Upper Abdominal Pain in the Emergency Department

Critical Diagnoses of Upper Abdominal Pain


  • Work-up for upper abdominal pain begins with resuscitation and exclusion of critical diagnoses
  • Then, through a detailed history and physical, consider all the causes of upper abdominal pain (see below)
  • The differential may then come down to Gallstone etiology vs Gastritis/PUD → will need further imaging based on suspicion (US abdomen)


  • IV/O2/Monitor, IV Fluids, Labs as needed, pregnancy test

Rule Our Critical diagnoses of Upper Abdominal Pain:

Emergent Gastrointestinal ( GI ) Causes of Upper Abdominal Pain

1. Billiary Tract Disease


  • The goal is to find the location of the stone and its associated complications → Is it still in the gallbladder (symptomatic cholelithiasis), in the cystic duct (cholecystitis), or in the CBD (choledocholithiasis, gallstone pancreatitis, ascending cholangitis)


  • Prevalence of 10% in US, usually asymptomatic (symptoms develop in 2%/yr)


  • Symptomatic cholelithiasis → obstruction of cystic duct by gallstones
  • Clinical: Episodic pain in Right Upper Quadrant (RUQ), minutes to hours, resolves spontaneously
    • Precipitated by meals/fatty foods
  • Treatment: Recurrent biliary colic → pain control, elective outpatient cholecystectomy


  • Clinical (vs biliary colic, may be difficult to distinguish)
    • Pain longer in duration (>6 hours), localizes to RUQ, ↑ N/V/F (more nausea, vomitus)
    • Murphy’s sign:
      • Localized peritonitis over gallbladder → arrest of inspiration on gallbladder palpation with pain
      • Highest LR+ of PE/lab values
      • Diminished in elderly
  • Course
    • 1/3 will worsen→ complications (cholangitis, perforation)
    • 1/2 will improve spontaneously (7-10days)
  • Laboratory: ↑ WBC, mild ↑ LFTs
  • Radiology
    • RUQ U/S (sensitivity 84-97%, specificity up to 100%)
    • Findings: Gallstones, pericholecystic fluid, gallbladder wall thickening (>3mm), sonographic Murphy’s
    • HIDA scan: non-visualization of contrast in gallbladder (cholecystitis) or intestine (choledocholithiasis)
  • Treatmentof Cholecystitis
    • NPO/IVF/Abx (antibiotics) (broad spectrum)
    • Semi-urgent Cholecystectomy, laparoscopic (at 24-48h) with CBD exploration or ERCP if CBD stone of concern
  • Complications of Cholecystitis: gallbladder perforation, emphysematous cholecystitis, gangrenous cholecystitis, cholangitis, gallstone ileus


  • Define: Gallstone lodged in common bile duct
  • Clinical: similar presentation to cholecystitis except elevated LFTs (↑Alk Phos, ↑T. Bili)
  • Radiology: RUQ U/S
    • Dilated CBD (>6mm)
    • Common bile duct stone?
  • ERCP
    • Diagnose and treat common duct stones (with sphincterectomy)
    • R/O other causes of obstruction (tumors…)


  • Elevated amylase, lipase
  • ERCP to decompress biliary tree


  • CBD obstruction causing infection proximal to obstruction → sepsis (↑ mortality)
  • Charcot’s triad (RUQ pain, fever, jaundice)
  • Reynold’s pentad (Charcot + hypotension + AMS)
  • Treatment
    • Conservative (NPO, IVF, broad-spectrum Abx → elective ERCP at resolution)
    • If failure of conservative tx (15%)→ emergent surgery (Percutaneous vs ERCP)

2. Acute Pancreatitis

Etiology of Acute Pancreatitis:

  • Gallstones (35%), Alcohol (30%)
  • Idiopathic (10%),ERCP complications (4%), Tumors, Drugs (furosemide, sulfa, thiazides, valproate, tetracyclines…), infection (viral, mycoplasma), blunt trauma (1.5%), scorpion, hypercalcemia, elevated triglycerides ( hypertriglyceridemia )

Symptoms and Signs of Acute Pancreatitis

  • Epigastric pain radiating to back
  • Nausea/ Vomitus /fever, +/- jaundice
  • Abdominal tenderness / guarding, Cullen’s (peri-umbilical ecchymosis), Gray Turner’s (flank bruising)

Diagnosis of Acute Pancreatitis:

  • Lipase
    • Levels peak (12-36h), duration (2 weeks)
    • Test of choice, better sensitivity and specificity over amylase → lipase level 3x normal, more specific
    • If high suspicion for pancreatitis and lipase negative → CT scan
    • Level of lipase not predictive of severity of pancreatitis
  • Amylase
    • Less specific, duration (1 week)
    • Not used: many false positives and false negatives
    • Many sources: bowel, uterus, pancreas
    • Amylase: level 3x normal, not specific
  • CT A/P
    • Unsure of diagnosis (high index of suspicion and lipase low)
      • Will see acute and chronic changes on CT
    • Rule out surgical issues
    • Staging system (Balthazar) → help stage and predict which patients will develop severe complication: necrotizing pancreatitis (Radiology 1994;193(2):297)
  • RUQ U/S → diagnose gallstone pancreatitis
Ranson’s criteria
Ranson’s criteria

Treatment of Acute Pancreatitis

  • Resuscitation
    • NPO / bowel rest / IVF/ NG suction
    • Fluid resuscitation (up to 10L/day → maintain adequate UOP)
  • Antibiotics
    • Meta-analysis→ prophylactic antibiotics for necrotizing pancreatitis decreased sepsis
    • and mortality
    • Save for sickest pts → Imipenem/meropenem (Ann Surg. 2006;243(2):154)
  • Necrotizing Pancreatitis
    • Antibiotics (Imipenem), CT A/P, Urgent surgical consultation, ICU
    • Fluid collections→ CT or U/S guided drainage
    • Infected pancreatic collections →benefit from early surgery
  • Gallstone Pancreatitis
    • RUQ US to diagnose
    • MRCP if not sure of obstructive etiology
    • Treatment: ERCP (but may cause pancreatitis)

Complications of Acute Pancreatitis

    • Pancreatitis → necrosis/liquefaction of tissue → local/systemic complications
    • Greatest life-threatening complication of pancreatitis (mortality up to 50%)
    • Predisposes to sepsis, multi-organ failure and death
    • Predictive factors:
      • Hemorrhage? (Gray-Turner, Cullen’s→ delayed 48h),
      • Pancreatic enzymes (low levels more consistent with necrosis),
      • ↑ Severity of pancreatitis (↑ Ranson’s)
        • i. Hemoconcentration: Hct >47% at 48h has high sensitivity and may need CT early in course (Am J Gastroenterol 1998;93:2130-4)
    • Treatment
      • ✓ Antibiotics (Imipenem), CT A/P, Urgent surgical consultation, ICU
      • ✓ Fluid collections→ CT or U/S guided drainage
      • ✓ Infected pancreatic collections → benefit from early surgery
    • Drainage → >6cm after 6 wks observation, or causing sx (abd pain, gastric outlet obstruction, biliary obstruction)
  • Other
    • ↓ Ca, ↑ glucose, ↑ TG, GI hemorrhage, ascites, pleural effusion, ARDS, renal failure

3. Gastritis , GERD , Peptic Ulcer Disease


  • If patient stable→ often considered default diagnosis when work-up negative and excluded lifethreats (MI, perforation…)
  • Empiric therapy given with abdomen re-check


  • GERD: Heartburn, atypical angina, water brash, cough
  • Gastritis: Asymptomatic vs epigastric pain, N/V, anorexia
  • PUD: Epigastric pain relieved (duodenal) or worsened (gastric) by food; back pain & ↑ lipase (post perforation)


  • Lifestyle change (↑ Head of bed), stop precipitants (NSAIDS / alcohol)
  • H. Pylori treatment, antacid / H2 blocker / PPI


  • Peptic Ulcer Disease:
    • Hemorrhage, Perforation, Intractable pain, Obstruction
    • Posterior perforation → may present like pancreatitis (back pain, ↑ enzymes, vomiting…)

Other Causes of Upper Abdominal Pain

  • Consider other causes above and below the area of tenderness
    • Acute hepatitis, liver abscess, appendicitis, splenic infarct/aneurysm (L sided pain), MI, lower lobe pneumonia