DIAGNOSTIC WORKUP

All patients with acute abdominal pain should have a stat, flat, and upright plate of the abdomen, a chest x-ray to rule out pneumonia, an electrocardiogram (EKG) to rule out myocardial infarction, and a complete blood count (CBC), urinalysis, amylase, and chemistry panel. Sometimes lateral decubitus films of the abdomen are necessary to show the step ladder pattern of intestinal obstruction. A pregnancy test is ordered when age and sex dictate it!

When these tests fail to confirm the clinical diagnosis, x-ray contrast studies or ultrasound may be necessary. For example, an intravenous pyelogram (IVP) can be done for a suspected renal calculus. Serial cardiac enzymes may confirm a myocardial infarction. Gallbladder ultrasound can be done to confirm cholecystitis and cholelithiasis. A nuclear scan of the gallbladder with iminodiacetic acid derivatives is very accurate in detecting acute cholecystitis. Ultrasonography may also help diagnose impending rupture of an abdominal aneurysm or ectopic pregnancy. A peritoneal tap may diagnose a ruptured ectopic pregnancy. Laparoscopy should also be considered. A urine porphobilinogen helps exclude porphyria. A double enema may help diagnose intestinal obstruction. A computed tomography (CT) scan of the abdomen is the next logical step.

If the diagnosis remains in doubt, an exploratory laparotomy must be done before the patient’s condition deteriorates. The only case where this might be risky is acute pancreatitis. If this is suspected and the serum amylase is repeatedly normal, a quantitative urine amylase or peritoneal tap may confirm the diagnosis. Endoscopy may need to be done to diagnose a peptic ulcer, gastritis, gastric tumor, or reflux esophagitis. In obscure cases of appendicitis and diverticulitis, a contrast barium enema may help confirm the diagnosis. Angiography can diagnose an aneurysm or mesenteric infarction.

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