Textbook of Urgent Care Medicine, Chapter 25, Abdominal Pain in the Adult Patient

Published on October 26, 2026

Original author: Elisabeth Scheufele

Originally published in 2014. Substantially updated and clinically reviewed in 2026 to reflect current evidence, guidelines, and urgent care practice.

INTRODUCTION

Abdominal pain is a frequent complaint in the medical setting, with severity ranging from a benign, short-lived issue to a life-threatening condition. The abdomen houses most of the gastrointestinal organs as well as other vital organs and vessels, and it is also adjacent to other major anatomic systems that can present with abdominal symptoms as visceral, parietal, or referred pain.

In urgent care, the first decision is whether the patient can be evaluated safely on site. Findings suggesting hemorrhage, ischemia, obstruction, perforation, sepsis, or pregnancy-related emergency take priority over identifying a precise diagnosis. Testing must not delay transfer when a dangerous process is suspected. ^[1,2]

PRESENTATION

The patient reports abdominal pain, discomfort, or burning.

TRIAGE PEARLS

It is important to check the ABC’s (airways, breathing, and circulation) and vital signs in case the abdominal pain is related to bleeding or severe dehydration.
Obtain blood pressure, heart rate, respiratory rate, temperature, oxygen saturation, and mental status. Repeat abnormal measurements. A patient with syncope, hypotension, altered mental status, hypoxia, persistent tachycardia, or signs of shock requires EMS transfer; do not wait for orthostatic testing.
A history of trauma (e.g., vehicular, assault, domestic abuse) may require involving local law enforcement.
Ask about possible pregnancy at triage when relevant. Sudden severe pain, pain out of proportion to examination, a rigid abdomen, or significant gastrointestinal bleeding warrants immediate higher-acuity assessment.

HISTORY PEARLS

Quality of pain: burning, sharp, dull, intermittent, or constant.
Pain scale: 1 to 10 (least to worst).
Chronicity: Ask whether pain is acute (new in the past several days), recurrent, or persistent for 3 months or more. New or rapidly worsening pain warrants triage regardless of duration.
Frequency and duration: Is the pain constant, hourly, or daily? If the pain is intermittent, how long is an average episode?
Relative location on the abdomen.
Referred pain: back, flank, or chest.
Association with foods and beverages: timing before, during, or after eating; alcohol, acidic foods, and lactose-containing products.
Stress association: Not sleeping well, working more hours than usual, death in the family, or other issues.
Other symptoms: Nausea, vomiting, diarrhea, rash, swelling, or trouble breathing.
Clarify onset and migration, bowel movements and flatus, urinary symptoms, vaginal bleeding or discharge, last menstrual period, sexual and pregnancy history when relevant, and previous similar episodes.
Review abdominal surgery, hernia, gallstones, vascular disease, atrial fibrillation, immunosuppression, and medications (particularly anticoagulants, NSAIDs, opioids, antibiotics, glucagon-like peptide-1 medications, and SGLT2 inhibitors). Ask about alcohol, recent travel, sick contacts, and possible foodborne exposure.

PHYSICAL EXAM PEARLS

Vitals: Abnormalities can indicate the severity of the condition.
Orthostasis: Impending vascular compromise from low volume from anemia or dehydration.
Tachycardia: Anemia, dehydration, severity of pain.
Temperature: Infectious or possibly inflammatory component.
Tachypnea: Pulmonary cause, severity of pain.
Normal vital signs do not exclude a dangerous diagnosis, especially in older or immunocompromised patients.

Abdominal exam

An optimal abdominal exam requires proper positioning of the patient as well as the practitioner.
The patient must be completely supine on a table or bed.
In order to maintain relaxation of the abdominal wall musculature, the patient’s head should be supported, and the patient should bend their knees and have their arms to their sides.
The practitioner should conduct the exam from the patient’s right side.
Also, out of respect for the patient, proper coverage with sheets and gowns should be ensured.
Inspect for distention, surgical scars, skin changes, ecchymoses, and visible hernias. Listen for bowel sounds when useful, but neither normal nor abnormal bowel sounds reliably exclude obstruction or peritonitis.
Percuss for tympany, marked distention, or ascites when indicated. Palpate gently, beginning away from the painful area; note location and depth of tenderness, guarding, rigidity, and focal masses.
Note that guarding is an indication of pain with palpation by muscle contraction (flinching).
Note that rigidity is when the abdomen wall does not give way at all and has a firmness when palpated.
Rebound tenderness may suggest peritoneal irritation, but repeated painful maneuvers are unnecessary. Assess costovertebral angle tenderness, inguinal hernia, and pelvic or testicular findings when suggested by the history.

TESTING, DIAGNOSIS, AND TREATMENT PEARLS

Testing, diagnosis, and treatment information is organized here by type of abdominal pain.

The typical urgent care center may have urine pregnancy testing, urinalysis, capillary glucose, ECG, and selected laboratory or imaging access. CBC, metabolic testing, lipase, advanced microbiology, ultrasound, and CT vary by site and turnaround time. Order only tests that can safely inform the immediate decision; suspected emergencies generally require ED-level imaging or serial assessment. ^[1,2]TABLE 1. Rapid disposition guide for adult abdominal pain

Priority	Urgent care action
Immediate EMS / ED transfer	Shock, syncope with ongoing pain, pulsatile mass or suspected aortic catastrophe, severe pain out of proportion, peritoneal signs, hematemesis with instability, suspected ectopic pregnancy with instability, suspected ischemia or perforation.
Prompt ED evaluation	Suspected appendicitis, bowel obstruction, acute cholecystitis/cholangitis, pancreatitis, ovarian torsion, ectopic pregnancy in a stable patient, infected obstructing urinary stone, or an unclear serious diagnosis requiring CT/ultrasound or monitoring.
Urgent care management may be appropriate	Mild, stable, well-localized complaint without red flags, with a reasonable working diagnosis, treatment within local capabilities, reliable follow-up, and explicit clinical reassessment/escalation plan.

Generalized Abdominal Pain

Acute Surgical Abdomen

Surgical abdomen is a clinical diagnosis and requires urgent surgical consultation and management.
Suspect a surgical abdomen with severe or progressive pain, involuntary guarding, rigidity, marked distention, persistent vomiting, or hemodynamic instability. Do not administer oral food or fluids. Arrange EMS/ED transfer; IV access, monitoring, and analgesia may be initiated only if available and without delaying transport.

Obstruction

Symptoms: Nausea, vomiting (particularly bilious), possible hematemesis, and loss of appetite.
Obstipation, inability to pass flatus, distention, colicky pain, previous abdominal operations, and hernia strengthen suspicion. Early or partial obstruction may still permit stool passage.
Physical exam: The abdomen may be distended and tender, with few bowel sounds or a bowel sound with a high timbre.
Laboratory tests at the receiving facility may include CBC, electrolytes, renal function, lipase when indicated, urinalysis, and pregnancy testing. Abnormal values support evaluation but do not rule obstruction in or out.
Imaging: Contrast-enhanced CT of the abdomen and pelvis is generally preferred for suspected acute small-bowel obstruction; plain abdominal films may be nondiagnostic and should not delay ED transfer. ^[3]
Disposition: Emergency surgical referral.

Peritonitis

Symptoms: Nausea, vomiting, possible hematemesis, or possible fever.
Physical exam: Distended, tender abdomen; extreme pain and rigidity may be present. Worsening pain with movement or jostling increases concern.
Peritonitis may reflect perforation, appendicitis, ischemia, or another intra-abdominal emergency. Obtain immediate EMS/ED assessment. Hospital management may require CT, IV fluids, broad-spectrum antibiotics, and source control; no urgent care antibiotic regimen replaces transfer.

Mesenteric Ischemia or Infarction (Ischemic Bowel)

Symptoms: Severe subjective pain and high level of suspicion in terms of personal history (vasculopathy with cardiac or vascular history, usually in older individuals).
Physical exam: Possibly only mild tenderness, guarding, or both on exam.
Pain out of proportion to examination, atrial fibrillation, vascular disease, hypotension, or unexplained acidosis should heighten concern. The absence of marked tenderness or normal early laboratory values does not exclude ischemia.
Work-up: CT angiography (CTA) of the mesenteric vessels without delay at the receiving hospital is recommended; catheter angiography is not the usual first diagnostic study. ^[4]
Disposition: Immediate EMS transfer for emergency vascular/surgical evaluation; do not delay for urgent care laboratory testing.

Ruptured Abdominal Aortic Aneurysm

Symptoms: Diffuse or localized abdominal symptoms that tend to mimic other abdominal conditions, such as renal colic, diverticulitis, pancreatitis, mesenteric ischemia, or biliary tract disease.
Physical exam: Assess for hypotension, abdominal or back pain, and pulsatile abdominal mass, although fewer than half of patients will present with the full triad.
In older patients with renal colic symptoms, consider abdominal aortic aneurysm until this has been ruled out.
Work-up: Suspected rupture is a time-critical vascular emergency. Bedside ultrasound may help identify an aneurysm if immediately available, but does not reliably exclude leak or rupture; a stable patient may undergo CTA in the ED. Do not obtain a routine noncontrast stone CT in urgent care when an aortic catastrophe remains plausible.
Disposition: Immediate EMS transport to an ED capable of vascular emergency evaluation.

Colitis from Viral, Bacterial, or Toxic Causes

Significant to severe abdominal pain is not a typical feature of acute, uncomplicated gastroenteritis. Alternative, more threatening diagnoses should be considered in the patient with vomiting, diarrhea, and significant abdominal pain.

Medical history: Sick contacts or other sick persons from the same food-centric event or activity.
Symptoms: Nausea, vomiting, diarrhea, or possible fever.
Physical exam: Usually generalized abdominal tenderness without significant guarding.
Laboratory tests: Most mild, self-limited watery diarrhea does not require stool testing. Consider stool PCR/culture for fever, bloody or mucoid stool, severe abdominal pain, sepsis, immunocompromise, or an outbreak; order Shiga toxin testing when STEC is suspected. Assess for C. difficile with compatible unexplained diarrhea and appropriate risk factors. ^[6]
Treatment: Oral rehydration when tolerated; IV fluids or ED care for significant dehydration. Ondansetron may be used when appropriate. Avoid empiric antibiotics for routine watery diarrhea and generally avoid antibiotics if STEC is suspected pending specialist assessment. Avoid antimotility agents when fever or bloody stools suggest invasive illness. ^[6]

Epigastric Pain

Acute and Severe Pain

Pancreatitis

Symptoms: Epigastric pain, classically described as sudden, sharp, and radiating to the back; nausea and vomiting; loss of appetite and overall discomfort.
History: The clinician should inquire about predisposing conditions and exposures for pancreatitis: gallstones, alcohol, hypertriglyceridemia, recent ERCP, infections, and certain medications.
Diagnosis generally requires two of three findings: compatible abdominal pain, lipase or amylase >3 times the upper limit of normal, or characteristic imaging. Lipase is preferred; routine amylase adds little. A normal or mildly elevated lipase does not settle a concerning presentation. ^[5]
Red flag: Pancreatitis can evolve into a severe systemic condition.
Disposition: Suspected acute pancreatitis requires ED/hospital assessment for severity, fluids, analgesia, and etiologic work-up. Do not use legacy Ranson or APACHE scores as urgent care discharge rules; urgent care cannot provide the serial assessment needed for risk stratification. ^[5]

Not Particularly Severe Pain

Gastritis

Symptoms: Pain or discomfort, bloating, nausea, and vomiting, often related to acidic food intake, including coffee and alcohol.
Review NSAID use, alcohol, anticoagulants, and gastrointestinal bleeding. Consider a limited trial of acid suppression in a stable patient without alarm findings; do not assume gastritis explains progressive focal pain or systemic illness.

Dyspepsia (Reflux, Ulcers, Gastric Malignancy)

Symptoms that prompt concern for malignancy include weight loss, persistent vomiting, dysphagia, anemia, hematemesis, palpable mass, family history of upper gastrointestinal carcinoma, and prior history of pathology or gastric surgery.
Work-up will require referral for mucosal visualization when there are alarm symptoms or persistent/recurrent problems. Age ≥60 with dyspepsia generally favors upper endoscopy; in younger patients alarm symptoms and individual risk factors guide referral. ^[8]
Gastroesophageal reflux: Periodic burning sensation, often in the upper abdomen or midchest and after meals.
Peptic ulcers: Often periodic and worsened with certain foods or medicines, including nonsteroidal anti-inflammatory drugs.
For uninvestigated dyspepsia without alarm features in patients younger than 60, noninvasive H. pylori testing and treatment if positive is preferred, with a proton pump inhibitor trial as appropriate. Avoid serology for active infection when better tests are available. ^[7,8]
H. pylori treatment decisions should follow current local guidance. When susceptibility is unknown, the 2024 ACG guideline prefers 14-day optimized bismuth quadruple therapy; avoid empiric clarithromycin triple therapy. Confirm eradication at least 4 weeks after treatment, after withholding PPIs for 2 weeks and antibiotics/bismuth for 4 weeks. ^[7]

Nonabdominal Causes of Upper Abdominal Pain

The etiology can be pleural or pulmonary, including pneumonia, pulmonary embolism, empyema, or pulmonary infarction.

Also consider acute coronary syndrome, especially with epigastric discomfort, diaphoresis, dyspnea, or cardiovascular risk. Obtain an immediate ECG when indicated. A nondiagnostic ECG does not exclude ACS; serial high-sensitivity troponin pathways generally belong in the ED or an appropriately equipped nonwaived laboratory, not typical CLIA-waived urgent care. Transfer when concern remains.

Right Upper Quadrant Pain

Biliary Tract Disease

Pain may radiate to the back or epigastrium, and possible diagnoses include ascending cholangitis and infection of the biliary tract.

Fever, right upper quadrant pain, and jaundice suggest acute cholangitis, but the complete triad is often absent. This is an ED emergency requiring antibiotics, biliary imaging, and possible urgent drainage; do not treat as outpatient biliary colic. ^[10]

Acute Cholecystitis

Symptoms: Abdominal pain with fever, nausea, vomiting, and loss of appetite; history of fatty food ingestion prior to onset of pain.
Physical exam: Right upper quadrant pain (Murphy sign) with fever.
Ultrasound is usually the first imaging test for suspected acute cholecystitis or gallstones; CT may identify alternative diagnoses or complications when ultrasound is inconclusive. Fever, persistent pain, systemic illness, or suspected cholecystitis warrants ED evaluation. ^[9]

Choledocholithiasis

Symptoms: Sudden pain in the right upper quadrant, pain between the shoulder blades or in the right shoulder.
Liver chemistry abnormalities, bilirubin elevation, ductal dilation on ultrasound, or jaundice strengthen concern for common bile duct obstruction. MRCP or EUS may be needed; ERCP is usually therapeutic and reserved for appropriately selected patients.
Treatment and disposition: Analgesia and ED/specialist evaluation. Concurrent fever or systemic illness raises concern for cholangitis and requires immediate ED transfer. ^[9,10]

Lower Abdominal Pain in Women

Pelvic Inflammatory Disease

Symptoms: Variable level of lower abdominal pain, sometimes fever, abnormal uterine bleeding, or trouble ambulating because of severe disease.
Physical exam: Cervical motion tenderness on bimanual exam; adnexal tenderness.
Testing: Pregnancy test; gonorrhea and chlamydia NAAT from appropriate specimens; evaluate other STIs as indicated. Pelvic pain with cervical motion, uterine, or adnexal tenderness warrants a low threshold for empiric treatment when no alternative cause is established. ^[11]
Treatment for mild-to-moderate PID when outpatient care is suitable: ceftriaxone 500 mg IM once (1 g if >150 kg and documented gonococcal infection), plus doxycycline 100 mg orally twice daily for 14 days, plus metronidazole 500 mg orally twice daily for 14 days. Reevaluate within 72 hours. Check pregnancy, drug allergies, interactions, and ability to tolerate oral therapy. ^[11]
Disposition: ED/hospital evaluation for pregnancy, severe illness, suspected tubo-ovarian abscess, possible surgical emergency, inability to tolerate outpatient treatment, or poor response within 72 hours. ^[11]

Adnexal Cysts or Masses with Bleeding, Torsion, or Rupture

Symptoms: Severe—almost debilitating—pain is present. Sudden onset of severe pain with nausea and vomiting may be caused by ovarian torsion.
Physical exam: Adnexal pain on bimanual exam.
Imaging: Transabdominal and transvaginal pelvic ultrasound with Doppler is generally the initial examination. Doppler flow does not exclude ovarian torsion. ^[12]
Disposition: Suspected torsion, significant hemorrhage, peritoneal findings, or hemodynamic instability requires immediate ED/gynecologic evaluation, not routine outpatient referral.

Ectopic Pregnancy

Symptoms in a pregnant female: Worsening lower abdominal and pelvic pain and bleeding.
Physical exam: Pain on bimanual exam, adnexal or cervical motion or lower abdominal tenderness.
Laboratory tests: Urine hCG is the typical initial urgent care test; serum quantitative hCG and transvaginal ultrasound are used in the receiving setting when ectopic pregnancy is possible. Very early pregnancy or rare false-negative urine tests should not override high clinical suspicion. ^[13]
Work-up: Urgent obstetrics consult, for possible surgical or medical management.
Disposition: Immediate EMS transfer if unstable, with syncope, peritoneal signs, or significant bleeding; otherwise same-day ED evaluation when ectopic pregnancy remains possible. ^[13]

Lower Abdominal Pain in General

Intestinal Etiology

Colitis or ileitis from infectious, ischemic, medication-associated, or inflammatory causes.
General symptoms: Lower quadrant pain, with diarrhea.
Inflammatory bowel disease should be considered with weight loss, intermittent abdominal pain, persistent diarrhea, or a history of bloody stool. Persistent symptoms require gastroenterology evaluation; severe pain, fever, bleeding, or dehydration may require ED imaging and treatment.

Appendicitis

Presentation: General periumbilical pain or discomfort, with accompanying anorexia, that moves toward the right lower quadrant.
Physical exam: Depending on the progression, localized pain occurs toward the right lower quadrant, one-third of the distance between the anterior superior iliac spine and the umbilicus (McBurney point).
Localized tenderness, migration, fever, and vomiting increase suspicion but may be absent, particularly early in the course or in older adults. Leukocytosis is neither required nor sufficient. Clinical scores may help stratify risk but are not standalone urgent care discharge rules. ^[14]
Imaging: CT abdomen/pelvis with IV contrast is usually appropriate for nonpregnant adults; ultrasound or MRI may be preferred in pregnancy or selected patients. ^[18]
Disposition: Same-day ED/surgical evaluation whenever appendicitis is a meaningful possibility. Antibiotic-only treatment is an option for selected patients with confirmed uncomplicated disease after appropriate imaging and shared decision-making—not empiric urgent care treatment. ^[14]

Diverticulitis

Symptoms: Lower abdominal pain, usually more the left lower quadrant versus the right lower quadrant.
Physical exam: Pain on exam in the left lower quadrant (or right lower quadrant).
CT is often needed to confirm a first episode and to assess for complicated disease. Consider alternative diagnoses when pain is atypical. ^[15]
Treatment: Antibiotics are not required routinely for otherwise healthy, immunocompetent adults with confirmed mild uncomplicated diverticulitis. Use selectively; antibiotics are recommended for complicated disease, immunocompromise, frailty/comorbidity, prolonged or refractory symptoms, vomiting, or high-risk inflammatory findings. ^[15]
Disposition: A stable patient with reliably confirmed uncomplicated disease may be managed as an outpatient with follow-up. Severe pain, peritoneal signs, fever with systemic illness, inability to take oral fluids, uncertain diagnosis, or concern for abscess/perforation warrants ED evaluation. ^[15]

Urinary Etiology

Referred Renal Colic Pain

Symptoms: The disorder often occurs as a sudden, intense pain that comes in waves (but can present with mild ache as well) and is possibly accompanied with passing “sands” and hematuria.
The site of obstruction can result in referred pain: upper ureter or renal pelvis obstruction results in flank pain, whereas a lower ureteral obstruction causes pain in the ipsilateral testicle or labium.
Laboratory tests: Urinalysis for hematuria (not always present); assess for infection and obtain pregnancy testing when applicable. Urinary stone composition is not usually part of immediate urgent care testing.
Imaging: Noncontrast CT is usually appropriate for an initial adult presentation when imaging is indicated; ultrasound may be favored for pregnancy or selected recurrent presentations. ^[16]
Treatment: NSAIDs are generally preferred for renal colic when not contraindicated, with antiemetics and hydration to normal volume status. Do not prescribe forced hydration or assume pain relief excludes obstruction.
Disposition: Fever or sepsis with possible obstructing stone, anuria, acute kidney injury, solitary kidney, uncontrolled pain/vomiting, or diagnostic uncertainty requires ED evaluation. Aortic disease remains an important alternative diagnosis in older patients.

Bladder Distention

Symptoms: Lower abdominal pain.
Physical exam: Bladder feels like a solid mass.
If available, bladder scanning can help confirm retention. Catheterization may relieve uncomplicated acute retention when staff are trained and follow-up is secure. Fever, neurological deficits, sepsis, severe renal compromise, traumatic injury, or failed catheterization warrants ED care.

Abdominal Wall

Symptoms: Pain from the abdominal wall injury, including muscle strain, trauma, or hematomas; hernia, generally without pain (unless incarcerated or strangulated).
Pain increased by tensing the abdominal musculature can support an abdominal wall source, but should not supersede red flags. Painful irreducible hernia, vomiting, skin discoloration, or systemic illness raises concern for strangulation and requires immediate ED evaluation.

Special Considerations

Elderly

In patients over 50 years, consider abdominal pain a serious complaint.
Consider renal colic as indicating abdominal aortic aneurysm until it has been ruled out.
Consider mesenteric ischemia early in the differential, especially if the pain is out of proportion to tenderness (atrial fibrillation, cardiovascular disease or peripheral vascular disease, and recent myocardial infarction increase the likelihood of ischemia).
Older adults may have muted fever, leukocytosis, or peritoneal signs. Age alone does not mandate ED transfer; concerning findings, frailty, risk factors, or inability to complete needed imaging and serial assessment should lower the transfer threshold.

Sickle Cell

Symptoms: Splenomegaly; splenic infarct.
Also consider vaso-occlusive pain, splenic sequestration where applicable, cholelithiasis, infection, and mesenteric complications. Fever, hypotension, severe pain, or concerning examination requires ED evaluation.

Human Immunodeficiency Syndrome or Acquired Immunodeficiency Syndrome

Symptoms: Enterocolitis in acquired immunodeficiency syndrome from cytomegalovirus; obstruction from Kaposi sarcoma, lymphoma, or Mycobacterium avium complex.
In advanced HIV or other significant immunosuppression, presentations may be atypical; seek early ED evaluation for severe pain, systemic symptoms, bleeding, or dehydration.

Endocrinopathies

Symptoms: Diabetic ketoacidosis; adrenal crisis.
A point-of-care glucose is useful when clinically indicated. DKA can present with abdominal pain and vomiting, including euglycemic presentations associated with SGLT2 inhibitors. Suspected DKA or adrenal crisis requires EMS/ED treatment; office glucose alone cannot exclude these conditions. ^[17]

DISPOSITION PEARLS

Patients with severe abdominal pain, particularly if it is reproducible on exam and accompanied by guarding, rebound, or rigidity, will require urgent work-up, including laboratory tests, imaging, and transport to a higher-acuity facility.
Abnormal vital signs, when not attributable to simple dehydration and not normalized with basic fluid resuscitation, are a red flag for more threatening causes or sequelae and require a higher level of care and work-up.
Do not delay transport for laboratory tests or imaging when rupture, ischemia, perforation, torsion, ectopic pregnancy, or a septic process is suspected. A reassuring single examination does not rule out evolving surgical illness.
For patients retained in urgent care, document reassessment of pain and vitals, the working diagnosis and alternatives considered, test limitations, return precautions, and the specific timing and setting for follow-up.

MEDICOLEGAL PEARLS

Patients with abdominal pain and abnormal vital signs warrant transfer to a high level of care.
It is necessary to be wary of patients with pain out of proportion to exam findings. Ischemic bowel can also occur in younger patients using methamphetamine or cocaine.
Document pregnancy consideration and pregnancy testing when appropriate, abnormal vitals, key positive and negative examination findings, reasons for transfer, and communication with the receiving facility. Refusal of recommended transfer requires a careful capacity assessment and documented discussion of risks.
Do not apply an absolute rule that every older patient with abdominal pain belongs in an ED. Disposition should reflect age-related risk, clinical findings, local testing capability, and reliability of follow-up.

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