ACUTE ABDOMINAL PAIN

Condition

Pathophysiology

Risk Factors

Key History
findings

Examination
findings

Bedside tests/
useful tips

Investigations

Treatment

Complications

Generalised
peritonitis

Serious condition
resulting from either:
Infection e.g.
perforated appendix/
diverticula
Chemical irritation
from leaking bowel
contents e.g.
perforated ulcer
Acute inflammation
with production of
inflammatory
exudate
Ulcer = Disruption to
mucosal lining of
stomach
Perforation leaks
acidic gastric
contents into the
peritoneum, causing
generalised
peritonitis

- Peptic/duodenal
ulcer
- Undiagnosed/
delayed
treatment for
appendicitis
- Diverticulitis
- Gall stone
disease
- Crohns /UC
- Local peritonitis

- Generalised severe
abdominal pain
- Worse on movement
- Nausea
- Vomiting
- Anorexia

Generalized tenderness
Rebound tenderness
Guarding
Distended abdomen
Board-like rigidity
Absent bowel sounds

Look for hypovolaemic

shock:
- Hypotension
- Weak thready pulse
- Tachypnoea
- Low urine output
- Clammy cold
peripheries
- Hypothermia
- Confusion
- Weakness
- Thirst

Erect CXR look for

pneumoperitoneum
Serum amylase (rule
out pancreatitis)
CT/ultrasound for
diagnosis

Resuscitation (IV fluids, NG

tube and ABX)
Then surgery: peritoneal
lavage, and specific
treatment of underlying
condition

- Superadded infection due to

E. coli or bacteroides
- Any delay can lead to
toxaemia, septiceamia and
multi-organ failure
- Local abscess formation
(swinging fever, high WCC
and continuing pain)

Alcohol
NSAIDS
H Pylori.
Steroids
Smoking
Blood group O

- Longstanding meal
related dyspepsia
- Sudden onset severe
acute epigastric pain
- Vomiting
- Collapse and shock
- Temporary relief in
symptoms, before
general pain and
distension from
peritonitis develops.

- Tenderness in LUQ or
epigastrium
- Guarding, rebound
tenderness
- Board-like rigidity
- Abdominal distension
- Absent bowel sounds.
- Anaemia if large blood
loss
- Shallow breathing with
minimal abdominal wall
movement

Alarm symptoms:
Anaemia
Loss of weight
Anorexia
Recent onset
progressive symptoms
Malaena or
heamatemesis
Swallowing difficulty

Erect CXR
(pneumoperitoneu
m
FBC (CRP, U&E, LFT,
Hb)
H. Pylori breath test
OGD with biopsy
after peritonitis
settles

- Likely to recur, so manage

risk factors aggressively

Inflammation of the
pancreas on
background of
normal healthy
pancreas
Proteolytic Autodigestion due to
raised intracellular
levels causes
pancreatic necrosis
Or: Stone occlusion
of ampulla causing
pancreatic ductal
hypertension,
increasing free
cytosolic ionized
calcium, initiating
auto-digestion and
necrosis.

I GET SMASHED:
- Idiopathic
- Gall stones
- Ethanol
- Trauma
- Steroids
- Mumps
- Autoimmune
disease
- Scorpion venom
- Hypercalcaemia
hyperlipidaemia
hypothermia
- ERCP & Emboli
- Drugs

- Severe epigastric
pain that radiates to
the back
- Pain slightly relieved
when sitting forward
- Nausea, vomiting,
anorexia
- Tachycardia, fever
&jaundice are
possible
- Diarrhoea
(steatorrhoea)
- Peripheral oedema/
ascites
- Hypovolaemia/shock

- Examination shows
little at first until
peritonitis develops
- Tender upper abdomen
- Fever
- Ascites + huge
peripheral oedema
- Bruising at flanks (GreyTurners signs)
- Cullens sign:
periumbilical or loin
bruise due to bleeding
into falciform ligament
= severe necrotizing
pancreatitis.
- Guarding reduced or
absent bowel sounds
- May be tachycardic,
hypotensive or oliguric

Elevation of
CRP>200mg/L in
first day predicts
severe attack.
Ranson and
Glasgow scoring
system have 80%
sensitivity for
predicting severe
attack when done
48hrs after initial
presentation
BMI>25 causes
worse outcome as
adipose tissue is
substrate for
activated
proteolytic activity
and inflammation

FBC (amylase,
lipase + CRP, WCC,
LFT etc)
Urinary amylase
Ultrasound
pancreas
Erect CXR to exclude
perforated ulcer
CT abdo enhanced
to look at pancreatic
necrosis extent.
Abdominal X-Ray
look for paralytic
ileus
MRCP to assess
damage

Surgery to repair
perforation, and wash out
peritoneum
PPI (Omeprazole) or H2
receptor antagonist
(ranitidine)
Stop NSAID use
Lifestyle alcohol, stop
smoking
Triple therapy if H pylori
+ve: (PPI, amoxicillin/
metronidazole &
clarithromycin)
ITU if severe case
predicted test after 24hrs
& 48hrs.
IV fluids & electrolyte
balance
NG tube and suction to
prevent abdo distension
and aspiration
Oxygen (monitor ABG)
Catheterization to monitor
fluid balance
Furosemide
Analgesia
Pancreatic enzymes
(Creon, pancrex)
Anti-coagulate for DVT
prophylaxis
Surgery if required

Results after stone

impaction at the
neck of the
gallbladder
Increase in glandular
secretions,
Progressive
distension and

- Hypercalcaemia
- Hypercholesterol
aemia
- Fatty diet
- Known history of
biliary colic

- Initial biliary colic

- Progression with
severe RUQ pain
(parietal peritonitis)
- Fever,
- Nausea and Vomiting
- Anorexia
- Referred pain to the

- Local Peritonism
(Tenderness and
guarding in RUQ)
- Pyrexia
- Murphys sign (+)

NBM
Opiate Analgesia &IV fluids
Cefuroxime (IV ABX)
Cholecystectomy after a
few days when symptoms
settle
Urgent surgery if
symptoms dont settle e.g.

- Chronic cholecystitis: abdo

distension, discomfort,
nausea, flatulence, fat
intolerance= elective
cholecystectomy
- Empyaema
- Abscess formation
- Acute gangrenous

Perforated
Peptic/
duodenal
ulcer

Acute
Pancreatitis

Cholecystitis

Alcohol and gall

stones are the 2
most common

Bloods: WCC,
CRP.
bilirubin and alk
phos indicates CBD
obstruction
Ultrasound: thick
wall, stones in gall
bladder neck or

- Diabetes
- Renal failure from volume
depletion
- 25% cases are severe,
leading to haemolytic
instability, multiple organ
failure and mortality of 4050%: need to predict severe
cases early.

Appendicitis

compromised
vascular supply.
Bile retention causes
inflammatory
response
Resulting infection
Acute inflammation
of the appendix after
obstruction with a
feacolith

shoulder-tip

- Idiopathic

Bowel
Obstruction

Mechanical
obstruction of the
bowel
Non-functioning e.g.
after abdominal
surgery or peritonitis

- Hernia
- Previous abdo
surgery
(adhesions)
- Crohns
- Intussusception
- Volvulus
- Tumour
- Gall stones
- Diverticulitis
- Constipation

Acute
diverticulitis

High intraluminal
pressures cause
pouches of mocosa
to extrude through
weakened muscle
wall near blood
vessels, forming
diverticulae
Feacal obstruction of
neck of diverticula
causing stagnation,
bacterial
accumulation and
inflammation.

- Low fibre diet

- Age >50
- Constipation

GI conditions causing
chronic abdo pain:
1. IBS
2. Crohns disease

fever, pain, empyaema

or gangrene develops

cholecystitis perforation
- Risks of cholecystectomy:
biliary leak/ injury to bile
duct, biliary sepsis, 2o biliary
liver injury.

FBC (CRP,WCC)
Ultrasound
enlarged appendix,
inflamed, fluid
surrounded.
CT appendix fluid
filled, distended,
periappendiceal fat
stranding

Laparoscopic
appendicectomy
Or if appendix mass
present treat
conservatively:
IV fluids and ABX (mass will
disappear over a few
weeks, pain within a few
days, then elective
appendectomy to prevent
recurrence.

- Perforation and generalised

peritonitis
- Acute gangrenous
appendicitis
- Abscess formation

Drip & Suck: NG tube

(decompression), IV fluids
(isotonic saline and
potassium) and analgesia
Catheterization
Flexible sigmoidoscopy to
un-kink volvulus
If deterioration (temp,
HR, more pain and rising
WCC) you need urgent CT
and possible laparotomy
Can have colorectal stent
for carcinoma causes
IV Antibiotics
Analgesia
Fluids
Osmotic Laxatives
Drain an abscess
Surgery if complicated and
persistent

- Paralytic ileus = painless, no

bowel sounds
- If pain becomes constant/
persistent with abdo
tenderness this suggests
intestinal ischaemia from
e.g. strangulated hernia,
requiring urgent surgery.
- Strangulated bowel can
become gangrenous and
needs resecting before
peritonitis/ perforation
occurs.
- Perforation leadiung to
paracolic abscess, pelvic
abscess or peritonitis
(generalized)
- Fistula formation to bladder
(colovesical) or vagina
causing dysuria or discharge
- Intestinal obstruction
- Haemorrhage if invading
local artery
- Mucosal inflammation that
looks like colitis on
endoscopy

cystic duct,
tenderness, fluid
surrounding it
CT abdomen
ERCP/MRCP

- Sudden onset colicky

umbilical pain
(inflamed midgut
viscus)
- Migration to
persistent pain and
tenderness in RIF
(localized peritoneal
inflammation)
- Nausea
- Vomiting
- Anorexia
- Occasional diarrhoea
- Vomiting (prolonged)
- Colicky pain central
abdo
- Absolute
Constipation (no
passage of wind)
- Nausea and vomiting
- Distension above
block

- Fever
- Tenderness in RIF
- Guarding in RIF
(localized peritonitis)
- Possible palpable mass
- Signs of sepsis
- Rovsings +ve
- Psoas/obturator test
+ve
- Pelvic peritonitis on
rectal examination

Simple bedside tests:

- Rovsings sign
- Kochers sign
- Blumbergs sign
- Psoas sign
- Obturator sign
- Dunpheys sign
- Sitkovskys sign

- Distension
- Tinkling/absent bowel
sounds depending on
cause
- Surgical scars, hernias
past or present
- Mass present
- Visible peristalsis
- Marked tenderness =
strangulation act
quickly!
- Check for hernia

- Small bowel
obstruction produces
less distension,
earlier vomiting, and
pain higher in the
abdomen that large
bowel obstruction.

Abdominal X-ray:
Small bowel
=central gas
shadows & valvulae
conniventes Large
bowel= peripheral
gas shadows &
haustra
CT to localize the
obstruction
Bloods: amylase,
FBC, U&E

- Severe pain in Left

iliac fossa
- Fever
- Constipation
- Longstanding Hx of
constipation not fully
relieved by laxatives

Look for local

peritonitiss
- Hip flexion test
- Cough test
- Blumbergs test

Bloods: ESR CRP

Polymorphonuclear
leukocytosis present
Spiral CT abdo:
streakiy increased
density extending
into pericolic fat,
and thickening of
pelvic fascia planes
Ultrasound colonic
wall thickening,
diverticular and
pericolic collections

Febrile
Tachycardia
Tenderness LIF
Guarding
Rigidity on L side
Palpable tender mass

Non-GI causes of acute abdo pain:

1. Ruptured AAA, mesenteric infarction
2. Pyelonephritis, renal/ureteric caliculi
3. Ectopic pregnancy, pelvic inflammatory disease,
testicular/ovarian torsion.
4. Myocardial Infarction (atypical)
5. Pleurisy, Pneumonia
6. Diabetic Ketoacidosis
7. Acute vertebral collapse, spinal cord compression

- Alvorado scoring
system

Other GI presenting complaints to

learn about:
1. Change in bowel habit
2. GI bleed
3. Vomiting & haematemesis
4. Jaundice

References:
1. Davey, P. 2006. Medicine at a Glance. Blackwell Publishing
2. Grace, P. A. & B. N. R. 2009. Surgery at a Glance. Blackwell publishing
3. Kumar, P. & M. Clark. 2009. Clinical Medicine. Saunders, Elsevier
4. Longmore, M., I. B. Wilkinson, E. H. Davidson, A. Foulkes & A. R. Mafi.
2010. Oxford Handbook of Clinical Medicine. Oxford University Press
5. Macleod, J. 2009. Macleod's Clinical Examination. Churchill
Livingstone, Elsevier
Hermione Leach