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CDHB

Abdominal Pain

Initial assessment and resuscitation

• Airways, Breathing, Circulation: if sepsis or hypovolaemia evident, oxygen delivery should be optimized and intravenous fluids given.

Complete assessment

History

• Site
  • Abdominal
  • Pelvic
  • Retroperitoneal (flank/back)
• Nature
  • Severity: mild, moderate, severe.
  • 'Visceral' - dull, ill-defined.
  • 'Somatic' - sharp, localized.
  • 'Peritoneal' - constant, patient lies still.
  • 'Colicky' - intermittent, patient writhes around
  • Radiation:
    • To back - retroperitoneal.
    • To groins and thighs - genitourinary or major vessels.
    • To shoulder - diaphragmatic irritation.
• Associated symptoms
  • Vomiting, diarrhoea, genitourinary, possible pregnancy.
  • Always consider extra abdominal causes of the pain, e.g., myocardial infarction, DKA, pneumonia etc.

Examination

• General
  • Perfusion, hydration.
  • Colour: pallor, jaundice.
  • Peripheral manifestations of liver disease.
  • Peripheral manifestations of vascular disease.
• Abdomen
  • Appearance: scars, masses, distension.
  • Palpation
    • Tenderness - inflammation.
    • Guarding - peritoneal inflammation
    • Rigidity - generalized inflammation
    • Masses, including aortic aneurysm
  • Examination of hernial orifices, genitalia (any abdominal pain in males mandates a testicular exam).
  • Auscultation: bowel sounds, bruit.
  • Rectal examination (looking for masses, blood - not useful in assessing appendicitis).

Investigations

Guided by findings above - not all are routinely indicated.

• Urine dipstick for protein and blood. Urine microscopy and culture.
• Pregnancy test - either urine or blood.
• CBC + diff.
• Urea, creatinine, Na, K, Ca, glucose, amylase, bili, AST, ALT, GGT, ALP.
• Erect CXR if perforation is suspected. Supine/erect abdominal X-ray or CT scan if obstruction is suspected.
• Ultrasound - liver, biliary system, pancreas, kidneys, ureters, pelvis, aorta.
• CT abdomen.

Note: Faecal loading on a plain AXR does not confirm constipation as the diagnosis.

Definitive management

According to the cause. Possible causes:

• Gastrointestinal
• Hepatobiliary
• Pancreatic
• Urological
• Gynaecological - complications of pregnancy (e.g., ectopic)
• Musculoskeletal
• Respiratory
• Vascular
• Metabolic

Important to exclude

• Abdominal aortic aneurysm (may present like renal colic)
• Ischaemic bowel (non-tender abdomen initially but pain may be out of proportion for clinical signs)
• Ectopic pregnancy
• Torsion of testicle.

Topic Code: 1274