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Acute Abdominal Pain (general)

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Approach to Pacemaker And Icd Related Presentations Approach to Acute Limb Ischemia And Leg Pain Approach to Suspected Deep Vein Thrombosis Symptoms Approach to Hypertension Approach to Chest Pain Approach to Palpitations And Tachyarrhythmia Symptoms Approach to Bradycardia Symptoms Approach to Syncope And Presyncope Approach to Syncope With Neurologic Concern Approach to Unilateral Leg Swelling Approach to Bilateral Leg Swelling Approach to Calf Pain And Swelling

Approach to Wheezing, Undifferentiated Approach to Wheezing In Infants Approach to Stridor And Upper Airway Symptoms Approach to Dyspnea Approach to Aspiration Event Approach to Cough Approach to Hemoptysis Approach to Upper Respiratory Infection Symptoms Approach to Suspected Pulmonary Embolism Presentation Approach to Smoke Inhalation Concern Approach to Smoke Exposure And Inhalational Injury

Approach to Abdominal Distension Approach to Abdominal Pain, Undifferentiated Approach to Acute Abdominal Pain (general)Approach to Suspected Incarcerated Or Strangulated Hernia Approach to Pancreatitis Concern Approach to Biliary Colic And Cholecystitis Concern Approach to Appendicitis Concern Approach to Diverticulitis Concern Approach to Rectal Pain And Anorectal Complaints Approach to Dysphagia And Food Bolus Impaction Approach to Foreign Body Ingestion Approach to Refractory Vomiting And Recurrent Vomiting Syndromes Approach to Cannabis Associated Hyperemesis Approach to Upper Gastrointestinal Bleeding Symptoms (melena)Approach to Lower Gastrointestinal Bleeding And Hematochezia Approach to Constipation And Obstipation Approach to Diarrhea Approach to Acute Hepatitis And Jaundice Concern Approach to Right Upper Quadrant Pain Approach to Epigastric Pain Approach to Left Upper Quadrant Pain Approach to Right Lower Quadrant Pain Approach to Left Lower Quadrant Pain Approach to Suprapubic Pain

Approach to Oliguria And Anuria Approach to Catheter Related Urinary Complaints Approach to Dialysis Patient Presentations Approach to Flank Pain And Renal Colic Concern Approach to Urinary Retention Approach to Hematuria Approach to Scrotal Pain

Approach to Transient Neurologic Deficits Approach to Acute Aphasia And Speech Disturbance Approach to Acute Confusion And Delirium Approach to Postictal State And Seizure Recurrence Concern Approach to Seizure Approach to Acute Vision Loss Approach to New Tremor And Involuntary Movements Approach to Headache Approach to Vertigo Approach to Acute Weakness Or Numbness Approach to Gait Instability And Ataxia

Approach to Atraumatic Back Pain Approach to Sciatica And Radicular Back Pain Approach to Back Pain With Neurologic Deficit, Cauda Equina Concern Approach to Back Pain With Fever Or Immunosuppression, Spinal Infection Concern Approach to Atraumatic Neck Pain Approach to Neck Pain After Trauma Approach to Neck Pain With Meningismus Concern Approach to Acute Torticollis

Approach to Vaginal Discharge Approach to Hyperemesis Gravidarum Concern Approach to Hypertensive Disorders Of Pregnancy Symptoms Approach to Postpartum Hemorrhage Concern Approach to Postpartum Infection Concern Approach to Sexual Assault Medical Evaluation Overview Approach to Pelvic Pain Approach to Vaginal Bleeding, Nonpregnant Approach to Vaginal Bleeding In Pregnancy Approach to Pelvic Pain In Pregnancy Approach to Post Procedure Or Post Abortion Complications Concern

Approach to Fever In The Immunocompromised Patient Approach to Fever With Rash Approach to Animal Bites And Rabies Risk Assessment Approach to Tick Exposure And Tick Borne Illness Concern Approach to Sepsis Concern Without Clear Source Approach to Soft Tissue Infection Concern Approach to Abscess And Skin Infection Concern Approach to Sore Throat Approach to Sore Throat And Pharyngitis Symptoms Approach to Meningitis Approach to Envenomation And Bites

Approach to Pruritus Without Rash Approach to Contact Dermatitis And Eczema Flare Approach to Herpes Zoster Concern Approach to Drug Eruption Concern And Severe Cutaneous Reaction Red Flags Approach to Urticaria Approach to Angioedema Concern Approach to Unexplained Bruising Or Bleeding Symptoms

Approach to Shoulder Pain Approach to Elbow Pain Approach to Wrist Pain Approach to Hand Pain Approach to Hip Pain Approach to Knee Pain Approach to Ankle Pain Approach to Foot Pain Approach to Cast Or Splint Complication Symptoms Approach to Wound Check And Suture Related Visits Approach to Joint Swelling And Monoarthritis Approach to Suspected Septic Joint Presentation Approach to Suspected Tendon Rupture Presentation Approach to Limp Or Refusal To Bear Weight

Approach to Motor Vehicle Collision Evaluation Approach to Chest Wall Trauma And Rib Injury Approach to Blunt Abdominal Trauma Evaluation Approach to Penetrating Trauma Evaluation Approach to Pediatric Minor Head Trauma Approach to Pediatric Head Trauma Approach to Facial Lacerations And Dental Trauma Approach to Hand Lacerations With Tendon Injury Concern Approach to Puncture Wounds And Retained Foreign Body Concern Approach to Electrical Injury Approach to Burn Injury Approach to Fall Evaluation Approach to Assault And Interpersonal Violence Evaluation Approach to Eye Trauma And Hyphema Concern

Approach to Dysphagia And Odynophagia Approach to Throat Pain Approach to Ear Pain Approach to Foreign Body In Ear Or Nose Approach to Vision Loss Complaint Approach to Flashes And Floaters Approach to Atraumatic Eye Pain Approach to Red Eye Approach to Dental Abscess Concern Approach to Post Extraction Pain And Complications

Approach to Hyperglycemia Approach to Hypoglycemia Approach to Hyponatremia Symptoms Approach to Hyperkalemia Symptoms Approach to Hypokalemia Symptoms Approach to Rhabdomyolysis Concern Approach to Anticoagulation Related Abnormal Coagulation Studies Approach to Acute Kidney Injury And Elevated Creatinine Referral Approach to Symptomatic Anemia Concern

Approach to Undifferentiated Overdose Approach to Opioid Toxicity Approach to Opioid Withdrawal Approach to Alcohol Intoxication Approach to Alcohol Withdrawal Approach to Stimulant Toxicity Approach to Pediatric Ingestion Approach to Carbon Monoxide Exposure Approach to Inhalational Or Chemical Exposure Approach to Suicidal Ideation And Self Harm Risk Assessment Approach to Acute Psychosis And Mania Symptoms Approach to Anxiety And Panic Symptoms Approach to Capacity Assessment And Safe Disposition Approach to Behavioral Escalation And Restraint Considerations

Approach to Fever In The Neonate And Young Infant Approach to Pediatric Fever By Age 0 To 28 Days Approach to Pediatric Fever By Age 29 To 60 Days Approach to Pediatric Fever By Age 2 To 24 Months Approach to Pediatric Respiratory Distress Approach to Croup And Stridor In Children Approach to Pediatric Dehydration Approach to Pediatric Abdominal Pain Approach to Febrile Seizure Approach to Rash In The Child Approach to Poor Feeding And Lethargy In The Infant Approach to Vomiting In The Child Approach to Diarrhea In The Child Approach to Pediatric Trauma Evaluation Approach to Brief Resolved Unexplained Event In The Infant And Apparent Life Threatening Event Concern Approach to Lethargy And Altered Mental Status In The Child

Approach to Heat Illness Approach to Hypothermia And Cold Exposure Approach to Frostbite Concern Approach to Drowning And Submersion Injury

Acute Abdominal Pain (general)

Clinical Assessment Checklist

Browse categories and answer follow-up questions to refine your symptom profile.

History

Symptom context and baseline

Context and baseline

Time course pattern

First episode

Recurrent

Similar prior episodes and diagnosis

Baseline bowel and urinary pattern

Baseline gynecologic pattern

Onset

Onset

Sudden onset

Gradual onset

Maximal at onset

Post prandial onset

After exertion

After trauma

Provocation and palliation

Provocation and palliation

Worse with meals

Worse with fatty foods

Worse with movement

Worse with cough

Worse with deep inspiration

Relief with vomiting

Relief with bowel movement

Relief with antacids

Relief with position change

Quality

Quality

Colicky

Constant

Burning

Cramping

Sharp

Tearing or ripping

Pressure

Region and radiation

Region and radiation

Right upper quadrant

Epigastric

Left upper quadrant

Right lower quadrant

Left lower quadrant

Suprapubic

Diffuse

Radiation to back

Radiation to right shoulder

Radiation to groin

Migration

Severity

Severity

Pain score trend

Function limiting

Able to tolerate oral intake

Sleep interruption

Timing

Timing

Intermittent

Continuous

Progressively worsening

Waxing and waning

Nocturnal predominance

Associated symptoms

Associated symptoms

Fever

Chills

Nausea

Vomiting

Hematemesis

Diarrhea

Constipation

Obstipation

Hematochezia

Melena

Jaundice

Dark urine

Pale stools

Dysuria

Urinary frequency

Hematuria

Vaginal bleeding

Vaginal discharge

Testicular pain

Dyspnea

Chest pain

Syncope

Focal neurologic symptoms

Location directed history

Location directed history

Right upper quadrant cluster

Biliary colic pattern

Post prandial pain

Prior gallstones

Cholangitis symptoms

Epigastric cluster

Alcohol use

Hypertriglyceridemia history

Peptic ulcer risk

ACS equivalent symptoms

Aortic symptoms overlap

Abrupt severe pain maximal at onset

Pain radiating to back

Syncope or neurologic symptoms

Left upper quadrant cluster

Trauma

Infectious mononucleosis risk

Pleuritic component

Splenic infarct risk

Right lower quadrant cluster

Pain migration to right lower quadrant

Anorexia

Periumbilical start

Gynecologic overlap

Left lower quadrant cluster

Prior diverticulitis

Change in bowel habits

Recent constipation

Immunosuppression risk

Suprapubic cluster

UTI symptoms

Pregnancy possibility

Pelvic inflammatory symptoms

Urinary retention symptoms

Aortic emergency screen (any location)

Sudden severe pain maximal at onset (abdomen, flank, back, chest)

Syncope or near syncope

New focal neurologic deficit

Limb pain, weakness, numbness, coolness

Known aneurysm or prior aortic disease

Connective tissue disorder or bicuspid aortic valve history

Recent cocaine or stimulant use

Alarm Features

Immediate escalation triggers

Immediate escalation triggers

SBP under 90 mmHg

HR 130 or higher with symptoms

RR 30 or higher

SpO2 under 92 percent on room air

New confusion

Lactate 4 mmol/L or higher

Active GI bleeding with instability

Peritonitis and ischemia features

Peritonitis and ischemia features

Rebound tenderness

Involuntary guarding

Rigid abdomen

Pain out of proportion

Severe distension with tympany

Absent bowel sounds with toxicity

High risk populations

High risk populations

Pregnancy

Postpartum under 6 weeks

Age 65 or older

Anticoagulated

Immunocompromised

Chronic kidney disease

Cirrhosis

Aortic red flags

Aortic red flags

Sudden severe pain maximal at onset, especially with back radiation

Hypotension or shock, or unexplained syncope

New focal neurologic symptoms

New pulse deficit or limb ischemia symptoms

Asymmetric arm blood pressures (check both arms if concern)

New diastolic murmur suggesting aortic regurgitation

Unexplained severe abdominal, flank, or back pain in older adult with vascular risk

Known aneurysm with new pain

Time critical diagnoses by location

Time critical diagnoses by location

Right upper quadrant

Ascending cholangitis

Acute cholecystitis with sepsis

Acute hepatic failure with encephalopathy

Epigastric

Acute coronary syndrome

Perforated ulcer

Necrotizing pancreatitis

Aortic catastrophe (aneurysm rupture, dissection)

Left upper quadrant

Splenic rupture

Splenic infarct with sepsis source

Lower lobe pneumonia with sepsis

Right lower quadrant

Appendicitis with perforation

Ovarian torsion

Ectopic pregnancy

Left lower quadrant

Complicated diverticulitis

Ischemic colitis

AAA leak or rupture

Suprapubic

Ectopic pregnancy

Ovarian torsion

Urinary retention with AKI

Fournier gangrene

Medications

Medication reconciliation

Medication reconciliation

Current prescribed medications

Recent medication changes

OTC analgesics

Antacids and acid suppression

Herbal supplements

Medication risks for abdominal pain

Medication risks for abdominal pain

NSAIDs

Steroids

Anticoagulants

Antiplatelets

GLP 1 receptor agonists

Opioids

Antibiotics with C difficile risk

Contraindications and interactions

Contraindications and interactions

Pregnancy teratogens

QT prolonging combinations

Renal dosing risk

Hepatic dosing risk

Diet

Recent intake and exposures

Recent intake and exposures

Poor oral intake

Dehydration risk

Recent fatty meal

Recent high protein meal

Recent large meal after fasting

Alcohol and substances

Alcohol and substances

Heavy alcohol intake

Recent binge

Cannabis exposure

Cocaine or stimulant exposure

Review of Systems

GI and constitutional

GI and constitutional

Fever

Weight loss

Appetite change

Nausea

Vomiting

Dysphagia

Odynophagia

Diarrhea

Constipation

GI bleeding

GU and gynecologic

GU and gynecologic

Dysuria

Frequency

Flank pain

Hematuria

Vaginal bleeding

Vaginal discharge

Dyspareunia

Cardiopulmonary and neuro

Cardiopulmonary and neuro

Chest pain

Dyspnea

Cough

Pleuritic pain

Syncope

Focal neurologic symptoms

Collateral History and Family History

Collateral and reliability

Collateral and reliability

Witnessed timeline

Baseline cognition

Medication adherence reliability

Family history relevant to abdominal pain

Family history relevant to abdominal pain

Early coronary disease

Gallstones

Inflammatory bowel disease

Colorectal cancer

Thrombophilia

Family history of aortic aneurysm or sudden death

Exposure history

Exposure history

Sick contacts

Foodborne exposure

Recent travel

Recent antibiotics

Risk Factors

Vascular and thrombosis risks

Vascular and thrombosis risks

Atrial fibrillation

Known atherosclerosis

Smoking

Estrogen exposure

Recent surgery

Prior VTE

Aortic aneurysm and dissection risk factors

Aortic aneurysm and dissection risk factors

Age 65 or older

Smoking history

Hypertension

Known AAA or thoracic aneurysm

Family history of AAA or thoracic aneurysm

Atherosclerosis

Prior aortic surgery or known aortic disease

Bicuspid aortic valve

Connective tissue disorder (Marfan, Loeys Dietz, vascular EDS)

Recent cocaine or stimulant use

Pregnancy and postpartum period (dissection risk)

Hepatobiliary and pancreatic risks

Hepatobiliary and pancreatic risks

Gallstones history

Alcohol use disorder

Hypertriglyceridemia

Prior pancreatitis

Known cirrhosis

Infection and immunosuppression risks

Infection and immunosuppression risks

Neutropenia

Transplant

Chronic steroids

HIV

Pregnancy and gynecologic risks

Pregnancy and gynecologic risks

Pregnancy possibility

Ectopic history

IUD in situ

Assisted reproduction

Differential Diagnosis

Life threatening

Life threatening

Ruptured abdominal aortic aneurysm (I71.3)

Back, flank, or abdominal pain

Hypotension or syncope

Pulsatile mass (absence does not exclude)

Aortic dissection (I71.00)

Abrupt severe pain maximal at onset (chest, back, abdomen)

Neurologic symptoms or syncope

Pulse deficit, limb ischemia, or malperfusion signs

New aortic regurgitation murmur

Mesenteric ischemia (K55.9)

Pain out of proportion

Atrial fibrillation risk

Perforated viscus (K63.1)

Peritonitis

Free air on imaging

Ectopic pregnancy (O00.9)

Positive pregnancy test

Vaginal bleeding

Ovarian torsion (N83.5)

Sudden unilateral pelvic pain

Adnexal tenderness

Ascending cholangitis (K83.09)

Fever

Jaundice

Hypotension or confusion

Acute coronary syndrome (I21.9)

Epigastric pain

Diaphoresis

Common

Common

Biliary colic (K80.20)

Post prandial right upper quadrant pain

Normal inflammatory markers

Acute cholecystitis (K81.0)

Right upper quadrant tenderness

Fever

Acute pancreatitis (K85.9)

Epigastric pain radiating to back

Lipase elevation

Appendicitis (K35.80)

Right lower quadrant pain

Migration

Diverticulitis (K57.32)

Left lower quadrant pain

Fever

Gastroenteritis (A09)

Diarrhea

Sick contacts

Nephrolithiasis (N20.0)

Flank to groin radiation

Hematuria

Cystitis (N30.90)

Dysuria

Suprapubic tenderness

Less common and location mimics

Less common and location mimics

Hepatitis (K75.9)

Jaundice

Transaminitis

Peptic ulcer disease (K27.9)

Burning epigastric pain

NSAID use

Splenic infarct (D73.5)

Left upper quadrant pain

Embolic risk

Pneumonia lower lobe (J18.9)

Cough

Pleuritic pain

Ischemic colitis (K55.9)

Crampy pain

Hematochezia

Incarcerated hernia (K46.9)

Irreducible mass

Obstruction symptoms

Abdominal wall pain

Focal tenderness

Positive Carnett sign

Past Medical History

Relevant conditions

Relevant conditions

Prior abdominal surgeries

Prior bowel obstruction

Known gallstones

Known peptic ulcer disease

Known inflammatory bowel disease

Known malignancy

Known AAA, thoracic aneurysm, or prior aortic repair

Devices and procedures

Devices and procedures

Biliary stent

Dialysis access

IUD

Recent endoscopy or colonoscopy

Baseline function and supports

Baseline function and supports

Baseline oral intake

Baseline mobility

Home supports

Ability to return if worse

Physical Exam

Initial appearance and vitals pattern

Initial appearance and vitals pattern

Toxic appearance

Diaphoresis

Hydration status

Orthostatic symptoms

Abdomen exam core

Abdomen exam core

Distension

Bowel sounds pattern

Focal tenderness by quadrant

Rebound

Guarding

Percussion tenderness

Aortic focused exam (add for suspected aneurysm or dissection)

Aortic focused exam

Blood pressure in both arms if dissection concern

Pulse exam

Radial pulses bilaterally

Femoral pulses bilaterally

Pulse deficit

Cardiac exam

New diastolic murmur suggesting aortic regurgitation

Neuro exam

Focal deficits

Limb perfusion

Cool limb, pallor, pain, weakness, paresthesia

Location specific maneuvers

Location specific maneuvers

Right upper quadrant

Murphy sign

Hepatomegaly

Epigastric

Epigastric focal tenderness

Grey Turner or Cullen sign

Left upper quadrant

Splenomegaly

Left costovertebral angle tenderness

Right lower quadrant

Rovsing sign

Psoas sign

Obturator sign

Left lower quadrant

Localized tenderness

Mass

Suprapubic

Suprapubic tenderness

Bladder distension

Extra abdominal exam

Extra abdominal exam

Lung bases exam

Skin rash

Jaundice

Testicular exam when indicated

Pelvic exam when indicated

Hernia and rectal exam

Hernia and rectal exam

Inguinal and femoral hernias

Perineal skin changes

Rectal bleeding evidence

Rectal tone when indicated

Lab Studies

Core labs for undifferentiated abdominal pain

Core labs for undifferentiated abdominal pain

CBC

Electrolytes including creatinine

Glucose

Venous blood gas when ill

Lactate when sepsis or ischemia concern

Type and screen if severe pain, hypotension, or surgical concern

Hepatobiliary and pancreatic labs

Hepatobiliary and pancreatic labs

AST

ALT

ALP

Bilirubin

Lipase

Infection and inflammation markers

Infection and inflammation markers

CRP trend support

Blood cultures if febrile and toxic

Urine culture when UTI suspected

Pregnancy and gynecologic labs

Pregnancy and gynecologic labs

Urine pregnancy test

Serum hCG when high risk or equivocal

Rh status with first trimester bleeding

Urine and renal stone labs

Urine and renal stone labs

Urinalysis

Microscopy for RBC

Ketones with dehydration

Coagulation and bleeding risk labs

Coagulation and bleeding risk labs

INR in anticoagulated

Platelets trend

Aortic focused labs (supportive only)

Aortic focused labs (supportive only)

Lactate if shock or malperfusion concern

Troponin if chest or epigastric overlap

D dimer only in select low risk dissection strategies

Do not use to rule out dissection in high risk features or late presentation

Interpretation pitfalls

Interpretation pitfalls

Normal WBC does not exclude appendicitis

Normal lipase early does not exclude pancreatitis

Mild transaminitis can occur in biliary obstruction

Hematuria can be absent in nephrolithiasis

Imaging

Scoring Systems

Scoring systems

Appendicitis probability tools

Alvarado score

AIR score

Pancreatitis severity tools

BISAP score

Ranson criteria

Cholecystitis support tools

Tokyo guideline diagnostic criteria

MRI

MRI

MRCP for suspected choledocholithiasis when ultrasound equivocal

MRI abdomen in pregnancy when ultrasound nondiagnostic and CT avoided

Contraindications

Non MRI compatible implants

Severe claustrophobia

CT

CT

CT abdomen pelvis with IV contrast for

Undifferentiated severe pain

Suspected appendicitis with unclear ultrasound

Suspected diverticulitis complications

Suspected ischemia or perforation

CT abdomen pelvis without IV contrast for

Suspected renal colic

Contrast contraindication with alternative strategy

Ultrasound

Ultrasound

Right upper quadrant ultrasound for

Gallstones

Cholecystitis findings

Biliary duct dilation

Pelvic ultrasound with Doppler for

Ectopic pregnancy evaluation

Ovarian torsion evaluation

POCUS adjuncts

Aorta screen for AAA in abdominal, flank, or back pain with risk

Hydronephrosis screen in flank pain

Aortic emergency imaging pathway

Aortic emergency imaging pathway

Suspected ruptured AAA

If unstable: immediate bedside aortic ultrasound and resuscitation, activate vascular or surgery pathway

If stable enough: CTA abdomen pelvis (often with chest if diagnosis unclear)

Suspected aortic dissection with abdominal pain presentation

If stable: CTA chest abdomen pelvis is preferred definitive test

If unstable and high suspicion: do not delay definitive management for CT

Use echo strategy depending on local resources (TEE if available for proximal dissection)

Special Tests

Bedside tests and maneuvers

Bedside tests and maneuvers

Carnett sign for abdominal wall pain

Bladder scan for retention

Rectal exam when GI bleed or impaction concern

Procedural diagnostics

Procedural diagnostics

Paracentesis when new ascites with infection concern

NG tube aspiration when obstruction with vomiting

Pelvic exam when PID concern

Microbiology and stool testing

Microbiology and stool testing

C difficile testing with recent antibiotics

Stool culture with severe dysentery features

Ova and parasite with prolonged travel associated diarrhea

ECG

When ECG matters in abdominal pain

When ECG matters in abdominal pain

Epigastric pain in age 40 or older

Diaphoresis

Dyspnea

Syncope or presyncope

Significant cardiac risk factors

High risk ECG patterns

High risk ECG patterns

STEMI criteria

New ischemic ST depression

Dynamic T wave changes

New LBBB with ischemic presentation

Ventricular arrhythmia

Serial strategy

Serial strategy

Repeat ECG with ongoing symptoms

Repeat ECG with troponin strategy per local protocol

Assessment

Problem representation

Problem representation

Pain location and acuity pattern

Toxicity and stability classification

Probability framing

Aortic aneurysm and dissection assessment

Aortic aneurysm and dissection assessment

When to think of it in abdominal pain

Sudden severe pain maximal at onset, especially with back or flank radiation

Unexplained hypotension, shock, or syncope

Neuro deficits, limb ischemia symptoms, or pulse deficit

Known aneurysm or significant aortic risk factors

Bedside evaluation bundle

BP both arms if dissection concern

Pulses in all extremities

Focused neuro exam

Cardiac auscultation for new diastolic murmur

POCUS abdominal aorta if AAA is plausible

Imaging decision

High risk dissection features and stable: CTA chest abdomen pelvis

High risk AAA rupture features and stable: CTA abdomen pelvis (extend to chest if unclear)

Unstable suspected ruptured AAA: POCUS plus immediate vascular or surgery pathway

Unstable suspected dissection: emergent cardiothoracic pathway and echo strategy if available

Location based working diagnoses

Location based working diagnoses

Right upper quadrant

Biliary colic (K80.20)

Acute cholecystitis (K81.0)

Cholangitis (K83.09)

Hepatitis (K75.9)

Epigastric

Acute pancreatitis (K85.9)

Peptic ulcer disease (K27.9)

Gastritis (K29.70)

ACS equivalent (I21.9)

Aortic dissection or aneurysm complication (I71.00, I71.3)

Left upper quadrant

Splenic pathology

Lower lobe pneumonia (J18.9)

Gastritis or ulcer

Right lower quadrant

Appendicitis (K35.80)

Ovarian torsion (N83.5)

Ectopic pregnancy (O00.9)

Ureteric stone (N20.0)

Left lower quadrant

Diverticulitis (K57.32)

Colitis

Ischemic colitis (K55.9)

AAA leak or rupture (I71.3)

Suprapubic

Cystitis (N30.90)

PID (N73.9)

Retention with obstructive uropathy

Ectopic pregnancy (O00.9)

Complications to rule out

Complications to rule out

Sepsis

Perforation

Abscess

Obstruction

Ischemia

Hemorrhage

Aortic rupture or malperfusion

Uncertainty and alternative diagnoses

Uncertainty and alternative diagnoses

Atypical presentations in elderly

Blunted fever in immunocompromised

Early disease with normal labs and imaging

Extra abdominal sources

Plan

First 5 minutes for critical patient

First 5 minutes for critical patient

Monitors

Continuous pulse oximetry

Cardiac monitoring when unstable

IV access

Two large bore IV when shock concern

IO access if no IV and unstable

Fluids

Balanced crystalloid bolus 10 to 20 mL per kg for hypoperfusion

Reassess after each bolus

Antibiotics

Within 1 hour if septic shock concern

Source directed selection per local protocol

Early consult triggers

Surgery for peritonitis

OB GYN for suspected ectopic or torsion

Aortic emergency actions

Aortic emergency actions

If suspected ruptured AAA

Activate vascular or surgery pathway early

Type and cross, consider massive transfusion if hemorrhagic shock

Bedside aorta ultrasound immediately if it will not delay definitive care

Avoid delays to CT if unstable

If suspected aortic dissection

Activate appropriate pathway early (cardiothoracic or vascular depending on type and local practice)

Aggressive pain control

Reduce shear stress when suspected

Control heart rate first with a beta blocker when available and appropriate

Then address blood pressure if still hypertensive

Avoid vasodilator alone before heart rate control

Analgesia and antiemetics

Analgesia and antiemetics

Acetaminophen PO or IV

1000 mg PO or IV

Max 3000 mg per day in older adults or liver disease

Ketorolac IV when renal function acceptable

15 mg IV

Avoid in GI bleed risk and pregnancy third trimester

Hydromorphone IV for severe pain

0.2 to 0.5 mg IV

Repeat every 10 to 15 minutes to effect with monitoring

Ondansetron

4 mg IV or ODT

QT risk awareness

Diagnostic sequencing

Diagnostic sequencing

Pregnancy test early in reproductive age with uterus

ECG and troponin pathway when epigastric atypical ACS concern

Aortic screen when red flags present

POCUS aorta for suspected AAA

CTA chest abdomen pelvis for suspected dissection if stable

Ultrasound first for right upper quadrant and pelvic etiologies

CT abdomen pelvis when diagnosis unclear or complications suspected

Location based pathways

Location based pathways

Right upper quadrant pathway

Ultrasound first line

Antibiotics if cholecystitis or cholangitis concern

ERCP pathway coordination when obstructing stone suspected

Epigastric pathway

Lipase and LFTs

ACS evaluation when risk factors or atypical features

CTA chest abdomen pelvis if aortic red flags

Left upper quadrant pathway

Chest imaging if pulmonary features

CT if splenic injury or infarct concern

Right lower quadrant pathway

Appendicitis scoring support

Ultrasound in pregnancy and pediatrics

CT when adult and ultrasound nondiagnostic

Left lower quadrant pathway

CT for first episode or severe presentation

Antibiotics strategy per severity and local guidance

Consider AAA leak or rupture in older patient with hypotension or back pain

Suprapubic pathway

Urinalysis and culture strategy

Pelvic ultrasound for ectopic or torsion concern

Reassessment loop

Reassessment loop

Pain and vitals reassessment every 30 to 60 minutes in ED

Abdominal exam repeat after analgesia

Escalate to CT or consult if worsening or persistent peritoneal signs

Disposition

ICU and high acuity criteria

ICU and high acuity criteria

Vasopressor requirement

Lactate 4 mmol/L or higher after fluids

Persistent hypotension

Altered mental status with sepsis

Suspected or confirmed aortic emergency

Admission criteria

Admission criteria

Peritonitis

Uncontrolled pain or vomiting

Inability to tolerate oral intake

Complicated diverticulitis

Acute cholecystitis requiring IV antibiotics

Pancreatitis with systemic features

Suspected ectopic pregnancy or torsion

Suspected aortic aneurysm complication or dissection

Observation pathway criteria

Observation pathway criteria

Diagnostic uncertainty with stable vitals

Serial abdominal exams needed

Serial labs needed

Trial of PO tolerance planned

Discharge criteria

Discharge criteria

Stable vital signs

No peritonitis

Pain controlled on oral regimen

Tolerating oral intake

Reliable follow up

Clear return precautions provided

Discharge Instructions

Copy discharge instructions

Copy discharge instructions

Return now for worsening pain, fainting, trouble breathing, new chest pain, or confusion

Return now for fever or shaking chills

Return now for persistent vomiting or inability to keep fluids down

Return now for black stools, bloody stools, or vomiting blood

Return now for new jaundice or dark urine

Return now for new severe one sided pelvic pain or vaginal bleeding

Return now for sudden severe abdominal, back, or chest pain, or new weakness or numbness

Take prescribed pain and nausea medicines as directed

Avoid alcohol until symptoms resolved

Avoid NSAIDs if ulcer or bleeding concern

Follow up with primary care within 24 to 72 hours or sooner if advised

Imaging and lab follow up plan provided if pending results

References

Guidelines and decision tools

References

American College of Radiology ACR Appropriateness Criteria acute nonlocalized abdominal pain 2023

American College of Radiology ACR Appropriateness Criteria right upper quadrant pain 2023

Tokyo Guidelines acute cholangitis and cholecystitis 2018 update

Revised Atlanta classification of acute pancreatitis 2012

Alvarado score appendicitis clinical decision tool

AIR score appendicitis clinical decision tool

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Medical Disclaimer

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Last Reviewed: February 24, 2026 by SymptomDX Medical Team

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

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