1. acute abdominal pain How to approach a patient with Andrew McGovern
Brighton and Sussex Medical School

2. Introduction Plan Epidemiology Common causes History and examination
Investigations
Case example
Epidemiology
Abdominal pain present in 10% of hospital admissions.
1/3 of these require surgical intervention.

3. Causes Diffuse RUQ/LUQ RUQ LUQ RLQ LLQ RLQ/LLQ Acute pancreatitis DKA
Gastroenteritis
Intestinal obstruction
Peritonitis
Mesenteric ischaemia
RUQ/LUQ
Acute pancreatitis
Lower lobe pneumonia
Myocardial ischaemia
RUQ
Cholecystitis
Biliary colic
Hepatitis
Hepatic abscess
LUQ
Gastritis
Splenic rupture/abscess
RLQ
Appendicitis
Caecal diverticulitis
Meckel’s diverticulitis
LLQ
Sigmoid diverticulitis
RLQ/LLQ
IBD
Renal stones
Cystitis
Endometriosis
Ruptured ectopic pregnancy
Incarcerated hernias
Psoas abscess

4. Pain History SOCRATES Site – has the pain moved?
Character – visceral, somatic, colic
Radiation
- pain in retroperitoneal structures radiates to the back
- Loin to groin in ureteric colic
Associated symptoms
GI symptoms: nausea, vomiting bleeding
- also GU symptoms and cardiopulmonary symptoms
Severity – elderly patients have increased pain threshold/reduced visceral sensation.

5. Other history Fever Recent travel Past surgical and medical history
Psychiatric disorders
Menstrual and gynaecological history

6. Examination Abdominal examination Vitals – HR, RR, BP, Temperature
General appearance – jaundiced, anaemia, nutritional status
Check for signs of dehydration
Cardiorespiratory examination
Abdominal examination
Inspection – scars, distension
Palpation - hernial orifices
Percussion
Auscultation – high pitched tinkling
bowel sounds

7. Examination Special signs Murphy’s sign – cholecystitis Cullen’s Sign
– pancreatitis
Grey-Turner’s sign
– pancreatitis, ruptured AAA, RTA
Rectal and pelvic examination

8. Investigations General investigations
FBC, ESR – ↓Hb in peptic ulcer disease, malignancy. ↑WCC in infective/inflammatory disease.
U&E – ↑urea/creatinine in renal conditions. Electrolyte disturbance in D&V.
LFTs – abnormal in cholangitis and hepatitis.
Amylase – ↑↑ in acute pancreatitis. ↑ in perforated peptic ulcer or infarcted bowel.
MSU
CXR – Gas under diaphragm in perforation. Pneumonia.
AXR – Dilated bowel – IBD, obstruction. Sentinel loop – pancreatitis, appendicitis. Renal stones, etc.
USS

9. Case History Examination
Mr G: 62 year old male with gradual onset of severe epigastric pain.
Examination
BP 132/79 SaO2 98% on air HR 78/min
Patient comfortable at rest.
Heart sounds normal: I + II + O
Chest clear
Abdomen soft – tender in RUQ, Murphy’s +ve
no palpable masses, no organomegally,
BS present

10. Case Investigations Diagnosis Treatment Bloods – CRP 28 [NR <5]
AXR – normal
USS – thickened GB wall, stones and pericholecystic fluid.
Diagnosis
Acute cholecystitis
Treatment
NBM, pain relief, antibiotics, cholecystectomy within 72h.