 Welcome to the Emergency Medicine Video Series on Approach to Abdominal Pain. We'll divide up the approach into history, physical, investigation, and finally putting it all together. In this part, we'll discuss how to approach abdominal pain by history. There are four elements we want to know about. Where it is, what the onset of the pain was, the course of the pain, and other associated symptoms besides the pain. From these four elements, we will try to piece together the diagnosis we should be working towards. Let's see how we can approach each of these four elements. First, location. We can divide up the abdomen into mainly nine different areas. With the umbilicus right in the middle. We now have the right upper and left upper quadrant, the epigastrium, the umbilicus area, right and left flank. Both of these also include the posterior part, right lower quadrant, left lower quadrant, and the hypogastric area. For each location, we want to discuss the GI causes and the non-GI causes. First, the right upper quadrant. In the right upper quadrant, we have the liver, gallbladder, and the pancreas slightly off to the midline. When we think about GI causes, anything that affects the liver, the gallbladder, and the pancreas will give patients right upper quadrant pain. They include gallstone giving rise to biliricolic, inflammation of the gallbladder, also known as cholecystitis, stone in the common bowel duct, or inflammation of the pancreas or pancreatitis. Inflammation of the liver, or hepatitis, or abscess can give patients right upper quadrant pain as well. Since the duodenum also passes through this area, conditions such as duodenitis and peptic ulcer disease can also give patients pain there. What about non-GI causes? Right on top of the right upper quadrant is the diaphragm in the lungs. Therefore conditions such as pneumonia and pleurofusion can give patients pain in the right upper quadrant. Next is the epigastric area. What lifts here? The stomach, the duodenum, the pancreas behind the stomach. So what should be the GI causes of pain? From the stomach it could be peptic ulcer disease, gastritis, pancreatitis, and duodenitis. What about non-GI causes? What's adjacent to this area? The heart sits right above this area. Therefore any cardiac conditions such as ischemia and MI can produce pain in the epigastric area. Don't be fooled just because the pain is a little lower than expected. Let's move on to the left upper quadrant. What lifts there? The spleen, tip of the pancreas, and part of the stomach. What are the GI causes of pain in this area? Splitting disorders such as infarct or rupture, pancreatitis, or gastritis. What about non-GI causes? Similarly to the right upper quadrant, the lung in the diaphragm sits right above this area. And therefore conditions such as pneumonia and pleurofusion will give pain to the left upper quadrant. What about the umbilical area? What lifts there? Transverse colon, the small bowel. GI causes therefore include colitis, bowel obstruction, perforation. What about non-GI causes? What runs there? Well the aorta runs right there. Therefore any aortic disorder such as dissection or aneurysm can give pain to that area. Interestingly, even though the appendix does not live in this area, early appendicitis can give pain in this area. We'll group right and left flank together. What lifts there? The large bowel. GI causes therefore include colitis, perforation, volvulus, or obstruction. What are non-GI causes? The kidneys and the ureters live right there. Therefore kidney stones or infection can give pain in the flank area. What about the right lower quadrant? What lifts there? Terminal ilium, cecum, and the appendix. The main GI cause is appendicitis. It can also include colitis. What about non-GI causes? What can refer pain to the right lower quadrant? The gynecological tract can refer pain to the right lower quadrant. Therefore ectopic pregnancy, pelvic inflammatory disease, and tubular inapsis can refer pain to the right lower quadrant. In males, testicular disorder can also refer pain to the right lower quadrant. That include torsions, epididomitis, anarchitis. What about the hypogastric area? What lifts there? The small bowel. Therefore conditions giving pain to the area can include obstruction or inflammation. What about non-GI causes? The bladder sits right in this area. Therefore conditions such as cystitis, stones can give pain to this area. Lastly, the left lower quadrant. What lifts there? The descending colon. GI causes can include colitis, diverticulitis. As with the right lower quadrant, there are other conditions that can radiate to this area. In females we need to think about gynecological conditions such as ectopic pregnancy, tubular inapsis. In males we need to think about torsion and infection. We can also approach the pain by how it started. It can be an abrupt onset where the pain peaked instantaneously or gradual when the pain built slowly over time. Disorder that gave patient abrupt pain suggests vascular or obstructive causes. For vascular we want to think about aortic disorders or ischemia leading to infarcts. Obstruction can be in the bilirary tree leading to biliracolic, in the GI tract or in the urinary tract in the case of renal colic. Other non-vascular, non-obstructive causes of pain tend to give an insidious picture. A typical example would be inflammatory condition or an infectious condition where the pain slowly built through time. The next helpful clue in the history is the course of pain. We're interested to know whether the pain is constant over time or colicky in nature. Colicky pain tend to be associated with obstruction. Similar to what we've discussed, it can be obstruction in the bilirary tree, the GI tract or the urinary tract. Next part of the history is associated symptoms. Infectious conditions can have symptoms such as vomiting, diarrhea and fever. They may also have a sick contact history. Inflammatory conditions can be associated with fever. The patient may also give a previous diagnosis of inflammatory diseases. For obstruction in the GI tract, we will see vomiting and decreased or no-flatus. Pain that is worse with movement or cough suggests peritoneal irritation. Other associated symptoms such as urological symptoms, including hematuria, dysuria, suggest a urological cause. While vaginal bleeding or discharge suggests a gynecological cause. In summary, we discussed the approach on history you may wish to take in patients with abdominal pain. We can divide it into location, how the pain started, what is the course of the pain and any other associated symptoms. In part two, we'll discuss how to use our physical examination to narrow down the diagnosis. We hope you find this helpful. Thank you for watching.