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Abdominal Pain



  • 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.


    • 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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