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Probability diagnosis

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Acute gastroenteritis

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Acute appendicitis

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Mittelschmerz/dysmenorrhoea

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Irritable bowel syndrome

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Biliary colic/renal colic

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Peptic ulcer

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Serious disorders not to be missed

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Vascular:

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  • myocardial infarction (esp. inferior)

  • splenic infarction

  • ruptured AAA

  • dissecting aneurysm aorta

  • mesenteric artery occlusion

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Cancer:

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  • of bowel with large or small bowel obstruction

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Infection:

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  • acute cholecystitis

  • acute salpingitis

  • peritonitis/spontaneous bacterial peritonitis

  • ascending cholangitis

  • intra-abdominal abscess

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Other:

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  • pancreatitis

  • ectopic pregnancy

  • small bowel obstruction/strangulated hernia

  • sigmoid volvulus

  • perforated viscus (esp. perforated peptic ulcer)

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Pitfalls (often missed)

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Acute appendicitis (atypical)

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Myofascial tear/muscle wall pain

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Pulmonary causes:

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  • pneumonia

  • pulmonary embolism

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Faecal impaction (elderly)

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Acute diverticulitis

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Herpes zoster

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Acute hepatitis

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Inflammatory bowel disease

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Rarities:

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  • porphyria

  • lead poisoning

  • haemochromatosis

  • haemoglobinuria

  • Addison disease

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Masquerades checklist

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Depression

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Diabetes (ketoacidosis)

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Drugs (e.g. NSAIDS, iron tablets, narcotics, cytotoxics)

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Anaemia (sickle cell)

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Spinal dysfunction (referred)

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UTI (inc. urosepsis)

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Is the patient trying to tell me something?

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May be very significant. Consider Munchausen syndrome, sexual dysfunction and abnormal stress.

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Key history

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Pain has to be analysed according to the usual SOCRATES features. In respect to associated symptoms and signs, special attention has to be paid to anorexia, nausea or vomiting, micturition, bowel function, menstruation and drug intake.

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Key examination

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A useful checklist is:

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  • general appearance

  • oral cavity

  • vital parameters incl. temperature, pulse

  • abdominal examination: inspection, auscultation, palpation and percussion (in that order)

  • rectal examination

  • inguinal region

  • vaginal examination (if appropriate)

  • urine analysis

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Key investigations

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  • FBE

  • ESR/CRP

  • Serum lipase or amylase

  • Urine MC

  • LFTs

  • H. pylori tests

  • Faecal blood

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Consider:

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  • imaging including plain X-ray, ultrasound, IVU, CT scan and others according to suspected conditions

  • upper GI endoscopy

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Diagnostic tips

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  • Upper abdominal pain is caused by lesions of the upper GIT.

  • Lower abdominal pain is caused by lesions of the lower GIT or pelvic organs.

  • Early severe vomiting indicates a high obstruction of the GIT.

  • Acute appendicitis features a characteristic ‘march’ of symptoms:

    • pain → anorexia, nausea → vomiting.

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