abdomen to decide if it is "peritonitic" (otherwise known as a surgical abdomen). Peritonitis is the inflammation of the peritoneum, the sac that encases much of our abdominal organs, and is an ominous finding that suggests surgical intervention is needed. Features most suggestive of peritonitis on physical exam that warrant urgent surgical consultation, in the order in which they would be assessed as per the Inspect-Auscultate-Percuss-Palpate (IAPP) approach to the abdominal exam as is standard medical school teaching, include:

• "Bump the stretcher test"
  • Literally you pretend to accidentally bump the stretcher and see if the patients respond with pain. It's not nice if there really is peritonitis, as any sudden movements can cause significant pain, but if it helps you to figure out they have peritonitis, I think the pain caused by bumping their stretcher is far outweighed by the pain of a missed diagnosis of peritonitis.
• Percussion tenderness
  • ​Another test of something that should otherwise not cause any measurable degree of discomfort, in a patient with peritonitis, even gentle percussion on the abdominal wall can produce pain out of proportion to the tap, increasing the likelihood that the patient has a peritonitic process occurring in their abdomen.
• Guarding/rigidity
  • Guarding and rigidity are phenomena whereby patients tense their abdominal wall muscles in order to protect the underlying organs in the abdomen. On examination, the abdominal wall feels firm. The difference between guarding and rigidity is that in the former, the muscle tension is voluntary, such that if you can get a patient distracted, maybe by asking them questions that take their mind ever-so-momentarily off the fact that you're feeling their tender abdomen, the abdominal wall becomes softer. Rigidity, on the other hand, is involuntary contraction of the abdominal wall musculature. With a peritonitic process, the irritation of the peritoneum causes a reflex contraction of the muscles in processes not requiring conscious contraction. So neat. As you may expect, rigidity has a much greater likelihood ratio in predicting the presence of peritonitis than does guarding, but even guarding does increase the likelihood of peritonitis so is important not to overlook if full on rigidity is absent.
• Rebound tenderness
  • ​To elicit this finding, you push down on the abdominal wall as you do when palpating in general, and then you release. In the force of pushing in on a peritonitic abdomen, this will likely cause the patient significant pain already, but the likelihood of the patient with acute abdominal pain having peritonitis is actually greater if the pain on removal of the force inward on the abdomen (the pain on rebound) is worse.

**A tangent on how the management of disease in children differs from adults: A consideration that a  physician must have when working up a pediatric concern is how the potential for harm and benefit of various interventions is different from that of an adult or geriatric patient. For example, the potential for harm from repeated CT scans could increase a person's risk of cancer down the road, and having hopefully much more time to live and bear secondary mutations possibly related to effects of radiation, the risk to benefit ratio of performing CT scans in pediatric patients is not the same as in older patients. Although the harm of a single CT scan is not so significant if it means possibly saving a life, it is something to consider if your pre-test probability of ominous disease is low. The converse is also true for the elderly or other patients that have risk factors for true and serious pathology: where the weight balances on the risk vs benefit scale shifts. The same general rationale regarding management decisions applies to considering interventions in pediatric patients as compared to other demographics, and the wise physician will remember to consider that the benefit to harm ratio of anything we choose to do or abstain from doing will differ depending on the individual before us. 

Key Feature 1a: Given a patient with abdominal pain, paying particular attention to its location and chronicity: Distinguish between acute and chronic pain.
Skill: Clinical Reasoning
Phase: History

While on my family practice ward rotation I received a consult from the gastroenterology service to assess a patient in the emergency department (ED) to determine whether or not they would be suitable for admission to our service. I was told the patient had a chronic history of abdominal pain that began about 10 years ago, and that there were no acute concerns from gastroenterology's perspective apart from the fact that the patient was in significant pain and so their service felt uncomfortable for her to be sent home. I came to the ED to assess the patient, and on taking her history I learned that there was indeed a history of previous episodes of abdominal pain that stemmed back at least 10 years. I also discovered that the abdominal pain over this time was intermittent, typically spread apart by years at a time. These episodes of abdominal pain were distinct - this was a case of acute abdominal pain, and in this patient it started 3 days ago. 

Deciding whether a concern of abdominal pain is acute or chronic is important in order to inform the working differential diagnosis, but there is no clear time cutoff that absolutely distinguishes these presentations. The UpToDate article, "Evaluation of the adult with abdominal pain" (2017) states:

"There is no strict time period that will classify the differential diagnosis unfailingly. A clinical judgment must be made that considers whether this is an accelerating process, one that has reached a plateau, or one that is longstanding but intermittent. Patients with chronic abdominal pain may present with an acute exacerbation of a chronic problem or a new and unrelated problem.

Pain of less than a few days’ duration that has worsened progressively until the time of presentation is clearly "acute." Pain that has remained unchanged for months or years can be safely classified as chronic. Pain that does not clearly fit either category might be called subacute and requires consideration of a broader differential than acute and chronic pain."

It could reasonably be argued that presenting on the third day after the onset of abdominal pain may better fit the "subacute" classification. In any case, if a presentation is thought to be "subacute," this would necessitate a broader working differential, including those of a more acute nature, and I think it would be prudent for these to first be in the forefront of the clinician's mind. 

My conclusion: When assessing a patient with abdominal pain, it is important to distinguish whether the presentation is acute or chronic in order to narrow the working differential diagnosis. When in doubt (i.e., the presentation flirts with being subacute), first consider the possibility that the pain is a manifestation of an acute disease process and investigate accordingly.