A N A P P R O A C H TO

A B D O M IN A L PA IN
Dr. Matthew Smith
Emergency Specialist

 Types of pain
Special Populations
Assessment
History
Examination
Investigations
Differential Diagnosis

Management - overview
Cases ( if time permits)

Types O fPain
Visceral
Parietal Pain

VisceralPain
Stretching of nerve

fibres of walls or
capsules of organs
Crampy
Dull
Achy

Often unable to lie

still
Bilateral
innervation

ParietalPain
Parietal peritoneum irritated
Usually anterior abdominal wall
Localised to the dermatome

superficial to the site of painful

stimulus

Course

Referred Pain
Examples of referred pain?

SpecialPopulations

Elderly
May lack physical findings despite having

serious pathology
As patients age increases diagnostic accuracy
declines
Risk of Vascular Catastrophes
Assume surgical cause until proven otherwise
30-40% of geris with abdo pain need surgery
Biliary tract Disease is the commonest cause
Age > 65 need to think of reasons not to CT!
Mortality is 7% in the over 80s - equivalent to
AMI!

Elderly Patient think N asties!

AAA
Ischaemic Gut
Bowel Obstruction
Diverticulitis
Perforated Peptic

Ulcer
Cholecystitis
Appendicitis

W om en ofChildbearing Age
Must Ascertain whether PREGNANT
ALL WOMEN OF CHILDBEARING AGE

WITH ABDO PAIN NEED BHCG

Gravid uterus displaces intraabdominal organs making
presentations atypical
Pregnant women still get common
surgical abdominal conditions

H istory
What are the key points of the

abdominal pain history?

H istory
HPC
Pain
Provocative
Palliative
Quality
Radiation
Symptoms associated

with
Timing
Taken for the pain

Consultations/

Presentations

Associated
Symptoms
Gastro intestinal
Genito-urinary
Gynaecologic

H istory
PMH
DM
HT
Liver Disease
Renal Disease
Sexually Transmitted Infections

PSH
Abdominal Surgery
Pregnancies

Deliveries/ Abortions/ Ectopics

Trauma

H istory
Meds
NSAIDs
Steroids
OCP/ Fertility Drugs
Narcotics
Immunosuppressants
Chemotherapy agent
ALLS
Contrast
Analgesic

H igh Yield Q uestions

Which came first pain or vomiting?
How long have you had the pain?
Constant or intermittent?
History of cancer, diverticulosis, gall

stones,Inflammatory BD?
Vascular history, HT, heart disease or
AF?

Exam ination
Lots of information from the end of

the bed
Distressed vs. non distressed
Lying still - peritonitis
Writhing Renal Colic

Vital Signs
NEVER ignore abnormal vital signs!
Always document as part of your

assessment

Investigations
Bedside
UA
Blood?
Leucocyte Esterase and nitrites
Urine HCG
ECG anyone with upper abdominal pain or

elderly

Bloods
ALL WOMEN OF CHILDBEARING AGE NEED

BHCG
What are your differentials?
Avoid machine gun approach!

Radiology
CXR ?perforation
?Extra abdominal pathology
?Complications of intra-abdominal disease

Which of the following is NOT an

indication for plain abdominal imaging?
1. Bowel Obstruction
2. Constipation
3. Tracking Renal Calculi
4. Foreign Body

O ther im aging
USS

Biliary Disease
Good for gynae complaints
Rule out Ectopic pregnancy
Appendicitis in children
No radiation

 CT is accurate for

diagnosis of

Renal colic
Appendicitis
Diverticulitis
AAA
Intraabdominal
Abscesses
Mesenteric
Ischaemia
Bowel Obstruction

Avoid repeated CT

scans
Limit use in
younger patients
Avoid where
possible in
pregnant females

Imaging

Dose (mSV)

CXR equivalents

Pelvic XR

0.6

Abdominal XR

0.7

CT abdo-pelvis

14

140

CT aortogram

24

240

M anagem ent
Resuscitate
Large bore access
N Saline bolus 20ml/kg x 2 if shocked
If bleeding think hypotensive resuscitation
All should be NBM until provisional diagnosis
Ensure normothermia

Maintenance fluids and fluid balance

Analgesia doesnt mask signs
Use a the pain scale
Morphine titrated to pain. Normally 0.1mg/Kg
Paracetamol adjunct
NSAIDs for renal colic

Correct Electrolytes
Thromboprophylaxis

Cases

Case 1
21 year old female
24 hour history of vague periumbilical abdominal pain.
Moved down to the RIF.
Now constant and sharp.
Associated with 2x vomits and feels
flushed
No appetite
Normal Bowels

W hat clinicalsigns m ay lead you to a

diagnosis ofappendicitis?

Lie still
RIF tenderness
Rebound
Rovsigs sign
Psoas Sign

Im aging?
AXR rarely useful
USS
Not as good as CT
Good for female to exclude gynae pathology
If appendix is visualised is useful
CT
Only if there is doubt about diagnosis
Sensitivity up to 98%
High radiation dose
Diagnose other pathology if no appendicitis
Elderley

M anagem ent
NBM
Analgesia
Anti-emetic if necessary
Maintenance fluids
IVABs e.g. Ceftriaxone, Gentamicin

and Metronidazole
Surgical Referral

Case 2
40 yr old obese female
RUQ pain
Pain is constant
nausea, vomiting
fevers and chills
PMH Asthma
MEDS OCP
SH
Drinks 2 std / week
Smokes 20/day
Nil drugs

O n Exam ination
Looks distressed.
Not jaundiced
T 38 C
P 120
BP 100/60
RR 20
Sats 98% RA
Tender in the RUQ

and Murphys
positive.

W hat bloods w illyou order on

this patient?

 HB 138
WCC 16.0

EUC Normal
Bil 9 (<18)

Neuts 12.4
Lymph 1.6

ALP 450 (30-130)

GGT 320 (<60)
ALT 41 (5-55)
AST 30 (5-55)
Amylase 28 (<120)
Lipase 40 (<60)

M anagem ent

NBM
IVF
IV abs Ampicillin + Gentamicin
Analgesia +- anti emetic
Refer to surgeons

Case 3
52 yr old alcoholic
Constant epigastric pain radiating to

the back. Worsening over the past 2

days
Improved with sitting up and forwards
Nausea and vomiting
Bowels OK
PMH Chronic Airways Limitation
Alcoholic Gastritis
MEDS Thiamine 100 mg daily
SH Boarding house resident
Drinks 4 litres wine/day
Smokes 20/day

 Looks unwell and

dehydrated
T38.4C
P105
BP 130/70
RR 18
Sats 93% RA

 Reduced AE L

base
Tender
Epigastrium
and RUQ
No guarding/
rebound

W hat blood tests w illyou

order?

Blood Results

Biochem
Na 129
K 4.0
Cr 62
Ur 8.0

Glucose 15
Alb 23
Ca (Corr) 2.0

Amylase 1080 (<120)

Lipase 950 (<60)
Bil 11 ( 18)
GGT 900 (<60)
ALP 200 ( < 140)
AST 300 (5-55)
ALT 250 (5-55)
LDH 800( 105-333)

Haem
HB 114
WCC 17
Coags Normal

W hat im aging w illyou perform

( ifany)?

CXR

Im aging
CT
Confirms diagnosis
Identifies

complications
Helps grade severity
Not always necessary
in ED

USS
Poor visualisation of

pancreas
Good for looking at
gall stones/ biliary
tree dilatation

CXR
Look for

complications
Pleural Effusion,
Atelectasis, ARDS

M anagem ent

O2
NBM
IVF
Analgesia
+-Antibiotics (controversial)
Correct Electrolytes
Thromboprophylaxis
IDC/Art-line/CVC depending on severity
Surgical Admit +_ ICU review

Causes
G all stones
E toh
T rauma
S teroids
M umps
A utoimmune
S corpion Bites
H yperlidaemia/hypercalcaemia/hypothermia
E RCP
D rugs

Case 4

27 yr old female
6/40
LIF constant severe sharp pain
Radiating to the back
Light bright red PV spotting
Feels light headed

PMH
IVF
Previous D+C x 2
Ovarian Cysts

MEDS Nil
SH Lives with partner
Non-smoker
Non-Drinker

O n Exam ination
Looks unwell. Pale, diaphoretic, restless
P 150
BP 70/40
RR 26 Sats
98% RA
Tender and guarding in the LIF
PV
Bright red blood spotting
L adnexal tenderness ++

H ow do you m anage this

patient?
Panic! ( dont!)
Call for senior help
Large bore IV access x 2 (16 G or

larger)
Urgent Cross Match
Fluid resuscitation
Call O+G urgently
Needs OT immediately

Case 5
88 yr old female.
Peri-umbilical, colicky abdominal pain for 2

days
Abdominal distension
Vomits x 10
Reduced flatus and NOB for 2 days.
PMH

Cholecystectomy
appendectomy
TAH BSO
Hypertension

O n exam ination

Looks distressed
Lying Still
T 37.5
P 110 sinus
BP 150/80
RR 18
Sats 98% RA
Abdomen

Distended
Generally tender
No guarding rebound or rigidity
High pitched bowel sounds

Investigations

Investigations
EUC/CMP/FBP
AXR
CXR
CT

M anagem ent
NBM
Fluid resuscitation
Monitor volume status may have large

volume shifts
Correct Electrolytes
Analgesia
NG if vomiting
IV Abs Amp+Gent+Met
Urgent Surgical consult for OT

Sm allBow el

Adhesions
Hernias
Polyps
Lymphoma
Adenocarcinoma
Gall Stones
Inflammatory BD

Large Bow el
Almost never

adhesions or
hernia
CARCINOMA
Diverticulitis
Sigmoid Volvulus
Faecal Impaction

Case 6
73 yr old male presents with sudden onset of central

abdominal pain radiating to the back. He also reports

weakness to both legs
PMH
HT
Hypercholesterolemia
Current smoker 30/day

MEDS
Aspirin 100mg Daily
Perindopril 5 mg Daily
Atorvastatin 10 mg Daily

SH
Lives Alone
Fully independent with ADLS
Occasional alcohol

Exam ination

Distressed
P 130
BP 80/60
RR 26 Sats
99% RA
Abdomen
Non-distended
Generally tender

Reduced power 3/5

to hip flexors

Bedside U ltrasound

9cm

M anagem ent ofruptured AAA

Senior help
ABC
Large Bore IV Access x 2
Hypotensive resuscitation
Analgesia
Ensure O neg available
Ensure normothermia
Urgent Vascular Consult
To OT

Last Case!

85 yr old male. Nursing home resident

Central Abdominal Pain
Sudden onset. Severe
PMH
Dementia
MI

MEDS
Clopidogrel 75 mg Daily
Metoprolol 25 mg BD
Perindopril 5 mg daily

SH
Mild dementia
Forgetful
Requires some assistance with bathing and

toileting
Feeds Self
Walks with frame
Non-smoker
Non-drinker

Exam ination
Looks dry and emaciated
P 120- 140
BP 110/70
RR 30
Sats 96% RA
T 37.4 C
Abdomen
Generally tender
No guarding rigidity or rebound

ECG

D iff
erential?

ABG
pH 7.10
pCO2 15
P02 80
Bic 8
BE -15
Lactate 10.2

M anagem ent

02
NMB
IV access
IVF
Analgesia
IV abs
Urgent Surgical Consult
Urgent CT mesenteric angiogram
OT

Take H om e M essage
Exclude life threatening pathology
BHCG in female of child bearing age
Be mindful of radiation exposure
Beware of Abdominal pain in the

Elderly
Never ignore abnormal vital signs

M esenteric Ischaem ia
Surgical Emergency
Small bowel has warm ischaemic time

of 2-3 hours
Rapidly progresses to gangrene, septic
shock and death
Need high index of suspicion to
diagnose it
Severe pain but little tenderness on
examination

Case 7
40 yr old male presents with sudden

onset of severe R loin to groin pain.

Excruciating pain.Coming in waves.
Feels nauseated and has vomited x 2.
Patient is agitated, pacing around the
room, unable to sit still.
Screaming in pain.
P 120 sinus BP 160/80 T 37.0 C RR 18
Sats 99% RA
R renal angle tender

D iff
erentialD iagnosis?
Renal Colic
Pancreatitis
Cholecystitis
Appendicitis
Ruptured/leaking AAA

 UA
Erythrocytes ++++
No leucocytes
No nitrites

Investigations
UA
EUC
FBC
(other bloods if diagnosis unclear)
CT KUB

M anagem ent
Analgesia
NSAID e.g. PR indomethacin 100 mg 1st

line
Morphine IV titrated to pain
IV fluids maintenance only
Observe

W ho should w e CT
CT
Ongoing pain
Impaired renal function
Fever
Diagnosis not clear

Indications for adm ission

Infection
Impaired Renal Function
Pain ongoing needing IV opiates
Stone > 5mm
Obstruction/hydronephrosis on CT
Stag horn Calculus on CT

ECG
What does the ECG show?
1. Sinus Tachycardia
2. VT
3. VF
4. Rapid Atrial Fibrillation
5. No idea!

ECG