Broadening the scope of abdominal pain beyond the intraabdominal reminds us that the clinical focus of the ED physician is quite different from that of his or her surgical colleagues. Surgeons, quite appropriately, approach abdominal pain seeking a binary answer to the question "Does this patient need an operation?" ED physicians, in contrast, must first identify sick or possibly sick patients as early as possible in the course of their illness. Once this determination is made clinically, the ED physician must rapidly decide which additional diagnostic tests, if any, are needed. Although ED physicians may quickly arrive at the same dichotomous question as their surgical counterparts, because they encounter undifferentiated abdominal pain, they must first cast a much broader net that considers causes located both within and outside of the abdominal cavity.
Finally, nonspecific abdominal pain (NSAP), which is the most common "cause" of undifferentiated abdominal pain among ED patients, is listed as a third category. NSAP stands alone since it is unknown to what extent it may represent an underlying intra- versus extraabdominal problem.
ABDOMINAL TOPOGRAPHY By combining the four-quadrant approach traditionally used by U.S. physicians with selected aspects of a strategy widely employed throughout Europe and Asia,1 a simple model of abdominal topography can be developed. In addition to the standard four quadrants—right upper quadrant (RUQ), right lower quadrant (RLQ), left upper quadrant (LUQ), and left lower quadrant (LLQ)—this model includes four areas of the abdomen that are not discrete but rather constitute combinations of all or part of two or more quadrants: (1) upper half of abdomen (UHA), which includes an area of pain as small as the midepigastrium or as large as the RUQ plus LUQ combined; (2) lower half of abdomen (LHA), which similarly includes an area of pain as small as the midhypogastrium or as large as the RLQ and LLQ combined; (3) central (CTL), which includes an area of pain comprising the centermost "quarters" of all four discrete quadrants, such that carving out these areas from each quadrant defines a periumbilical or "central" quadrant and (4) generalized (GEN), which includes poorly localized pain encompassing much or perhaps most of the abdomen, including at least some portion of all four discrete quadrants.
This topographic configuration is particularly relevant to the broad spectrum of undifferentiated abdominal pain seen in emergency practice. It incorporates both the early (visceral, poorly localized) and late (parietal, better localized) pain of an evolving intraabdominal pathologic process, as well as the more generalized pain associated with toxic-metabolic derangements.
Of greater importance, however, is the inherent limitation in any approach to abdominal pain that relies principally on abdominal topography. Following the first critical examination of the association between the location of overlying pain/tenderness and underlying surgical disease, Staniland and colleagues concluded that "the most striking feature" of their findings was the observation that "the 'stereotype' site of pain is seen to be little more than an approximate guide to the diagnosis of the disease concerned [italics added]."6 Their seminal observation that about one-third or more of cases of abdominal pain that come to operation present in a fashion that clinicians mistakenly regard as "atypical" may represent the largest single reason that the error rate in the clinical diagnosis of abdominal pain is so high. A corollary to this is that one cannot exclude a particular diagnosis based solely on the location of abdominal pain or tenderness.
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