Approach to Upper Abdominal Pain: The UPPER STOMACH Mnemonic
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Example Case
A male patient presents with abdominal pain that has been worsening over the past 24 hours. Symptoms began yesterday after waking up. Pain at that time was a dull localized pain to the epigastric region. It has since intensified throughout the day today and is now radiating to the back.
He describes the pain as sharp. No specific remitting or exacerbating factors. He has not tried anything for his symptoms. His pain is associated with nausea but no vomiting. He denies fevers, chest pain, shortness of breath, changes to stool, or urinary symptoms.
Abdominal Pain
Not only is abdominal pain a common chief complaint but the list of potential diagnoses is extensive, some of which are life threatening while others can be managed outpatient.
It is important to be able to identify the emergent from the non-emergent causes.
Having a systematic approach to abdominal pain can help ensure that the patient is managed appropriately without missing emergent etiologies.
This post will provide you with the necessary tools to best approach an undifferentiated patient with upper abdominal pain.
Similar to the BREATHE mnemonic used for shortness of breath and the 4-2-1 rule used for chest pain, you will learn an easy method to remember the main emergent causes of upper abdominal pain using a simple UPPER STOMACH mnemonic.
You’ll also learn what questions to ask the patient, what tests to order, what to consider in the differential, and buzzwords for certain diagnoses.
Since abdominal pain is a large topic, we’ll focus on how to approach upper abdominal pain in this post and there will be a future one on lower abdominal pain.
As with the other chief complaint blog topics, the purpose is to help provide a general guide and is not intended to advise on how to definitively manage the patient as every case is going to be different.
Initial Approach
As with any new patient, it is important to begin with a primary survey.
Assess the patient’s airway, breathing, and circulation.
Does the patient look sick or not sick?
Assess the patient’s vital signs upon arrival. If abnormal, begin to consider why. If they are hypotensive start thinking through your different types of shock.
As the primary survey is performed, the patient should be hooked up to cardiac monitor and pulse oximetry.
IV should also be established.
Always consider cardiac etiologies as a potential source to the patient’s upper abdominal pain, and obtain an EKG on arrival if deemed necessary.
Chart Review
If time allows and the patient is stable, then performing a quick chart review of the patient can also be helpful.
Review the patient’s age, sex, past medical history, medications, vital signs, previous abdominal work ups, previous abdominal imaging such as CT abdomen/pelvis, previous EKGs, and previous visits for similar complaints.
A quick chart review may help you understand the patient better prior to entering the room, and it may also drive you to ask more detailed questions about certain diagnoses.
Use caution, however, to not let a chart review bias you or to form premature closure on one particular diagnosis as that could lead to error.
Upper Abdominal Pain Chart Review Considerations
Vital Signs
Age
Sex
Past Medical History, Social History, Family History, Surgical History
Medications
Previous abdominal work up?
Previous CT abdomen pelvis or other abdominal imaging?
Previous EKG?
UPPER STOMACH Mnemonic
Below demonstrates the extensive list of potential diagnoses that can cause upper abdominal pain.
The above list demonstrates how challenging it can be to think of every single diagnosis that could be causing the patient’s upper abdominal pain.
Fortunately, not every diagnosis is life threatening.
Therefore, the first step in every patient with abdominal pain is to rule out or at least consider the emergent causes.
I came up with a simple mnemonic that I will share with you to help you remember the main emergent causes of upper abdominal pain.
The mnemonic is: UPPER STOMACH
That is not to say other causes of abdominal pain cannot become life threatening, but these are the main ones.
It can be stressful wondering if you have thought of every emergent diagnosis and you will always question if you are missing something.
Committing this simple 12 letter mnemonic to memory can help to obviate those doubts.
It helps organize the lengthy differential diagnostic list above, and it will help you to consider the main emergent causes of upper abdominal pain in every patient presenting with this chief complaint.
UPPER STOMACH
Urinary stone/infection
Pulmonary embolism/Pneumonia
Ectopic pregnancy
Really early appendicitis
Stomach perforation or bleed
Twisting bowel (volvulus, ischemic bowel)
Obstruction (bowel, foreign body)
Myocardial infarction
Aortic aneurysm, dissection, or rupture
Cholecystitis/Colangitis
Hepatitis
Upper Abdominal Pain Differential
After the UPPER STOMACH mnemonic has been considered in each patient with upper abdominal pain, then there are many other diagnoses that can cause similar complaints.
It is challenging to remember every single one.
The best way to approach this is to organize the diagnoses into intra-abdominal and extra-abdominal sources, and then go by organ system/body part.
Use information from the history, physical, and work up to support or negate potential diagnoses.
First, consider intra-abdominal organ systems/body parts that could be causing pain: stomach, liver, biliary system, pancreas, spleen, intestines, aorta, kidneys, bladder, appendix, genitourinary, etc.
Next, consider extra-abdominal sources that could be causing referred pain: chest, skin, endocrine, toxidromes, psychiatric, etc.
Of note, since upper abdominal pain can be caused by intrathoracic etiologies as well, I encourage you to apply the 4-2-1 rule of chest pain for a more complete emergent differential.
This is to help ensure you are at least considering as much as possible.
Then once you have obtained your history and physical, you can refine and/or prioritize your differential.
The list below is not meant to be exhaustive, but rather an example on how to organize and think through your differential.
Upper Abdominal Pain Differential = Organize by intra-abdominal and extra-abdominal sources
Intra-abdominal Sources
Stomach - gastritis, GERD, PUD, gastric perforation, foreign body ingestion
Liver - hepatitis, hepatic abscess, Fitz-Hugh-Curtis
Biliary - cholecystitis, biliary colic, cholangitis
Pancreas - pancreatitis, mass
Spleen - splenic infarct, splenic rupture
Intestines - volvulus, obstruction, gastroenteritis, IBD, IBS, mesenteric ischemia
Aorta - aneurysm, dissection, rupture
Appendix - appendicitis
Genitourinary - kidney stone, pyelonephritis, UTI, ovarian/testicular torsion
Extra-abdominal Sources
Chest - ACS, stable angina, pericarditis, myocarditis, pulmonary embolism, pneumonia, pleurisy, pericardial effusion/tamponade, coronary dissection, coronary spasm, endocarditis, esophagitis, achalasia, food impaction, esophageal spasm/perforation
Skin - herpes zoster
Toxidrome - intentional ingestion,
Endocrine - DKA
History of Present Illness
Obtaining a thorough history and having a clear understanding about the onset and nature of the patient’s upper abdominal pain is important as this can help to prioritize your differential.
For example, understanding if the pain is sharp, achy, stabbing, sudden onset, gradual, burning, post-prandial, alleviated with eating, trauma induced, exertional, localized, radiating, etc will all be helpful.
Unfortunately, there is no textbook presentation for any particular cause of abdominal pain, and symptoms can vary and overlap between diagnoses.
However, obtaining a strong history can help to organize and prioritize the differential. At the end of this post there are examples of buzzword associations and presentations commonly tested on exams and boards.
Once you have had the patient provide as much information as they can, then ask any additional questions that may help to refine your differential.
First, focus on any additional questions you may have pertaining to the UPPER STOMACH mnemonic of emergent causes.
Then consider other diagnoses by performing a review of systems and asking questions by organ system.
Lastly, make sure to ask questions about other extra-abdominal diagnoses such as intrathoracic, skin, endocrine, toxidromes, etc.
Physical Examination
Abdominal pain physical examination may include, but is not limited to:
Palpation of all abdominal quadrants, assessment for rebound tenderness or guarding, assessment for intra-abdominal masses, auscultation of the abdomen, auscultation of heart and lungs, assessment for costovertebral angle (CVA) tenderness, assessment of pulses, genitourinary and rectal exam if deemed necessary, and assessment of the skin.
Diagnostic Investigation
Upon completion of the primary survey, history, and physical examination, you will likely have a fairly refined and prioritized differential for the patient’s abdominal pain.
Work up will be based on your differential and will be used to further support or potentially negate the etiologies in your list. Work up considerations include:
Labs
Basic abdominal labs can be considered for a patient with upper abdominal pain such as CBC, chemistry, LFTs, and lipase.
Consider a urinalysis if deemed appropriate.
Pregnancy test should be obtained for females of child-bearing age.
Elderly patients and/or higher risk patients may also benefit from a lactate or coagulation studies.
If there is any concern for sepsis, then blood and urine cultures can also be considered.
In addition to intra-abdominal labs, other extra-abdominal labs should be considered if deemed appropriate.
For example, this could include a troponin or d-dimer if concerned for potential intrathoracic etiologies to their symptoms.
EKG
Consider obtaining an EKG in patient’s with upper abdominal pain, especially if at higher risk for a cardiac etiology.
Imaging
Diagnostic imaging will be dependent on the differential and the case at hand.
Considerations may include CT abdomen/pelvis, abdominal X-ray, RUQ US, aortic US, FAST exam, chest X-ray, CT chest, renal US, etc.
Exam and Board Prep
I want to highlight a few classic presentations and buzzword associations that should trigger you to think of a particular diagnosis either on an exam or practically.
Again, many patients with abdominal pain do not present with the classic textbook symptoms so you must use caution.
For example, burning upper abdominal pain after meals can still be ACS and not GERD/PUD.
However, this section may help you with exam or board prep.
You can also see why it is important to obtain a good history from the patient regarding the nature of the pain as this can help to create a differential.
Conclusion
I hope that helps to organize your approach to abdominal pain.
Start out with that primary survey and a chart review if time allows and the patient is stable.
Remember the UPPER STOMACH mnemonic for the main emergent causes of upper abdominal pain that should always be considered.
Obtaining a thorough history and understanding the nature of the pain can help delineate and prioritize your differential.
Perform a thorough examination.
Work up should be based on ruling out emergent causes and investigating your most likely differential diagnoses.
Lastly, there are keywords and phrases that are commonly tested on exams. Knowing these will help you identify what the examiner is testing you on.
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