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
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
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
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.
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.