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Red !ag symptoms: Abdominal pain

By Dr Pipin Singh on the 31 May 2021

Dr Pipin Singh provides an update on identifying potentially

serious causes of abdominal pain.

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Red !ag symptoms

Gastrointestinal red !ags

Sudden onset abdominal pain

Haematemesis
Change in bowel habit (more loose stool) for > 3 weeks
Dysphagia
New onset dyspepsia
Persistent unexplained vomiting
 Any distention of the abdomen
Not passing wind/absolute constipation

Urological red !ags

Haematuria
Testicular pain +/- swelling
Inability to pass urine

Gynaecological red !ags

Unexplained PV bleeding
Post-coital bleeding
Increased vaginal discharge
Blood-stained vaginal discharge
Amenorrhoea

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Other red !ags

Fever
Presyncopal symptoms
Shortness of breath
Unexplained weight loss
Associated lightheadedness
Associated back pain
 Raised blood sugar
New rash

Abdominal pain is a common presenting problem in primary care. Many

potentially life-threatening diagnoses present with acute abdominal pain.

However, a focused history and examination should lead to a diagnosis

and appropriate management.

History

Begin by locating the pain and ask the patient how and when it began and
what they were doing at the time. Ask about severity and whether the pain
radiates elsewhere. Are they acutely unwell?

Are there any aggravating or relieving factors, and has the pain eased,
remained constant or worsened? Is it colicky, relieved by defecation, or
altered following ingestion of food?

A careful drug history, including over-the-counter drugs, may yield clues.

The patient may be taking medications that could aggravate dyspepsia,
such as bisphosphonates, NSAIDs or SSRIs. There may be a history of
opiate use leading to constipation.

Ask about any new rash, particularly one that may be very itchy – shingles
can present with abdominal pain. The pain will often be reported as
sharp/burning, and then the vesicular rash may appear in a dermatomal
pattern.

Enquire about smoking and alcohol intake.

It is also very important to consider whether the patient has presented

with similar pain before and if so, whether this was investigated, and the
outcome of any investigations. Is there a history of recent endoscopy or
abdominal imaging such as ultrasound or CT scanning?
Gastrointestinal symptoms

Ask about GI symptoms, including changes in bowel habit, rectal bleeding,

nausea, vomiting, haematemesis, heartburn, odynophagia or dysphagia.
Has the patient tried any over-the-counter medicine to help with these
symptoms?

If diarrhoea and vomiting predominate, has there been a history of foreign

travel? Does the patient work with food? Is anyone else unwell in the
family? Consider whether there is a risk of COVID-19.

Urological symptoms

Urological symptoms may be very relevant, particularly if a renal or lower

urinary tract cause is suspected. Ask about any pain or inability to pass
urine, as well as any testicular pain or swelling.

Determine whether the patient has undergone any abdominal surgery.

In women, pay close attention to gynaecological symptoms and ascertain

whether the patient could be pregnant. Cardiac pain can also present as
epigastric pain, thus associated shortness of breath and vomiting may be
relevant.

A sexual history may be relevant if PID is suspected. Has there been any
recent change in sexual partners or any known exposure to chlamydia or
gonorrhoea?

Examination

Careful observation of how the patient enters the room will provide much
information. Check BP, pulse, oxygen saturation and temperature.

Is the patient well hydrated? Is the patient jaundiced? Is there evidence of

anaemia? Is there any stigmata of chronic liver disease? Does the
abdomen look distended? If so, is there evidence of ascites? Weigh the
patient if there is a history of weight loss.

Palpate the abdomen systematically focusing on all nine areas. Is there

any evidence of guarding, rigidity or percussion pain? Are there any noted
masses or evidence of organomegaly? Rectal examination may be
necessary.

Check hernial orifices if the history suggests that an inguinal hernia is a

possible cause. It may be important to listen for bowel sounds.

In men, you may wish to check the testicles if testicular torsion is

suspected. In women, speculum and vaginal examination may be
indicated.

For face-to-face examinations, ensure you wear appropriate PPE.

Causes of acute abdominal pain

Several causes of acute abdominal pain can be life threatening if not
identified.

Gastrointestinal causes

Perforated viscus, for example, duodenal or gastric ulcer

Acute pancreatitis
Acute cholecystitis
IBD
Bowel obstruction
Incarcerated inguinal hernia
Ischaemic colitis
Acute hepatic failure

Urological causes

Renal stone
 Pyelonephritis
Testicular torsion
Urinary retention

Gynaecological causes

Ectopic pregnancy
PID
Ovarian torsion

Other causes

MI
Ruptured abdominal aortic aneurysm
Diabetic ketoacidosis
Appendicitis
Diverticulitis
Shingles

Consider paediatric multisystem in!ammatory syndrome (PIMS) in

children if they are severely unwell. Additional diagnoses to consider in
children include mesenteric adenitis.

Chronic abdominal pain

Causes that you should consider in presentations of chronic abdominal
pain are:

Gastric cancer
Hepatocellular cancer
Pancreatic cancer
Colorectal cancer
Coeliac disease
Fatty liver
Chronic pancreatitis
 Endometriosis
Adhesions (if there is a history of abdominal surgery)
Functional abdominal pain
Abdominal migraine in children

Investigations

Investigations will be guided by the history and any findings on

examination, but could include:

Bloods (including FBC, U&Es, CRP, HbA1c, amylase, LFTs, ESR, tissue
transglutaminase and liver screen)
Urinalysis looking for UTI or evidence of renal calculi
ECG
Stool testing for Helicobacter pylori
Stool culture and sensitivity
Faecal calprotectin and faecal immunochemical test (FIT)
Chest X-ray (right basal pneumonia can present with right upper
quadrant pain)
Urinary hCG
Triple swabs
Abdominal, pelvic or renal ultrasound
CT of abdomen and pelvis
CT colonography
Pancreatic protocol CT

Plain abdominal film can be considered if constipation is suspected, a HAD

score if a psychological cause is suspected, and an AUDIT questionnaire if
alcohol dependence is suspected.

Tumour markers are not recommended in the primary care setting,

although CA125 can be considered if ovarian malignancy is suspected.

Depending on local resources, CT abdomen and pelvis can be considered,

although most CT investigations are undertaken in secondary care.