Acute Abdomen

Question 1

Associated symptoms to ask for

Answer 1

1. Vomiting and the nature of vomitus (undigested food or bile suggests upper GI pathology or obstruction; faeculent vomiting suggests lower GI obstruction).
2. Haematemesis or melaena.
3. Stool/urine colour.
4. New lumps in the abdominal region/groins.
5. Eating and drinking - including when the patient’s last meal occurred.
6. Bowels - including presence of diarrhoea, constipation and ability to pass flatus.
7. Fainting, dizziness or palpitations.
8. Fever/rigors.
9. Rash or itching.
10. Urinary symptoms.

11.Recent weight loss.

12. Gynaecological and obstetric history - surgery/ ectopic pregnancy
13. Contraception (including intrauterine contraceptive device (IUCD) use).
14. Last menstrual period.
15. Vaginal bleeding.

Question 2

Prehospital care of suspected acute abdomen

Answer 2

Keep the patient nil by mouth.
Apply oxygen as appropriate.
(IV) fluids
Consider passing a nasogastric (NG) tube if severe vomiting occurs, there are signs of intestinal obstruction or the patient is extremely unwell and there is danger of aspiration.
Analgesia
Antibiotics: if systemic sepsis, or peritonitis, or severe urinary tract infection (UTI) is suspected.
IV cephalosporin plus metronidazole are commonly used in acutely unwell patients in whom peritonitis is suspected.

Arrange investigations such as ECG if a medical cause is likely.

Question 3

Diagnosing

Answer 3

With the exception of a urinary pregnancy test and urine dipstick, there are few tests that are useful in the community assessment of the patient with acute abdominal pain.

The following tests are often used but can be nonspecific and must be interpreted in the clinical context and with appropriate medical/surgical expertise:
Blood tests: FBC, U&Es, LFTs, amylase, glucose, clotting, and occasionally calcium; arterial blood gas (pancreatitis).

Radiology - abdominal X-ray (supine), CXR (erect, looking for gas under the diaphragm), intravenous pyelogram (IVP), CT scan, ultrasound scan, as appropriate.

Consider ECG and cardiac enzymes.

Peritoneal lavage if there is a history of abdominal trauma.

Question 4

Red flags

Answer 4

Hypotension.
Confusion/impaired consciousness.
Signs of shock.
Septic-looking.
Signs of dehydration.
Rigid abdomen.
Patient lying very still or writhing.
Absent or altered bowel sounds.
Associated testicular pathology.
Marked involuntary guarding/rebound tenderness.
Tenderness to percussion.
History of haematemesis/melaena or evidence of latter on examination per rectum (PR).

Question 5

Older patients

Answer 5

Aortic aneurysm and bowel ischaemia are more prevalent in the elderly.
Angiodysplasia of the colon is more common and can cause GI haemorrhage.

‘Top 5’ medical causes to consider:
Inferior myocardial infarction.
Lower-lobe pneumonia/pulmonary embolism causing pleurisy.
Diabetic ketoacidosis
Pyelonephritis.
Inflammatory bowel disease (Crohn’s disease or ulcerative colitis).

Question 6

Examination

Answer 6

ABC
Lyng still - peritonitis or moving around in agony - (intestinal, biliary, renal colic)

Abdominal exam
Cullens sign - bruising around umbilicus - pancreatitis
Grey turners - bruising around flanks - retro haemotoma