Abdominal Pain ER Visit: 4 Diagnoses We Cannot Miss
“Dr Cois, I’ve got abdominal pain. What will happen to me when I come to the ED?”
It’s one of the most common things I get asked — in clinic, in DMs, and from friends-of-friends at barbecues. Abdominal pain sits in the top three reasons people come to my Emergency Department, every single shift. So if you’ve been on the fence about coming in, or you’re sitting in the waiting room right now wondering what we’re actually doing back there, this post is for you.
Step One: The Conversation, Not the Scan
When you walk through the doors with abdominal pain, here’s the honest truth about what’s happening in my head: I’m running through a list of things I cannot afford to miss. Most patients are going home. But there’s a small group of diagnoses that need antibiotics, surgery, or admission — and our entire workflow is built to find those quickly.
Step one is the history. Not the labs. Not the CT scan. The conversation.
I use an acronym called SOCRATES to make sure I don’t miss anything: Site, Onset, Character, Radiation, Associations, Timing, Exacerbating and relieving factors, and Severity. It sounds clunky, but if you walk a patient through every one of those, the classical presentations of the big diagnoses tend to declare themselves.
The Four Big Diagnoses We Cannot Miss
1. Cholecystitis (Gallbladder)
Right upper quadrant pain, often after a fatty meal, sometimes radiating to the back or the right shoulder tip. Usually needs antibiotics and a surgeon.
2. Appendicitis
Often starts as a vague, dull ache around the belly button, then migrates over hours to the right lower quadrant. Patients tell me it hurt going over speed bumps on the drive in. On exam, hopping on one foot lights it up. A surgical problem.
3. Diverticulitis
Left lower quadrant pain, change in bowel habit, sometimes blood in the stool. Diverticula are small outpouchings in the colon wall — when they get infected, that’s diverticulitis. Usually antibiotics; occasionally surgery for perforation, abscess, or recurrent disease.
4. Small Bowel Obstruction
Severe, crampy pain with vomiting, a distended belly, and not passing wind or stool. Almost always a hospital admission, sometimes the operating theatre.
Together, these four account for a huge chunk of the abdominal pain we admit. They’re the ones we genuinely cannot miss.
And before we move on — abdominal pain isn’t always the gut. I’m also thinking about urinary tract infections, kidney stones, and on the more serious end, vascular catastrophes: aortic aneurysm or dissection, and mesenteric ischaemia.
The Bigger Story: Most Abdominal Pain Is About Food
Here’s the part I want patients to really hear. After we’ve ruled out the can’t-miss diagnoses, the conversation I have with most people in Bay Three is not about surgery. It’s about food.
Three of the most common drivers of recurrent abdominal pain I see are constipation, reflux disease, and non-alcoholic fatty liver disease. All three sit on the same root cause: the modern Western diet.
Constipation and Fiber
The average American eats around 12 to 15 grams of fiber a day. The recommended intake is closer to 30 to 40. That gap is enormous, and it’s a huge driver of chronic constipation — which over years can lead to diverticulosis, the outpouchings that go on to become diverticulitis.
Critical caveat: don’t go from 15 grams of fiber to 40 in one day. The bacteria in your colon need time to adapt. Build it up gradually — one apple a day this week, a serving of beans next week, swap white bread for wholegrain the week after. Let fiber-rich foods displace the ultra-processed stuff and the heavy meat and dairy.
Reflux and Non-Alcoholic Fatty Liver Disease
These are increasingly common, and increasingly young. NAFLD is now the leading cause of liver failure in the developed world, and it is largely a disease of caloric excess. Lose weight, shift toward plant-rich foods, reduce saturated fat, and the fatty liver reverses — a remarkable thing for a disease that can otherwise march toward cirrhosis.
Reflux follows the same playbook: smaller meals, more plant-based foods, less abdominal weight, no alcohol, no unnecessary NSAIDs. A proton pump inhibitor like omeprazole or pantoprazole is fine, but I tell my patients it’s a two-to-six-week tool, not a forever medication. If symptoms persist, follow up with your primary care provider for consideration of a gastroenterology referral.
A Quick Word on Imaging
Almost everyone who comes in with abdominal pain wants a CT scan. I get it — you’re in pain, you want a picture. But CT scans are not free. They deliver a meaningful dose of radiation, and we should reach for them when the history, exam, and labs say we need to — not as a default. There’s almost never an indication for an emergency MRI of the abdomen, although we use MRI in pregnant patients and children when we want to avoid radiation.
If I don’t order a scan on you, it’s not because I’m cutting corners. It’s because the evidence said you didn’t need one and the risk of the radiation outweighed the benefit of the picture.
How Should This Modify Your Practice?
If You’re a Patient
• If your pain is severe, sudden, associated with vomiting, fever, or blood in your stool — come in. Don’t wait.
• If we send you home with no surgical pathology, that’s good news — but the work isn’t done. The next step is your Tier 1 habits: 80% of your plate as plant foods, slowly increasing fiber, less alcohol, fewer ultra-processed foods.
• Establish a relationship with a primary care provider. Recurrent abdominal pain is best managed in clinic, not in the ED.
If You’re a Trainee
• History first. The SOCRATES framework will get you most of the diagnosis before you order a single test.
• The patient with a normal CT and “no surgical pathology” is the most underrated counselling moment in the department. Two minutes on fiber, weight, alcohol, and NSAIDs is genuinely high-yield medicine.
• Be honest with patients about why you’re ordering — or not ordering — a scan. Diagnostic uncertainty is part of the job.
The Bottom Line
If you come to the ED with abdominal pain and we don’t find a life-threatening cause, the next step isn’t another scan. It’s your Tier 1 habits.
That’s not glamorous medicine. But it’s the medicine that keeps you out of my Emergency Department — and that’s the whole point of this show.
Author
Dr Adrian Cois is a board-certified Emergency Physician and the host of Overheard in the Emergency Room. He writes and podcasts about evidence-based medicine translated for everyday people at DrCois.com.
Related Reading
• Quick Hits Bonus Ep 1 — What to Expect When You Come to the ED with Chest Pain
• Episode 9 — Gut Feelings: Fibre, Bugs & Bloating
• Episode 13 — Protein, Plant Forward Eating, and What the Evidence Actually Says
• Episode 11 — Lipid Screening and the Numbers That Matter
