Acute abdominal pain

Data gathering

  • History
    • SOCRATES – review differentials below depending on site
    • Urinary – dysuria, frequency
    • GI – bowel habit, flatus, vomiting, melaena
    • Systemic – weight loss, E+D, fevers
    • Gynae – LMP, PV discharge, PMB, PCB
    • Cardiac – risk factors, epigastric
    • PMH – previous abdominal surgery
  • Examine
    • Obs – pulse, BP, temperature, RR, sats
    • Abdomen (inspect, palpate, percuss, auscultate)
    • PR

Clinical management

  • Investigations
    • Urine
      • Dipstick, MSU
      • Pregnancy test
    • Bedside glucose measurement
    • Bloods
      • FBC, U+E, LFTs, ESR, CRP
    • Stool
      • MC&S, OCP
      • H.pylori antigen
    • Imaging
      • CXR
      • USS Abdomen
  • Treatment
    • If referring, consider keeping patient nil by mouth

Differential diagnosis

  • RUQ
    • Gallbladder – Acute cholecystitis, Biliary colic
    • Liver – Acute hepatitis, Congestive hepatomegaly
    • GI – Gastric ulcer
  • Epigastric
    • Heart – MI
    • GI – Gastric ulcer
    • Pancreas – Acute pancreatitis
  • LUQ
    • Spleen – Rupture
    • GI – Gastric ulcer
  • Lower abdomen
    • GI – Appendicitis (RLQ), Diverticulitis (LLQ), IBD
    • Gynae – Ruptured ectopic, PID, Ovarian torsion
    • Urology – UTI, Pyelonephritis, Testicular torsion
  • Generalised
    • Intestinal obstruction – absolute constipation, vomiting, previous bowel surgery, absent bowel sounds
    • Incarcerated hernias – painful enlargement of previously reducible hernia +- bowel obstruction
    • Volvulus – bilious (yellow/green) vomiting, cyclical vomiting, recurrent abdominal pain
    • Perforation
    • Meckel’s diverticulum – painless PR bleeding, can have symptoms of obstruction, can mimic appendicitis
  • Medical causes
    • Pneumonia
    • Diabetic Ketoacidosis or HONK – BM > 15, ketones, polyuria, polydipsia
  • Vascular
    • Acute intestinal ischaemia
    • Abdominal aortic aneurysm
  • More common in children
    • Constipation – mainly left sided/suprapubic
    • Gastroenteritis
    • Intussusception – mostly < 2 years old, paroxysms of colicky abdominal pain, vomiting, sausage shaped mass, red currant jelly stool
    • Mesenteric adenitis – fever,  fluctuating severity of RLQ pain, URTI, Generally occurs age 5-10 years, no peritonism, child may be hungry. Far more common than appendicitis.
    • Henoch Schonlein Purpura – Diffuse / colicky abdominal pain, non-blanching rash, swollen ankles/ knees, haematuria/ proteinuria
    • HUS – Unwell child with bloody diarrhoea and triad of: anaemia, thrombocytopenia & renal failure
  • Gynae
    • Mittelschmerz – one sided, sharp, usually lasts a few hours, in the middle of cycle (ovulation)