Abdominal pain, acute

Question 1

The commonest causes

Answer 1

in two general practice series were:

Series 1:

• acute appendicitis (31%)
• colics (29%)

Series 2: included children.

• acute appendicitis (21%)
• colics (16%)
• mesenteric adenitis (16%).

Question 2

Probability diagnosis

Answer 2

Acute gastroenteritis

Acute appendicitis

Mittelschmerz/dysmenorrhoea

Irritable bowel syndrome

Biliary colic/renal colic

Peptic ulcer

Mittelschmerz/dysmenorrheoa

Question 3

Serious disorders not to be missed

Answer 3

Vascular:

• myocardial infarction (esp. inferior)
• splenic infarction
• ruptured AAA
• dissecting aneurysm aorta
• mesenteric artery occlusion
• ectopic pregnancy

Cancer:

• of bowel with large or small bowel obstruction

Infection:

• acute cholecystitis / ascending cholangitis
• acute salpingitis
• peritonitis/perforated viscus /spnot bacterial peritonitis
• ascending cholangitis
• intra-abdominal abscess

Other:

• pancreatitis
• ectopic pregnancy
• small bowel obstruction/strangulated hernia
• sigmoid volvulus
• perforated viscus (esp. perforated peptic ulcer)

Question 4

Pitfalls (often missed)

Answer 4

Acute appendicitis (atypical)

Myofascial tear/muscle wall pain

Pulmonary causes:

• pneumonia
• pulmonary embolism

Faecal impaction (elderly)

Acute diverticulitis

Herpes zoster

Acute hepatitis

Inflammatory bowel disease

Rarities:

• porphyria
• lead poisoning
• haemochromatosis
• haemoglobinuria
• Addison disease

Question 5

Masquerades checklist

Answer 5

Depression

Diabetes (ketoacidosis)

Drugs (e.g. NSAIDS, iron tablets, narcotics, cytotoxics)

Anaemia (sickle cell)

Spinal dysfunction (referred)

UTI (inc. urosepsis)

Question 6

Key history

Answer 6

Pain has to be analysed according to the usual SOCRATES features.

In respect to associated s/s, special attention has to be paid to:

• anorexia
• nausea or vomiting
• micturition
• bowel function
• menstruation
• drug intake.

Question 7

Pain patterns

Answer 7

Colicky pain is a rhythmic pain with regular spasms of recurring pain building to a climax and fading.

It is virtually pathognomonic of intestinal obstruction.

Ureteric colic is a true colicky abdominal pain, but so-called biliary colic and renal colic are not true colics at all.

Question 8

Is the patient trying to tell me something?

Answer 8

May be very significant. Consider:

1. Munchausen syndrome
2. sexual dysfunction
3. abnormal stress.

Question 9

Key examination

Answer 9

general appearance

oral cavity

vital parameters incl. temperature, pulse

abdominal examination: inspection, auscultation, palpation and percussion (in that order)

rectal examination

inguinal region

vaginal examination (if appropriate)

urine analysis

Question 10

Diagnostic tips

Answer 10

Upper abdominal pain is caused by lesions of the upper GIT.

Lower abdominal pain is caused by lesions of the lower GIT or pelvic organs.

Early severe vomiting indicates a high obstruction of the GIT.

Acute appendicitis features a characteristic ‘march’ of symptoms:

pain → anorexia, nausea → vomiting.

Question 11

Red flag pointers for acute abdominal pain

Answer 11

• fever
• light-headedness/hypotension/collapse at toilet
• ischaemic heart disease
• pallor and sweating
• progressive vomiting, pain, distension
• menstrual abnormalities
• atrial fibrillation
• rebound tenderness and guarding
• lack of flatus

Question 12

Key investigations

Answer 12

• FBC
• ESR/CRP
• Serum lipase or amylase
• Urine MC
• LFTs
• H. pylori tests
• Faecal blood
• Consider:
• imaging including plain X-ray, ultrasound, IVU, CT scan and others according to suspected conditions
• upper GI endoscopy