Abdominal Pain Differential

Abdominal pain is a symptom produced by many systems, not a diagnosis waiting to be named. The same epigastric pain may arise from pancreatitis, perforated ulcer, myocardial ischemia, or an aortic catastrophe. Right-lower-quadrant pain may reflect appendicitis, ureteric colic, ileitis, ovarian disease, or ectopic pregnancy. Location narrows the field; it does not close it. The first clinical task is to identify threats to perfusion, the peritoneum, the gastrointestinal tract, and pregnancy. The second is to use the history and examination to estimate probability. Testing should then answer a specific question, not substitute for thinking. An experienced clinician notices trajectory early: pain that is rapidly intensifying, a patient becoming quieter or less interactive, new tachycardia, reduced urine output, or increasing tenderness may matter more than one reassuring initial value. Analgesia belongs in the initial plan. Early opioid analgesia does not make the physical examination unreliable or increase diagnostic error, so withholding pain relief until a diagnosis is established is not evidence-based. Give analgesia, document the pre-treatment examination, and reassess the patient’s physiology and abdominal findings as the workup proceeds.