Stomach Pain - What's Urgent and What's Not, a Doctor's Thought Process

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Stomach Pain - What's Urgent and What's Not, a Doctor's Thought Process

Read what a doctor thinks about when you walk in with abdominal pain.

Posted on May 24, 2017 by Team Medicine after an interview with Dr. Daniel King, MD, PhD

First thoughts when a patient walks in with abdominal pain

Pain location

Tests ran after initial questioning

Signs of Emergency

Non-emergent situations

Additional fun fact from Dr. King

First thoughts when a patient walks in with abdominal pain

What do you think about first when a patient walks in with abdominal pain?

First it depends on who the patient is. My first thoughts are what's the patient's age, and gender and where is the abdominal pain? These are the sorts of things that start to shape my suspicion on what's likely going on.

Mid 20's female with nausea

So for example, if the patient is a young lady in her mid 20's who's complaining about abdominal pain, nausea and vomiting, the first thing that comes to my mind is that she's pregnant. I would want to rule out [pregnancy] right away. You can do that with a urine test or blood test to make sure the woman is not pregnant.

Other things that first come to mind are what's associated with the stomach pain. So, for example, is the abdominal pain associated with diarrhea? If so, that brings into play a whole host of infectious kinds of virus, for example, viral gastroenteritis or norovirus like the cruise ship virus. Those are the kinds of things that come to mind immediately.

Older woman with skin changes

If the patient is an older woman in her 70's or 80's and she also has irregular heart beat with skin changes, then I would start to think it's something vascular. In other words, I would be thinking about things like venous ischemia or Ischemic Colitis.

Alcoholic history

If the patient has a heavily alcoholic history, then I start to think about alcoholic gastritis as the cause of abdominal pain.

Bloody diahrrea

If the patient is a mid-aged and has some blood in his or her diarrhea, then I might also think of Inflammatory Bowel Disease

Kidney stone

Abdominal pain can also be due to kidney stones. If so, I would be asking if the pain is very severe, in the back, and travels down to the groin. I also ask if the patient has seen blood in the urine. Those would make me think of kidney stones

Stomach ulclers

Ulcers in the stomach can cause severe abdominal pain and people often have a history of ulcers.

Not stomach related but manifests as stomach pain

Sometimes, people can have stomach pain that isn't caused by the stomach. For example, lower pneumonia can manifest as stomach pain. Exertionary heart pain i.e. angina sometimes manifests as gastric discomfort but are actually two different things.

In all, abdominal pain could be caused by one of many and it depends on the symptoms. But those are what I think first.

What factors give you the most clue about what's going on?

Pain location and natural of the pain are the first things and then it's the symptoms that are also associated with the abdominal pain. What else is going on? Diarrhea? Nausea and vomitting? Chest pain?

Pain location

Right upper quadrant abdominal pain

Right upper abdominal pain, where the liver and the gallbladder is located, tells me that the patient may have liver problems like hepatitis or gallbladder problems.

Upper middle quadrant abdominal pain

If it's epigastric pain (upper central region of the abdomen), then I would think more pancreatitis, gastric ulcer or gastritis.

Belly button or right lower quadrant

If the pain is toward the belly button, I start to think about appendicitis, which is also lower right stomach pain. In that case, the pain that starts from the belly button and radiates toward the right lower side. That's a typical sign of appendicitis.

Lower than belly button

Then I think about urinary infections. Especially if the pain is in the groin area, I think about ovarian cysts or other pregnancy related causes.

Diffuse pain that's all over

That could be more like intestinal ischemia, Colitis or diverticulitis.

Tests ran after initial questioning

What do you look for next after going through the thinking described so far

After the initial questioning, I might start to look at the vital signs of the patient. For example, I would want to make sure that there is no fever because if there's fever, that might suggest something infectious or catastrophic. I would order a CBC test to look at the white blood cell count to see if there is an infection. Then I would ask for tests on the pancreas, gallbladder, and liver to make sure there are no problems there. Depending on the situation, I can also ask for a beta-hCG test which is a pregnancy test or look at the lactate level which is to detect ischemia.

Depending on the tests, the treatment options would then vary accordingly.

Signs of Emergency

What symptoms would prompt you to ask the patient to go to the emergency room?

It's hard to say exactly but here are a couple of things that would indicate an emergency off the top of my head. This is not exhaustive.

Large amount of blood

If there is a large amount of blood seen in the toilet bowl or vomiting blood would be an emergency. Anyone with something like that should come straight away.

Severe nausea

Patients who have such bad nausea that they are not able to eat or take essential medications. They should come right away.

Very high fever

Patients who have an extremely high fever between the range of 102 to 103 or above with abdominal pain should come straight away.

Vaginal bleeding in pregnancy

Patients with severe abdominal pain and vaginal bleeding should come to the ER right away.

A history of heart attack

Patients who have had a heart attack and is now experiencing epigastric pain (upper central abdominal pain) should come immediately.

Non-emergent situations

Diarrhea and vomitting

First, absence of the above symptoms would make me feel better about the patient's situation. In addition, diarrhea in itself is not an emergency but is actually quite common. People get diarrhea from infections all the time. Even diarrhea with vomitting in itself, limited to one or just a few episodes, is not an emergency. They are something you could wait until the next day to visit an urgent care clinic rather than coming into the ER.

Additional fun fact from Dr. King

Any fun facts that the average person wouldn't know that's related to the abdomen?

One thing that's interesting and most people don't know is how much intestines we have in our belly. Even though our belly is a small area, our intestines measure 25 feet long from beginning to end, and since they are lined with a multitude of absorptive pockets, its surface area is about the same as a tennis court! While all these cells enable remarkable absorptive capacity, all these cells can sometimes go haywire and result in various disease states, like colon cancer.

Disclaimer: The article does not replace an evaluation by a physician. Information on this page is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes.
Buoy Health | Dr. Daniel King, MD, PhD

Dr. Daniel King, MD, PhD

Internal Medicine at Columbia University New York - Presbyterian Hospital

Dr. King received his MD at Wayne State University and a PhD at the University of the Cambridge. He is now a second-year resident in Internal Medicine at Columbia University's New York - Presbyterian Hospital and will be going to Stanford University for a fellowship in Oncology.

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