Abdominal Pain

Question 1

A 57 year old man presents with abdominal pain. There are no signs of abdominal rebound tenderness or guarding. What are possible diagnoses and which investigations may be helpful?

Impression/DDx/Goals

Answer 1

Impression:
Non-specific abdominal pain has a broad spectrum of potential causes. Reassuring no signs of peritonism but would still like to consider, some life-threatening causes.

Life-threatening:

• SBO/LBO + perforation
• Pancreatitis
• Volvulus/ ischaemic bowel
• Complicated cholecystitis/appendicitis
• Malignancy

Otherwise, differentials for abdo pain can be considered anatomically, or based on further hx/exam findings.

• Oesophagus; GORD, oesophagitis,
• Stomach: gastritis, peptic ulcer,
• Small bowel: IBD, SBO
• Large bowel: appendix, diverticulitis, IBD, colitis. LBO
• Kidney: malignancy, pyelo
• Liver: hepatitis
• Pancreas: pancreatitis
• Reproductive
• Other: endocrine, UTI, (masqueraders)

Goals:

• Identify underlying aetiology
• Rule out red flags
• Manage accordingly, with appropriate disposition + triage

Question 2

Abdo pain - History

Answer 2

Assessment:
Would first utilise A to E approach to quickly identify serious clinical presentation requiring urgent management. Assess for haemodynamic stability to guide assessment.

History:

• Sx: SOCRATES, bowel changes, urinary sx, systemic signs infection, signs malignancy, haematemesis, fever
• PHX, FHX (malignancies)
• Risk factors for cancer
• SNAP

Question 3

Abdo pain - Examination

Answer 3

Exam:

• Vitals
• Inspection
• Gastro exam: signs of peritonism, abdo masses, bowel sounds, stigmata of chronic disease
• examine the testicles
• rectal exam

Question 4

Abdo pain - Investigations

Answer 4

Investigations: will be based on the findings of the history and exam
Bedside - VBG, ECG, UA
Bloods - Septic screen, FBC, EUC, LFT, Blood cultures if febrile, coags + GH (pre surgical), lipase, troponins
Imaging - Erect abdominal Xray - gas - perforated viscus, CT abdomen with contrast
Special test - gastroscopy/colonoscopy, ERCP

Question 5

Abdo pain - Management

Answer 5

Management
If unstable:
- Disposition - Immediately consult the surgical team and ICU
- Fluid resuscitation - 2x lg cannulas
- May require IV abx - empirical treatment for sepsis from - GIT source = gentamicin IV + amoxicillin IV + - Metronidazole IV
- If bleeding may require MTP e.g ruptured peptic ulcer, AAA
- May require vasopressor support

If stable:

• Disposition - surgical ward, gen med ward
• Supportive management:
• NBM/ NG Tube
• Analgesia - paracetamol, morphine?
• Fluid resuscitation
• General surgical consult
• Perform relevant investigations
• Catheter to monitor urine output
• DVT prophylaxis