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, paediatrics, geriatrics and psychiatry. For acute abdominal conditions it is important to make a rapid diagnosis in order to reduce morbidity and mortality. Most cases of ‘acute abdomen’ require surgical referral. Lower abdominal pain in women adds another dimension to the problem and will be presented in a separate chapter (CHAPTER 95).
Key facts and checkpoints
The commonest causes of the acute abdomen in a general practice series were: acute appendicitis (21%), the colics (16%) and mesenteric adenitis (16%).2
An international study involving referral to 26 surgical departments in 17 countries revealed the most common conditions to be: non-specific abdominal pain (34%), acute appendicitis (28%) and cholecystitis (10%).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 always precedes the vomiting (contrast with gastroenteritis)
Mesenteric artery occlusion must be considered in an older person with arteriosclerotic disease or in those with atrial fibrillation presenting with severe abdominal pain or following myocardial infarction.
Up to one-third of presentations of abdominal pain have no specific cause found.
A summary of the separate diagnostic models for acute abdominal pain and chronic abdominal pain are presented in TABLES 24.1 and 24.2.
Table 24.1Acute abdominal pain (adults): diagnostic strategy model (excluding trauma) ||Download (.pdf) Table 24.1 Acute abdominal pain (adults): diagnostic strategy model (excluding trauma)
Irritable bowel syndrome
Biliary colic/renal colic
Serious disorders not to be missed
myocardial infarction (usually inferior)
dissecting aneurysm of aorta
mesenteric artery occlusion/ischaemia
Small bowel obstruction/strangulated hernia