Abdominal pain

Question 1

“A 14-years-old male attends an Emergency Department with severe lower abdominal pain. He describes mild pain since completing Rugby training this evening but now presents having woken overnight with increased pain. On arrival to the ED he is now unable to walk due to pain in the lower abdomen.”

Imp/DDx/Goals

Answer 1

Impression:
moderate abdominal pain. History of rugby training may suggest some form of traumatic injury - need to consider/rule out red flag differentials including
- Ruptured viscus (appendicitis, etc)
- ischaemic bowel (volvulus)
- Testicular torsion/appendix testis
- Incarcerated hernia
- SBO/LBO
- if female --> Gynaecological causes (ovarian torsion, ectopic)

Goals

• identify underlying aetiology
• determine patient disposition
• initiate appropriate management in timely fashion

Question 2

Abdo pain - History

Answer 2

History:

• sx: SOCRATES, bowel change, urinary change
• HxPC: occurred previously
• risk factors: undescended testes, low fibre diet, previous abdo surgery
• PMHx, PSHx
• HEADSSSS

Question 3

Abdo pain - Examination

Answer 3

Examination:

• general appearance + vitals
• gastrointestinal examination
• external genitalia examination
• hernia exam (if indicated)

Take ABCDE approach if unstable/presents as unwell

Question 4

Abdo pain - Investigations

Answer 4

Investigations:

• Bedside: urinalysis, VBG (if unwell),
• Bloods: FBC, CRP/ESR, lactate, LFT, lipase, EUC, CMP, serum ketones, BSL, pre-operative bloods
• Imaging: Abdominal X-Ray (upright), Ultrasound, CT (generally not used to limit radiation exposure in young patient)

Question 5

Abdo pain - Management

Answer 5

Management:
Depends on underlying aetiology

1- Manage instability supportively:

• Fluids
• Analgesia
• ABx as bridge to surgery
• NBM
• Pre-operative bloods

2- Appropriately disposition patient (surgical, medical, discharge)

3-