Abdominal pain without peritonism

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?

Answer 1

Impression
The lack of rebound tenderness of guarding on abdo examination rules out peritonism, and thereby makes serious causes of this presentation less likely (‘acute abdomen’). It would be necessary to keep a wide range of differentials in mind when assessing this patient

Question 2

Abdo pain - Differentials

Answer 2

Differentials
GIT: gastro, PUD, pancreatitis, SBO/LBO, biliary colic, cholecystitis, cholangitis, hernia (complicated) hepatitis, volvulus, diverticulitis, malignancy, abscess, IBD
Cardio: inferior STEMI, AAA
Resp: pneumonia, PE
Gynae: ovarian torsion, PID, TOA, ectopic, etc
Genitourinary: renal colic, UTI, testicular torsion, etc
Psychiatric: factitious/malingering, somatic illness disorder

Question 3

Abdo pain - History

Answer 3

History

• sx: Pain - SOCRATES (flesh this out), bowel/urinary changes, infective sx
• REDS: weight loss, night sweats.
• RISKS: previous abdo surgery, IVDU/sex practices, immunisations,

Question 4

Abdo pain - Examination

Answer 4

Examination

• General appearance + vitals
• Abdo exam: tenderness, shifting dullness, rebound, guarding,
• systems review
• other relevant

Question 5

Abdo pain - Investigations

Answer 5

Investigations
- Resp: CXR, other chest imaging
- Cardiac: ECG, trops, BNP, coronary angiography
- Genitourinary: CT KUB, urinalysis +/- MCS
GIT, UEC
- PUD: H.pylori breath test, upper endoscopy + biopsy
- Gastro: stool sample MCS + PCR, FBC, blood cultures
- Hepatitis: viral serology, LFTs
- SBO/LBO: CT Abdo (oral + portal contrast): transition point,
- IBD: Colonoscopy, biopsy, CT abdo
- Pancreatitis: lipase, CT abdo
- Appendicitis: abdo US, FBC,
- Cholangitis/etc: MRCP, ERCP, LFTs, FBC, blood cultures