Systematic Approach to

Abdominal Pain
Dr Devinder Singh Bansi BM DM FRCP

Consultant Gastroenterologist
Imperial College Healthcare NHS Trust
What Do They Have?
 As you go through this
presentation, think about each of
these cases:
 An 18 mo old that suddenly
became inconsoleable from AP
while playing
 A 20 yo man with 12 hours of
diffuse crampy AP that migrated to
RLQ that became sharp
 78 yo woman with h/o chronic
steroid use with sudden sharp AP
and a rigid exam
Scale of the Problem
GI symptoms in primary care
 7.1-9.6% of all primary consultations are with
regard to GI complaints

 Gastric pain: 5.0 per 1000/yr

 Regurgitation: 2.0
 Abdominal pain: 6.1
 Nausea: 2.9
 Diarrhoea: 6.7
 Constipation: 8.1

– Thompson WG, Gut 2000: 46: 78-82

Scale of the Problem:
Abdominal pain in the general population

 Community prevalence 15-20%

 75% of these abdominal complaints
non-consulting
 25% consulting
 23.5% stay in primary care
 1-2% referred to secondary care
 Scale of the Problem:
Abdominal pain in general practice
 578 cases of non-acute abdominal pain presenting to 11
general practices
 Follow up 15 months
 Females predominated in the younger age groups
 80% visited GP <3 times during F/U
 83% managed entirely in the practices
 64% received a prescription
 Only 20% were additionally investigated in anyway by the GP
 Hardly any differences in dx between patients who had
complaints less than 1 week or more than 1 week before
presenting to their GP

Family Practice Vol 10: 4. 387-400

 Scale of the Problem:
Prevalence of GI disease
 Peptic ulcer: 1.9 per 1000/yr
 Oesophagitis: 2.9
 IBD: 1.5
 GI cancer: 1.6

 Functional dyspepsia: 12
 GORD: 5.8
 IBS: 10.5

80% of chronic GI disease has a functional background

Thompson WG . Gut 2000: 46: 78-82

Scale of the problem;
Acute abdominal pain
 Acute abdominal pain is not
uncommon.
 Approximately 5 admissions to the
MRI/day with acute abdominal pain
from a population base of 500,000.
 1 case per GP per month for an
average list size of 2,000.
Acute Abdominal Pain
 Approximately 6% of ED visits
 Admission rates vary by
population, up to about 65% in
high risk elderly populations
 Most common diagnosis is
NONSPECIFIC (ie, “I dunno”)
 Use H+P, risk factors, and directed
studies to arrive at diagnosis
 MUST rule out emergency
conditions
 Acute Abdominal Pain
Causes in 10320 patients

 Appendicitis 28%
 Cholecystitis 10%
 Small bowel obstruction 4%
 Gynaecological 4%
 Pancreatitis 3%
 Renal colic 3%
 Peptic ulcer 2%
 Cancer 2%
 No clinical diagnosis 34%

De Dombal, Scand J Gastroenterol 1988

Abdominal Pain Across
the Ages
 Ages 0-2
 Colic, GE, viral illness, constipation
 Ages 2-12
 Functional, appendicitis, GE, toxins
 Teens to adults
 Addition of genitourinary problems
 Elderly
 Beware of what seems like
everything!
Special Populations

 Elderly/ nursing home patients

 Immunocompromised

 Post operative patients

 Infants
Abdominal Pain in the Elderly

 Diminished sensation of pain in the

elderly
 Comorbid diseases
 Polypharmacy
 Combinations of above result in many
more vague, nonspecific presentations
 Twice as likely to require surgery with
presentation over age 65
 Social factors
Understanding the Types of
Abdominal Pain
 Visceral
 Stretch fibers in capsules or walls
of hollow viscus that enter both
sides of spinal cord
 Somatic
 Fibers dermatomally distributed
and enter unilaterally in the spinal
cord
 Referred
 Overlap of fibers from other
locations
Understanding the Types of
Abdominal Pain
 Visceral
 Crampy, achy, diffuse,
 Poorly localized

 Somatic
 Sharp, lancinating
 Well localized

 Referred
 Distant from site of generation
 Symptoms, but no signs
Understanding the Types of
Abdominal Pain
 Location, location, location
 Organs and their corresponding
fiber entry to the spinal cord
 C3-5 – liver, spleen, diaphragm
 T5-9 – gallbladder, stomach,

pancreas, small intestine

 T10-11– colon, appendix, pelvic

viscerat11-l1 – sigmoid, renal

capsules, ureters, gonads
 S2-4 - bladder
History Taking in Abdominal Pain
Presentations
 “OLD CARS”

 O- onset
 L- location

 D- duration

 C- character

 A-alleviating/aggravating factors

associated symptoms
 R- radiation

 S- severity
History Taking for Abdominal
Pain Presentations
 PMH
 Similar episodes in past
 Other medical problems that increase disease
likelihood of problems (ex: DM and gastroparesis)
 PSH
 Adhesions, hernias, tumors
 MEDS
 Abx, NSAIDS, acid blockers, etc
 GYN/URO
 LMP, bleeding, discharge
 Social
 Tob/EtoH/drugs/home situation/agenda
Physical Exam in Abdominal
Pain Presentations
 General appearance
 “Sick versus not sick”
 Mobile versus still

 Obvious pain or discomfort

 “Doorway” impression

 Vital signs
 “That’s why they’re called vital”
Physical Exam in Abdominal
Pain Presentations
 Inspection
 Distention, scars, bruises
 Auscultation
 Present, hyper, or absent
 Actually not that helpful!

 Palpation
 Often the most helpful part of exam
 Tenderness versus pain

 Start away from painful area first

 Guarding, rebound, masses

Physical Exam in Abdominal
Pain Presentations
 Signs
 Iliopsoas
 Murphy’s
 Extra-abdominal exam
 Pelvic or scrotal exams
 Lungs, heart
 Remember it’s a patient, not a part
 Rectal
 Adds very little (despite the angst) beyond
gross blood or melena
Laboratory Testing
 Everybody likes a CBC, but…

 Lacks sensitivity, no specificity

 Little to no change in diagnostic

probabilities
 Should not dramatically alter

approach (tender is still tender)

Laboratory Testing

 Directed approach to lab studies

 There are no “standard belly labs”
 Pregnancy test in women of child
bearing age
 Urine dipsticks
Imaging
 Plain films
 Free air, obstruction, air-fluid, FBs
 Ultrasound
 Rapid “yes or no” ED evaluations
 Formal studies

 May add doppler

 Computed Tomography
 Revolutionized acute care
 Often better than we are!
Common Diagnoses by Quadrant
Management of
Abdominal Pain
 Always right to start with ABC’s
 IV access
 Fluid administration
 Antiemetics
 Analgesics
 Directed testing and imaging
 Re-evaluations
 Antibiotics
 Consultants
 Surgeons, OB/GYN, urologists,
cardiologists, etc
Now How About Those Cases

 18 mo old had classic presentation

of intussusception, and symptoms
may wax and wane; rectal would
be to look for current jelly stool. Air
enema for diagnosis and reduction.
Involve consultants early in the
course.
Now How About Those Cases

 20 year old with classic

presentation of appendicitis, which
likely does not need CT scan. Most
do not present so simply, quite a
wide array of presentations.
General surgery consultation, pain
meds, IVF, and an operation would
all be good, but don’t be shocked if
CT requested.
Now How About Those Cases

 78 yo has perforated abdomen,

with age, multiple problems, and
chronic steroids risks for
perforation. Rapid resuscitation,
plain films to confirm free air,
antibiotics, pain medicine, and a
surgeon as fast as you can would
be good practice.
 Pearls, Pitfalls and Myths
 Do not restrict the diagnosis solely by
the location of the pain.
 Consider appendicitis in all patients
with abdominal pain and an appendix,
especially in patients with the presumed
diagnosis of gastroenteritis, PID or UTI.
 Do not use the presence or absence of
fever to distinguish between surgical
and medical causes of abdominal pain.
 The WBC count is of little clinical value
in the patient with possible appendicitis.
 Any woman with childbearing potential
and abdominal pain has an ectopic
pregnancy until her pregnancy test
comes back negative.
 Pain medications reduce pain and
suffering without compromising
diagnostic accuracy.
 An elderly patient with
abdominal pain has a high
likelihood of surgical disease.
 Obtain an ECG in elderly
patients and those with cardiac
risk factors presenting with
abdominal pain.
 A patient with appendicitis by
history and physical
examination does not need a
CT scan to confirm the
diagnosis; they need an
operation.
 The use of abdominal
ultrasound or CT may help
evaluate patients over the age
of 50 with unexplained
abdominal or flank pain for the
presence of AAA.
Simplified rules for the diagnosis of acute
abdominal pain.
 Think in terms of the area of the
pain.
 Common conditions are common.
 Disease prevalence changes with
age.
 Different patterns of disease
between men and women.