acute abdominal pain

Andrew McGovernBrighton and Sussex Medical School

How to approach a patient with

IntroductionPlan1. Common causes

2. History and examination

3. Investigations

4. Case example

EpidemiologyAbdominal pain present in 10% of hospital admissions.

1/3 of these require surgical intervention.

CausesDiffuseAcute pancreatitisDKAGastroenteritisIntestinal obstructionPeritonitisMesenteric ischaemia

RUQCholecystitisBiliary colicHepatitisHepatic abscess

LUQGastritisSplenic rupture/abscess

RUQ/LUQAcute pancreatitisLower lobe pneumoniaMyocardial ischaemia

RLQAppendicitisCaecal diverticulitisMeckel’s diverticulitis

LLQSigmoid diverticulitis

RLQ/LLQIBDRenal stonesCystitisEndometriosisRuptured ectopic pregnancyIncarcerated herniasPsoas abscess

Pain HistorySOCRATESSite – has the pain moved?

Character – visceral, somatic, colic

Radiation

- pain in retroperitoneal structures radiates to the back

- Loin to groin in ureteric colic

Associated symptoms

-GI symptoms: nausea, vomiting bleeding

- also GU symptoms and cardiopulmonary symptoms

Severity – elderly patients have increased pain threshold/reduced visceral sensation.

Other historyFever

Recent travel

Past surgical and medical history

Psychiatric disorders

Menstrual and gynaecological history

ExaminationVitals – HR, RR, BP, Temperature

General appearance – jaundiced, anaemia, nutritional status

Check for signs of dehydration

Cardiorespiratory examination

Abdominal examinationInspection – scars, distension

Palpation - hernial orifices

Percussion

Auscultation – high pitched tinkling

bowel sounds

ExaminationSpecial signsMurphy’s sign

– cholecystitis

Cullen’s Sign

– pancreatitis

Grey-Turner’s sign

– pancreatitis, ruptured AAA, RTA

Rectal and pelvic examination

InvestigationsGeneral investigationsFBC, ESR – ↓Hb in peptic ulcer disease, malignancy. ↑WCC in infective/inflammatory disease.

U&E – ↑urea/creatinine in renal conditions. Electrolyte disturbance in D&V.

LFTs – abnormal in cholangitis and hepatitis.

Amylase – ↑↑ in acute pancreatitis. ↑ in perforated peptic ulcer or infarcted bowel.

MSU

CXR – Gas under diaphragm in perforation. Pneumonia.

AXR – Dilated bowel – IBD, obstruction. Sentinel loop – pancreatitis, appendicitis. Renal stones, etc.

USS

CaseHistoryMr G: 62 year old male with gradual onset of severe epigastric pain.

ExaminationBP 132/79 SaO2 98% on air HR 78/min

Patient comfortable at rest.

Heart sounds normal: I + II + O

Chest clear

Abdomen soft – tender in RUQ, Murphy’s +ve

no palpable masses, no organomegally,

BS present

CaseInvestigationsBloods – CRP 28 [NR <5]

AXR – normal

USS – thickened GB wall, stones and pericholecystic fluid.

DiagnosisAcute cholecystitis

TreatmentNBM, pain relief, antibiotics, cholecystectomy within 72h.