Acute Abdominal Pain
Most patients with abdominal pain do not have acute pathology, let alone a need for urgent surgery, but it’s vital to spot the ones who do. Primary care is often the first or only port of call for the patient, so there’s no margin for mistakes.
Take your time. You will regret it if you rush your assessment and get it wrong. You do not need to make an exact diagnosis. You only need a working diagnosis to guide your management.
Safety netting can be the difference between life and death.
Peritoneal irritation (localised or generalised peritonitis, which can be infective, chemical or traumatic in origin) is very important. Always look for it in patients with abdominal pain.
Children or pregnant women with abdominal pain can worsen rapidly. They may have different pathology too. In children, mesenteric lymph nodes can enlarge and become painful when there is tonsillitis. In late pregnancy, upper abdominal pain can be a warning sign of eclampsia (see Chapter 30).
History
Let the patient tell you about the pain, but be sure to fill in the gaps, noting especially when the pain started and what it is like (using SOCRATES or similar).
If the pain is worse on movement, it’s more likely to be peritonitis. The opposite is true of ureteric colic.
‘Have you ever had this pain before?’ Previous episodes (and what helped) can guide you this time, especially with biliary pain.
Ask about vomiting and bowel movements.
Classic symptoms of obstruction are colicky pain, vomiting and constipation (no flatus or stools).
Does the patient feel bloated or distended? Any weight loss?
Are there genito-urinary symptoms? Think UTI and pelvic inflammatory disease. When was the last menstrual period (LMP)? Ask ‘Was it a completely normal period for you?’
Take the previous medical history. Ischaemic heart disease is linked with ischaemic colitis and with aortic aneurysm. Is the patient on medication? What about alcohol? Excess intake can lead to pancreatitis or acute alcoholic hepatitis. Don’t forget travel (malaria, parasitic infections) and trauma (splenic rupture).
Family history can be important in sickle cell disease, pancreatitis and irritable bowel syndrome, amongst other conditions.
Examination
Is your patient shocked or dehydrated? Check the colour and feel of the skin, pulse, blood pressure and oxygen saturation (if you have a pulse oximeter). Is there fever? This suggests inflammation but isn’t specific to sepsis. The elderly often have little fever and no tachycardia even in advanced sepsis.
Can you smell a foetor? This is more likely in appendicitis and other forms of sepsis within the gut.
When you start examining the abdomen itself, make your patient comfortable, with their hands by their side to help relax the abdominal muscles. One pillow under the head can help.
Look for any masses, visible peristalsis and signs of trauma. Site can be important (see Figure 46), or it may be misleading.
Check for any signs of peritoneal irritation including:
Pain on coughing
