Abdominal Pain
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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