Abdominal Pain Syndrome
Clinical Approach – Diagnosis – Practical Management.
Classification According to Abdominal Segmentation 📚 🚨 RED FLAGS
Rebound tenderness or rigid
abdomen (+)
RIGHT LEFT Severe or progressively
EPIGASTRIUM
HYPOCHONDRIUM HYPOCHONDRIUM worsening pain
Cholelithiasis / Functional Chronic Abdominal distension
chronic cholecystitis dyspepsia pancreatitis Persistent vomiting / absence
Chronic hepatitis Peptic ulcer disease Splenomegaly of flatus
Hepatic abscess Chronic gastritis Splenic flexure Fever ≥ 38 °C
Liver or gallbladder Chronic pancreatitis syndrome (irritable Hypotension or tachycardia
cancer GERD bowel syndrome) Gastrointestinal bleeding,
hematuria, or vaginal bleeding
Poor general condition
MESOGASTRIUM
RIGHT FLANK LEFT FLANK
Irritable bowel
Chronic pyelonephritis
Renal lithiasis
syndrome
Celiac disease
Irritable bowel
syndrome
¿WHEN TO REFER? 🚑
Irritable bowel Intestinal parasitosis Diverticulosis Suspected surgical abdomen
syndrome Abdominal aortic Renal lithiasis Severe, persistent abdominal
Constipation aneurysm (AAA) Constipation pain
Hemodynamic instability,
Persistent vomiting or
intestinal obstruction
RIGHT ILIAC FOSSA HYPOGASTRIUM LEFT ILIAC FOSSA Altered laboratory tests (if
available)
Chronic appendicitis
(rare)
Chronic appendicitis
(rare)
Chronic diverticulitis
Irritable bowel
⚠️Appendicitis, Intestinal
obstruction, Complicated
Crohn’s disease Crohn’s disease syndrome
diverticulitis, Ectopic
Endometriosis Endometriosis Endometriosis
pregnancy, Pancreatitis,
Ovarian cysts Ovarian cysts Ovarian cysts
Complicated ovarian cyst,
Mesenteric ischemia.
📌 Management
OUTPATIENT MANAGEMENT 💊 🩺 MANAGEMENT AT FIRST-LEVEL
REFERRAL
Biliary Colic: No systemic signs, no jaundice, 1. Assess ABCs(Oxygen if desaturation, Two
Right upper quadrant pain < 6 hours, peripheral IV lines if needed)
Postprandial pain after fatty meals. 2. Absolute fasting (NPO) + vital signs monitoring
Management: Metamizole 1 g IV + Scopolamine 3. IV hydration: Normal saline 0.9%: 1–2 L over
20 mg IV + Dimenhydrinate 25 mg IV on IV fluids 30–60 minutes
(0.9% NaCl, 500 mL) 4. Analgesia: Metamizole 10–20 mg/kg IV, Adult
Uncomplicated Renal Colic: Diclofenac 75 mg dose: 1 g IV diluted in 50 mL NS,Alternative:
IM + Oral hydration Paracetamol 1 g IV
Gastroenteritis: Oral or IV hydration (1 L over 1 5. Antiemetics (if significant nausea/vomiting):
hour in adults) + ORS + Probiotics + Hyoscine 10 Dimenhydrinate 1 mg/kg IV/IM (max 50 mg),
mg PO every 8 hours if pain Metoclopramide 10 mg IV
Vomiting Syndrome / Food Intoxication: IV 6. Nasogastric tube(intestinal obstruction,
hydration (1 L over 1 hour) + Dimenhydrinate 50 paralytic ileus, or persistent vomiting)
mg every 8 hours. Clinical observation 7. Suspected abdominal sepsis, Hypotension,
Urinary Retention: Foley catheter placement + fever or hypothermia, tachycardia, altered
Urology referral mental status.Empiric antibiotics: Ceftriaxone
4
Constipation: Oral lactulose + Nutritional and 1-2 g IV ± Metronidazole (intra-abdominal
lifestyle education focus
Clinical Approach – Diagnosis – Practical Management.
Classification According to Abdominal Segmentation 📚 🚨 RED FLAGS
Rebound tenderness or rigid
abdomen (+)
RIGHT LEFT Severe or progressively
EPIGASTRIUM
HYPOCHONDRIUM HYPOCHONDRIUM worsening pain
Cholelithiasis / Functional Chronic Abdominal distension
chronic cholecystitis dyspepsia pancreatitis Persistent vomiting / absence
Chronic hepatitis Peptic ulcer disease Splenomegaly of flatus
Hepatic abscess Chronic gastritis Splenic flexure Fever ≥ 38 °C
Liver or gallbladder Chronic pancreatitis syndrome (irritable Hypotension or tachycardia
cancer GERD bowel syndrome) Gastrointestinal bleeding,
hematuria, or vaginal bleeding
Poor general condition
MESOGASTRIUM
RIGHT FLANK LEFT FLANK
Irritable bowel
Chronic pyelonephritis
Renal lithiasis
syndrome
Celiac disease
Irritable bowel
syndrome
¿WHEN TO REFER? 🚑
Irritable bowel Intestinal parasitosis Diverticulosis Suspected surgical abdomen
syndrome Abdominal aortic Renal lithiasis Severe, persistent abdominal
Constipation aneurysm (AAA) Constipation pain
Hemodynamic instability,
Persistent vomiting or
intestinal obstruction
RIGHT ILIAC FOSSA HYPOGASTRIUM LEFT ILIAC FOSSA Altered laboratory tests (if
available)
Chronic appendicitis
(rare)
Chronic appendicitis
(rare)
Chronic diverticulitis
Irritable bowel
⚠️Appendicitis, Intestinal
obstruction, Complicated
Crohn’s disease Crohn’s disease syndrome
diverticulitis, Ectopic
Endometriosis Endometriosis Endometriosis
pregnancy, Pancreatitis,
Ovarian cysts Ovarian cysts Ovarian cysts
Complicated ovarian cyst,
Mesenteric ischemia.
📌 Management
OUTPATIENT MANAGEMENT 💊 🩺 MANAGEMENT AT FIRST-LEVEL
REFERRAL
Biliary Colic: No systemic signs, no jaundice, 1. Assess ABCs(Oxygen if desaturation, Two
Right upper quadrant pain < 6 hours, peripheral IV lines if needed)
Postprandial pain after fatty meals. 2. Absolute fasting (NPO) + vital signs monitoring
Management: Metamizole 1 g IV + Scopolamine 3. IV hydration: Normal saline 0.9%: 1–2 L over
20 mg IV + Dimenhydrinate 25 mg IV on IV fluids 30–60 minutes
(0.9% NaCl, 500 mL) 4. Analgesia: Metamizole 10–20 mg/kg IV, Adult
Uncomplicated Renal Colic: Diclofenac 75 mg dose: 1 g IV diluted in 50 mL NS,Alternative:
IM + Oral hydration Paracetamol 1 g IV
Gastroenteritis: Oral or IV hydration (1 L over 1 5. Antiemetics (if significant nausea/vomiting):
hour in adults) + ORS + Probiotics + Hyoscine 10 Dimenhydrinate 1 mg/kg IV/IM (max 50 mg),
mg PO every 8 hours if pain Metoclopramide 10 mg IV
Vomiting Syndrome / Food Intoxication: IV 6. Nasogastric tube(intestinal obstruction,
hydration (1 L over 1 hour) + Dimenhydrinate 50 paralytic ileus, or persistent vomiting)
mg every 8 hours. Clinical observation 7. Suspected abdominal sepsis, Hypotension,
Urinary Retention: Foley catheter placement + fever or hypothermia, tachycardia, altered
Urology referral mental status.Empiric antibiotics: Ceftriaxone
4
Constipation: Oral lactulose + Nutritional and 1-2 g IV ± Metronidazole (intra-abdominal
lifestyle education focus
