Abdominal pain

Question 1

What are differential causes for Right upper quadrant pain?

Answer 1

• Gallbladder disease (cholecystitis, cholanigitis etc.)
• Duodenal Ulcer
• Acute Pancreatitis

Medical disorders: pneumonia (referred pain)

Question 2

What are the differential causes for left upper quadrant pain?

Answer 2

• Acute Pancreatitis
• Spontaneous splenic rupture

Medical disorders: pneumonia

Question 3

What are the differential causes for right iliac fossa pain?

Answer 3

• Acute Appendicitis
• Perforated duodenal ulcer
• Crohn’s Disease
• Diverticulitis
• Constipation
• Renal Colic
• Obstetrics and Gynaecology: Ectopic pregnancy, ruptured ovarian cyst, salpingitis

Question 4

What are the differential causes for left iliac fossa pain?

Answer 4

• Diverticulitis
• Constipation
• Obstetrics and Gynaecology: Ectopic pregnancy, ruptured ovarian cyst, salpingitis

Question 5

What are the differential causes for epigastric pain?

Answer 5

• Peptic or duodenal ulcer

- Acute Pancreatitis

Question 6

What are the differential causes for umbilical/central pain?

Answer 6

• Early appendicitis (pain often starts in centre of abdomen before moving to right iliac fossa)
• Small bowel obstruction
• Acute pancreatitis
• Mesenteric thrombosis

Question 7

What are the differential causes for suprapubic pain?

Answer 7

• Acute Urinary retention
• Urinary Tract Infection
• Ectopic pregnancy

Question 8

What is an acute abdomen?

Answer 8

Someone who becomes acutely ill and in whom symptoms and signs are chiefly related to the abdomen has an ACUTE ABDOMEN.

Prompt laparotomy is sometimes essential.

Question 9

What investigations are used for an acute abdomen?

Answer 9

Depends on your clinical suspicion but usual tests are:

• Full blood count
• Biochemical profile – U&Es; Liver function tests
• CRP
• Serum Amylase
• Serum glucose
• Blood gas including lactate measurement
• Pregnancy Test in women (always!)
• Urine dipstick (haematuria in UTI)
• Erect Chest x-ray
• Supine abdominal film

If continuing suspicion of an acute abdomen a CT scan of abdomen usually performed prior to surgery.

Question 10

When is a laparotomy required in an ACUTE ABDOMEN?

Answer 10

1. Rupture of an organ (spleen, aorta, ectopic pregnancy)
   o Shock, abdominal swelling, recent trauma, peritonism (mild)
2. Peritonitis (perforation of peptic/duodenal ulcer, diverticulum, appendix, bowel or gallbladder)
   o Prostration, shock, lying still, positive cough test, tenderness (rebound/percussion pain), board-like abdominal rigidity, guarding, absent bowel sounds
   o Erect CXR = gas under the diaphragm (pneumoperitoneum)

Question 11

What else might cause an acute abdomen, but doesn’t necessarily need a laparotomy?

Answer 11

1. Local peritonitis caused by diverticulitis, cholecystitis, salpingitis, and appendicitis (will need surgery).
   o If abscess formation is suspected (swelling, fever, and increased WCC), do USS or CT.
   o Drainage can be percutaneous or by laparotomy.
2. Colic is a waking and waning pain, caused by muscular spasm in a hollow viscus e.g. gut, ureter, salpinx, ureter, bile duct or gallbladder.
   o Colic causes restlessness and the patient will be pacing around.

Question 12

What causes a ‘medically acute abdomen’?

Answer 12

Irritable bowel syndrome is the chief cause, so always ask about episodes of pain associated with loose stool, relived by defecation, bloating and urgency. Other causes
• Myocardial infarction
• Pneumonia, Tuberculosis, 
• Diabetes, DKA, 
• Pneumococcal peritonitis
• Malaria, typhoid fever, cholera, 
• Sickle cell crisis
• Pheochromocytoma