Evaluation of chronic abdominal pain

Any change in the description of pain or emergence of new symptoms should alert the physician to an acute-on-chronic condition (e.g., perforation, obstruction, or abscess formation in known Crohn disease) or a new condition that warrants investigation.

Red flags from the history include fever, vomiting, inability to move the bowels (obstipation), involuntary weight loss, early satiety, syncope, concomitant chest or back pain, respiratory distress, and acute vaginal or gastrointestinal bleeding (including coffee-ground emesis or dark black tarry stool).[2]Yarger E, Sandberg K. Updates in diagnosis and management of chronic abdominal pain. Curr Probl Pediatr Adolesc Health Care. 2020 Aug;50(8):100840. https://www.sciencedirect.com/science/article/abs/pii/S1538544220301061?via%3Dihub http://www.ncbi.nlm.nih.gov/pubmed/32859509?tool=bestpractice.com ​​

Fever, tachycardia, tachypnea, and hypotension require urgent evaluation.

Peritonitis or obstruction are the most serious outcomes and require immediate evaluation and intervention. Signs of peritoneal involvement include rebound tenderness and diminished bowel sounds. The location of pain/tenderness can guide diagnosis (e.g., right lower quadrant pain in appendicitis, right upper quadrant pain in acute cholecystitis), but specificity is low.

If features such as abdominal distention, high-pitch/absent bowel sounds, hypertympanic percussion, and palpable abdominal masses are elicited, intestinal obstruction is likely and should be treated immediately.