ACUTE ABDOMINAL PAIN

Give analgesia early before further assessment if the patient is in severe pain
Consider early IV access, surgical opinion, fluid resuscitation prior to completing assessment if patient is shocked
Don't forget cardiothoracic emergencies in upper abdominal pain such as acute MI

ASSESSMENT

There are many causes for acute abdominal pain. A thorough/methodical clinical assessment usually narrows the possibities to less than a handful of conditions
All the following systems should be assessed gastro-oesophageal, colonic, genito-urinary, obstetric/gynaecological, hepato-biliary/pancreatic

See Acute abdomen Assessment Form (printable form)

See Diagnosing abdominal pain - Simple rules

CLINICAL FEATURES OF SERIOUS PATHOLOGY

Bilious vomiting
Haemetemesis
Malaena
Abdominal distension
Pain requiring frequent simple analgesia

Fever
Tachycardia
Hypotension
Cough/Percussion/Rebound tenderness
Involuntary guarding (see below)

	Voluntary Guarding	Involuntary guarding
Pathophysiology	Voluntary contraction of abdominal muscles in response to pain or anxiety	Increased muscle tone due to irritation of parietal peritoneum
Relieved with pillow under feet/back	Yes	No
Relieved with distraction	Yes	No
Relieved with analgesia	Yes	No
Relieved with distraction	Yes	No
Relieved with deep inspiration	Yes	No

COMMON TRAPS

Constipation should not be considered a diagnosis before it is a considered a symptom (of something serious)
Diagnosing renal colic in a AAA
Ignoring the vital signs
Severe abdominal pain without abdominal findings = ischaemic bowel

INVESTIGATIONS

Urinalysis (most patients)
ECG (in upper abdominal pain without abdominal findings)

Should be selective according to the suspected pathology
(e.g. do not do a FBC, EUC/LFT, AXR on every person with abdominal pain!)

INVESTIGATION	INDICATION
HB	GI blood loss Ectopic pregnancy Ruptured AAA
WCC	Fever, Localizing tenderness
EUC	Protracted diarrhoea/Vomiting (not for simple gastroenteritis) Bowel obstruction Renal colic
LFT	Hepato-biliary disease
Amylase	Biliary colic Pancreatitis
CK/Phosphate	Ischaemic bowel
Calcium/Urate	Renal colic Pancreatitis (Ca++ for Ranson's criteria)
ABG	Shock Sepsis Ischaemic bowel

IMAGING

IMAGING MODALITY	INDICATION
CXR	Perforated viscus Pancreatitis (Ranson's criteria)
AXR	Bowel obstruction
Upper abdominal Ultrasound	Biliary Colic Cholecystitis
Pelvic Ultrasound	Ectopic pregnancy (if stable) Ovarian torsion Ovarian cyst rupture
CT abdomen	AAA (if stable) Renal calculi Intrabdominal collection/abscess

INDICATIONS FOR URGENT LAPAROTOMY

Hypotension
Severe metabolic acidosis

DISPOSAL

Indications for admission

Fever

Tachycardia

Peritonism

Other considerations:

Elderly and children

Intellectually disabled

Spinal patients

Chronic steroid use

'Second presentation'

'Came in the middle of the night'

Discharge Criteria

Mild pain

Tolerating fluids/Not vomiting

Afebrile

Not tachycardic

No peritonism

Investigations normal

ACUTE ABDOMINAL PAIN

ASSESSMENT

CLINICAL FEATURES OF SERIOUS PATHOLOGY

COMMON TRAPS

INVESTIGATIONS

IMAGING

IMAGING MODALITY

INDICATION

INDICATIONS FOR URGENT LAPAROTOMY

DISPOSAL