symptom.abdominal_pain.ed.v1PRODUCTION

symptom.abdominal_pain.ed.v1

Abdominal pain (ED workup)

symptomacuteundifferentiatedadult

Hard-required inputs

0 / 28

Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Pain onset, location, quality; "worst-of-life" flag; hemodynamic state; pregnancy status anchor (Brun 2016)

Inputs

Actions

Advance rule

Set

Advance when

pain characterized + life-threat screen run

Severity triggers (13)

13 need judgement

informationallife_threateningaaa_leak_pattern
Flank or abdominal pain + hypotension + pulsatile abdominal mass + age >65 (especially male smoker with vascular risk) — STAT CTA aorta if hemodynamically stable, OR direct if not (Sakalihasan PMID 15866312)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningmesenteric_ischemia_pattern
Pain out of proportion to exam + AF or atherosclerotic risk + elevated lactate >2 (often >4) + metabolic acidosis — STAT CTA mesenteric (Kärkkäinen 2016 PMID 40513642)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningperforated_viscus
Sudden-onset severe abdominal pain + peritonitis (rigidity, rebound, guarding) + free air on upright CXR or CT — immediate surgical consult (Brun 2016)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningruptured_ectopic
Positive β-hCG + abdominal pain + hypotension + free fluid on FAST or pelvic US — emergent OR (Brun 2016)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningthoracoabdominal_dissection
Tearing thoracoabdominal pain + BP differential between arms >20 mmHg + risk factors (HTN, Marfan, bicuspid AV, prior dissection, pregnancy) — STAT CTA chest/abdomen (AHA 2022)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereovarian_torsion
Sudden unilateral pelvic pain + nausea + adnexal mass on US + decreased or absent Doppler flow — emergent OR (Brun 2016)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveretesticular_torsion_referred
Sudden lower abdominal or scrotal pain + high-riding/horizontal lie testis + negative cremasteric reflex (referred abdominal pain in 25%) — emergent urology / OR within 6 h salvage window
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereacute_cholangitis_charcot_reynolds
Tokyo 2018 cholangitis criteria — Charcot triad (fever + jaundice + RUQ pain) or Reynolds pentad (+ hypotension + AMS); severity grade I/II/III (PMID 29032610)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveresevere_acute_pancreatitis_bisap_atlanta
Atlanta 2012 pancreatitis (2 of 3: epigastric pain radiating to back + lipase >3× ULN + cross-sectional imaging) + BISAP ≥3 OR persistent organ failure >48 h (PMID 23100216)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereseptic_abdomen_qsofa
Intra-abdominal infection suspected + qSOFA ≥2 OR lactate >2 OR SBP <100 → sepsis pathway (SSC 2026)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereacs_equivalent_epigastric
Epigastric pain in elderly (>60) or diabetic + nausea/diaphoresis ± dyspnea + abnormal ECG or hs-cTn — atypical ACS presentation (Gulati 2021 PMID 34709879)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverecirrhotic_decompensation_overlay
Known cirrhosis + new abdominal pain + ascites tenseness + fever or AMS — SBP / variceal bleed / portal vein thrombosis (Brun 2016)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderateappendicitis_alvarado_ripasa
Migratory RLQ pain + anorexia + nausea + RLQ tenderness + rebound + leukocytosis + low-grade fever — Alvarado ≥7 or RIPASA ≥7.5 → high probability; CT or surgical consult (PMID 32468754)
Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONoptionalDrives risk stratification

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Recommended regimen

ed playbook — drug actions (6)

1. isotonic crystalloid
LR 30 mL/kg over 1-3 h for sepsis/pancreatitis OR 1-2 L bolus for volume depletion • IV • titrate to MAP ≥65 + lactate trend
trigger: Sepsis screen positive OR hypotension OR severe pancreatitis (BISAP ≥3)
SSC 2026 — LR preferred (less hyperchloremic acidosis); 30 mL/kg crystalloid in 1-3 h for sepsis-induced hypoperfusion
2. morphine OR fentanyl
Morphine 4-8 mg IV OR fentanyl 25-50 mcg IV • IV • q15-30 min PRN
trigger: Moderate-severe pain (NRS ≥4)
Pines AAP 2007 PMID 17636812 — early opioids do NOT mask surgical exam; pain control improves clinical assessment + patient experience
3. ondansetron
rxcui 26225
4-8 mg IV • IV • q6-8h PRN
trigger: Nausea or vomiting
First-line ED antiemetic; QT-monitoring if other QT-prolonging agents
4. piperacillin-tazobactam
rxcui 74169
4.5 g IV • IV • q8h (loading; renal dose adjust)
trigger: Suspected intra-abdominal sepsis: cholangitis (Tokyo grade II/III), perforation, diverticulitis with abscess, complicated appendicitis, secondary peritonitis
IDSA 2010 IAI + Tokyo 2018 — broad-spectrum gram-neg + anaerobe coverage; add vancomycin if MRSA risk; add antifungal if perforation + immunocompromised
5. pantoprazole IV
rxcui 40790
40 mg IV • IV • daily; transition PO when tolerating
trigger: Suspected PUD / GI bleed overlay (epigastric pain + melena/hematemesis)
PPI for suspected upper GI bleed pending EGD; if variceal source suspected, switch to octreotide + route to gi.variceal_bleed.v1
6. esmolol or labetalol
Esmolol 500 mcg/kg bolus then 50 mcg/kg/min; labetalol 10-20 mg IV • IV • titrate HR <60 + SBP <120
trigger: Suspected thoracoabdominal aortic dissection / AAA — impulse control FIRST per AHA 2022
AHA 2022 Acute Aortic Disease — beta-blocker before vasodilator to reduce dP/dt; route to cardio.aortic-dissection.core.v1 or vasc.aaa.v1

Auto-drafted A&P note

Subjective

- Possible entry pathways: Acute abdominal pain presenting to ED — drives quadrant-anchored differential (Brun review PMID 35543712); RUQ pain — cholecystitis / cholangitis / hepatitis (Tokyo 2018 cholangitis PMID 29032610); RLQ pain — appendicitis / tubo-ovarian / hernia (Alvarado/RIPASA PMID 32468754).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Abdominal pain (ED workup)** (symptom.abdominal_pain.ed.v1).
Phenotype framing: Quadrant-anchored ddx with pre-test priors: appendicitis (RLQ adults ~5-10%, kids 20-30%), cholecystitis (RUQ middle-aged ~20%), pancreatitis (epigastric ~15-20%), SBO (post-surgical diffuse ~10-15%), diverticulitis (LLQ >50 ~10-15%), mesenteric ischemia (>60 with AF ~5-10%), AAA (flank >65 ~1-3%), ectopic (pregnant pelvic ~5%), ovarian torsion (~1-5%), nonspecific (~30-40%) (Brun 2016)
Scope: Pain onset, location, quality; "worst-of-life" flag; hemodynamic state; pregnancy status anchor (Brun 2016)

No severity triggers fired against current inputs.

Plan

No regimen axis selected (engine has no regimen_axes or could not match).

Setting playbook (ed) — Quadrant-anchored triage; rule out life-threats (AAA leak / mesenteric ischemia / perforation / ruptured ectopic / torsion / cholangitis / septic shock / ACS-equivalent); risk-stratify pancreatitis (BISAP / Atlanta 2012) + cholangitis (Tokyo 2018) + appendicitis (Alvarado/RIPASA); disposition (OR / admit / observation / discharge with PCP follow-up) (Brun 2016 PMID 35543712)
1. isotonic crystalloid LR 30 mL/kg over 1-3 h for sepsis/pancreatitis OR 1-2 L bolus for volume depletion IV titrate to MAP ≥65 + lactate trend — Sepsis screen positive OR hypotension OR severe pancreatitis (BISAP ≥3) (SSC 2026 — LR preferred (less hyperchloremic acidosis); 30 mL/kg crystalloid in 1-3 h for sepsis-induced hypoperfusion)
2. morphine OR fentanyl Morphine 4-8 mg IV OR fentanyl 25-50 mcg IV IV q15-30 min PRN — Moderate-severe pain (NRS ≥4) (Pines AAP 2007 PMID 17636812 — early opioids do NOT mask surgical exam; pain control improves clinical assessment + patient experience)
3. ondansetron 4-8 mg IV IV q6-8h PRN — Nausea or vomiting (First-line ED antiemetic; QT-monitoring if other QT-prolonging agents)
4. piperacillin-tazobactam 4.5 g IV IV q8h (loading; renal dose adjust) — Suspected intra-abdominal sepsis: cholangitis (Tokyo grade II/III), perforation, diverticulitis with abscess, complicated appendicitis, secondary peritonitis (IDSA 2010 IAI + Tokyo 2018 — broad-spectrum gram-neg + anaerobe coverage; add vancomycin if MRSA risk; add antifungal if perforation + immunocompromised)
5. pantoprazole IV 40 mg IV IV daily; transition PO when tolerating — Suspected PUD / GI bleed overlay (epigastric pain + melena/hematemesis) (PPI for suspected upper GI bleed pending EGD; if variceal source suspected, switch to octreotide + route to gi.variceal_bleed.v1)
6. esmolol or labetalol Esmolol 500 mcg/kg bolus then 50 mcg/kg/min; labetalol 10-20 mg IV IV titrate HR <60 + SBP <120 — Suspected thoracoabdominal aortic dissection / AAA — impulse control FIRST per AHA 2022 (AHA 2022 Acute Aortic Disease — beta-blocker before vasodilator to reduce dP/dt; route to cardio.aortic-dissection.core.v1 or vasc.aaa.v1)

Non-pharmacologic actions:
- Two large-bore IVs; type & screen if hemodynamically unstable or surgical/bleeding source
- NPO until disposition (potential OR / endoscopy / ERCP)
- NG decompression if SBO / vomiting
- Foley catheter if hemodynamic instability or expected GU intervention
- Surgical consult for peritonitis / surgical abdomen / SBO with strangulation features / Hinchey III-IV diverticulitis
- GI consult for ERCP within 24-72 h for moderate/severe cholangitis (Tokyo 2018 PMID 29032610)
- OB/gyn consult for ovarian torsion / ruptured ectopic
- Urology consult for testicular torsion (golden 6-h salvage window)
- Vascular surgery + IR for AAA leak / mesenteric ischemia

Monitoring

Setting (ed) monitoring:
- Vital signs q15 min × 1 h then q30 min × 2 h then per disposition
- Continuous SpO2
- Serial abdominal exams q4-6h documented on 0-10 scale + new findings
- Lactate trend q2-4h if mesenteric ischemia / sepsis / shock suspicion
- Repeat CBC + electrolytes if bleeding source or significant 3rd-spacing
- I/O monitoring with goal urine output ≥0.5 mL/kg/h

Follow-up plan: Discharged nonspecific abdominal pain: PCP within 48-72 h + return precautions (worsening pain, vomiting, fever, blood in stool, syncope); discharge bundle for diverticulitis (liquid diet → low-residue + outpatient colonoscopy 4-8 wks); cholecystitis post-op (lap chole 7-10 day follow-up); pancreatitis (alcohol/lipid counseling + outpatient MRCP if biliary)
- Close-out criterion: discharge bundle prescribed + follow-up scheduled

Monitoring phase: Serial abdominal exams q4-6h on observation; serial vitals + lactate trend for sepsis or ischemia; reassess pain after analgesia; repeat CBC + lipase if pancreatitis observation (Brun 2016)

Disposition

Current setting: ed — Quadrant-anchored triage; rule out life-threats (AAA leak / mesenteric ischemia / perforation / ruptured ectopic / torsion / cholangitis / septic shock / ACS-equivalent); risk-stratify pancreatitis (BISAP / Atlanta 2012) + cholangitis (Tokyo 2018) + appendicitis (Alvarado/RIPASA); disposition (OR / admit / observation / discharge with PCP follow-up) (Brun 2016 PMID 35543712)

Disposition criteria:
- Discharge: stable vitals + benign serial exam + negative imaging (or low pretest with low Alvarado/RIPASA) + reliable PCP follow-up ≤48-72 h + return precautions documented
- Observation: equivocal exam/labs awaiting trop trend / lactate trend / serial WBC / repeat imaging
- Admit: confirmed cholecystitis (early lap chole); pancreatitis (Atlanta moderate); diverticulitis Hinchey I-II IV abx; SBO managed conservatively; pyelonephritis with sepsis
- OR direct: peritonitis / surgical abdomen / appendicitis / ruptured ectopic / ovarian or testicular torsion / Hinchey III-IV diverticulitis / perforated viscus
- ICU: hemodynamic instability; pancreatitis BISAP ≥3 or with organ failure; septic shock; postoperative ventilatory support; mesenteric ischemia post-revascularization

Escalation triggers (move to higher acuity):
- Hemodynamic instability despite resuscitation → ICU + immediate surgical/vascular consult
- Suspected AAA leak (flank pain + hypotension + pulsatile mass) → STAT CTA aorta → vasc.aaa.v1 + vascular surgery OR
- Suspected mesenteric ischemia (pain out of proportion + lactate + AF/atherosclerosis) → STAT CTA mesenteric + vascular surgery + IR
- Suspected ruptured ectopic pregnancy (positive β-hCG + free fluid on FAST + hypotension) → OR + ob.ectopic-pregnancy.v1
- Suspected ovarian torsion (sudden unilateral pelvic pain + nausea + adnexal mass) → OR + gyn.ovarian-torsion.v1
- Suspected testicular torsion (sudden testicular pain + high-riding/horizontal lie + negative cremasteric) → STAT urology + OR + uro.testicular-torsion.v1
- Suspected cholangitis (Charcot triad / Reynolds pentad) Tokyo grade II/III → ERCP within 24-72 h + gi.cirrhosis.core.v1 overlay if cirrhotic
- Suspected pancreatitis BISAP ≥3 or organ failure → ICU + gi.acute-pancreatitis.core.v1
- Septic shock (lactate >4 OR persistent MAP <65 despite IVF) → vasopressors + ICU + id.sepsis.core.v1
- Acute coronary syndrome equivalent (epigastric + ECG ST-changes or hs-cTn +) → cardio.nstemi.core.v1
- Variceal bleed / upper GI bleed in cirrhotic → gi.variceal_bleed.v1

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Flank or abdominal pain + hypotension + pulsatile abdominal mass + age >65 (especially male smoker with vascular risk) — STAT CTA aorta if hemodynamically stable, OR direct if not (Sakalihasan PMID 15866312)
- [LIFE_THREATENING] Pain out of proportion to exam + AF or atherosclerotic risk + elevated lactate >2 (often >4) + metabolic acidosis — STAT CTA mesenteric (Kärkkäinen 2016 PMID 40513642)
- [LIFE_THREATENING] Sudden-onset severe abdominal pain + peritonitis (rigidity, rebound, guarding) + free air on upright CXR or CT — immediate surgical consult (Brun 2016)

Citations

- 2007 Pines AAP analgesia + 2016 Brun review undifferentiated abdominal pain + 2012 Atlanta + BISAP (Banks Gut 2013) + 2018 Tokyo cholangitis + 2018 Sakalihasan AAA + 2016 Kärkkäinen mesenteric ischemia + 2021 Gulati AHA/ACC Chest Pain + SSC 2026 sepsis + AHA 2022 Acute Aortic Disease [PMID:40107126](https://pubmed.ncbi.nlm.nih.gov/40107126/)
- Cited evidence (PMID 37133836) [PMID:37133836](https://pubmed.ncbi.nlm.nih.gov/37133836/)

Last reconciled with current guidelines: 2026-05-30.

References

2007 Pines AAP analgesia + 2016 Brun review undifferentiated abdominal pain + 2012 Atlanta + BISAP (Banks Gut 2013) + 2018 Tokyo cholangitis + 2018 Sakalihasan AAA + 2016 Kärkkäinen mesenteric ischemia + 2021 Gulati AHA/ACC Chest Pain + SSC 2026 sepsis + AHA 2022 Acute Aortic Disease — PMID:40107126
Cited evidence (PMID 37133836) — PMID:37133836

Clinical Commander