Introduction

Abdominal pain is a common presenting problem in primary care or A&E. Symptoms

may be acute (an 'acute abdomen'), subacute or chronic. There are many possible causes -
often it is not possible to reach a definite diagnosis in primary care. What is more
important is to assess how ill the patient is, to identify any life-threatening problems or
'red flags' and to decide the next step in management - eg, whether to monitor, investigate
or refer and how urgently.

Urgent or easily missed causes of acute abdominal pain

There are numerous causes of acute abdominal pain - this list points out some of the most
urgent or the more easily missed causes to keep in mind:

Medical
Myocardial infarction.
Diabetic ketoacidosis.
Lower lobe pneumonia.
Sickle cell crisis.
Hypercalcaemia.
Hereditary angio-oedema.
Gynaecological/obstetric
Ectopic pregnancy - may present with nonspecific symptoms - eg, syncope,
urinary symptoms, diarrhoea or shoulder tip pain or without 'missed period'.
Placental abruption, heavy vaginal bleeding and other pregnancy complications.
Ovarian hyperstimulation syndrome (during assisted conception).[2 ]
Surgical
Aortic aneurysm and aortic dissection - may present with abdominal pain, back
pain or renal colic.
Bowel ischaemia (eg, mesenteric infarction or volvulus) - typically presents with
pain out of proportion to the clinical signs.
Generalised peritonitis.
Acute bowel obstruction.
Testicular torsion - pain may be referred to the abdomen.
Urinary obstruction - an enlarged bladder can be missed if not percussed.
Abscess (subphrenic, pelvic or psoas abscess) - pain and fever but may have few
localising signs.

smeAssesnt of patients with abdominal pain

How ill is the patient?
For acute abdominal pain:[1 ]
Use the 'ABCD' approach and always check - and document - vital
signs.
 Subtle changes in vital signs may indicate serious illness - eg,
unexplained tachycardia can indicate a ruptured ectopic pregnancy.
If the patient is shocked, give intravenous fluids/colloid until the
radial pulse is palpable and get senior help.
Give analgesia if needed: intravenous (IV) opiates may be given
and do not affect clinical assessment; titrate small doses and monitor
blood pressure.
Aim to identify urgent problems (see under 'Urgent or easily
missed causes of acute abdominal pain', above).

Always consider ectopic pregnancy in any woman of childbearing age.

For subacute or chronic abdominal pain - look for 'red flags' and other
alerting features such as:
Age >60 years.
Relevant family history - ovarian or bowel cancer, familial
polyposis coli.
History suggesting gastrointestinal (GI) bleed.
Unexplained weight loss (or poor growth in children).
Repeated consultations for the same problem; change in pattern of
consultation ('beware the patient with thin notes').
Anaemia.
Masses or organomegaly.
History and examination initial investigations (see 'History' and 'Examination'
sections, below).
Decide initial management:
Have a low threshold for admission/referral of young children, the elderly,
the immunocompromised and those with learning difficulties - these groups
are more likely to present late or without classical symptoms and signs and
may deteriorate quickly.
Symptoms and signs may evolve over time - reassessment is an important
tool.
If the patient is discharged, ensure they know when to seek further help.

History
Location, nature and severity of pain:
Colicky (waves of pain): suggests obstructed viscus - eg, intestinal
obstruction, renal colic, biliary colic.
 Tearing pain: suggests aortic dissection or rupture.
Constant sharp pain, worse on movement or coughing: suggests
peritonitis.
Constant dull ache: suggests inflammation - eg, appendicitis, diverticulitis.
The pattern of pain may change over time - eg, early appendicitis,
mesenteric ischaemia or bowel strangulation may begin as colicky pain and
then become constant as the condition progresses; pain may localise as the
parietal peritoneum becomes involved.
Any radiation or referred pain?
Aortic aneurysm, renal and pancreatic pain: may radiate to the back.
Renal colic: may radiate to the groin.
Diaphragmatic irritation: may cause shoulder tip pain.
Gallbladder pain: may radiate to the scapula.
Onset of pain:
Very sudden onset suggests rupture or torsion of an organ (eg, ruptured
aneurysm, ectopic pregnancy, torsion of testis or ovary).
Other symptoms:
Systemic symptoms: fever, night sweats, weight loss.
Vomiting: may be due to severe pain (eg, testicular torsion), gastroenteritis
or obstruction.
Bleeding: upper GI (haematemesis or melaena) or lower GI (rectal bleed).
Constipation or diarrhoea.
Vaginal bleeding or discharge: consider gynaecological/obstetric causes.
Past medical history:
Note any similar episodes.
Note previous illness or surgery.
Note Medication/allergies/last meal.

Investigations

Initial investigations in primary care

A urine pregnancy test should be offered to all women of childbearing age who
have abdominal pain (to help rule out ectopic pregnancy).[3 ] Serial human beta-
chorionic gonadotrophin (beta-hCG) levels are no longer recommended; if the GP
suspects ectopic pregnancy, the woman should be referred for urgent hospital
assessment, even if the urine test is negative.[4 ]
Urinalysis microscopy and culture.
Depending on the clinical scenario, consider:
Blood tests:
FBC (for occult bleeding).
 Erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP) -
for inflammatory bowel disease.
Coeliac antibodies (anti-endomysial antibody or tissue
transglutaminase test).
U&E, glucose, LFT, amylase, calcium.
ECG.
Ultrasound of the abdomen and pelvis.

Initial investigation in A&E

Urine pregnancy test.
Urinalysis microscopy and culture.
Depending on the clinical scenario, consider:
ECG.
Blood tests:
FBC.
Group/crossmatch blood.
ESR/CRP
U&E, glucose, amylase, calcium.
Erect CXR (looking for air under the diaphragm).
Plain abdominal X-ray (or erect and supine abdominal X-rays if an
obstruction is suspected) - may show up obstruction, volvulus, ischaemia,
severe constipation.
Ultrasound or CT scans.

Further investigations
Upper or lower GI endoscopy.
Ultrasound or CT scans targeted at suspected pathology.
Diagnostic laparoscopy.
Laparotomy.

Abdominal pain in particular patient groups

Elderly patients[9 ]
Presentation tends to be different from younger patients - it may lack classical symptoms
and signs and it tends to present later.

Common causes of abdominal pain in the elderly are:

Peptic ulcer disease.

Cholecystitis.
Acute pancreatitis.
 Mesenteric ischaemia/infarction.
Aortic aneurysm.
Bowel obstruction - small or large bowel.
Diverticular disease/diverticulitis.
Constipation.
Urinary retention.
Medical causes (see table 'Causes of abdominal pain by regions', above).
PatientPlus
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Abdominal Examination
Right Upper Quadrant Pain
Left Upper Quadrant Pain
Read more articles

Immunocompromised patients[10 ]
The classical signs of an acute abdomen may be absent in the immunocompromised
patient.

Patients with the most severe immunocompromise are chemotherapy patients with
neutropenia and HIV patients with CD4+ cell count <200/mm3. Mild-to-moderate
immune deficiency occurs in those who are:

Malnourished.
Taking steroids.
Elderly.
Patients with diabetes.
Patients with cancer.
HIV-positive with CD4+ cell count >200/mm3.
Particular causes of abdominal pain in this group include:

Gastritis - can be due to pathogens such as Candida spp., Cryptosporidium spp.

and cytomegalovirus (CMV).
Hepatic pathology - cholecystitis with atypical pathogens, AIDs-related
cholangitis, liver abscess.
Pseudomembranous colitis.
Typhlitis (neutropenic enterocolitis) - fever and abdominal pain, particularly right
iliac fossa pain.
CMV colitis - a small-vessel vasculitis mainly affecting the colon; it affects AIDS
 and renal transplant patients.
Abdominal tuberculosis - usually ileocaecal.
Disseminated Mycobacterium avium intracellulare (MAI) - usually in AIDS
patients, affecting the jejunum or small bowel; severe abdominal pain and systemic
symptoms.
Acute graft-versus-host disease - after bone marrow transplant.
Bowel obstruction or intussusception - due to lymphoma or Kaposi's sarcoma.
Side-effects of antiretrovirals, chemotherapy or other treatments.

Athletes
Abdominal pain during exertion is a common symptom among endurance sports athletes
such as long-distance runners. There are many possible causes which may need careful
evaluation. These are discussed in the literature.

Preparation
The patient should be adequately undressed (from xiphisternum to pubis) and
lying comfortably with the head a little elevated and well supported (one pillow). The
arms should be placed alongside the body. This relaxes the abdominal muscles.
A warm room, comfortable patient and a calm and reassuring approach from the
doctor will create the necessary relaxation. If the patient is tense, very little
information can be gained and if you hurt the patient there will be tension and loss of
confidence.
Explain what you are about to do and ask permission to start.
Your own comfort is also important. The height of the examination couch should
permit a comfortable examination whilst standing upright. A bed in a patient's home is
usually lower and sitting on a chair may be preferable.
Obesity and a pendulous abdomen may make the examination more difficult.

Inspection[1 ][2 ]

General inspection
Does the patient look unwell?
Is pain apparent? If the patient is writhing it could be due to colic in some form. A
person with peritonitis lies still.
Is there jaundice? This may not be easily apparent in artificial light.
Is there evidence of dehydration?
 Are there signs of weight loss or wasting (may be a sign of malabsorption or
malignancy)?
Look for purpura (may be present in hypersplenism or impaired clotting function).
Look for spider naevi (liver disease).
Xanthelasma (symmetrical yellow plaques around the eyelids) may be present in
primary biliary cirrhosis or chronic biliary obstruction.
Kayser-Fleischer rings (a brown-yellow ring in the outer rim of the cornea) may
be present in Wilson's disease.[3 ]
Leaning over the face to inspect respiration can be used to smell the patient's
breath - eg, for alcohol. Hyperventilation may be a sign of acidosis (chronic kidney
disease).

Examination of the hands

Look for:

Whether the hands warm and well perfused or cold and clammy.
Finger clubbing: may occur with ulcerative colitis, Crohn's disease, coeliac
disease, cystic fibrosis or other malabsorption syndromes.
Koilonychia: suggests iron deficiency.
Liver palms (palmar erythema): a sign of liver dysfunction.
Asterixis or a flapping tremor: can be a sign of liver disease (hepatic
encephalopathy). Asterixis is 'lapse of posture' or negative clonus exhibited by a
flapping tremor at the wrist, metacarpophalangeal joints and hips. It can also be seen
in the tongue, foot or any skeletal muscle. Take the fingers in your palm and
hyperextend them. A positive flap is a flexion-extension movement at a slow rate.
Alternatively, with the patient relaxed, supine and knees bent, feet flat on couch, the
knees may flap as the legs fall to the side. It is not specific for hepatic encephalopathy
but occurs also in, for example, chronic kidney disease, respiratory failure, electrolyte
disturbance and drug intoxication.

Examination of the neck

Palpate the supraclavicular fossa: Troisier's sign is left supraclavicular
lymphadenopathy due to metastatic thoracic or abdominal malignancy. The
supraclavicular node is known as Virchow's node on the left or the right.

Examination of the mouth

May show, for example, angular stomatitis (which may be due to iron deficiency),
thrush, signs of dehydration, ulcers, etc.

Inspection of the abdomen

Note any distension, abdominal respiration, bruising, scars, stoma, herniae and
 any visible peristalsis.
A mass may be apparent. To exaggerate the presence of a mass, inspect with the
head raised from the bed to tense the abdominal muscles and with the Valsalva
manoeuvre for lateral regions. Alternatives include Carnett's method of straight leg
raising and Kamath's test of straining as if at stool (essentially the Valsalva
manoeuvre). The Kamath's test may help to identify small anterior abdominal wall
hernias.

Palpation of the abdomen[1 ][2 ]

Many of the instructions will have to be modified or reversed if you are left-
handed and examine from the patient's left side.
A pillow under the patient's knees may sometimes aid relaxation of abdominal
musculature.
Ask the patient to point to the site of any pain.
During palpation, be aware of the response of the patient's abdominal muscles and
watch their face for signs of discomfort.
Start with light palpation to gain the patient's confidence and relax them and then
perform deeper palpation.
Use the flat of the hand with the flexor surfaces of the fingers for deep palpation,
sometimes superimposing the other hand's fingers for an even distribution of pressure.
This technique can reach progressively deeper through each relaxation phase of
respiration.
Develop your own routine, examining each region of the abdomen in turn, starting
away from any site of pain.
Look for signs of localised guarding (the reflex tensing of the abdominal muscles
over the painful area which represents peritonism) and rebound tenderness (initial
pressure does not cause pain but when the examining hand is released, pain is felt).
Rebound tenderness suggests peritoneal irritation.
Generalised 'board-like' rigidity indicates peritonitis. In peritonitis, the abdomen
also does not move during respiration and bowel sounds are absent.
The 'plastic abdomen' may also be detected and occurs with chronic peritonitis -
eg, tuberculosis of the abdomen.
It is useful to include the following techniques in your abdominal palpation to
examine for enlargement of the liver, spleen, gallbladder or kidneys.

Examination of the liver

Start in the right iliac fossa and move gently up towards the right hypochondrium.
The examining hand should be flat on the abdomen and the fingers should be
pointing upwards so that the fingertips are on a line parallel to the expected liver
 edge.
Palpation should be gentle but deep if there is no pain.
You should press inwards and upwards and hold this position while asking the
patient to take a deep breath in through their mouth. At the patient's maximal
inspiration, release your inward pressure but maintain your upward pressure. Your
fingertips should then move over any palpable liver edge.

Examination of the gallbladder

Murphy's sign can be elicited by placing your examining fingers over the
gallbladder area and then asking the patient to take a deep breath.
If Murphy's sign is positive, there will be sudden accentuation of the pain on
inspiration and inspiration will be inhibited.

Examination of the spleen

To detect splenomegaly, place the examining hand flat on the abdomen as before,
well below the left costal margin. Press inwards and upwards and ask the patient to
breathe in again. An enlarged spleen should be felt against the fingertips.
If you cannot feel an enlarged spleen, move your hand upwards after each
inspiration until your fingertips are under the left costal margin.
If an enlarged spleen is still not palpable, ask the patient to lie on their right side,
facing towards you and palpate up into the left hypochondrium as before, asking for
deep breaths on the way. Your other hand can be placed behind the rib cage on the
patient's left side for support.
If this does not work, you can examine the patient from their left side, curling the
fingers of your left hand beneath their left costal margin as they breathe deeply.
If you can just feel the tip of the spleen, it is significantly enlarged and perhaps
twice the size of normal.

Palpation of the kidneys

This technique uses two hands.
Reach one hand round to the patient's right loin with your other hand over the
right upper quadrant. Push your hands together whilst asking the patient to breathe in
and out. Try to palpate any enlarged kidney between your two hands (called
'balloting').
Repeat for the left kidney. This can either be done by examining the patient from
the left side with your right hand under their left loin or by examining them from the
right side with your left hand reaching round under their left loin area.
In a very thin person who relaxes well, it may be just possible to feel a kidney,
especially on the left but usually it is abnormal.
Examine for enlarged kidneys, renal masses or loin tenderness.
Palpation for pelvic masses
To look for masses arising from the pelvis, such as an enlarged bladder or an
ovarian cyst , examine the abdomen as before but starting above the umbilicus and
working down towards the pubis.

Percussion of the abdomen[1 ][2 ]

Percussion of the abdomen can be very useful. It is really to allow you to
determine if abdominal distension is because of solid or cystic tumours, ascites or gas.
A generally resonant abdomen suggests much flatus whilst solid or liquid under
the fingers will be dull.
Sometimes it is helpful to use percussion to define the edge of the liver. It can also
be used to delineate an enlarged bladder or a tumour arising from the pelvis.

Techniques to demonstrate ascites

Fullness of the flanks may be the first indication of ascites. Techniques to demonstrate
ascites include:

Percussion for shifting dullness: the patient should be lying on their back. Percuss
from the umbilical region moving down towards one side. When the sound becomes
dull, mark the spot (or keep your finger there) and ask the patient to move on to the
opposite side. Give a short while for the fluid to sink and percuss again. If the marked
spot now becomes resonant that is a positive sign. Percuss back down towards the
umbilicus until dullness is reached again. Repeat on the other side.
Eliciting a fluid thrill: this is more difficult to demonstrate. With one hand on the
patient's flank, flick the skin over the other flank using a finger. If an impulse or 'fluid
thrill' is felt, this indicates a positive sign. However, to be certain, you should repeat
the examination with the patient's hand along their midline in the sagittal plane to
dampen any possible thrill transmitted by the abdominal wall.

Auscultation of the abdomen[1 ][2 ]

Bowel sounds can be irregular, so patience is required to decide if they are
reduced or normal. On average, you can hear them every 5-10 seconds through a
stethoscope.
If bowel sounds are absent, this may indicate paralytic ileus or peritonitis.
Diarrhoea is associated with increased bowel sounds.
Intestinal obstruction produces a classical 'tinkling' bowel sound like water being
poured from one cup to another.
Listen for arterial bruits over the aorta. They may also arise from stenosis of
mesenteric or renal arteries.
Pelvic examination
Full abdominal examination includes pelvic examination.
See separate Gynaecological History and Examination article.

Rectal examination
Examination of the abdomen is incomplete without a rectal examination.
However, in primary care it is usual to perform such an examination only if there is a
significant expectation of a finding that will influence management. For example, if
you have already decided to refer a patient with suspected appendicitis, performing a
rectal examination will not influence that decision. It will be performed by at least
one admitting doctor, so if the GP does it too, this would be an additional unpleasant
intrusion. This is most important in children.
Pelvic peritonitis may only be detected by rectal examination in some cases.
If a rectal or pelvic examination is about to be performed, it must be preceded by
an abdominal examination. A bimanual vaginal examination can easily miss a large
uterine or ovarian mass.
See separate Rectal Examination article.

Children[4 ]
Examining children can be much more difficult. They often complain of 'tummy pain'
and point to the umbilicus.

Remember that the differential diagnosis can include tonsillitis, otitis media and
meningitis.
Children are often difficult to relax and may be both apprehensive and ticklish so
that abdominal muscles are tense.
Examination may be more useful with the child sitting on their parent's lap rather
than on the couch.
Too firm palpation will easily overcome guarding. Be gentle to avoid missing this
important sign.
Try to distract the child during the examination. Some people take the child's hand
and use it to palpate the abdomen. Another technique is to ask the child to do a few
jumps or hops. This will not be done freely if there is an acute abdomen.