Abdominal pain

Acute abdominal pain: step-by-step assessment

1

Evidence of shock?

Rapidly identify patients who are shocked

with hypotension and evidence of tissue
hypoperfusion (see Box 28.1, p. 249).
Remember that young, fit patients can
often maintain BP in the face of major fluid
losses; in these patients hypotension occurs
late, so look carefully for early features
such as HR, RR, narrow pulse pre
ssure, anxiety, pallor, cold sweat or lightheadedness on standing postural BP.
If the patient has overt or incipient
shock, secure two large-bore IV lines;
send blood for cross-match, U+E, FBC,
amylase and LFTs; and begin aggressive
resuscitation.
The diagnoses to consider first are rupture
of an AAA, ectopic pregnancy or other
viscus, as these may require immediate surgical intervention.
Suspect ruptured AAA in any patient
with known AAA, a pulsatile abdominal
mass or risk factors e.g. male >60 years,
who experiences sudden-onset, severe
abdominal/back pain followed rapidly
by haemodynamic compromise.
Suspect ruptured ectopic pregnancy in
any pregnant woman or woman of
child-bearing age with recent-onset
lower abdominal pain or PV bleeding;
perform an immediate bedside
pregnancy test.
Consider splenic rupture in any shocked
patient with abdominal pain who has a
history of recent trauma, e.g. road traffic
accident.

medical conditions, e.g. diabetic

ketoacidosis, myocardial infarction,
adrenal crisis, pneumonia
any condition associated with repeated
vomiting, e.g. intestinal obstruction,
gastroenteritis.
2

Generalised peritonitis?

Generalised peritonitis occasionally results

from acute pancreatitis but is usually the
manifestation of a perforated hollow viscus,
e.g. stomach, duodenum or colon. Suspect
it if there is severe, non-colicky abdominal
pain that is worse on movement, coughing
or deep inspiration, and which is associated
with inflammatory features and generalised abdominal rigidity. The patient will
usually be lying still, taking shallow breaths,
and will be in obvious distress or discomfort; reconsider the diagnosis if the patient
appears well or is moving freely.
Patients require aggressive resuscitation,
antibiotics and immediate surgical referral.
Free air under the diaphragm on erect CXR
(present in 5075% of cases) confirms the
diagnosis; if CXR non-diagnostic consider
contrast CT (Fig. 4.4). Serum amylase may
help to differentiate perforation from pancreatitis. A very high index of suspicion is
required in the elderly and in patients
taking systemic steroids; signs are often
subtle, so reassess frequently.

If any of these diagnoses is suspected,

arrange immediate surgical review prior to
imaging.
In the absence of these conditions,
perform an ECG, CXR, urinalysis and ABG,
continue to assess for an underlying cause,
as described below, and refer for urgent
surgical review. Other important diagnoses
to consider include:
perforated viscus
mesenteric ischaemia
acute inflammatory conditions, e.g.
pancreatitis, colitis, cholangitis

Fig. 4.4 Free air under the diaphragm.

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