Acute Abdominal Pain

Differential Diagnosis
Location Right upper quadrant Epigastrium Left upper quadrant and umbilical Right or left flank Suprapubic Right iliac fossa Left iliac fossa Groin Pathology Gallbladder disease Peptic ulcer, peptic perforation, pancreatitis Splenic rupture, small bowel obstruction, early appendicitis, mesenteric ischaemia, gastroenteritis Ureteric colic, pyelonephritis, leaking AAA Cystitis, acute urinary retention and pelvic appendicitis Appendicitis, carcinoma of caecum, mesenteric adenitis, Crohn s of the terminal ileum, ovarian cyst, salpingitis, ectopic pregnancy Diverticulitis, carcinoma of the sigmoid colon, ulcerative colitis, constipation, ovarian cyst, salpingitis, ectopic pregnancy Irreducible hernia

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Stabbing short, sudden, sharp pain eg. ureteric colic Gripping often associated with smooth muscle spasm, as seen in bowel obstruction o The patient will often describe it with a wringing motion of their hands

Progression how has the pain changed over time? y Constant eg. peptic ulcer y Colicky each sharp pain may last seconds (bowel), minutes (ureteric) or tens of minutes (gallbladder) y It may change in character o Appendicitis begins as a colicky, central abdominal pain that then localises to the RIF as a sharp pain that is worse on movement Radiation: y Back pancreas and other retroperitoneal structures y Shoulder tip referred diaphragmatic pain/irritation y Scapula gallbladder y Sacroiliac region ovary y Loin to groin ureteric colic Cessation does the pain go away slowly or quickly? y Colicky pains usually have an abrupt ending y Inflammatory pain and biliary colic resolve slowly Exacerbating & relieving factors: y Peritonitis pain on movement so patient lies still y Ureteric colic neither exacerbated nor relieved with movement and patients roll around trying to get comfortable y Food or defecation may relieve or exacerbate the pain Associated symptoms: y Nausea and vomiting y Constipation there is a sudden onset of constipation (esp. absolute constipation, where neither faeces nor flatus is passed) associated with vomiting faeculent fluid and colicky abdominal pain in bowel obstruction these same features in the absence of colicky pain may be seen in ileus y Anorexia y Rectal bleeding y Fever and malaise associated with inflammatory and infective conditions y Menstrual irregularity

Medical conditions mimicking an acute abdomen includes: y Lower lobe pneumonia y Inferior MI y Hypercalcaemia y Hyperglycaemia

Focused History

Site may change as the disease progresses: y Foregut epigastric y Midgut umbilical y Hindgut suprapubic y As inflammation progresses the parietal peritoneum overlying the organ becomes inflamed and this causes a localised pain in that area Onset is the pain sudden in onset or more insidious? y An inflammatory condition tends to produce a gradual onset of pain that increases as the inflammatory reaction progresses y A ruptured viscus typically causes a sudden onset of pain y Smooth muscle colic, as in a bowel obstruction or ureteric colic, has a rapid onset y Hormonally-induced smooth muscle colic, such as bilary colic, has a slow onset because the hormone (eg. CCK) only gradually increases in concentration

Focused Examination

Severity on a scale of 1-10 ureteric colic is said to be worse than childbirth. Nature: y Aching dull pain that is poorly localised y Burning eg. peptic ulcer

General appearance: y Sweating may be associated with pyrexia and is also seen in hypotension due to intraabdominal bleeding or sequestration of fluid (eg. pancreatitis, peritonitis) y Pallor the patient may be anaemic due to bleeding but may also be peripherally shut-down in hypotensive states y Peritonitic facies pale sweaty face with sunken eyes and grey complexion y Attitude in bed:

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Restless typically seen in colic Still peritonitis Drawing up their knees severe peritonitis Sitting forward lifts retroperitoneal structures away from the spine aids in pancreatitis

Investigations
Blood tests: y FBE: o Low Hb in GI bleeding/chronic blood loss o High Hb in severe dehydration and have pancreatitis or peritonitis o Increased WCC in infection U/E/C: o Renal function o Assess dehydration LFT Amylase/lipase pancreatitis ABGs severe sepsis or ischaemic bowel Group and hold if GI bleeding is suspected or an operation is likely

Temperature: y Low in states of shock eg severe peritonitis or pancreatitis y High if infective pathology, esp. pyelonephritis Vital signs: y BP may be low in cases of haemorrhage or peritonitis (where large volumes of fluid can be lost un the gut and there is no intake of fluid y Pulse tachycardia reflects hypovolaemia or infection y Respiration shallow, rapid breaths are associated with generalised peritonitis Abdominal examination: y Inspection: o Scars there may be adhesions from previous surgeries or possibility of recurrent tumour o Masses large masses may be visible o Movement in peritonitis, the patient will breathe shallowly to minimises abdominal movement o Pulsatility epigastric pulsation is normal prominent pulsations may be due to AAA o Hernias irreducible hernias can cause small bowel obstruction y Palpation: o Search for masses and tenderness o Signs of peritoneal inflammation include:  Guarding - localised  Rigid abdomen generalised peritonitis  Rebound tenderness y Percussion: o Best test for rebound tenderness o Distinguishing solids from liquids and gases y Auscultation: o Bowel sounds are absent in ileus due to peritonitis o Loud, high-pitched bowel sounds are heard in bowel obstruction Rectal examination may reveal: o Tenderness of the appendix in pelvic appendicitis o Boggy swelling of a pelvic abscess o A large prostate gland causing urinary retention o An obstructing rectal carcinoma Vaginal examination may reveal: o Vaginal discharge in salpingitis o Cervical tenderness or excitation in salpingitis or ectopic pregnancy o Retained tampon causing toxic shock o Pelvic mas such as ovarian cyst, pelvic abscess or fibroid uterus

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Urinalysis if any of the following are present M/C/S should be done: y Red cells seen in ureteric colic and infection y White cells seen in infection y Nitrites a breakdown product of urea seen in infection y Pregnancy test Radiography: y CXR: o o o y AXR: Dilated loops of bowel associated with an obstruction Free gas perforation Thick-walled inflamed bowel suggested by a widened space between adjacent loops of bowel o Stones may be seen generally kidney stones o Gas in the biliary tree gallstone ileus with a cholecystoduodenal fistula Ultrasound: o Gallstones, dilated common bile duct, abnormal gall bladder o Inflamed pancreas or pseudocyst o Liver metastases or cysts o Aortic aneurysm o Large bladder o Dilated pelvicalyceal system in ureteric obstruction o Ovarian cysts o Hydro- or pyosalpinx o Abdominal or pelvic collections o Masses CT better for demonstrating retroperitoneal structures as well as masses Limited barium or gastrograffin enema if the AXR shows dilated large bowel or an empty rectum Laparotomy when signs of peritonism cannot be diagnosed Laporoscopy lower abdominal pain o o o Subphrenic free gas perforation of a hollow viscus Subphrenic bubbles subphrenic abscess LL pneumonia may cause hypochondrial pain

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