Abdominal pain is a very common presenting symptom that all junior doctors should be able to appropriately investigate and manage.
Abdominal pain can be difficult due to the wide list of differentials. It is important to consider the diagnosis in context of the patient. For example, in a young female patient with lower abdominal pain you should consider gynaecological causes high on your differential list. In an elderly person with left iliac fossa pain, diverticular disease would be a common diagnosis.
The differential for abdominal pain should be divided by organ systems.
A common cause of acute abdominal pain. Gastrointestinal causes can range from common benign pathologies (i.e. gastroenteritis) to life-threatening (i.e. perforation).
Gastrointestinal causes can be further divided based on location, organ or system affected.
Abdominal pain is very commonly the result of urinary pathology.
Acute cystitis (i.e. urinary tract infection) is an extremely common cause for abdominal pain in females. Renal colic is another common cause of abdominal pain that presents with classical loin-to-groin pain.
Gynaecological diagnoses should always be considered in female patients.
As a general rule, pregnancy-related complications (i.e. ectopic pregnancy) always need to be excluded in young females by performing a pregnancy test. Gynaecological causes of abdominal pain include the following:
Vascular causes are less common, but you need to have a high index of suspicion, especially in elderly patients.
Always consider vascular causes in patients with a history of cardiovascular disease (i.e. ischaemic heart disease, peripheral vascular disease)
Several alternative causes of abdominal pain should be considered, especially when more common diagnoses have been excluded.
Alternative causes of abdominal pain can include problems with the abdominal wall, retroperitoneal space, pain referred from another area (i.e. myocardial infarction) or abdominal pain associated with ‘medical’ diagnoses (i.e. DKA).
Key aspects in the history include age, gender, pain characterisation, location and associated features.
You should always make a note of the patients’ age and gender. Certain diagnoses are more common in one sex (i.e. cystitis in females) and others will only occur in one sex (i.e. testicular torsion in males). Many diagnoses are more common at particular ages (i.e. vascular disease in elderly or mesenteric adenitis in children)
Always take a full pain history in patients with abdominal pain using the SOCRATES mnemonic. It is important to determine if pain came on acutely or is chronic. Assess whether the pain persists, or comes and goes, and determine whether it radiates. Always ask whether the pain has ever occured before.
Location should be based on the nine regions of the abdomen or more broadly the four quadrants.
Associated features help you to support or refute the potential diagnosis. Important features include change in bowel habit, nausea and vomiting, urinary symptoms (i.e. dysuria, haematuria), gynaecological symptoms (i.e. PV bleeding, dysparunia), or PR bleeding.
The examination should include a full abdominal assessment including checking the hernial orifices and consideration of a digital rectal exam.
Examination of acute abdominal pain can be broadly divided into the general exam, abdominal exam and additional exams.
Always start by assessing the patient formally by inspection. Are they lying comfortably? Are they writhing in pain? Are they lying rigid so they do not aggrevate the pain? Does the patient appears flushed and sweaty suggesting pyrexia?
Make note of the observations. Acute pain can cause tachycardia and hypertension. Note whether the patient is febrile or has any other features of sepsis that need to be acted on swiftly. Make note of any stigmata of previous disease. Are there any abdominal scars? Are they jaundiced? Do they have a hernia?
As with all examinations, you should asess the abdomen through inspection, palpation, percussion and auscultation.
Look for any abdominal scars or hernias that may suggest bowel obstruction from adhesions or incarceration. Palpate the abdomen lightly to look for evidence of peritonitis. Is this localised to a region (i.e. RIF in appendicitis) or generalised (i.e. perforation)?. If you suspect peritonitis check percussion tenderness: exquisite pain on percussion of the abdomen associated with guarding. Palpate the abdomen deeply to assess for any masses.
Check for any organomegaly and auscultate for bowel sounds, especially if concern regarding bowel obstruction.
A digital rectal examination should always be considered as part of the abdominal examination.
If there is concern about gynaecological pathology, a formal vaginal and speculum examination should be completed looking for any discharge, bleeding, cervical excitation due to pelvic inflammatory disease or adnexal tenderness in ectopic pregnancy.
Simple bedside investigations are critical in acute abdominal pain including observations, urine dip, pregnancy test, and ECG.
Key investigations can be divided into bedside test, blood tests, imaging and special tests.
Practical recommendations to help you in the assessment and diagnosis of acute abdominal pain
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