Common Symptoms
Abdominal Pain
Undifferentiated abdominal pain is one of the highest-stakes outpatient complaints when the diagnosis isn't yet clear. Before you commit to a working diagnosis, you have to rule out the surgical and vascular catastrophes that look benign at first — appendicitis, bowel obstruction, mesenteric ischemia, ruptured AAA, perforated viscus, ectopic pregnancy. This page provides a structured first-pass approach: red flags that demand same-day imaging or transfer, the minimum safe workup (focused history, vitals, full abdominal exam, urine pregnancy, lactate when available), what can be safely managed outpatient with a return plan, escalation criteria, documentation under uncertainty, and explicit safety-net return precautions. Written for NPs, PAs, and MDs caring for older adults and adults with complex presentations.
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Common Symptoms
Abdominal Pain
Why this symptom matters
Abdominal pain is pattern-driven. ACR Appropriateness Criteria pick imaging by location, severity, fever, and exam findings — not by reflex. Match the workup to the presentation.
What must I not miss first?
- Appendicitis
- Bowel obstruction or perforation
- Mesenteric ischemia (pain out of proportion to exam, AFib, vascular disease)
- Ectopic pregnancy / ovarian torsion
- AAA rupture (older male, back/flank pain, hypotension)
- Cholecystitis / cholangitis / pancreatitis
- Sepsis from intra-abdominal source
- GI bleed
Red flags — escalate or work up urgently
- Peritoneal signs (rigidity, rebound, guarding)
- Hemodynamic instability or fever
- Pain out of proportion to exam
- Intractable vomiting or obstipation
- GI bleeding, hematochezia, melena, hematemesis
- Pregnancy with abdominal pain and bleeding
- Immunocompromise, recent surgery, anticoagulation
- Older adult with new severe pain
Minimum safe first-pass workup
- Vitals + abdominal exam (location, peritoneal signs, masses, hernias)
- Pregnancy test in reproductive-age women — always
- UA if GU symptoms or flank pain
- CBC, CMP, lipase if pancreaticobiliary suspected
- Imaging: pattern-driven (RUQ ultrasound for biliary; CT for suspected appendicitis/obstruction; bedside US for AAA in older male)
- ECG if upper abdominal pain in older adult or cardiac risk factors
What can usually be managed outpatient
- Mild gastroenteritis with normal vitals and tolerating PO
- Stable functional / IBS-pattern pain with reassuring exam
- Constipation with benign exam responding to bowel regimen
- Uncomplicated GERD or known PUD
When to escalate to ED / higher level of care
- Any peritoneal sign or hemodynamic change
- Suspected surgical abdomen, ectopic, torsion, AAA, or ischemia
- Pregnant patient with significant pain
- Severe pain in immunocompromised or post-op patient
- Inability to tolerate PO or signs of obstruction
What to document when the diagnosis is still uncertain
- Location, onset, character, radiation, associated GI/GU/GYN symptoms
- Surgical abdomen considered and exam findings
- Pregnancy test result if relevant
- Why specific imaging was or was not chosen
Safety-net & return precautions to give
- Return or go to ED for severe worsening pain, persistent vomiting, fever, blood in stool/vomit, fainting, or inability to pass stool/gas.
- Return for pregnancy concerns or vaginal bleeding.
- Follow up in [X days] if pain persists.
Educational guidance for clinicians. Not a substitute for clinical judgment. Always individualize to the patient and your local resources.
Evidence sources
- · ACEP Clinical Policies
- · AAFP Abdominal Pain Workup references
Review status
Last reviewed: 2026-04
Reviewed by the MyClinicianGuide editorial team. Cadence: annual.
Educational reference for licensed clinicians (NP, PA, MD, DO). Not a substitute for clinical judgment, institutional protocols, or specialty consultation. Apply in context of the full clinical picture, patient goals, and current standards of care. See About AI guidance for AI-related limitations.
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