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Symptoms
 
 

Abdominal Pain

 
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Overview

Abdominal pain is a common presentation, and it important to rapidly assess for imminently life-threatening surgical issues such as appendicitis, bowel perforation, mesenteric ischaemia and cholecystitis. A thorough history will provide direction and assist in the diagnosis of the underlying pathology.

Aetiology

  • Causes of Abdominal Pain

  • Gastrointestinal

  • Oesophageal - oesophagitis
  • Gastric - gastritis, gastric ulcer
  • Small bowel - duodenal ulcer, gastroenteritis, small bowel obstruction, intussusception
  • Colonic - appendicitis, diverticulitis, obstruction, IBD, malignancy, neutropaenic colitis, infectious colitis, ischaemic colitis, volvulus, faecal impaction
  • Hepatobiliary

  • Hepatic - hepatitis
  • Biliary - cholelithiasis, cholecystitis, cholangitis
  • Pancreatic - pancreatitis
  • Other Abdominal / Pelvic Organs

  • Peritoneal - mesenteric adenitis, spontaneous bacterial peritonitis
  • Abdominal wall - soft tissue injury, strangulated hernia, haematoma
  • Vascular - ruptured AAA, aortic dissection, mesenteric ischaemia
  • Renal / urologic - nephrolithiasis, cystitis, pyelonephritis, urinary retention
  • Male sexual - testicular torsion, epididymitis, prostatitis
  • Gynaecologic - ectopic pregnancy, ovarian cyst rupture / haemorrhage / torsion, fibroids, PID, endometriosis, mittelschmerz
  • Thoracic

  • Respiratory - lower lobe pneumonia, pulmonary embolism
  • Cardiac - acute coronary syndrome
  • Systemic

  • Metabolic - diabetic ketoacidosis, hypercalcaemia, porphyria
  • Endocrine - Addison’s disease, hyperthyroidism
  • Haematologic - sickle cell crisis, acute leukaemia

History of Presenting Complaint

  • Site

    Where in the abdomen the pain presents.
  • Right upper quadrantHepatobiliary, hepatic flexure, right renal or right lower lobe pathology
  • EpigastriumHepatobiliary, gastric, pancreatic, vascular or cardiac pathology
  • Left upper quadrantGastric, pancreatic, spleic flexure, left renal, left lower lobe or vascular pathology
  • PeriumbilicalGastric, small bowel or vascular pathology
  • Right lower quadrantColonic, gynaecologic or right renal pathology
  • SuprapubicColonic, gynaecologic or renal pathology
  • Left lower quadrantColonic, gynaecologic or renal pathology
  • Generalised abdominal painSuggestive of bowel obstruction, perforation, spontaneous bacterial peritonitis or IBD
  • Moving from periumbilical area to right lower quadrantCharacteristic of appendicitis
  • Onset

    Whether the pain began suddenly or gradually, and what the patient was doing at the time.
  • Sudden onset, severe painRed flag severe, life-threatening cause
  • Character

    The type of pain - sharp, dull, tight, burning or tearing.
  • Dull, diffuse painVisceral pain, e.g. from intra-abdominal organs
  • Sharp, localised painParietal pain, e.g. from peritoneum
  • Burning pain in the epigastriumSuggestive of oesophagitis, gastritis or peptic ulcer disease
  • Radiation

    Whether the pain radiates anywhere else in the abdomen, chest, shoulders or back.
  • Radiation to the flankSuggestive of renal or biliary cause
  • Radiation to the backSuggestive of pancreatitis, ruptured AAA, aortic dissection, duodenal ulcer
  • Radiation to the shoulderSuggestive of diaphragmatic irritation, e.g. intra-abdominal gas or blood
  • Associated Symptoms

    Whether the pain is associated with any other symptoms.
  • Nausea / vomitingNon-specific symptom of abdominal disease
  • Faeculant vomitingSerious indicator of bowel obstruction
  • DiarrhoeaNonspecific symptom of GI cause; may still be present in obstruction
  • ConstipationPotential faecal impaction or bowel obstruction
  • Lack of flatusSuggestive of bowel obstruction
  • Bloody stoolsPotential diverticulitis or ischaemic colitis
  • Frank PR bloodSuggestive of lower GI bleed or massive upper GI bleed
  • Haematemesis or malaenaSuggestive of peptic ulcer
  • FeversSuggestive of infectious cause e.g. appendicitis, cholecystitis, diverticulitis
  • RUQ / LUQ pain with cough and feverSuggestive of pneumonia
  • HeartburnSuggestive of gastritis / peptic ulcer
  • Dysuria / urinary frequencySuggestive of cystitis or pyelonephritis
  • HaematuriaSuggestive of nephrolithiasis
  • Vaginal dischargeSuggestive of pelvic inflammatory disease (PID)
  • AnorexiaSuggestive of appendicitis
  • Timing

    How long the pain has been going on for, and whether it is constant or comes and goes.
  • Colicky pain: sharp pain that comes and goesHollow visceral pain e.g. gallstones, nephrolithiasis, small bowel obstructon
  • Cyclical pain worse with menstruationSuggestive of endometriosis
  • Exacerbating Factors

    Whether there is anything that makes the pain worse.
  • Worse with coughing or movementSuggestive of peritonitis e.g. perforation, SBP, pancreatitis
  • Worse after eatingSuggestive of gastric ulcer, gastritis, cholelithiasis or mesenteric ischaemia
  • Worse with fatty foods specificallySuggestive of cholelithiasis
  • Alleviating Factors

    Whether there is anything that relieves the pain, and if the patient has taken any analgesia.
  • Relieved with eatingSuggestive of duodenal ulcer
  • Relieved with vomitingSuggestive of small bowel obstruction
  • Severity

  • How severe the pain is out of 10, with 10 being the worse possible pain.
  • How the pain is impacting the patient’s life, such as work, hobbies or even mobility.
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