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Abdominal Pain

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%); Series 2 acute appendicitis (21%), the colics (16%) and mesenteric adenitis (16%). The latter study included children.

Red flag pointers for acute abdominal pain

  • Fever

  • Light-headedness/hypotension/collapse at toilet

  • Ischaemic heart disease

  • Pallor and sweating

  • Progressive vomiting, pain, distension

  • Menstrual abnormalities

  • Atrial fibrillation

  • Rebound tenderness and guarding

  • Lack of flatus

Table A7Acute abdominal pain: diagnostic strategy model
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Table A7 Acute abdominal pain: diagnostic strategy model

Probability diagnosis

Acute gastroenteritis

Acute appendicitis

Biliary colic/renal colic

Mittelschmerz/dysmenorrheoa

Irritable bowel syndrome

Serious disorders not to be missed

Vascular

  • ruptured AAA

  • dissecting aneurysm aorta

  • myocardial infarction (esp. inferior)

  • mesenteric artery ischaemia

  • ectopic pregnancy

Severe infection

  • ascending cholangitis

  • peritonitis/perforated viscus

  • acute salpingitis

  • pancreatitis

Neoplasia

  • bowel obstruction

Strangulated hernia

Pitfalls (often missed)

Appendicitis (atypical)

Myofascial tear

Pulmonary, e.g. pneumonia

Faecal impaction

Peptic ulcer

Seven masquerades checklist

Depression

Diabetes (ketoacidosis)

Drugs, esp. narcotics

Anaemia–sickle cell

Endocrine (Addison, thyroid storm)

Spinal dysfunction–referred

UTI including urosepsis

Is this patient trying to tell me something?

Consider psychogenic in recurrent atypical pain and Munchausen syndrome

Abnormal stress/anxiety

Diagnostic guidelines

General rules

  • 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

Pain patterns The pain patterns are presented in Figure A2. Colicky pain is a rhythmic pain with regular spasms of recurring pain building to a climax and fading. It is virtually pathognomonic of intestinal obstruction. Ureteric colic is a true colicky abdominal pain, but so-called biliary colic and renal colic are not true colics at all.

Figure A1

Typical sites of abdominal pain

An illustration represents the typical sites of abdominal pain. The typical sites of abdominal pain are as follows. Epigastrium: cardiac (referral), oesophagitis/reflux, ulcer/perforated, pancreatitis, and biliary pain. Left hypochondrium: renal colic, pyelonephritis, left lung lesions, and splenic infarct. Left lumbar: renal/ureteric colic, urinary infection, and constipation. Left iliac: ureteric colic and colitis. Hypogastrium: acute P I D, ruptured ectopic, ovarian lesions, and Mittelschmerz. Right iliac: appendicitis and Crohn. Right lumbar: renal and ureteric colic and urinary infection. Right hypochondrium: biliary colic, cholecystitis, cholangitis, hepatitis, and right lung lesions. Periumbilical: small bowel obstruction, mesenteric A embolism, appendicitis (early), ruptured A A A, large bowel obstruction, and I B S ¬ gastroenteritis.
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Figure A2

Characteristic pain patterns for various causes of ‘colicky’ acute abdominal pain

A graph represents pain patterns for various causes of ‘colicky’ acute abdominal pain. The horizontal axis represents time in seconds and the vertical axis represents pain intensity. The graph shows three curves. The curve representing intestinal colic resembles a sine waveform that varies between moderate and low pains. The curve representing ureteric colic resembles a sine waveform that varies between high and low pains. The curve representing biliary ‘colic’ begins with no pain, increases steeply to high pain, maintains high pain throughout, and starts decreasing drastically to low or no pain.
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ABDOMINAL PAIN IN CHILDREN

Abdominal pain is a common complaint in children, esp. recurrent abdominal pain.

Infantile ‘colic’ (period of infant distress)

Synonyms: ‘period of purple crying’ or ‘crying and unsettled babies’.

Typical features

  • Baby 2–16 wks, esp. 10 wks

  • Prolonged crying in healthy child at least 3 h/day, 3 d/week for 3 months

  • Crying during late afternoon and early evening

  • Child flexing legs, clenching fists as if ‘stomach ache’, passes gas, red face

  • Normal physical examination

Management

  • Reassurance and explanation to the parents that it’s ...

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