From clinical examination to CT diagnosis: An emergency nurse–led approach to acute abdominal pain

Yasmin Banu H1*, Gowdham Pannirselvam2

1Nursing Officer, Kauvery Hospital, Marathahalli, Bangalore

2Nursing Educator, Kauvery Hospital, Marathahalli, Bangalore

*Correspondence

Abstract

Acute abdominal pain remains one of the most frequent clinical presentations encountered in emergency and outpatient settings. The diagnostic challenge arises due to the involvement of multiple organ systems including gastrointestinal, genitourinary, and gynecological structures. This case report discusses a 24-year-old female presenting with bilateral flank pain, initially suspected to be renal calculi based on ultrasound findings. However, further evaluation with computed tomography (CT) KUB revealed no evidence of renal stones, instead demonstrating incidental findings of a right ovarian cyst and features suggestive of epiploic appendagitis. The case highlights the importance of advanced imaging in accurate diagnosis, avoidance of unnecessary interventions, and appropriate conservative management. It also emphasizes the clinical significance of correlating imaging findings with patient presentation to prevent misdiagnosis and overtreatment.

Key words: Acute abdominal pain; Computed tomography (CT); Emergency Severity Index (ESI)

Introduction

Abdominal pain is a complex clinical symptom that often requires a systematic and multidisciplinary approach for accurate diagnosis. The differential diagnosis is broad, ranging from benign self-limiting conditions to life-threatening surgical emergencies. In young female patients, the evaluation becomes even more intricate due to the added dimension of gynaecological causes. Imaging modalities such as ultrasound and computed tomography play a crucial role in narrowing down the diagnosis. CT KUB, in particular, is widely used for assessing suspected renal calculi and urinary tract obstruction. However, it also has the advantage of detecting incidental findings that may be clinically relevant. This case report illustrates how CT imaging can change the diagnostic pathway and guide effective management.

Case Presentation

A 24-year-old female presented to the hospital with complaints of acute onset bilateral flank pain for a duration of one day. The pain was described as moderate to severe in intensity, non-radiating, and not associated with any specific aggravating or relieving factors. There was no history of fever, vomiting, dysuria, hematuria, or bowel disturbances. The patient had no significant past medical or surgical history. On physical examination, vital signs were stable, and abdominal examination revealed mild tenderness in the flank regions without guarding or rigidity. Based on the clinical presentation, a provisional diagnosis of renal calculi was considered. An ultrasound examination was performed, which suggested the possibility of small renal calculi and mild hydronephrosis, prompting further evaluation with CT KUB.

Emergency Nursing Assessment and Triage

On arrival to the emergency department, the patient was assessed by the triage nurse using the Emergency Severity Index (ESI), a five-level triage system widely used to categorize patients based on acuity and resource needs. The ESI algorithm prioritizes patients from Level 1 (most urgent) to Level 5 (least urgent), considering both the severity of the condition and the anticipated number of healthcare resources required.

Based on the presenting complaint of acute bilateral flank pain, absence of life-threatening features, and stable vital signs, the patient was categorized as ESI Level 3, indicating a condition requiring multiple resources but not posing an immediate threat to life.

Initial vital parameters were assessed and recorded. The patient was afebrile, with stable hemodynamic status. Heart rate, blood pressure, respiratory rate, and oxygen saturation were within normal limits, suggesting clinical stability.

Pain assessment was performed using the Numeric Pain Rating Scale, and the patient reported a pain score of 7/10, consistent with moderate to severe pain. Appropriate analgesic measures were initiated as per protocol.

Abdominal Examination

A systematic abdominal examination was performed following the standard sequence of inspection, auscultation, percussion, and palpation, ensuring minimal alteration of bowel activity during assessment.

Inspection

The patient was positioned supine with adequate exposure of the abdomen under proper lighting. On inspection, the abdomen appeared symmetrical with no visible distension, scars, striae, dilated veins, or skin discoloration. The umbilicus was centrally located and inverted. There were no visible peristalsis or pulsations. Respiratory movements of the abdomen were normal. All nine abdominal regions—right hypochondrium, epigastric, left hypochondrium, right lumbar, umbilical, left lumbar, right iliac, hypogastric, and left iliac regions—appeared normal without any localized bulging or abnormal contour.

Auscultation

Auscultation was performed prior to palpation and percussion using a stethoscope placed gently over the abdominal wall. Bowel sounds were present in all nine regions, with normal frequency (approximately 5–30 sounds per minute) and character, indicating active peristalsis. No abnormal sounds such as bruits over the abdominal aorta, renal, or iliac arteries were detected. There were no venous hums or friction rubs.

Percussion

Percussion of the abdomen revealed a predominantly tympanic note over most regions, consistent with normal gas distribution within the intestines. No abnormal areas of dullness were noted to suggest organomegaly, mass, or fluid accumulation. Percussion over the liver and spleen areas did not indicate enlargement. There was no evidence of shifting dullness, thereby ruling out ascites.

Palpation

Palpation was performed gently, starting superficially and progressing to deep palpation. The abdomen was soft on palpation with mild tenderness noted in the bilateral flank (lumbar) regions. There was no guarding, rigidity, or rebound tenderness. No palpable masses or organomegaly were detected. The liver, spleen, and kidneys were not palpable. There was no evidence of localized tenderness in other abdominal regions.

Radiological Findings

Computed tomography of the kidney, ureter, and bladder (CT KUB) was performed without contrast. The imaging revealed that both kidneys were normal in size, shape, and position, with preserved cortical thickness and no evidence of calculi or hydronephrosis. The ureters appeared normal in course and caliber, and the urinary bladder showed normal contour and wall thickness. An incidental finding of an ill-defined ovoid structure measuring approximately 16.9 × 10 mm was noted in the left lower quadrant adjacent to the descending colon, demonstrating a central hyperdense focus. These features were suggestive of epiploic appendagitis or focal fat necrosis. Additionally, a well-defined cystic lesion measuring 3.6 × 2.9 cm was identified in the right ovary, consistent with an ovarian cyst. Mild diffuse decrease in liver attenuation suggestive of fatty liver changes and a few small mesenteric lymph nodes were also observed.

Textbook Correlation

Epiploic appendagitis is a rare inflammatory condition involving the epiploic appendages, which are small fat-filled pouches along the colon. It is typically caused by torsion or spontaneous venous thrombosis, leading to localized inflammation. According to standard surgical textbooks such as Sabiston and Schwartz, patients present with localized abdominal pain without significant systemic symptoms. CT imaging is considered the gold standard for diagnosis, demonstrating an oval fat-density lesion with surrounding inflammatory changes and a hyperattenuating rim. Ovarian cysts, on the other hand, are common findings in women of reproductive age. Functional cysts are usually benign and resolve spontaneously. However, they may occasionally present with abdominal pain due to stretching of the ovarian capsule or complications such as rupture or torsion. Radiological correlation is essential to differentiate these conditions from more serious pathologies.

Management

The patient was managed conservatively based on the imaging findings and clinical stability. Analgesics and non-steroidal anti-inflammatory drugs were administered for pain relief. Adequate hydration and rest were advised. Antibiotics were not initiated as there was no evidence of infection. The patient was counseled regarding the benign nature of epiploic appendagitis and reassured about its self-limiting course. Follow-up ultrasound was recommended to monitor the ovarian cyst. The patient showed significant improvement in symptoms over the next few days, with complete resolution of pain, confirming the effectiveness of conservative management.

Discussion

This case underscores the importance of imaging in the evaluation of abdominal pain, particularly when initial clinical findings are inconclusive. The initial suspicion of renal calculi was ruled out by CT imaging, which instead revealed epiploic appendagitis, a condition that is often underdiagnosed due to its nonspecific presentation. Misdiagnosis can lead to unnecessary hospital admissions, antibiotic use, or even surgical intervention. Awareness of this condition among clinicians and radiologists is crucial to ensure appropriate management. Additionally, incidental findings such as ovarian cysts should be carefully evaluated in the clinical context to avoid unnecessary anxiety and interventions. The role of CT imaging in identifying such conditions cannot be overstated.

Conclusion

In conclusion, this case highlights the diagnostic value of CT KUB in patients presenting with abdominal pain. Accurate identification of epiploic appendagitis and incidental ovarian cyst allowed for appropriate conservative management, thereby avoiding unnecessary interventions. A thorough understanding of imaging findings and their clinical correlation is essential for optimal patient care.

References

  1. Townsend CM, Beauchamp RD, Evers BM, Mattox KL. Sabiston textbook of surgery. 21st ed. Philadelphia: Elsevier; 2021.
  2. Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Kao LS, Hunter JG, et al. Schwartz’s principles of surgery. 11th ed. New York: McGraw-Hill Education; 2019.
  3. Grainger RG, Allison DJ, Adam A, Dixon AK. Grainger & Allison’s diagnostic radiology: a textbook of medical imaging. 7th ed. Philadelphia: Elsevier; 2020.
  4. Williams NS, O’Connell PR, McCaskie AW. Bailey & Love’s short practice of surgery. 28th ed. Boca Raton: CRC Press; 2022.

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