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488
Clinical Pearls
• The NIH prostatitis classification scheme is useful to cat-
egorize men who present with lower abdominal pain and
irritative or obstructive urinary complaints.
• If acute bacterial prostatitis is being considered, use cau-
tion with digital rectal exam as prostatic massage may
induce bacteremia.
• Chronic prostatitis/chronic pelvic pain syndrome is a diag-
nosis of exclusion and may require a long course of antibi-
otic and a prostate-specific alpha-antagonist.
• Benign prostatic hyperplasia is a common entity among
older men, but clinicians should appreciate that lower uri-
nary tract symptoms may indicate other etiologies like
overactive bladder.
• Prostate cancer screening with serum PSA levels is falling
out of favor among many professional organizations. Be
sure that patients are fully informed about the strengths
and weaknesses of the test.
Don’t Miss This!
• Acute bacterial prostatitis can present with lower abdomi-
nal and pelvic pain.
• Prostatic abscess may be the problem in men who don’t
respond to initial course of antibiotics.
• Sexually transmitted infections like Neisseria gonorrhea,
Chlaymdia trachomatis, and HIV can occur in older men
and should always be part of the differential diagnosis.
• Remember that there are causes of LUTS besides BPH:
overactive bladder, urethral stricture, or bladder
carcinoma.
References
1. Krieger JN, et al. Epidemiology of prostatitis: new evidence for
a world-wide problem. World J Urol. 2003;21(2):70–4.
2. Krieger JN, Nyberg L Jr, Curtis Nickel J. NIH consensus defini-
tion and classification of prostatitis. JAMA. 1999;282(3):236–7.
M. Fried
489
3. Coker TJ, Dierfeldt DM. Acute bacterial prostatitis: diagnosis
and management. Am Fam Physician. 2016;93:2.
4. Holt JD, et al. Common questions about chronic prostatitis. Am
Fam Physician. 2016;93:4.
5. Yoon BI, et al. Acute bacterial prostatitis: how to prevent and man-
age chronic infection? J Infect Chemother. 2012;18(4):444–50.
6. Trinchieri A, et al. Prevalence of sexual dysfunction in men
with chronic prostatitis/chronic pelvic pain syndrome. Archivio
Italiano di Urologia Andrologia. 2007;79(2):67.
7. Payne CK, et al. Interstitial cystitis and painful bladder syn-
drome. J Urol. 2007;177(6):2042–9.
8. Lipsky BA, Byren I, Hoey CT. Treatment of bacterial prostatitis.
Clin Infect Dis. 2010;50(12):1641–52.
9. Rees J, Abrahams M, Doble A, Cooper A. Prostatitis Expert
Reference Group (PERG). Diagnosis and treatment of chronic
bacterial prostatitis and chronic prostatitis/chronic pelvic pain
syndrome: a consensus guideline. BJU Int. 2015;116(4):509–25.
10. Litwin MS, et al. The National Institutes of Health chronic
prostatitis symptom index: development and validation of a new
outcome measure. J Urol. 1999;162(2):369–75.
11. Anothaisintawee T, et al. Management of chronic prostatitis/
chronic pelvic pain syndrome: a systematic review and network
meta-analysis. JAMA. 2011;305(1):78–86.
12. Alexander RB, et al. Ciprofloxacin or tamsulosin in men with
chronic prostatitis/chronic pelvic pain syndrome: a randomized,
double- blind trial. Ann Intern Med. 2004;141(8):581–9.
13. Parsons JK, et al. Prevalence and characteristics of lower
urinary tract symptoms in men aged ≥ 80 years. Urology.
2008;72(2):318–21.
14. McVary KT, et al. Update on AUA guideline on the management
of benign prostatic hyperplasia. J Urol. 2011;185(5):1793–803.
15. D’Silva KA, Dahm P, Wong CL. Does this man with lower
urinary tract symptoms have bladder outlet obstruction? The
rational clinical examination: a systematic review. JAMA.
2014;312(5):535–42.
16. Brown CT, et al. Self management for men with lower uri-
nary tract symptoms: randomised controlled trial. BMJ.
2007;334(7583):25.
17. Nabi G, et al. Anticholinergic drugs versus placebo for overac-
tive bladder syndrome in adults. The Cochrane Library. 2006;
18. Tacklind J, et al. Serenoa repens for benign prostatic hyperplasia.
The Cochrane Library. 2012;
30. Prostate Problems
490
19. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2017. CA
Cancer J Clin. 2016;66:7–30.
20. Schröder FH, et al. Screening and prostate-cancer mortality in a
randomized European study. N Engl J Med. 2009;360(13):1320–8.
21. Andriole GL, et al. Mortality results from a randomized prostate-
cancer screening trial. N Engl J Med. 2009;360(13):1310–9.
22. Wilt TJ, et al. Systematic review: comparative effectiveness and
harms of treatments for clinically localized prostate cancer. Ann
Intern Med. 2008;148(6):435–48.
23. Moyer VA. Screening for prostate cancer: US Preventive
Services Task Force recommendation statement. Ann Intern
Med. 2012;157(2):120–34.
24. Carter HB, et al. Early detection of prostate cancer: AUA
Guideline. J Urol. 2013;190(2):419–26.
25. Delongchamps NB, Singh A, Haas GP. The role of prevalence in
the diagnosis of prostate cancer. Cancer Control. 2006;13(3):158.
26. Baquet CR, et al. Socioeconomic factors and cancer incidence
among blacks and whites. J Natl Cancer Inst. 1991;83(8):551–7.
27. Hamdy FC, et al. 10-year outcomes after monitoring, surgery,
or radiotherapy for localized prostate cancer. N Engl J Med.
2016;375(15):1415–24.
M. Fried
Part X
Gastroenterologic
493© Springer International Publishing AG 2018
E. Sydney et al. (eds.), Handbook of Outpatient Medicine,
https://doi.org/10.1007/978-3-319-68379-9_31
Introduction
Abdominal pain is one of the most common presenting com-
plaints in outpatient medicine and one of the most challeng-
ing. The etiology of abdominal pain may be related to a
structural abnormality of any of the abdominal organs, part
of a more systemic process (e.g., vascular or metabolic), or
referred pain from a non-abdominal structure (e.g., myocar-
dial ischemia, pleuritis). The initial assessment of abdominal
pain involves an assessment of the severity and the timing—
acute versus chronic [1]. There is no clear delineation for
when abdominal pain is considered chronic; processes which
are long-standing yet intermittent, ongoing for months or
years, and/or unchanged and not progressive may safely be
considered chronic. In the primary care setting, in about
Chapter 31
Abdominal Pain
Rosemarie L. Conigliaro and Sreekala Raghavan
R.L. Conigliaro, MD (*)
Department of Internal Medicine, Montefiore Medical Center/
Albert Einstein College of Medicine,
111 East 210th Street, Suite 649 NW, Bronx, NY 10467, USA
e-mail: rconigli@montefiore.org
S. Raghavan, MD
Department of Medicine, Montefiore Medical Center/Albert
Einstein College of Medicine,
111 East 210th Street, Suite 351 NW, Bronx, NY 10467, USA
e-mail: sraghava@montefiore.org
494
one-third of patients with abdominal pain, the underlying
cause is not identified [2]. However, any patient with severe
abdominal pain and/or pain of recent onset requires an
immediate and thorough evaluation.
Key History and Physical Exam
The history is key for the diagnosis of acute abdominal pain;
the most important is the chronological sequence of symp-
toms. Other important information includes a complete
description of the pain including localization, characteriza-
tion, precipitating and relieving factors, and previous epi-
sodes [3]. Additional history should include previous surgeries,
family history, constitutional symptoms, and extraintestinal
manifestations. Finally, a complete medication history, includ-
ing all over-the-counter medications and supplements, should
be obtained, as well as an evaluation for known systemic
diseases and risk factors for such (e.g., cardiac or
pulmonary).
A careful physical exam begins with inspection to assess
the acuity of the pain and if there is evidence of peritoneal
inflammation or irritation. The intensity of the pain is less
helpful in this situation than the fact that the pain is made
worse with any pressure changes in the abdomen, such as
with palpation, coughing, or movement [3]. Thus the patient
with peritonitis will lie quietly, avoiding movement, and will
likely exhibit considerable guarding (tensing of the abdomi-
nal wall musculature) upon examination and rebound ten-
derness. The presence or quality of bowel sounds does not
significantly aid in diagnosis [3], although a completely quiet
abdomen is consistent with severe peritonitis. Otherwise, spe-
cific abdominal signs may be minimal.
Other acute abdominal symptoms may be related to either
complete or partial obstruction of a hollow viscus. This pain
usually comes in waves, intermittently, and thus is referred to
as colicky pain. Patients with colic pain will usually be unable
to sit still and may be restless [3]. This pain may be related to
R.L. Conigliaro and S. Raghavan
495
a gastrointestinal, biliary, genitourinary, or gynecologic pro-
cess, although it may be less well localized than peritoneal
pain and thus more difficult to evaluate.
Additional physical examination findings which may be
helpful include checking for ascites, vascular bruits, organo-
megaly or other masses, Murphy’s sign (inspiratory arrest due
to pain from deep palpation below the right costal margin),
costovertebral angle tenderness, and sensory evaluation and
palpation of the abdominal wall and muscles. All patients
reporting acute abdominal pain should underdo digital rectal
examination with testing for occult blood, and pelvic exami-
nation should be performed in female patients to assess for
pelvic pathology when appropriate.
Laboratory studies which may help determine a specific
etiology include urinalysis, serum bilirubin, transaminase and
lipase levels, and pregnancy testing. Abnormalities of the
leukocyte count, amylase level, electrolytes, and renal func-
tion may indicate severity of illness or degree of hydration
without elucidating any specific diagnosis. Imaging should be
focused and thoughtful and based on clearly delineated dif-
ferential diagnoses.
For acute abdominal pain, delineating the pain as primar-
ily originating from one of the four abdominal quadrants
(right upper, right lower, left upper, left lower) or non-local-
ized pain allows for an initial differential diagnosis (see
Fig. 31.1). Physical examination in patients with abdominal
pain has low specificity and low sensitivity, and few labora-
tory tests are diagnostic; thus the differentiation of causes of
acute abdominal pain may require targeted imaging studies
[1]. Plain radiography may be useful in cases of suspected
bowel obstruction, nephrolithiasis, or foreign body ingestion.
More commonly employed are abdominal computerized
tomography (CT), usually with contrast, or ultrasound, or no
imaging for diagnoses made with alternative testing. CT scan
may detect a cause of abdominal pain in approximately half
of patients; higher yield of CT occurs in the pediatric setting,
in patients with leukocytosis, and with identifying a specified
diagnosis prior to obtaining a CT [4]. In the interest of
31. Abdominal Pain
496
Fig. 31.1 Acute abdominal pain evaluation. (Asterisks) Substitute ultrasound or MRI for pregnant patients with acute
abdominal pain requiring imaging. (Ampersand) Denotes ovarian torsion, ovarian cyst, or ectopic pregnancy. Pelvic
inflammatory disease may be diagnosed by pelvic examination and does not require imaging
Acute abdominal pain
Right upper
quadrant
History, physical,
liver tests,
serologies
Ultrasonography
(with or without
doppler)
Acute cholecystitis
Hepatic abscess
Portal vein
thrombosis
Acute cholangitis
Hepatocellular CA
Non-localized,
midline, epigastric
History, physical,
CBC, electrolytes,
amylase, lipase,
liver tests
Targeted imaging
(Plain films, CT
abdomen/Pelvis
Endoscopy
PUD/gastritis
Pancreatitis
Abd.Aortic
Aneurysm
Bowel ischemia
Hemorrhage
Left upper
quadrant
History, physical,
CBC electrolytes,
urinalysis,
pregnancy test*
Targeted imaging
(Chest x-ray,
ultrasound, CT,
Endoscopy)
Peptic Ulcer/
Gastritis
Splenic pathology
Splenic cell crisis
Adrenal hemorrhage,
infarct
Renal pathology,
Pleural/diaphragm
irritation
Pancreatic
complications
Right lower
quadrant
History, physical,
CBC, electrolytes,
pregnancy test*
CT abdomen/
Pelvis with
contrast
Acute
appendicitis
Ovarian
pathology#
Left lower
quadrant
History, physical
CBC, pregnancy
test*
CT abdomen/
pelvis with
contrast
Diverticulitis
Colitis
Urolithiasis
Ovarian
pathology#
R.L. Conigliaro and S. Raghavan
497
decreasing radiation exposure, magnetic resonance imaging
(MRI) and ultrasound have been utilized more, reserving CT
only for nondiagnostic studies in selected cases.
Chronic abdominal pain requires a different approach (see
Fig. 31.2). The diagnosis of functional disease relies heavily
on the history because there are no characteristic physical or
laboratory findings to aid in diagnosis. Functional conditions
may be identified by their symptomatology, which is usually
vague and insidious, and lack of alarm symptoms (e.g., family
history of gastrointestinal cancer, onset after the age of 55,
weight loss, dysphagia, palpable mass, or evidence of bleed-
ing) [5]. For abdominal wall pain, diagnosis is made by physi-
cal exam; a positive Carnett test, where there is an increase of
palpable pain with tensing of the abdominal wall muscles, is
highly sensitive and specific [6].
Decision-Making/Differential Diagnosis
Patients with right upper quadrant (RUQ) pain with an
enlarged, tender liver on physical examination, jaundice, and
elevated transaminase levels likely have acute hepatitis,
either viral or toxin (e.g., drug or alcohol) induced. Pain may
be accompanied by nausea, anorexia, and fatigue. These
patients do not require further imaging; appropriate serologic
tests can discern the underlying etiology, most commonly
hepatitis A, B, and C, Epstein-Barr virus, cytomegalovirus, or
herpes viruses. Other causes of acute RUQ pain include
hepatic infection with abscess formation, which may be of
pyogenic, parasitic, or fungal origin [7]. Hepatic tumors may
be symptomatic if associated with hemorrhage or rupture.
Vascular causes include portal or hepatic vein thrombosis;
additional physical exam findings may include hepatomegaly,
fever, jaundice, and ascites. Rarely RUQ pain may be caused
by peri-hepatic inflammation usually associated with pelvic
inflammatory disease [7]. In addition to hepatic causes, right
upper quadrant pain may be due to underlying disease of the
gallbladder. Biliary colic, which is not colicky but rather a
31. Abdominal Pain
498
Chronic Abdominal Pain
History and physical
Previous testing and
physical exam normal or
non-diagnostic
Positive Carnett test
History of previous acute
process
Abdominal Wall Pain
Selective EGD, H.pylori
stool Ag, colonoscopy,
TTGA, CRP*
Consider mood disorder
screening (PHQ-9, GAD-7)
History c/w Functional
Dyspepsia, IBS, Functional
Abdominal Pain Syndrome
Consider FMF, AIP,
angioedema,
endometriosis, SMA
syndrome
Functional GI Disorder
Chronic cholecystitis,
pancreatitis, gastritis
CBC, basic metabolic
panel, liver tests
Fig. 31.2 Chronic abdominal pain evaluation. (Asterisks) Based on
symptoms and/or to rule out alternative disorders
R.L. Conigliaro and S. Raghavan