INTRODUCTION Abdominal pain refers to discomfort that is felt between the chest and the groin.,which can be acute or chronic on presentation. Categorised into 4 quadrant and 9 regions for analysis of underlying pathologies and their localization ,patient may also present with ;-Bloating, N/V, diarrhea or constipation, fever, visible swelling or tenderness. It Can occur due to Gastrointestinal pathologies like peptic ulcer ,appendicitis, obstructions, cholecystitis etc or gynecologycal, vascular, peritoneal pathologies EPIDEMIOLOGY 5 – 10% of all ED visits. Among them, 14 – 40 % patients need surgical intervention Most common diagnosis is Non specific Males were more affected than females with male to female ratio of 1.14 : 1 Highest number of patients were in 15 – 24 years of life Most common cause found to be acute appendicitis for acute abdomen in a range of 57.5 % of total admission. CAUSES Gastrointestinal Gastrointestinal Gastroduodenal Peptic ulcer Gastritis Malignancy Gastric volvulus Intestinal Appendicitis Obstruction Inverticulitis Gastroenteritis Mesentric adenitis Strangulated hernia Inflammatory bowel disease Intussusception Volvulus TB Case History of Present Illness A 26-year-old woman comes to the office because of a 3-day history of lower abdominal pain. She is 18 weeks pregnant by dates. The patient describes the pain as sharp, steady, and radiating across her lower abdomen bilaterally. Last night she developed new nausea and vomiting. She has not been able to keep down any food or drink this morning. She had a normal bowel movement yesterday. She says she felt cold and shivering this morning, followed by feeling warm; however, she did not check her temperature. She denies vaginal bleeding. General: Patient feels generally weak and ill but was in her usual state of health until 3 days ago. She has gained approximately 5 lbs (2.3 kg) in the pregnancy so far. Skin: She denies rash. HEENT: Her mouth feels dry. No headache, nasal congestion, or sore throat.  Pulmonary: She denies cough or shortness of breath. Cardiovascular: She denies chest pain or palpitations. Gastrointestinal: She has had a decreased appetite for 1 day and has been unable to keep any food or drink down this morning due to nausea and vomiting. She has not had diarrhea or constipation.  Genitourinary: She reports a frequent urge to urinate and a sensation of incomplete bladder emptying for the past 3 days. No dysuria or hematuria. She is G1P0A0 and has been seeing an obstetrician for all routine visits and testing. No vaginal bleeding.  Musculoskeletal: She reports mild diffuse low back pain. No generalized muscle aches. Neurologic: Noncontributory Past Medical History Medical history: Mild intermittent asthma diagnosed in childhood requiring only occasional rescue inhaler use, no hospitalizations for asthma. She is otherwise healthy.  Surgical history: Wisdom teeth removed at age 18. Medications: Albuterol inhaler as needed, about once a month.

1. ABDOMINAL PAIN
BRINCELET M BIJU

2. INTRODUCTION
❑ Abdominal painrefers to discomfortthatis felt between the chest and the
groin.,which can be acute or chronic on presentation.
❑ Categorised into 4 quadrant and 9 regionsfor analysis of underlying pathologies and their
localization ,patient may also present with ;-Bloating, N/V, diarrhea or constipation, fever,
visible swelling or tenderness.
❑ It Can occur due to Gastrointestinal pathologies like peptic ulcer ,appendicitis, obstructions,
cholecystitis etc or gynecologycal, vascular, peritoneal pathologies

3. EPIDEMIOLOGY
❑ 5 – 10% of all ED visits.
❑ Among them, 14 – 40 % patients need surgical intervention
❑ Most common diagnosis is Non specific
❑ Males were more affected than females with male to female ratio of 1.14 : 1
❑ Highest number of patients were in 15 – 24 years of life
❑ Most common cause found to be acute appendicitis for acute abdomen in a
range of 57.5 % of total admission.

4. Gastrointestinal
Gastroduodenal
Peptic ulcer
Gastritis
Malignancy
Gastric volvulus
Intestinal
Appendicitis
Obstruction
Inverticulitis
Gastroenteritis
Mesentric adenitis
Strangulated hernia
Inflammatory bowel disease
Intussusception
Volvulus
TB
Hepatobiliary
Acute cholecystitis
Chronic cholecystitis
Cholangitis
Hepatitis
Pancreatic
Acute pancreatitis
Chronic pancreatitis
Malignancy
Splenic
Infarction
Spontaneous rupture
Urinary tract
Cystitis
Acute retention of urine
Acute pyelonephritis
Ureteric colic
Hydronephrosis
Tumour
Pyonephrosis
Polycystic kidney
Gynaecological
Ruptured ectopic pregnancy
Torsion of ovarian cyst
Ruptured ovarian cyst
Salpingitis
Severe dysmenorrhea
Mittelschmerz
Endometriosis
Red degeneration of a fibroid
CAUSES
A Common cause of the symptom or sign
Will only rarely cause the symptom or sign Might occasionally give rise to the symptom or sign

5. Vascular
Aortic aneurysm
Mesenteric embolus
Mesenteric angina
Mesenteric venous thrombosis
Ischaemic colitis
Acute aortic dissection
Peritoneum
Secondary peritonitis
Primary peritonitis
Abdominal wall
Strangulated hernia
Rectus sheath haematoma
Cellulites
Retroperitoneum
Retroperitoneal hemorrhage eg:- anticoagulants
Referred pain
Myocardial infarction
Pericarditis
Testicular torsion
Pleurisy
Herpes zoster
Lobar pneumonia
Thoracic spine disease eg.:- disc, tumour
Medical causes
Hypercalcemia
Uraemia
Diabetic ketoacidosis
Sickle cell disease
Addison’s disease
Acute intermittent prophyria
Henoch – schönlein purpura
Tabes dorsalis

9. CASE
❑ History of Present Illness
➢ A 26-year-old woman comes to the office because of a 3-day history of lower
abdominal pain. She is 18 weeks pregnant by dates. The patient describes the
pain as sharp, steady, and radiating across her lower abdomen bilaterally. Last
night she developed new nausea and vomiting. She has not been able to keep
down any food or drink this morning. She had a normal bowel movement
yesterday. She says she felt cold and shivering this morning, followed by feeling
warm; however, she did not check her temperature. She denies vaginal
bleeding.

10. ➢ General: Patient feels generally weak and ill but was in her usual state of health until 3
days ago. She has gained approximately 5 lbs (2.3 kg) in the pregnancy so far.
➢ Skin: She denies rash.
➢ HEENT: Her mouth feels dry. No headache, nasal congestion, or sore throat.
➢ Pulmonary: She denies cough or shortness of breath.
➢ Cardiovascular: She denies chest pain or palpitations.
➢ Gastrointestinal: She has had a decreased appetite for 1 day and has been unable to
keep any food or drink down this morning due to nausea and vomiting. She has not had
diarrhea or constipation.
➢ Genitourinary: She reports a frequent urge to urinate and a sensation of incomplete
bladder emptying for the past 3 days. No dysuria or hematuria. She is G1P0A0 and has been
seeing an obstetrician for all routine visits and testing. No vaginal bleeding.
➢ Musculoskeletal: She reports mild diffuse low back pain. No generalized muscle aches.
➢ Neurologic: Noncontributory

11. ❑ Past Medical History
➢ Medical history: Mild intermittent asthma diagnosed in childhood requiring only
occasional rescue inhaler use, no hospitalizations for asthma. She is otherwise healthy.
➢ Surgical history: Wisdom teeth removed at age 18.
➢ Medications: Albuterol inhaler as needed, about once a month. Daily prenatal vitamin.
➢ Allergies: No known drug allergies.
➢ Family history: Mother is healthy at age 50. Father is 53 years old with high blood
pressure.
➢ Social history: Patient is employed as an engineer. She exercises 3 days/week. She
drinks 2 glasses of wine per week but stopped when she found out she was pregnant.
She does not smoke or use any illicit drugs. She has not had any recent travel. She is
monogamous with 1 male partner.

12. ❑ Physical Examination
➢ General appearance: Well-developed female, appears tired and ill but in no apparent
distress.
➢ Vital signs:
✓ Temperature: 38.8° C
✓ Pulse: 120 beats/minute
✓ BP: 110/76 mm Hg
✓ Respirations: 20/minute
➢ Skin: Hot, diaphoretic. No rash or cyanosis.
➢ HEENT: Dry mucous membranes, no scleral icterus or conjunctival injection, neck is supple,
no adenopathy.
➢ Pulmonary: Breath sounds are equal bilaterally with good air movement in all fields. There
are faint inspiratory crackles present on the left side heard more at the base. No wheezing.
➢ Cardiovascular: Mild tachycardia with regular rhythm; no murmurs, rubs, or gallop. No
peripheral edema.

13. ➢ Gastrointestinal: Bowel sounds normal. Abdomen soft, diffusely tender across
the lower abdomen bilaterally with no guarding, rigidity, or rebound. No
tenderness in the upper quadrants, gravid, non-tender uterus 2 cm below the
level of the umbilicus. No inguinal or femoral hernias. Rectal examination non-
tender, stool brown, heme negative.
➢ Genitourinary: Normal external genitalia, no cervical motion tenderness, scant
thin white discharge from the cervical os, which appears closed. Fetal heartbeat
regular at 150 beats/minute.
➢ Musculoskeletal: No swelling, tenderness or deformity of joints or extremities.
Positive costovertebral angle tenderness bilaterally.
➢ Neurologic: Unremarkable
➢ Mental status: Alert and oriented, with fluent and coherent speech.

14. ❑ Essential list of Differential Diagnosis
➢ At this time, which of the following differential diagnoses cannot be excluded?
And would you like to add more to the list??
✓ Appendicitis
✓ Diverticulitis
✓ Ectopic pregnancy
✓ Irritable bowel syndrome
✓ Pelvic inflammatory disease (PID)
✓ Placental abruption
✓ Pyelonephritis
✓ Sepsis
✓ Septic abortion
✓ Ulcerative colitis
✓ Viral syndrome
✓ Zika virus infection

15. ➢ Appendicitis-Appendicitis may cause lower abdominal pain, nausea, and vomiting.
➢ Diverticulitis-Diverticulitis is uncommon in this age group.
➢ Ectopic pregnancy-Although ectopic pregnancy very rarely can accompany an intrauterine pregnancy, it
should manifest well before 18 weeks gestation.
➢ Irritable bowel syndrome-Irritable bowel syndrome would not cause fever and vomiting.
➢ Pelvic inflammatory disease (PID)-Although uncommon, PID may occur during pregnancy and cause
significant morbidity.
➢ Placental abruption -Placental abruption is not likely since this patient has no bleeding and her uterus is not
tender.
➢ Pyelonephritis -Pyelonephritis can cause fever and urinary frequency.
➢ Sepsis-Patient has significant fever, tachycardia, and systemic symptoms, and she should be evaluated for
sepsis.
➢ Septic abortion-Although patient has signs of possible infection, she has not passed fetal tissue and fetal
heart tones are present.
➢ Ulcerative colitis -There is no diarrhea or bloody stool that would suggest ulcerative colitis.
➢ Viral syndrome -Numerous viral infections can cause fever, malaise, vomiting, and abdominal discomfort.
➢ Zika virus infection-This patient has no headache, muscle aches, or conjunctivitis, and abdominal pain is not
a prominent feature of Zika virus infection.

16. ❑ Relevant Testing
➢ the most appropriate initial diagnostic studies?
➢ Basic metabolic profile (BMP)
➢ Blood culture
➢ Complete blood count (CBC)
➢ STD testing
➢ Ultrasonography of the kidney and bladder
➢ Urinalysis and culture

17. ➢ Blood
Test Result Results (SI Units)
Hemoglobin 12.5 g/dL 125 g/L
WBC count 17.0 x 103/µL 17.0 X 109/L
Plateletcount 150 x 103/µL 150 X 109/L
Test Result Results (SI Units)
Sodium 137 mEq/L 137 mmol/L
Potassium 3.9 mEq/L 3.9 mmol/L
Creatinine 0.7 mg/dL 62 micromol/L
Glucose 78 mg/dL 4.3 mmol/L
BUN 23 mg/dL 8.2 mmol/L
➢ Ultrasonography:
Renal/bladder ultrasound: No hydronephrosis noted. Incidentally noted intrauterine fetus
with heartbeat of 156 beats/minute.
➢ Basic metabolic profile:
Normal
11.0 – 15.0g/dL
4500 – 11000 /µL
150000 – 400000/µL
Normal range
135-145mEq/L
3.5-5.0mEq/L
0.6 – 1.1 mg/dL
Less than 100 mg/dL
7-20 mg/dL

18. ➢ Urine:
Test Result Results (SI Units)
Hemoglobin 12.5 g/dL 125 g/L
WBC count 17.0 x 103/µL 17.0 X 109/L
Plateletcount 150 x 103/µL 150 X 109/L
Test Result Results (SI Units)
Sodium 137 mEq/L 137 mmol/L
Potassium 3.9 mEq/L 3.9 mmol/L
Creatinine 0.7 mg/dL 62 micromol/L
Glucose 78 mg/dL 4.3 mmol/L
BUN 23 mg/dL 8.2 mmol/L
Test Result
Leukocyte esterase Positive
Ketones Positive
Bacteria Numerous
WBCs 30-50 per high power field
Nitrites Positive
Protein Negative
STD panel
Urine
gonorrhea/chlamydia/trichomoniasis
negative

19. ❑ Diagnosis
❖ At this time, which of the following is a correct diagnosis for this patient?
➢ Acute Pyelonephritis
➢ Appendicitis
➢ Cystitis
➢ Nephrolithiasis
➢ Sepsis

20. ❑ Acute Pyelonephritis - This is a likely diagnosis.
➢ Patient has systemic manifestations including costovertebral tenderness
accompanied by indications of infection in the urine.
❑ Appendicitis-This is not a likely diagnosis.
➢ Although patients with appendicitis sometimes have moderate pyuria, the patient's
clinical picture is not consistent with appendicitis.
❑ Cystitis -This is not a likely diagnosis.
➢ Although the urine has signs of infection, the presence of significant systemic signs
plus costovertebral tenderness makes the diagnosis pyelonephritis and not just
cystitis.
❑ Nephrolithiasis -This is not a likely diagnosis.
➢ Although an obstructing stone increases risk of urinary infection, this patient's
symptoms are not consistent with a stone and there is no hydronephrosis or stone
detected on ultrasonography.
❑ Sepsis -This is a likely diagnosis.
➢ Patient appears ill and has fever, tachycardia, tachypnea, an elevated WBC count,
and an apparent source of infection.

21. ❑Treatment Orders
➢ Admit to the medical floor.Systemic bacterial infection is a threat to the pregnancy. This
patient needs IV antibiotics and fluids until her infection is controlled and she is able to
tolerate oral fluids and drugs.
➢ IV 0.9% saline 500 mL bolus.The patient needs IV fluids beyond the maintenance rate.
➢ Ceftriaxone 1 gm IV once a day-.A broad-spectrum cephalosporin is an acceptable initial
treatment of pyelonephritis and possible sepsis during pregnancy. Cefazolin and cefepime are
also acceptable antibiotics.