APPROACH TO

ABDOMINAL PAIN

Introduction

Abdominal pain is an unpleasant

experience commonly associated
with tissue injury. The sensation
of pain represents an interplay of
pathophysiologic and
psychosocial factors.

Pathophysiology
Visceral pain:
Poorly localized and may be colicky, intermittent and recurrent.
Stimulation of nociceptors investing the visceral peritoneum may cause
this. Eg: when hollow organs are distended or when capsules covering solid
organs are stretched.
Somatic pain:
It is localized, constant and intense.
May result from local irritation of the parietal peritoneum.
Localized more specifically to the area of pathology.
Referred pain:
Pain felt at a distance site of origin. It occurs because afferent pain fibers
from areas of high sensory input (the skin) enter the spinal cord at same
level as the nociceptive fibers from an area of low sensory input.
The brain, being more used to pain signals from the skin, wrongly
interprets the pain signal from the viscera as that from dermatome.
(Epigastric pain due to MI)

Differential Diagnosis

It is helpful to construct a list based upon

location of abdominal pain

Causes Of Diffuse Abdominal

Pain

Generalized diffuse pain that is poorly localized

may be due to benign causes (eg: constipation,
menstrual cramps) or from life threatening
conditions:
Haemoperitoneum ( eg: ruptured aortic
aneurysm, ruptured ectopic pregnancy, trauma)
Mesenteric ischemia
Peritonitis
Bowel obstruction
Diverticulitis
IBD
Metabolic disorders, sickle cell crisis, thyphoid
fever

Extra-abdominal Causes

Clinical Features
Vital signs and general condition:
During triage, rapid assessment is made
Obviously ill patient given priority
(severe pain/abnormal vital signs)
Although we can agree that history is
usually the most important part of the
encounter, urgent determination of
potential surgical emergencies is
essential.

History
Most diagnoses can be made by
history alone.
Careful attention must be paid to:
Time/mode

of onset

Duration
Location
Character/progression
Medical

history
Contributing symptoms
The basics : Demographics and
background

Common Causes Of
Abdominal Pain According To
Age Group And Gender

Pain Attributes

Onset and progress : acute vascular evens and rupture

of hollow viscos present with maximal pain
Ureteric and biliary colic also present with severe pain in
early stages.
In contrast to inflammatory conditions, example, acute
appendicitis, which tends to progress and mature over
hours
Location- help to identify pathology, although
sometimes misleading (ref pain)
Migration- pain from appendicitis typically starts at the
umbilicus or epigastrium and later localized to right iliac
fossa
Radiation may suggest specific conditions such as pain
from acute pancreatitis and perforated peptic ulcer often
radiates to the back

Severity: Severity doesnt always commensurate with

the severity of the underlying ilness. Eg: the elderly
have diminished sense of pain
Character: colicky pain usually results from obstruction
of hollow viscues, constant non colicky pain usually
denotes and inflammatory or vascular process
Precipitating and relieving factors: pains from
peritonitis worsens with movement, deep breathing,
coughing, or sneezing. Pain from PUD clasically
increases with hunger and decreases with food, antacid
or milk
Recurrent episodes: chronic conditions, PUD,
diverticulitis

Associated Symptoms

Constitutional symptoms : eg: fever, chills, rigor,

weight loss or athralgia
GI: anorexia, nausea, vomiting, diarrhoea,
constipation
Feculent vomitus intestinal obstuction
Vomiting of fresh blood or altered blood, passage
of black stool, indicates GI haemorrhage
Genitourinary: dysuria, frequency, urgency or
haematuria, UTI and other urinary tract
pathology
Purulent discharge : PID

Special Considerations

Patients bearing special

consideration
Women

of childbearing age
Elderly patients
Children
Patients on immunosuppressive

Women Of Childbearing Age

Childbearing women
atypical presentations
pregnant women with appendicitis
may present with RUQ pain when
uterus displaced other organs in
2nd/3rd trimesters

Elderly Patients
A low threshold should be used for
admitting or admitting elderly
patients.
Their presentation is rarely typical.
Their history is rarely clear.
Common conditions: intestinal
obstruction, AAA, aortic disection,
intraabdominal neoplasm

Children
Young children often have
difficulty localizing their pain.
History is limited.
Obtaining imaging is sometimes
difficult but imaging has cut
down on improper diagnoses.

Immunosuppressive
Anyone on prednisone or other
immunosuppressive medications
be more careful with as they
often present atypically.
Corticosteroids may mask pain.
Inflammatory response surpress,
abdominal signs from peritoneal
irritation maybe absent

Dangerous Mimics

Abdominal Catastrophes

Things not to miss

MI
AAA
Mesenteric

ischemia
Ectopic pregnancy
Ruptured viscous

MI

Consider
in

patients with risk factors

In patients with epigastric pain
In patients who are vomiting,
particularly inferior wall MIs
Diaphoresis is often common
diabetics

AAA
Used to be misdiagnosed
commonly as nephrolithiasis.
Consider in any patient with CAD,
hypertension, testicular pain,
flank pain.
Check for pulsatile mass,
abdominal bruits.

Mesenteric Ischemia

Pain out of proportion to exam is the

classical description.
High morbidity/mortality
Consider in older patients with
comorbidities such as A. Fib., severe
CAD, CHF
Angiography is test of choice but can
be hard to set up in a timely manner
so early consultation is essential.

Ectopic Pregnancy

Perform a pregnancy test in any

woman of child bearing age.

ABDOMINAL EXAMINATION
SPECIFIC EXAMINATION

Patient should be lying on supine

position

ABDOMINAL EXAMINATION

INSPECTION

Shape and movements of the abdomen with

respiration
Scars -from previous surgical procedure
Distension

Localised distension:Is due to organomegaly

Generalized distension : 5 Fs-can be due to fat,
fluid ,feces,flatus and fetus

Prominent veins.
Striae
Bruises
Pigmentation

Campbell de
Morgan spots-cherry
red papules on the
skin

Ascitic abdomen

ABDOMINAL EXAMINATION

PALPATION
1.

Ensure that your hands are warm

2.

Stand on the patients right side

3.

Help to position the patient

4.

Ask whether the patient feels any

pain before you start

5.

Begin with superficial examination

6.

Move in a systematic manner

through the abdominal quadrants

7.

Repeat palpation deeply.

ABDOMINAL EXAMINATION

PALPATION

Tenderness: discomfort and resistance to

palpation

Rebound tenderness: patient feels pain when

the hand is released

Tenderness + rigidity: perforated viscus

Palpable mass (enlarged organ, faeces, tumour)

Aortic pulsation(Press down deeply in the

midline of the umblicus.If there is a well
defined mass that is greater than 3cm then
aortic aneurysm is present.

ABDOMINAL EXAMINATION

MURPHYS SIGN

Pain in RUQ

It is a sign of gallbladder disease consisting of

pain on taking a deep breath when the
examiners finger are on the approximate
location of the gallbladder Pain on inspiration

during gentle palpation below the right

subcostal arch.

ABDOMINAL EXAMINATION

BLUMBERGS SIGN

Rebound tenderness is also known as

blumbergs sign.

Pain upon removal of pressure rather than

application of pressure to the abdomen

Peritonitis and/ or appendicitis

ROVSINGS SIGN
ROVSINGS SIGN
Palpation in the left iliac fossa
produces pain in the right iliac
fossa.The disease associated is
acute appendicitis.

ABDOMINAL EXAMINATION

MCBURNEYS POINT

1/3 from the anterior superior iliac spine

to umbilicus
It determines the location of appendix.
Deep tenderness (= acute appendicitis)

ABDOMINAL EXAMINATION

FLUID THRILL

Place the palm of your left

hand against the left side of the
abdomen

Flick a finger against the right

side of the abdomen

Ask the patient to put the edge

of a hand on the midline of
the abdomen

If a ripple is felt upon flicking

we call it a fluid thrill = ascites

ABDOMINAL EXAMINATION

PALPATION OF THE LIVER

1.

Start palpating in the right iliac fossa

2.

Ask the patient to take a deep breath in

3.

Move your hand progressively further up the

abdomen

4.

Try to feel the liver edge and work out if it is

enlarged or displaced downwards.

ABDOMINAL EXAMINATION

PALPATION OF THE SPLEEN

1.

Roll the patient towards you

2.

Palpate with your left hand while using your left

hand to press forward on the patients lower ribs
from behind

3.

Feel along the costal margin and work out if it is

enlarged or displaced downwards

ABDOMINAL EXAMINATION

PERCUSSION

Dull sounds: solid or fluid-filled structures

Resonant sounds: structures containing air

or gas

ABDOMINAL EXAMINATION

AUSCULTATION

Place the diaphragm of the

stethoscope to the right of the
umbilicus

Bowel sounds (borborygmi) are caused

by peristaltic movements

Occur every 5-10 sec.

Absence of bowel sound is due to

paralytic ileus or peritonitis

Bruits over aorta and renal area could

be a sign of an aneurysm and stenosis

Clinical Investigations

Urine pregnancy test

Urine analysis
ECG
Capillary blood sugar / dextrostix
FBC
Amylase and lipase suspected pancreatitis
LFT- suspicion of hepatobiliary disease/
urine bilinogen +ve
CRP- appendicitis

Imaging
Plain xray for bowel obstruction,
bowel perforation and foreign
body
Ultrasound , FAST (focused abd
sonogram for trauma) AAA,
ectopic pregnancy
CT scan
MRI

THANK

YOU