Definitions
Abdominal pain is a subjective unpleasant sensation felt in any of the abdominal regions. Acute abdominal pain is usually used to refer to pain of sudden onset, and/or short duration. Referred pain is the perception of pain in an area remote from the site of origin of the pain.
Key Points
- Important to assess the whole patient.
- Repeated clinical examination is very helpful.
- The diagnosis can often be made on the clinical findings (e.g. appendicitis).
- Examine the abdomen with the patient lying flat with one pillow supporting the head.
- Generally, very severe pain indicates generalized peritonitis or ischaemia (e.g. perforated DU, mesenteric infarction).
Important Diagnostic Features
History of the Pain
- The site of pain relates to its origin: foregut – upper; midgut – middle, hindgut – lower.
- Colicky (visceral) pain is caused by stretching or contracting a hollow viscus (e.g. gallbladder, ureter, ileum).
- Constant localized (somatic) pain is due to peritoneal irritation and indicates the presence of inflammation/infection (e.g. pancreatitis, cholecystitis, appendicitis).
- Associated back pain suggests retroperitoneal pathology (aortic aneurysm, pancreatitis, posterior DU, pyelonephritis).
- Associated sacral or perineal pain suggests pelvic pathology (ovarian cyst, PID, pelvic abscess).
- Pain out of proportion to the physical signs suggests ischaemia with or without perforation.
- Remember referred causes of pain: pneumonia (right lower lobe), myocardial infarction, lumbar nerve root pathology.
Abdominal Examination
Inspection: Scaphoid or distended, movement on respiration, swellings, scars, lesions, bruising.
Palpation: Superficial and deep.
- Tenderness: pain or discomfort when affected area is touched.
- Rebound tenderness: pain or discomfort on removing one’s hand from the affected area.
- Guarding (défense musculaire): involuntary spasm of the anterior abdominal wall muscles over inflamed abdominal vicera, e.g. in RIF in patients with appendicitis.
- Rigidity: stiff, hard, unyielding abdominal wall due to abdominal wall muscle spasm; indicates extensive peritonitis.
- Palpate for organs and masses: liver, spleen, bladder, gallbladder, appendix mass, AAA.
Percussion: May detect distended bladder or enlarged liver/spleen.
Auscultation: Listen for bowel sounds. Absent or deceased in peritonitis, increased with intestinal obstruction.
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