This document provides an overview of evaluating and diagnosing acute abdominal pain. It begins with basic definitions of the abdomen and acute abdomen. The key to diagnosis is carefully characterizing the patient's pain by details of onset, duration, location, and character. A broad differential diagnosis should be considered including inflammation, obstruction, ischemia, or perforation. The physical exam and investigations vary depending on the pain location but may include blood tests, urinalysis, ultrasound and x-rays. Non-surgical and extra-abdominal causes are also reviewed. Immediate treatment focuses on resuscitation before determining the need for surgery or other procedures.

1. S. Mutale
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2. OVERVIEW
 BASIC DEFINITIONS
 CLINICAL DIAGNOSIS AND DIF DIAGNOSIS
i. CHARACTERISING THE PAIN
ii. OTHER HISTORY TO ELICIT
iii. WAYS TO REMEMBER SUCH A WIDE
DIFFERENTIAL
iv. PHYSICAL/LAB/IMAGING
v. NON SURGICAL CAUSES
vi. INITIAL MANAGEMENT
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3. BASIC DEFINITIONS
ABDOMEN:
THAT PART OF THE BODY LYING BETWEEN THE
THORAX AND THE PELVIS, AND CONTAINING
THE ABDOMINAL CAVITY AND THE VISCERA
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4. BASIC DEFINITIONS
 ACUTE ABDOMEN
1. AN ACUTE INTRA ABDOMINAL
CONDITION, OF ABRUPT ONSET,
USUALLY ASSOCIATED WITH PAIN
DUE TO INFLAMMATION,
PERFORATION, OBSTRUCTION,
INFARCTION, OR RUPTURE OF
ABDOMINAL ORGANS, AND USUALLY
REQUIRES EMERGENCY SURGICAL
INTERVENTION
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5. BASIC DEFINITION
CONT’D
ACUTE ABDOMEN
2. A RELATIVELY NON SPECIFIC SYMPTOM
COMPLEX , IN WHICH A PT IS FIRST SEEN IN A
TOXIC STATE, COMPLAINING OF
INCAPACITATING ABDOMINAL PAIN, VARIABLY
ACCOMPANIED BY FEVER AND LEUCOCYTOSIS
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6. GENERAL INFORMATION
 ACUTE ABDOMEN KNOWS NO AGE, TIME, OR
PLACE
 CANNOT BE PREVENTED OR PREDICTED!
 EVERY CLINICIAN MUST KNOW THE BASIC
PRINCIPLES IN EVALUATING AND MANAGEMENT OF
ACUTE ABDOMEN
 DELAYS IN DIAGNOSIS, AND APPROPRIATE
MANAGEMENT HAVE RESULTED INTO
CATASTROPHIC CONSEQUENCES
 AN ACUTE ABDOMEN REQUIRES IMMEDIATE
EVALUATION AND DIAGNOSIS BECAUSE IT MAY
INDICATE A CONDITION THAT CALLS FOR SURGICAL
INTERVENTION.
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9. BASIC PRINCIPLES
 PROPER EVALUATION AND MANAGEMENT
REQUIRES ONE TO RECOGNISE;
DOES THIS PATIENT NEED SURGICAL
INTERVENTION?
IS IT EMERGENT, URGENT, OR CAN IT WAIT?( IS
THE PATIENT UNSTABLE OR STABLE)
LEARN TO THINK IN “WORST CASE “ SCENARIO
BUT REMEMBER MEDICAL CAUSES OF
ABDOMINAL PAIN
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10. CONSULT IF IN DOUBT
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11. Good judgment comes from experience,
and a lot of that comes from bad
judgment.
Will Rodgers

12. ACUTE SEVERE OR DEBILITATING ABDOMINAL PAIN
MUST NOT BE JOKED WITH!!
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13. CLINICAL DIAGNOSIS
CHARACTERISING THE PAIN IS
THE KEY
INFORMATION ABOUT THE ONSET,
DURATION, CHARACTER,
LOCATION, AND SYMPTOMS
ASSOCIATED WITH THE PAIN IS
CRITICAL IN MAKING AN
ACCURATE DIAGNOSIS.
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14. CHARACTERISING THE PAIN
ONSET(WHERE WAS IT FIRST
FELT?)
1. GRADUALLY INCREASING IN INTENSITY
2. ABRUPT AND SHARP
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15. CHARACTERISING THE PAIN
DURATION
HOW LONG THE PAIN HAS BEEN EXPERIENCED.
THIS MIGHT ALSO GIVE A CLUE TO SOME
COMPLICATIONS AND THE NEED FOR URGENT
INTERVENTION.
CONVERSELY, IT MIGHT ALSO RULE OUT THE
POSSIBILITY OF A SURGICAL ACUTE ABDOMEN!
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16. CHARACTERISING THE PAIN
LOCATION
ALTHOUGH THE THE PATIENT’S REPORT OF
THE LOCATION IS SOMETIMES MISLEADING
BECAUSE OF REFFERAL, RADIATION, OR
REFLECTION OF PAIN, IT MAY SERVE TO
IDENTIFY A SPECIFIC ORGAN OR SYSTEM
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17. CHARACTERISING THE PAIN
CHARACTER
1. WHAT DECREASES OR
INCREASES THE PAIN
2. CONSTANT
3. INTERMITTENT
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18. OTHER HISTORY
 GI symptoms
 Nausea, emesis (?
bilious or bloody)
 Constipation, (last BM or
flatus)
 Diarrhea (? bloody)
 Both Nausea/Diarrhea
present usu. medical
 Change in sx w eating?
 NSAID use (perf DU)
 Jaundice, acholic
stools, dark urine
 Drinking history
(pancreas)
 Prior surgeries
(adhesions → SBO, ?still
have gallbladder &
appendix)
 History of hernias
 Urine output
(dehydrated)
 Constituational Sx
 Fevers/chills
 Sexual history
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19. PHYSICAL EXAMINATION
 APPEARANCE AND POSITION OF PATIENT
 VITAL SIGNS
 APPEARANCE OF ABDOMEN
 DISTENTION
 HERNIA
 SCARS
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20. PHYSICAL EXAMINATION
 Tenderness
 Rigidity
 Masses
 Bowel sounds
 Rectal and Pelvic Examination
 Careful exam of heart, lungs and skin
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21. Physical Examination: The
Quadrants
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22. Clinical Diagnosis
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23. THINK BROAD CATEGORIES
FOR DDX
 Inflammation
 Obstruction
 Ischemia
 Perforation (any of above can end here)
 Offended organ becomes distended
 Lymphatic/venous obstrux due to ↑pressure
 Arterial pressure exceeded → ischemia
 Prolonged ischemia → perforation
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24. Differential Diagnosis: RUQ
Pain
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25. DIAGNOSIS; RIGHT UPPER
QUADRANT PAIN
INVESTIGATIONS
 X RAY
a. UPRIGHT CHEST
b. UPRIGHT AND SUPINE ABDOMINAL
 COMPLETE BLOOD COUNT
 URINALYSIS
 AMYLASE, CREATININE, BUN, ELECTROLYTES
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26. DDx: LUQ AND EPIGASTRIC
PAIN
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27. Differential Diagnosis: LUQ Pain
INVESTIGATIONS
 UPRIGHT CHEST XR
 UPRIGHT AND SUPINE ABDOMINAL XR
 CBC
 AMYLASE AND LIPASE (IF AVAILABLE)
 ULTRASOUND
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28. Differential Diagnosis: RLQ Pain
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29. Diagnosis: Right Lower
Quadrant (RLQ) Pain
INVESTIGATIONS
 URINALYSIS (TO EXCLUDE OBVIOUS URINARY
CAUSES)
 PREGNANCY TEST
 ULTRASOUND
 COMPLETE BLOOD COUNT
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30. Gynecologic Causes of RLQ
Pain
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31. Diagnosis: Left Lower Quadrant
(LLQ) Pain
 PREGNANCY TEST
 URINALYSIS TO EXCLUDE UNSUSPECTED
URINARY SOURCE
 ULTRASOUND
 COMPLETE BLOOD COUNT
 UPRIGHT AND SUPINE ABDOMINAL XR
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32. Differential Diagnosis: LLQ Pain
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33. Differential Diagnosis:
Periumbilical Pain
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34. Diagnosis: Periumbilical Pain
INVESTIGATIONS
 CBC
 Amylase and lipase, if available
 If severe, unrelenting pain, urgent surgical referral
 If pain colicky and no flatus, erect and supine
ABDOMINAL XR
 If diarrhea and vomiting, stool tests
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35. Extra-Abdominal Causes of the
Acute Abdomen
SUPRADIAPHRAGMATIC
 Myocardial infarction
 Pericarditis
 Left lower lobe pneumonia
 Pneumothorax
 Pulmonary infarction
HEMATOLOGIC
 Sickle cell disease
 Acute leukemia
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36. EXTRA-ABDOMINAL CAUSES OF
THE ACUTE ABDOMEN
 DRUGS
 HERPES ZOSTER
 TABES DORSALIS
 NERVE ROOT COMPRESSION
 DIABETIC KETOACIDOSIS
 ADDISONIAN CRISIS
 URAEMIA
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37. IMMEDIATE TREATMENT FOR ACUTE
ABDOMEN
 1. Start large bore IV with either saline or lactated
Ringer’s
 solution
 2. IV pain medication?
 3. Nasogastric tube if vomiting or concerned about
obstruction
 4. Foley catheter to follow hydration status and to obtain
 urinalysis
 5. Antibiotic administration if suspicious of inflammation
or
 perforation
 6. Definitive therapy or procedure will vary with diagnosis
 Remember to reassess patient on a regular basis.
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38. Take Home Points
 Careful history (pain, other GI symptoms)
 Remember DDx in broad categories
 Narrow DDx based on hx, exam, labs, imaging
 Always perform ABC, Resuscitate before Dx
 If patient’s sick or “toxic”, get to OR (surgical emergency)
 Ideally, resuscitate patients before going to the OR
 Don’t forget GYN/medical causes, special situations
 For acute abdomen, think of these commonly (below)
Perf DU Appendicitis
+/- perforation
Diverticulitis
+/- perforation
Bowel
obstruction
Cholecystitis Ischemic or
perf bowel
Ruptured
aneurysm
Acute
pancreatitis
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