Acute abdominal pain
Causes: –
| Surgical causes | Non-Surgical causes | |
| Non-specific abdominal pain Acute appendicitis Acute cholecystitis & biliary colic Peptic ulcer disease Small bowel obstruction Gynaecological disorders | Acute pancreatitis Renal & ureteric colic Malignant disease Acute diverticulitis Dyspepsia Miscellaneous | Acute myocardial infarction Diabetic keto-acidosis Hypercalcaemia Pneumonia Inflammatory bowel disease Urinary tract infection |
| Disease | Clinical features | Investigations/Management |
| Acute appendicitis | * Sudden-onset, constant, severe abdominal pain often periumbilical with migration to right lower quadrant * Poorly localised central abdominal pain that becomes localised to the right lower quadrant (McBurney’s point) * Guarding and rebound tenderness. * Rovsing’s sign (palpation of left lower quadrant elicits pain in the Rt lower quadrant), psoas sign (Rt lower quadrant pain with right thigh extension) * A palpable mass if a peri-appendiceal abscess is present due to perforation. * The most commonly used scoring systems are the Alvarado score, the Appendicitis Inflammatory Response (AIR) score & the Adult Appendicitis Score (AAS). * The AIR & AAS scores are better predictors of acute appendicitis than the Alvarado score. | @ Order a pregnancy test in all women of childbearing age. @ Use urinalysis to rule out UTI. @ Order blood include FBC, CRP. @ Order an ultrasound if radiation risk is a concern; it should be used as first line in pregnant women and children. @ Consider contrast-enhanced CT scan if an appendicular mass or abscess or malignancy are suspected, or U/S is not clear. @ Seek immediate surgical input and involve obstetric team for any pregnant woman. @ Keep the patient nil by mouth if surgery is being considered. |
| Acute pancreatitis | # Gallstones (40 – 70 % of cases) & excessive alcohol consumption (25 – 35 %). # Presented with Acute-onset, constant, severe mid-abdominal/ epigastric pain that often radiates to the back with upper abdominal tenderness. # Ecchymoses in the skin of one or both flanks (Grey-Turner’s sign) and/or the periumbilical area (Cullen’s sign). # Beware systemic inflammatory response syndrome and/or multi-organ failure – are the biggest risk to life in the first week. # Blood tests includes: FBC, UE, LFT, UE, S. glucose. # S. lipase or amylase: elevated (3-times the upper limit of normal). # S. calcium could also be elevated | – Abdominal imaging is not needed to confirm a diagnosis. Only request abdominal imaging if there is diagnostic doubt. – Do not request contrast-enhanced abdominal CT scanning to detect local complications in the first 3 days after presentation as Pancreatic necrosis often takes > 72 hours to develop. – Initial treatment consists of early goal-directed fluid resuscitation with a crystalloid fluid plus adequate pain control. – Establish oral feeding ASAP. – Arrange emergency ERCP within 24 hours for any patient with gallstone pancreatitis who has concurrent cholangitis |
| Perforated gastric ulcer | * Sudden-onset severe upper abdominal pain with fever, nausea, vomiting & peritoneal signs; referred pain to shoulders 2ry to diaphragmatic irritation. * Often points to site of pain (pointing sign). * Peritoneal signs with guarding & rebound | @ Blood — FBC, CRP, UE and ABG @ CT abdomen with Contrast — pneumoperitoneum @ Erect CXR or abdominal x-ray — free air under diaphragm. @ Seek immediate surgical input |
| Mallory-Weiss tear | # It’s a longitudinal mucosal tear or laceration of the mucous membrane in the region of the gastroesophageal junction and gastric cardia # The patient presents with small and self-limited episodes of haematemesis and/or melaena and has a recent history of forceful or recurrent retching, vomiting, coughing, or straining. | – Perform a risk assessment. If GBS ≤ 1, consider managing the patient as an outpatient if safe and appropriate to do so. – Refer all patients with suspected acute upper GI bleeding for upper GI endoscopy |
| Acute mesenteric ischaemia and infarction | * CC by: pain out of proportion to examination findings with soft non-tender abdomen despite severe abdominal pain, followed by rigid abdomen, guarding, and rebound tenderness with bowel necrosis and perforation. * History of AF, CAD, recent MI, and congestive heart failure. * Acute mesenteric ischaemia is a medical emergency — involve surgeon & ICU early. | @ Metabolic acidosis and Elevated serum lactate (late). @ CT abdominal scan with contrast is the first-line investigation of choice in the diagnosis. @ CT early signs include bowel wall thickening and luminal dilation. @ Late signs include pneumatosis (gas in the bowel wall) and mesenteric or portal venous gas |
| Oesophageal perforation (Boerhaave’s syndrome) | # History of vomiting followed by chest pain, recent endoscopy or chest/neck trauma. # Exam: mediastinal crunching sound on auscultation; subcutaneous emphysema of neck or chest; decreased breath sounds (usually on left side); tachypnoea and respiratory distress | – Erect CXR: pneumomediastinum, subcutaneous emphysema, left side pleural effusions. – Imaging includes CT chest with oral & IV contrast or upper GI endoscopy |
| Fitz-Hugh-Curtis syndrome | * It’s an inflammation of the liver capsule with adhesion formation resulting in right upper quadrant pain. * Female with history of PID presented with RUQ pain & tenderness on palpation | @ CT abdomen/pelvis with oral & IV contrast show enhancement of liver capsule. @ diagnostic laparoscopy (with lysis of adhesions & peritoneal cultures) |
| Budd-Chiari syndrome | # Caused by: hepatic venous outflow obstruction at any level from the small hepatic veins to the junction of the IVC with the right atrium, regardless of the cause of the obstruction. # Classic triad of symptoms: abdominal pain, ascites, and hepatomegaly. # Investigations: – Blood including serum protein, serum-ascites albumin gradient (SAAG) # Colour & pulsed Doppler ultrasound is the investigation of choice | The main treatment is: 1- Interventional Radiology 2-Trans-jugular intrahepatic porto-systemic shunts (TIPS) 3- Medical treatment is given parallel to IR/TIPS in the form of anticoagulants, diuretics, and treatment of the cause. |
| Acute diverticulitis | * Intermittent left lower quadrant pain; fever, anorexia, nausea, vomiting, and abdominal distension with blood in stool. * Diffuse tenderness with peritoneal signs (guarding, rebound tenderness, rigid abdomen) with perforation or ruptured abscess | – Contrast CT abdomen / pelvis or colonoscopy may see diverticula. – Treat with IV antibiotics and analgesics – Treat complication |
General management of a patient presenting with abdominal pain: –
- Resuscitate if signs of sepsis or haemodynamic instability are shown.
- Perform a pregnancy test in all females of child-bearing age to avoid missing an ectopic pregnancy.
- Morphine IV titrated to effect. IV anti-emetics such as cyclizine and ondansetron.
- There is no evidence for anti-spasmodic (Buscopan) in the management of acute pain.
- Anti-pyretic (IV paracetamol if necessary).
- Consider a Nasogastric tube insertion if a bowel obstruction is present.
- Consider a Urinary catheter insertion if the patient is unwell or peritonitis is suspected.
- Systemic broad-spectrum antibiotics should be considered for patients with signs of sepsis, strangulation or peritonism at presentation.
- Keep nil by mouth if acute surgical pathology suspected and give IV crystalloid fluids where required (e.g., dehydrated, shocked).
- Most patients with suspected acute surgical pathology will undergo imaging prior to surgical intervention (CT abdomen/pelvis with contrast or US scan).
- Refer to surgical team, consider involving critical care if indicated.