Where Do I Start With Abdominal Pain?

Cut to the Chase: General Surgery Survival Series — Post 20

The consult comes in as three words: abdominal pain, evaluate. By the time you reach the floor, the list is already scrolling behind your eyes — appendicitis, cholecystitis, pancreatitis, obstruction, perforation, ischemia, torsion, and ten more you drilled for the boards.

You walk in, ask a few questions, lay a hand on the belly, and then your senior asks what you think. And you hear your own voice go soft somewhere around "well, it could be a lot of things."

The length of that list is the problem, not the solution.

You think you're being asked to name the diagnosis. You're not, not yet. You're being asked to sort the patient, and sorting is a faster, more forgiving skill than solving.

The reason your voice went soft isn't that you don't know enough. It's that you reached for the list when the room was asking you to reach for the patient.

Start with the only question that can't wait: sick or not sick. Look at the person before you look at the chart.

The patient lying dead still, knees drawn up, bracing for the bump of the gurney, already knows movement is the enemy. The one who can't hold still, shifting and hunting a position that never comes, has a hollow organ cramping against something. You can make that read from the doorway, before you've said a word.

The differential can't tell you how much time you have. The patient's face can.

Once you know which clock you're on, let the patient talk. This is where the diagnosis actually lives.

The story provides the diagnosis. The exam and the tests confirm it.

So ask the two questions everyone skips. When exactly did it start, and where has it moved.

Onset speed sorts a belly before any lab does. "It hit me like a light switch" is mechanical: a twist, a rupture, a stone, a vessel that quit. "It built up over the last day" is inflammation, an organ getting angrier by the hour. Same spot on the belly, entirely different problems.

Then ask where it started, not just where it is now. Early pain from a sick organ is vague, dull, and parked in the midline, because the gut localizes poorly and reports to the wrong address.

But the wrong address still has a floor. Early visceral pain lands at one of three points on the midline, and the point tells you which stretch of gut is angry. Foregut — stomach, duodenum, biliary tree, pancreas — refers above the umbilicus. Midgut — small bowel, appendix, right colon — refers to the umbilicus itself. Hindgut — left colon, sigmoid, rectum — refers below it. That's why appendicitis, a midgut structure, opens as a vague ache around the navel long before it finds the right lower quadrant.

When the trouble reaches the peritoneum, the pain sharpens and picks a quadrant. That periumbilical ache hardens into the right lower quadrant over a day. Not two pains. One process, growing up.

A patient who tells you the pain moved and sharpened has handed you the diagnosis. Everything after that is confirmation.

Pain that migrates isn't wandering. It's localizing. The peritoneum has joined the conversation.

The exam isn't where you find the diagnosis — the story already gave it to you. You're palpating to answer one question: soft belly or peritoneal belly. A soft belly, tender in one spot, gives you time to work in order. A rigid one takes it back.

Guarding that softens when you get the patient talking about their dog was voluntary. Guarding that doesn't was never under their control to begin with, and that's peritonitis. Peritonitis is a different pace of day.

Skip the deep rebound press. It's crude and buys you almost nothing. Ask them to cough, or bump the bed — if the whole belly lights up, you have your answer without making anyone earn it in pain.

Rebound is theater. A cough gets you the same answer for free.

I still think about a woman in her seventies, in atrial fibrillation, who rated her pain a ten while her belly felt almost ordinary under my hand. The early labs were clean. The mismatch was the finding.

By the time the lactate climbed, the mesentery had already made its decision, and we were behind it. Pain out of proportion to the exam is not a patient exaggerating. It's the belly telling you the trouble is deeper than the wall you're pressing on.

Pain out of proportion to a benign exam is the loudest quiet finding in surgery. Respect the mismatch in the old, the arrhythmic, and the vasculopath.

And a belly is never a single data point. The exam you did at two o'clock expires. The patient who looked unimpressive at two and peritonitic at six told you more with that trajectory than any single finding could.

When the scan finally loads, you already know from last post what to do: read it with a question already in your head. The bedside builds the short list. The CT confirms it or kills it. It was never going to build the list for you.

A differential is what you recite when you don't yet know what you're worried about. A short list is what you carry when you do.

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What to Read Next: Post 21 — Working Up Appendicitis. You've just built the frame for any painful belly. Next we drop the consult you'll field more than any other into that frame and follow it from suspicion to disposition, without ordering the entire menu.