This is a guide for undergraduate students on how to approach a patient who presents with pain abdomen.

1. Approach to pain abdomen
Dr. Ankita Singh
Assistant Professor

2. Objectives
• Characteristics of pain
• Pain abdomen
– Acute vs. chronic
• Localization
– Differential diagnosis
– Diagnosis & Management

3. PAIN : on history
• Time of onset
• Mode of onset
• Duration
• Site- Shifting/ Radiating/ Referred
• Character
– Colicky/ Burning/ Agonizing/ Throbbing /Aching
– Change in character- position/ pressure/ food/
worse/ relief

4. PAIN : on history
• Association with
– Vomiting/ change in bowel habit/ jaundice/
micturition etc.
– Change in appetite/weight
– Constitutional symptoms
• Menstrual history
• Past history
– H/O recurrent attacks/ previous surgery

5. PAIN : on examination
• General appearance & vitals
– Abdominal facies/ Facies Hippocratica/ facies of
dehydration/ pale/ bluish discoloration/ jaundice/
gasping for air
– temperature
• Attitude/ decubitus
• Per abdominal examination on inspection
– Contour of abdomen
– Respiratory movements/ peristalsis/pulsations
– Signs of inflammation/ infection/ bleeding

6. PAIN : on examination
• Per abdominal examination on palpation:
– Hyperasthesia- e.g. Boas sign, Sherren’s triangle
– Tenderness- Pointing Test
• Murphy’s sign
• Mc Burney’s tenderness & appendicular tenderness
• Bapat/ bed shaking test
*Spread of tenderness
*Differentiation from Thoracic disease

7. PAIN : on examination
• Per abdominal examination on palpation:
– Rebound Tenderness
• AKA Blumberg’s/ Release sign
• Rovsing’s sign
• Cope’s Psoas Test
– Any associated
• muscular rigidity vs. guarding
• Distension
• Lump/ hernial sites

8. Acute vs. Chronic pain abdomen
• 'Acute abdomen' means
– the patient complains of an acute attack of
abdominal pain
– that may occur suddenly or gradually over a
period of several hours and
– presents a symptom complex which suggests a
disease that possibly threatens life and demands
an immediate or urgent diagnosis for early
treatment

9. Differentials: Acute Abdomen
• Extra-abdominal causes:
– Parietal wall- superficial cellulitis of the abdominal wall,
gas gangrene of the abdominal wall, abscess of the
abdominal wall, rupture of rectus abdominis muscle
– Thoracic conditions- diaphragmatic pleurisy, lobar
pneumonia, spontaneous pneumothorax, pericarditis,
angina pectoris, coronary thrombosis etc.
– Retro-peritoneal conditions- uremia, pyelitis, Dietl's
crisis, retroperitoneal lymphangitis and lymphadenitis,
leaking aneurysm of the aorta, dissecting aneurysm of the
aorta etc.

10. Differentials: Acute Abdomen
• Extra-abdominal causes:
– Diseases of the spine, spinal cord and intercostal
nerves- Pott's disease, acute osteomyelitis of lower dorsal
or lumbar vertebrae, gastric crisis in Tabes Dorsalis, herpes
zoster of lower intercostal nerves and intercostal neuralgia.
– General diseases- malaria, typhoid fever, porphyria,
diabetic crisis, sickle cell anaemia, haemophilia, purpura,
small pox, etc.

11. Differentials: Acute Abdomen
• Intra-abdominal causes:
– Inflammation- acute appendicitis, acute cholecystitis, acute
pancreatitis, acute diverticulitis, acute ulcerative colitis, acute
regional ileitis, acute salpingitis, acute pneumococcal peritonitis,
acute non-specific mesenteric lymphadenitis, amoebic liver
abscess, subdiaphragmatic abscess.
– Perforation of- peptic ulcer, typhoid ulcer, diverticular disease,
ulcerative colitis etc.
– Acute intestinal obstruction- mechanical/toxic/neurogenic/
vascular
– Haemorrhage- rupture of ectopic gestation, ruptured Lutein
cyst, spontaneous rupture of malarial spleen, Rupture or leaking
aortic aneurysm, aortic dissecting aneurysm.

12. Differentials: Acute Abdomen
• Intra-abdominal causes:
– Torsion of pedicle- twisted ovarian cyst, spleen
– Colics- (i) biliary, (ii) ureteric, (iii) appendicular and (iv)
intestinal

13. Differentials: Acute Abdomen
• The common causes in
– Children:
• Acute appendicitis; Intussusception; Intestinal
obstruction by round worms, congenital band or by
bands including Meckel's diverticula; Acute nonspecific
mcsenteric lymphadenitis; Meckel's diverticulitis;
Primary peritonitis.
– Females:
• Ruptured ectopic gestation; Ruptured lutein cyst;
Twisted ovarian cyst; Acute salpingitis; Tubo-ovarian
abscess; Torsion or degeneration of a uterine fibroid.

14. Differentials: Chronic Abdomen
• Peptic ulcers
– Gastric vs. duodenal ulcer
• Pyloric stenosis
• Carcinoma stomach
• Hiatus hernia
• Chronic cholecystitis & cholelithiasis
• CBD stones
• Chronic pancreatitis
• Carcinoma pancreas

15. Differentials: Chronic Abdomen
• Chronic appendicitis
• Crohn’s Disease
• Abdominal tuberculosis
– Intestinal, mesentric
• Diverticulitis
• Hirschsprung’s disease/ primary megacolon
• Ulcerative colitis
• Ischemic colitis
• Carcinoma colon

24. Thank you