Abdominal Pain Syndromes

A week never goes by that I do not see at least one patient in my office for abdominal pain. This is a challenging concern because the etiology can range from the minimally significant and self-limited to the life-threatening. Over the years, I have had to evaluate and treat patients with abdominal pain over the telephone, in person, and on video visits; I have cared for individuals with abdominal pain in the office, their home, the nursing home, the urgent care clinic, the emergency department, and the hospital. As I edited this monograph, I thought about some of the hundreds of patients I have treated for abdominal pain—the ones who were particularly sick, those who presented diagnostic challenges, and those with unexpected or unusual etiologies.

A surgeon who reviewed this monograph questioned whether some of the topics discussed were the territory of surgeons rather than family physicians. The case of abdominal pain that sticks with me most was an unassigned admission from the emergency department to our family medicine service. I was the senior resident on service, and we were at the end of a very long day of covering the unassigned admissions. I sent the medical student to talk with the patient while we checked out the rest of the service to night coverage. The medical student returned to present the patient, who was to be admitted to our service for right lower quadrant abdominal pain. The patient had been examined by the emergency medicine attending and the surgical resident, had an unremarkable computed tomography scan, and had laboratory results that were normal other than a borderline elevated white blood cell count. The medical student’s meticulous history and physical findings included notation of a rash. We went to talk with the patient as a team and found a band of vesicular rash on the right lower quadrant and right flank that stopped in the midline. Instead of completing admission paperwork for the patient, we returned them to the emergency medicine attending to discharge home on antiviral therapy and pain medication. This patient with a less common etiology for abdominal pain is always my reminder that even with all the advanced imaging and laboratory testing available to us, a careful history and physical examination are often the most valuable things we can do for our patients.

This monograph reviews the most common causes of abdominal pain, including acute appendicitis, gallstone disease, diverticular disease, and small bowel obstruction and ileus. Each section reviews the epidemiology, pathophysiology, and clinical presentation of the condition. Next, there is a discussion on the laboratory testing and imaging that are used for the condition, with a focus on how family physicians should evaluate patients in an outpatient setting. Finally, the monograph reviews the best evidence on treatment, scenarios in which surgical consultation should be considered, and actions that can be taken to prevent future episodes of abdominal pain and complications.

As family physicians, we see patients with abdominal pain on almost a daily basis. This monograph will give you the information to provide effective, evidence-based care for your patients, whether you are a resident still learning to manage these challenging conditions or, like me, you have been treating these conditions for decades but recognize that the science has moved beyond “the way we have always done it.”

Ryan D. Kauffman, MD, FAAFP, CCFP, Associate Medical Editor
Family Medicine Physician
Erie Shores Family Health Team, Leamington, Ontario, Canada

Katie L. Buel, DO, is an assistant professor of clinical family medicine in the Department of Family Medicine at the Indiana University School of Medicine in Indianapolis. She has a passion for teaching full-scope family medicine, including operative obstetrics, hospitalist care, and outpatient family medicine. Dr. Buel has previously published an article on acute abdominal pain in children in American Family Physician.

Paul T. Mingo, MD, is an assistant professor of clinical family medicine in the Department of Family Medicine at the Indiana University School of Medicine in Indianapolis. He has a full-spectrum practice including hospitalist care, outpatient care, and low-risk obstetrics. Dr. Mingo has a passion for medical education and has previously published an article on acute abdominal pain in children in American Family Physician.

Disclosure: It is the policy of the AAFP that all individuals in a position to control CME content disclose any relationships with ineligible companies upon nomination/invitation of participation. Disclosure documents are reviewed for potential relevant financial relationships. If relevant financial relationships are identified, mitigation strategies are agreed to prior to confirmation of participation. Only those participants who had no relevant financial relationships or who agreed to an identified mitigation process prior to their participation were involved in this CME activity. All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose.

• Manage patients with low, intermediate, and high risk of acute appendicitis.
• Choose laboratory testing and imaging to evaluate a patient at intermediate risk for acute appendicitis.
• Select the appropriate workup for patients with biliary colic.
• Counsel patients about the risks and benefits of laparoscopic cholecystectomy.
• Choose appropriate laboratory testing and imaging to evaluate a patient with suspected acute appendicitis.
• Recommend appropriate follow-up care, including screening and surgical consultation, for patients who have had an episode of diverticulitis.
• Diagnose small bowel obstruction.
• Counsel patients about lifestyle modifications that reduce their risk of postoperative ileus.