A great fit of the stone in my left kidney: all day I could do but three or four drops of water, but I drunk a draught of white wine and salet oyle, and after that, crabs’ eyes in powder with the bone in the carp’s head and then drunk two great draughts of ale with buttered cake; and I voyded with an hour much water and a stone as big as an Alexander seed. God be thanked!
JOHN DEE 1594
Abdominal pain represents one of the top 15 presenting symptoms in primary care1 and varies from a self-limiting problem to a life-threatening illness requiring immediate surgical intervention. Abdominal pain can be considered to be acute, subacute, chronic or recurrent. It can embrace all specialties, including surgery, medicine, gynaecology, geriatrics and psychiatry. For acute abdominal conditions it is important to make a rapid diagnosis in order to reduce morbidity and mortality. Most cases require surgical referral (see TABLE 34.1). Lower abdominal pain in women adds another dimension to the problem and will be presented in a separate chapter (CHAPTER 103).
Table 34.1Surgical causes of the acute abdomen ||Download (.pdf) Table 34.1 Surgical causes of the acute abdomen
|Process ||Organ involved ||Disorder |
|Inflammation ||Bowel ||Inflammatory bowel disease |
| ||Appendix ||Appendicitis |
| ||Gall bladder ||Cholecystitis |
| ||Liver ||Hepatitis |
| ||Pancreas ||Pancreatitis |
| ||Fallopian tube ||Salpingitis |
| ||Colonic diverticulae ||Diverticulitis |
|Perforation ||Duodenum ||Perforated duodenal ulcer |
| ||Stomach ||Perforated gastric ulcer |
| ||Colon (diverticula or cancer) ||Faecal peritonitis |
| ||Gall bladder ||Biliary peritonitis |
| ||Appendix ||Appendicitis |
|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 (haemoperitoneum) |
| ||Ovary ||Ruptured ovarian cyst |
| ||Abdominal aorta ||Ruptured abdominal aortic aneurysm (AAA) |
|Torsion (ischaemia) ||Sigmoid colon ||Sigmoid volvulus |
| ||Ovary ||Torsion ovarian cyst |
| ||Testes ||Torsion of testes |
Key facts and checkpoints
The commonest causes of the acute abdomen in two general practice series were:
Series 1—acute appendicitis (31%) and the colics (29%);2
Series 2—acute appendicitis (21%), the colics (16%), mesenteric adenitis (16%).3 The latter study included children.
An international study involving referral to 26 surgical departments in 17 countries revealed non-specific abdominal pain (34%), acute appendicitis (28%) and cholecystitis (10%) as the most common conditions.1
As a general rule, upper abdominal pain is caused by lesions of the upper GIT and lower abdominal pain by lesions of the lower GIT.
Colicky midline umbilical abdominal pain (severe) → vomiting → distension = small bowel obstruction (SBO).
Midline lower abdominal pain → distension → vomiting = large bowel obstruction (LBO).
If cases of acute abdomen have a surgical cause, the pain nearly ...