Priority Topic: Abdominal Pain

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.