Abdominal Pain

Causes of acute abdomen

Process Organ Involved Disorder

Inflammation Bowel Inflammatory bowel disease

Appendix Appendicitis
Gall bladder Cholecystitis
Pancreas Pancreatitis
Fallopian Tube Salpingitis
Colonic diverticulae Diverticulitis

Perforation Duodenum Perforated duodenal ulcer

Stomach Perforated gastric ulcer
Colon (diverticula or Faecal peritonitis
carcinoma) Biliary peritonitis
Gall bladder Appendicitis
Appendix

Obstruction Gall bladder Biliary colic

 Small intestine Acute small bowel obstruction
Large bowel Acute large bowel obstruction
Ureter Ureteric colic
Urethra Acute urinary retention
Mesenteric artery occlusion Intestinal Infarction

Haemorrhage Fallopian Tube Ruptured ectopic pregnancy

Spleen or liver Ruptured spleen or liver
Ovary Ruptured ovarian cyst
Abdominal aorta Ruptured AAA

Torsion (ischaemia) Sigmoid colon Sigmoid volvulus

Ovary Torsion ovarian cyst
Testes Torsion of testes

Left lower quadrant Colonic: colitis, diverticulitis, IBD, IBS

Renal: nephrolithiasis, pyelonephritis
Gynecologic: ectopic pregnancy, fibroids,
ovarian mass, torsion, PID

Key Facts

● International study revealed non specific abdominal pain (34%), acute appendicitis
(28%) and cholecystitis (10%) as the most common conditions.
● General rule: upper abdominal pain is caused by lesions of the upper GIT and lower ab
pain by lesions of lower GIT
● Colicky midline umbilical abd pain (severe) >vomiting > distension = small bowel
obstruction
● Midline lower abd pain > distension> vomiting = large bowel obstruction
● Surgical cause: pain nearly always precede vomiting
● Consider mesenteric artery occlusion in elderly person w atherosclerotic dx or in pt w AF
℅ sever abd pain or after MI
● Early severe vomiting indicates high obstruction of GIT

Acute abdominal pain

Probability diagnosis Serious disorders not to be missed

Acute gastroenteritis Cardio

Acute appendicitis ● MI
Mittelschermz/ dysmernorrhea ● Ruptured AAA
Irritable bowel syndrome Severe infections
● Acute salpingitis
● Peritonitis
 ● Asc cholangitis
● Intra abd abcess
Pancreatitis
Ectopic pregnancy
SBO
Sigmoid volvulus
Perforated viscus
● Duodenal ulcer
● Meckel’s diverticulum
● Colonic ca

Pitfalls (often missed) Seven masquerade checklist

Acute appendicitis elder,children, taking steroids. ● Depression
Myofascial tear ● Diabetes: -
Pulmonary cause ● Drugs: OH, AB (erythromycin), aspirin,
● Pneumonia corticosteroids, cytotoxic agents, TCA. iron prep,
nicotine, NSAIDS/ COX2 inh, Na valpraoate,
● Pulm embolism phenytoin
Faecal impaction (elcerly) ● Anemia: -
Herpes zoster elderly, unilateral abd pain in dermatome. ● Thryoid dx: -
Rarities: prophyria, lead poisoning, ● Spinal dysfx: referred pain from lower thoracic
haemochromatosis, sickle cell anemia, tabes and thoracolumbar
dorsalis, haemoglobinuria, addisons dx ● Uti:

Is the pt trying to tell me something: Red Flags

Strong possibility: consider hypocondriasis, ● Collapsing at toilet ( intraabd bleed)
anxiety, sexual dysfx ● Light headedness
● Progressive intractable vomiting
● Progressive intensity of pain
● Prostration

Chronic or recurrent abd pain

Probability diagnosis Serious disorders not to be missed

Irritable bowel syndrome Cardiovascular
Mittelschmerz/ dysmenorrhea ● Mesenteric artery ischemia
Peptic ulcer/ gastritis ● AAA
Neoplasia
● Carcinoma bowel/stomach/ pancreas
● Ovarian tumour
Severe infection- hepatitis, recurrent PID

Pitfalls Seven Masquerade

Food allergy, lactase def, constipation, chr
pancreatitis, Crohn’s disease, endometriosis, Depression
diverticulosis Drugs
Rarities: uraemia, lead poisoning, crohn’s dx, Spinal dysfunction
porphyria, sickle cell anaemia, UTI
hypercalcemia, addison’s syndrome
Dangers of misdiagnosis
● Ectopic pregnancy → rapid hypovolaemic shock
● Ruptured abdominal aortic aneurysm (AAA) → rapid hypovolaemic shock
● Gangrenous appendix → peritonitis/pelvic abscess
● Perforated ulcer → peritonitis
● Obstructed bowel → gangrene

Specific pitfalls
● Misdiagnosing a ruptured ectopic pregnancy in the patient on contraception or with a
history of normal menstruation or where the brownish vaginal discharge is mistaken for a
normal period.
● Failing to examine hernial orifices in a patient with intestinal obstruction.
● Misleading temporary improvement (easing of pain) in perforation of gangrenous
appendix or perforated peptic ulcer.
● Overlooking a perforation in the elderly or in patients taking corticosteroids, because of
relative lack of pain.
● Overlooking acute mesenteric artery obstruction in an elderly patient with colicky central
abdominal pain.
● Attributing abdominal pain, frequency and dysuria to a urinary infection when the cause
could be diverticulitis, pelvic appendicitis, salpingitis or a ruptured ectopic pregnancy.

History:

● What type of pain is it: is it constant or does it come and go?

● How severe would you rate it from 1 to 10?
● Have you ever had previous attacks of similar pain?
● What else do you notice when you have the pain?
● Do you know of anything that will bring on the pain? Or relieve it?
● What effect does milk, food or antacids have on the pain?
● Have you noticed any sweats or chills or burning of urine?
● Are your bowels behaving normally? Have you been constipated or had diarrhoea or
blood in your motions?
● Have you noticed anything different about your urine?
● What medications do you take?
● How much aspirin do you take?
● Are you smoking heavily or taking heroin or cocaine?
● How much alcohol do you drink?
● How much milk do you drink?
● Have you travelled recently?
● What is happening with your periods? Is it mid-cycle or are your periods overdue?
● Does anyone in your family have bouts of abdominal pain?
● Do you have a hernia?
 ● What operations have you had for your abdomen?
● Have you had your appendix removed?
● Any chronic cough, contact with known TB
● Any history of STI, abnormal PV discharge
● How is your mood. Any low mood or anhedonia
● Have you travelled anywhere recently
● Any history of heavy lifting or trauma

Summary of examination of patient with abdominal pain

General
 Posture—curled up/agitated (colic); flat/bent knees (peritonism)
 Colour—pale; jaundice
 Vital signs
o Atrial fibrillation: consider mesenteric artery obstruction
o Tachycardia: sepsis and volume depletion
o Tachypnoea: sepsis, pneumonia, acidosis
o Pallor and ‘shock’: acute blood loss
 Mouth, tongue, skin turgor for hydration
 Lymph nodes
Abdomen
 Look—distension, movement, flanks bruising
 Feel—evidence of peritonitis, pulses, hernial orifices
o Palpation: palpate with gentleness—note any guarding or rebound tenderness
o —guarding indicates peritonitis
o —rebound tenderness indicates peritoneal irritation (bacterial peritonitis, blood).
Feel for maximum site that corresponds to focus of the problem
o Patient pain indicator: the finger pointing sign indicates focal peritoneal irritation;
the spread palm sign indicates visceral pain
 Listen—bowel sounds
 Auscultation: note bowel activity or a sucussion splash
 Causes of a ‘silent abdomen’:
 —diffuse sepsis
 —ileus
 —mechanical obstruction (advanced)
 Hypertympany indicates mechanical obstruction.

 Testicles
 PR/PV if appropriate (be cautious if no chaperone)
Other
 Respiratory system
  Cardiovascular system

Signs
● Pallor and sweating
● Hypotension
● Atrial fibrillation or tachycardia
● Fever
● Rebound tenderness and guarding
● Decreased urine output

Investigation

Full Blood Count Hb- Anemia of chr blood loss (PUD, ca, oseophagitis)
WCC- leucocytosis w appendicitis, pancreatitis, mesenteric adenitis (1st day only),
cholecystitis (Esp w empyema), pyelonephritis

Peripheral blood film Abn red cells- sickle cell dx

ESR Raised w ca, crohn’s dx, abcess

CRP Ddx and monitoring infxn, inflammation. Preferable to ESR. Not

raised in SLE, syst sclerosis, UC, leukaemia.

LFT

Seum amylase/ lipase Raised greater than 5 times normal upper level-acute pancreatitis
Also raised in intraabd disasters- ruptured ectopic, perforated
peptic ulcers, ruptured empyema of GB, ruptured aortic aneurysm

UPT *BHCG Ectopic pregnancy

Urine ● blood: ureteric colic (stone or blood clot), urinary infection

● white cells: urinary infection, appendicitis (bladder
irritation)
● bile pigments: gall bladder disease
● porphobilinogen: porphyria (add Ehrlich's aldehyde
reagent)
● ketones: diabetic ketoacidosis
● air (pneumaturia): fistula (e.g. diverticulitis, other pelvic
abscess, pelvic carcinoma)

Faecal blood Mesenteric artery occlusion, intussusception (‘redcurrant jelly’),

carcinoma colon, diverticulitis, Crohn's disease and ulcerative colitis

Imaging ● kidney/uteric stones—70% opaque

● biliary stones—only 10–30% opaque
 Plain abd X-ray (Erect ● air in biliary tree
and supine) ● calcified aortic aneurysm
● marked distension sigmoid → sigmoid volvulus
● distended bowel with fluid level → bowel obstruction
● enlarged caecum with large bowel obstruction
● blurred right psoas shadow → appendicitis
● a sentinel loop of gas in left upper quadrant (LUQ) → acute
pancreatitis

Chest X- ray Air under diaphragm - perforated ulcer

US Gallstone, ectopic pregnancy, pancreatic pseudocyst, aneursm

aorta, hepatic mets, abd tumours, thickened appendix, paracolic
collection

IVP HIDA or DIDA nuclear scan- acute cholecystitis

Contrast enhanced X-ray CT scan
(bowel leakage) ERCP
Barium enema MRI
Ecg OGDS
Colonoscopy

Left Lower Quadrant

Male Female
FBC FBC
RP RP
Urinalysis Urinalysis
CT Abdomen Urine pregnancy test
Testicular exam Pelvic ultrasound
Pelvic Exam
CT Abdomen

Pain pattern
True colic: ureteric colic
Not true colic: biliary, kidney colic

Abdominal Pain in Children

1. Common causes/probability diagnosis

○ infantile colic 2. Serious causes, not to be missed
○ gastroenteritis (all ages) ○ intussusception (peaks at 6–9
○ mesenteric adenitis months)
○ acute appendicitis (mainly 5–
15 years)
○ bowel obstruction

3. Pitfalls 4. Seven masquerades checklist

 ○ child abuse ○ diabetes mellitus
○ constipation ○ drugs
○ torsion of testes ○ UTI
○ lactose intolerance 5. Psychogenic consideration
○ peptic ulcer ○ important cause
○ infections
○ —mumps
○ —tonsillitis
○ —pneumonia (especially right
lower lobe)
○ —EBM
○ —UTI
○ Rarities
○ Meckel's diverticulitis
○ Henoch-Schönlein purpura
○ sickle crisis
○ lead poisoning

Infantile colic Reassurance and explanation to the parents.

Typical features Advice for the parents:
● Baby between 2 and 16 weeks old ● Use gentleness (such as subdued
● Prolonged crying—at least 3 hours lighting where the baby is handled,
● Crying worst at around 10 weeks of soft music, speaking softly, quiet
age feeding times).
● Crying during late afternoon and early ● Avoid quick movements that may
evening startle the baby.
● Occurrence at least 3 days a week ● Make sure the baby is not hungry—
● Child flexing legs and clenching fists underfeeding can make the baby
because of the ‘stomach ache’ hungry.
● Normal physical examination ● If the baby is breastfed, express the
watery foremilk before putting the
baby to the breast.
● Provide demand feeding (in time and
amount).
● Make sure the baby is burped, and
give posture feeding.
● Provide comfort from a dummy or
pacifier.
● Provide plenty of gentle physical
contact.
● Cuddle and carry the baby around
(e.g. take a walk around the block).
● A carrying device such as ‘snuggly’ or
‘Meh Tai Sling’ allows the baby to be
carried around at the time of crying.
 ● Make sure the mother gets plenty of
rest during this difficult period.
Do not worry about leaving a crying child for 10
minutes or so after 15 minutes of trying
consolation

● Male babies > female DxT: pale child + severe ‘colic’ + vomiting =
● Age 6–12 months acute intussusception
● Range: birth to school age, usually 5–
24 months ● Pale, anxious and unwell
● Sudden-onset acute pain with shrill ● Sausage-shaped mass in right upper
cry at 15 minute intervals lasting for 2- quadrant (RUQ) anywhere between
3 mins the line of colon and umbilicus,
● Vomiting especially during attacks (difficult to
● Lethargy feel)
● Pallor with attacks ● Signe de dance (i.e. emptiness in RIF
● Intestinal bleeding: redcurrant jelly to palpation)
(60%) ● Alternating high-pitched active bowel
sounds with absent sounds
● Rectal examination: ± blood

Ix: US, O2 or barium enema

Tx: hydrostatic reduction by air or O2 or
surgical intervention

Table 34.5 Comparison of the features of acute appendicitis and mesenteric adenitis in
children (guidelines only)

Acute appendicitis Mesenteric adenitis

Typical child Older Younger

Site of onset of pain Midline RIF

Shifting to right Can be midline

Preceding respiratory illness Uncommon Invariable: URTI or tonsillitis

Anorexia, nausea, vomiting ++ ±

Colour Usually pale Flushed: malar flush

Temperature N or ↑ ↑↑→↑↑↑

Abdominal palpation Tender in RIF Tender in RIF

Minimal guarding
 Guarding ° Rigidity Usually no rigidity

Rectal examination Invariably tender Often tender but lesser degree

Psoas and obturator tests Usually positive Usually negative

At times the distinction may be almost impossible. In general, with mesenteric adenitis localisation of pain
and tenderness is not as definite, rigidity is less of a feature, the temperature is higher, and anorexia,
nausea and vomiting are also lesser features. The illness lasts about five days followed by a rapid
recovery

Organic Non Organic

● the pain is other than periumbilical ● acute and frequent colicky abdominal pain
● the pain radiates rather than remains ● pain localised to or just above umbilicus
localised ● no radiation of pain
● the pain wakens the child from sleep ● pain lasts less than 60 minutes
● the pain is accompanied by vomiting ● nausea frequent and vomiting rare
● the child is not completely well between ● diurnal (never wakes the child at night)
attacks ● minimal umbilical tenderness
● there is associated weight loss ● anxious child
● there is failure to thrive ● obsessive or perfectionist personality
● one or both parents intense about child's
health and progress

Abdominal pain in elderly

● DxT: intense pain + pale and ‘shocked’ ± back pain = RAAA

● DxT: anxiety and prostration + intense central pain + profuse vomiting ± bloody
diarrhoea = mesenteric arterial occlusion. thumb printing’ due to mucosal oedema on gas-
filled bowel
● DxT: localised RIF pain + a/n/v + guarding = acute appendicitis
● ± Superficial hyperaesthesia
● ± Psoas sign: pain on resisted flexion of right leg, on hip extension or on
elevating right leg (due to irritation of psoas especially with retrocaecal appendix)
● ± Obturator sign: pain on flexing patient's right thigh at the hip with the knee bent
and then internally rotating the hip (due to irritation of internal obturator muscle)
● Rovsing's sign: tenderness in RIF while palpating in LIF
● DxT: colicky central pain + vomiting + distension = SBO
● DxT: colicky pain + distension ± vomiting = LBO
● DxT: sudden severe pain + anxious, still, ‘grey’, sweaty + deceptive improvement =
perforated peptic ulcer
● DxT: intense pain (loin) → groin + microscopic haematuria = ureteric colic - most stones (75%) are
radio–opaque (calcium oxalate and phosphate)
● DxT: acute pain + left-sided radiation + fever = acute diverticulitis
● pain increased with walking and change of position
● usually associated with constipation
● DxT: severe pain + nausea and vomiting + relative lack of abdominal signs = acute
pancreatitis
● DxT: severe pain + vomiting + pain radiation = biliary colic
● DxT: intense pain (loin) → groin + microscopic haematuria = ureteric colic

Table 34.6 Small bowel obstruction: difference between a high and a low
obstruction

High Low

Frequency of spasms 3–5 minutes 6–10 minutes

Intensity of pain +++ +

Vomiting Early, frequent Later

Violent Less severe
Content: Gastric juices, then green Feculent (later)

Dehydration and degree of illness Marked Less prominent

Distension Minimal Marked

IBS