Introduction
Clinical Examination
Differential Diagnosis
Evaluation Priorities
Context: casualty
Introduction
Severe abdominal pain is a common reason for a visit to the emergency department. A number of cases settle spontaneously,
yet others may harbour lethal conditions that require you to make a rapid, accurate diagnosis and urgent intervention.
The patient groaning with abdominal pain, lying on a hospital stretcher is the true test of surgical diagnostic thinking- it easily
differentiates the competent clinician with a clear, structured approach, from a befuddled, uncertain one. It takes the
consultant one post-call ward round to decide which registrars to trust, and which ones need to go back to the basics !
There is no substitute for a sound approach and thorough clinical evaluation of such cases. You have to take time, ask a
comprehensive set of questions about the presenting symptoms, associated complaints, and a systematic enquiry.
Always examine the patient properly. Do not throw your hands up in the air, and “just do bloods and order a CT”; apply your
mind and MAKE A CLINICAL DIAGNOSIS! Don't poke the patient’s belly through his/her clothes and run off to “look at the
scans”. Be inquisitive, and take pride in the clinical assessment of each case.
Try to decide if this is a brand new symptom, or if it reflects a progression of long-standing disease. Is this an acute problem
or an exacerbation of a chronic condition?
DESCRIBE THE PAIN THOROUGHLY: define the presenting complaint
Where is it, and where does it radiate to?
RUQ- liver or biliary tree
Location and radiation Back- pancreatitis
Groin-renal colic
RIF- appendicitis
The onset, frequency, and duration of the pain are helpful
features
Temporal elements
Pancreatitis= gradual and persistent
Perforation/ peritonitis = sudden onset & high intensity
Burning pain= gastritis /peptic ulcer disease
Quality Colicky/cramping pain=gastroenteritis / intestinal
obstruction.
The severity of the pain generally is related to the severity of
the disorder, especially if acute in onset Excruciating= acute
Severity mesenteric ischemia
high intensity= biliary / renal colic / small bowel obstruction
moderate= gastroenteritis, appendicitis
Identify what precipitates or improves the pain
chronic mesenteric ischemia = starts within one hour of
eating
duodenal ulcers = relieved by eating and recur several
Precipitants or ameliorating factors
hours after a meal
pancreatitis = relieved by sitting up and leaning forward
& strong association with alcohol intoxication
Peritonitis = patients lie motionless on their backs
ASK ABOUT ASSOCIATED SYMPTOMS: what else is going on?
Is the gut working or not??
nausea, vomiting, diarrhoea, dysentery, constipation,
hematochezia, melena, and changes in the stool. When last
GIT symptoms did the patient pass flatus?
Is the liver working or not?
ask about jaundice and changes in the colour of urine and
stool
Genitourinary symptoms Is there a genitourinary cause for their abdominal pain? This is
quite common!
dysuria, frequency, hematuria and retention
Consider sexually transmitted diseases, pelvic inflammatory
disease, and pregnancy in premenopausal women
menstrual history (LMP, previous period, cycle length)
Gynaecological history
use of contraception
vaginal discharge or abnormal PV bleeding
dyspareunia or dysmenorrhea
fevers, rigors= peritonitis, UTI, cholangitis
Constitutional symptoms fatigue, weight loss, and anorexia =malignancy, TB, systemic
illnesses, inflammatory bowel disease
TAKE A COMPREHENSIVE HISTORY: this allows you to consider other causes, and contextualise the patient’s fitness for
intervention
Could there be a non abdominal cause of pain? Does the
patient have co-morbidities?
Cardio-respiratory symptoms
cough, shortness of breath, orthopnea, exertional dyspnea,
angina = pulmonary or cardiac aetiology for the pain?
Previous abdominal surgery = ? bowel obstruction
cardiovascular disease (CVD) = ?MI or mesenteric ischaemia
Past medical history recent trauma= ? traumatic pancreatitis
HIV+ve= abdominal tuberculosis
Previous malignancy= cancer recurrence/ obstruction?
Describe a comprehensive medication list, including over the
counter medications
NSAIDs= gastritis, peptic ulcer disease
Medication history recent antibiotics= Clostridium difficile
steroids = adrenal insufficiency
recent chemotherapy = immunosuppressed & atypical
presentations of abdominal pain.
alcohol = pancreatitis, acute gastritis, hepatitis
IV drug users= endocarditis, mesenteric ischaemia, hepatitis,
drug withdrawal states
Travel history= hepatitis, gastroenteritis, colitis, parasitic
Precipitants & other aetiological factors
disease
Recent blunt or penetrating trauma= delayed bowel
perforation, pancreatitis, diaphragmatic herniae, liver
haematoma, ruptured bladder
Clinical Examination
Consider the following conditions:
Any cause of peritonitis and septic shock
Does the patient need active resuscitation? Ruptured AAA
Myocardial infarct
mesenteric ischaemia & small bowel infarction
Severe acute pancreatitis
Pyrexia= peritonitis, TB, UTI, PID
Anaemia= malignancy , chronic disorders, AAA (acute GIT
bleeds seldom complain of pain)
General examination
Jaundice= biliary obstruction, hepatitis, sepsis
Dehydration/ malnutrition= bowel obstruction, malignancy, TB
Peripheral adenopathy= malignancy
Abdominal examination Does the patient have clinical signs of peritonism or not? This
takes much clinical experience and guidance. If unsure, take
time and re-examine after an interval. Distract the patient
whilst performing the examination
Inspect- for scars, herniae, masses, distention (examine the
groins & scrotum)
Percuss- pain with gentle percussion= peritonitis
Tympany = distended bowel
dullness = mass/ organomegaly
Shifting dullness = ascites
Palpation- Distract the patient and be gentle! Start AWAY
from the site of most pain, until the end of the examination.
Muscular rigidity/"guarding" is an important early sign.
Guarding is typically absent with deeper sources of pain such
as renal colic and pancreatitis.
Rebound tenderness = peritonitis
Auscultation- active, high-pitched bowel sounds = early bowel
obstruction.
Absent bowel sounds= ileus
Bruit or murmur= AAA, renal artery aneurysm
patients with severe abdominal pain must have a rectal
examination.
Stool bolus= Fecal impaction & obstruction in older adults
tender PR =retrocecal appendicitis & pelvic abscess
blood PR= colitis, colorectal malignancy, bleeding PUD
All women with acute lower abdominal pain should have a
Rectal and pelvic examination
pelvic examination
Cervical excitation tenderness= PID (Can also occur with
peritonitis)
Blood PV= miscarriage or failed abortion
PV discharge= PID
Tender PV, low BP & anaemia= ectopic pregnancy
Differential Diagnosis
There are multiple diagnoses to consider, and unless you use a structured approach the clinical scenarios can feel
overwhelming.
It is practical to consider a diagnostic algorithm that starts with a broad range of conditions and narrows down to the ones
most pertinent to a surgical unit.
Whilst not very “scientific”, approach the aetiology of the abdominal pain by considering two categories, medical causes &
surgical causes- if you are confident that the medical causes are not a factor, then the patient and the diagnosis is 100% your
responsibility!
“Medical” causes of severe abdominal pain
Very common Occasional Rare
Gastro-enteritis Colitis Herpes zoster
Pyelonephritis, renal colic, cystitis, Pneumonia, Pleurisy Porphyria
Urinary retention MI, acute pericarditis Hypercalcaemic crisis
PID DKA Addisonian crisis
Acute hepatitis Sickle cell crisis
Lead poisoning
Tabes dorsalis
Phaeochromocytoma & hypertensive
crisis
“Surgical” causes of severe abdominal pain
To differentiate the surgical causes of an acute abdomen, decide on where the “epicentre” of the pain is, consider the
anatomical structures in that region- accept that there may be overlap between diagnoses and that clinical symptoms and
signs evolve over time.
Irrespective of the abdominal site of the pain, ALWAYS CONSIDER APPENDICITIS in the differential diagnosis. It is the
commonest cause of peritonitis in any age group, and if misdiagnosed can be fatal.
Right upper quadrant pain
Common Causes Clinical Features
Intense, dull discomfort located in the RUQ or epigastrium.
Associated with nausea, vomiting, and diaphoresis. Generally
Biliary colic
lasts at least 30 minutes, plateauing within one hour. Benign
abdominal examination
Prolonged (>4 to 6 hours) RUQ or epigastric pain, fever.
Cholecystitis
Patients will have abdominal guarding and Murphy's sign
Cholangitis Fever, jaundice, RUQ pain.
Liver abscess Fever, RUQ pain, cachexia, anaemia
Subhepatic location of the appendix can mimic biliary
Appendicitis
disease
Rare causes Budd-Chiari syndrome/ adrenal haemorrhage/ Fitz Hugh
Curtis syndrome/metastatic liver disease/ complicated
hydatid disease
Left upper quadrant pain
This is the least common location for severe abdominal pain; the aetiology overlaps significantly with the common causes of
severe pain in the epigastrium
Rare causes Clinical Features
Associated with a variety of underlying conditions
(e.g., hypercoagulable state, atrial fibrillation, and
Splenic infarct splenomegaly). Commonly presents with pain
radiating to the tip of the shoulder, and sympathetic
pleural effusion
Splenic abscess Associated with fever and LUQ tenderness may be a
complication of splenic infarction
Splenic artery aneurysm LUQ pain, low Hb, and hypovolaemic shock –
abdominal apoplexy. Most common in pregnancy
Epigastric & central abdominal pain
Common Causes Clinical Features
Sudden, excruciating epigastric pain. Patient unable to move
Perforated PUD
with typical board-like rigidity and peritonism
Acute-onset, persistent upper abdominal pain radiating
Acute pancreatitis
to the back.
Abdominal pain, heartburn, nausea, vomiting, and
Gastritis hematemesis. True peritonism uncommon. Common
following an ethanol binge.
Fever, RUQ pain, cachexia, anaemia. If the abscess is in
Liver abscess left lobe of the liver it can cause excruciating epigastric
tenderness. A mass may also be palpable
Central, cramping, severe abdominal pain, with profuse biliary
Small bowel obstruction vomiting. Prominent abdominal distention. Peritonism only if
the bowel is ischaemic
In the early phases of appendicitis, the pain is centrally
Appendicitis located. In cases with a free perforation and generalized
peritonitis, the pain is diffuse.
Mesenteric ischaemia/ AAA/ acute on chronic pancreatitits/
Rare causes pancreatic malignancy/ perforated gastric carcinoma/
primary peritonitis
Lower abdominal pain
Common Causes Clinical Features
Periumbilical pain initially that radiates to the right lower
Appendicitis quadrant. Associated with anorexia, nausea, and vomiting.
Low-grade pyrexia and localised peritonism
Older patient. Pain usually constant in the left iliac fossa, and
Diverticulitis present for several days prior to presentation. May have
associated nausea and vomiting. Local signs depend on the
severity of local complications
Severe central or lateral pain. Sexually active. Vaginal
PID discharge. Marked cervical excitation tenderness. Less
impressive GI symptoms
Crohn's disease, TB enteritis, acute colitis, Meckel’s
Rare causes diverticulitis, perforated colon carcinoma, torted ovarian
neoplasm, endometriosis, iliopsoas abscess, intussusception
Flags for uncommon diagnoses
Patients with concomitant diagnoses (co-morbidity) are still more likely to have a COMMON cause of abdominal pain, than a rare
one, but the conditions below should alert you to some unusual pathology - just think about them!
TB peritonitis, lymphoma, Kaposi sarcoma of the small bowel,
HIV +
CMV colitis, TB iliopsoas abscess
Anaemia & Cachexia Obstructed/ perforated GIT cancer, Crohn’s disease, TB
Vasculopathy MI, Bowel ischaemia, AAA
Connective tissue disorders Bowel ischaemia, serositis
Primary peritonitis (in patients with peritoneal dialysis NB, or
Renal failure
nephrotic syndrome)
Liver failure Primary peritonitis
Obstructed/ perforated GI cancer
Elderly
MI, Bowel ischaemia, AAA
Necrotizing enterocolits, intussusception, Henoch Schonlein
Infant
purpura
Ectopic or extrauterine pregnancy, ovarian torsion, fibroid
Pregnant degeneration
Abruptio placenta
Recent chemotherapy Colitis
Psychiatry Swallowed foreign body, trauma, fictitious disorder
Urinary retention in Alzheimer's
Evaluation Priorities
How sick is the patient?
Do I need to start a resuscitation protocol?
Hb, blood gas, WBC
Start IV fluid rehydration, consider early IV antibiotics
The acidotic or confused patient is critically ill and needs urgent intervention. Beware the young fit patient with a normal PH but a
low PCO2(compensated metabolic acidosis) they may look well but decompensate quickly.
How bad is the pain?
Give adequate analgesia, typically parenteral opiates
What is the diagnosis?
Have I excluded “medical causes” of acute abdomen?
Check urine, pregnancy test, CXR, AXR, ECG, U&E, LFT, lipase
Does the patient OBVIOUSLY need an urgent operation?
Don't delay surgery when it is needed! Get on with it!
I am not quite sure what is going on, and I need more information
Re-evaluate the patient clinically at 6-12 hour intervals, review with a colleague
Commonly used emergency investigations
Test Ideal context Issues to consider
Thin patient, good in biliary and gynae Operator dependent, but widely available
Abdominal US pathology and relatively cheap
By far the best investigation but it is
Best for obese patients, or suspected
Abdominal CT expensive, uses IV contrast, and is not
retroperitoneal or pancreatic pathology
always available
Excellent to differentiate appendicitis Commits patient to surgery uses theatre
Laparoscopy
from PID resources, requires surgical expertise
A number of acute surgical conditions evolve (or resolve!) over 12 to 24 hours, and some diagnostic mysteries become
obvious with time and re-evaluation.
You will develop clinical wisdom to accept uncertainty, and constantly re-evaluate your diagnosis in light of the clinical
state of the patient.
Don't be dogmatic. If the patient isn’t responding to your management, revisit the story and the working diagnosis.
Think again.
Don’t accept “diagnostic labels” until they are unequivocally proven.
What other investigations must I consider?
Be selective in the investigations, and use common sense instead.
The investigations below are occasionally helpful.
Test Ideal context Issues to consider
Can demonstrate obstructions or subtle Largely replaced by CT scans with either
Contrast study leaks from the GIT, especially from the oral or rectal contrast.
oesophagus
Endoscopy Seldom helpful in acute abdominal pain VERY uncomfortable for the patient
Vascular cases with occult bleeding or Requires very specific endovascular
Angiography
false aneurysm skills
ERCP In selected cases of cholangitis only Requires very specific endoscopic skills
SHOULD I OPERATE OR NOT?
The decision to intervene surgically is the most significant of all the issues that pertain to the management of a patient with
acute abdominal pain.
Some cases HAVE to undergo emergency surgery, whilst others will be harmed by unnecessary surgery. Correct case
selection is THE CORE SKILL that you have to develop as a surgeon.
You have to know when to operate and when not to operate. There is no substitute for clinical experience, and the
heterogeneity of clinical conditions makes a one-size-fits-all approach impossible.
Almost all cases benefit from a few hours of preoperative resuscitation before an operation, .....BUT great harm comes from
delays in surgery, and reliance on un-necessary imaging tests only available in another hospital! Acute sepsis and ischaemic
bowel need surgery within a few hours, not days.
These are some thoughts to guide your decision making.
Need early surgery
Appendicitis
Perforated PU
Ischaemic bowel
Diffuse peritonitis from any cause
Can be treated conservatively
PID
Gastritis
Cholecystitis
Cholangitis
Appendicitis* occasionally
Best with interventional radiology & perc drain
Diverticular abscess
Appendix abscess
Liver abscess
Avoid surgery in these!
Any “medical cause” of acute abdomen
Acute pancreatitis
