Abdominal pain in ED

Mr Richard Ajuwon
Consultant, ED
MKUH
 Objectives

• Why it is important
• History
• Examination
• Investigations
• Management
• Common surgical emergencies
• Pitfalls
 Importance

• Common

• Life threatening

• Diagnosis can be difficult

• Medical errors
 History

• Nature of the pain

• Location
• Severity
• Frequency
• Associated symptoms-fever, vomiting, backpain, collapse
• Bowel movement
• Urinary symptoms
• LMP etc
• PMH & PSH
 Anatomy

• Large cavity

• Nipples to pelvis

• 9 quadrants
 Examination

• Inspection-bruising, swelling, peristalsis. Pulsation

• Light palpation
• Guarding, rebound tenderness, rigidity (peritonitis)
• Distension (5Fs)
• Hernia orifices
• Organomegaly-liver, spleen, uterus, bladder, kidneys
• External genitalia
• Rectal examination
• Bowel sounds
 Investigations (Bedside)

• Urinalysis & pregnancy test

• VBG-lactate, BM

• ECG (>50 years or cardiac hx)

• FAST scan-AAA & free fluid

 Blood tests

• FBC
• CRP
• Urea & electrolytes
• Amylase
• LFT
• Glucose
• Calcium
 Imaging

• Erect CXR-perforated viscus

• Ultrasound scan-GB, kidneys, AA, ovaries
• CT scan-benefits Vs risks

• Plane AXR-not usually helpful

 Management

Resuscitation maybe needed

• Airway

• Breathing

• Circulation

• Operative intervention-call the Surgeon/Specialist

 Life-threatening conditions

• AAA
• Ruptured solid organ(spleen. Liver, kidney)
• Perforated viscus (duodenum, appendix, colon)
• Ruptured ectopic pregnancy
• Ischaemic bowel
• Bowel obstruction
• Abdominal trauma (blunt & penetrating)

• Torsion of the testis/ovary

Kidney injury
Perforated Viscus
 Obstruction

• Abdominal pain
• Vomiting
• Previous surgery
• Hernia sites
• NBM
• Imaging
• Surgeons
 Testicular torsion

• May present as abdominal

pain
• Vomiting
• Usually tender
• Early surgical referral
 Ruptured Ectopic

1 in 250 pregnancies.
Risk factors
– previous ectopic
– PID
– Tubal damage ect.
Suspect and exclude in any
pregnant woman with
abdominal pain.
 Surgical conditions

• Acute appendicitis
• Acute pancreatitis
• Biliary colic
• Acute cholecystitis
• Acute diverticulitis
• Renal colic
 Appendicitis
• Classic presentation
• Atypical presentation
• RIF tenderness
• Peritonitis
• Pitfalls-FBC & CRP
• Surgical opinion
• Admit & observe
• Imaging
 Others

• Non specific abdominal pain (40%)

• Constipation

• Cancer (>50 years)

• Ovarian pathology
 Medical causes

• Acute Coronary Syndrome (ACS)

• Pneumonia

• DKA

• Hypercalcaemia
 General management

• Decision not diagnosis

• Analgesia-iv paracetamol, morphine(titrate)
• Anti-emetic
• Iv fluids
• Iv antibiotics for intraabdominal sepsis(guidelines)
• NBM
• NG tube
• Urinary catheter
 Decision making

• Resuscitation

• Immediate surgical intervention

• Admission for observation

• Admission for further investigations & possible intervention

• Discharge (after senior review)

 Pitfalls

• Exclude pregnancy in a female of child bearing age

• Abdominal pain in elderly patients (AAA, ischaemic bowel,

obstructed hernia)

• Patients who return to ED

• Think of & exclude serious pathology

• Over-reliance on investigations

• Consider medical causes of abdominal pain

Any Questions

?
 Conclusion

• History
• Examination
• Investigations
• Management
• Common acute surgical emergencies
• Pitfalls
 Further Reading

• www.rcemlearning.co.uk/abdominal pain without shock

• Oxford Handbook of Emergency Medicine