AN APPROACH TO ABDOMINAL

PAIN
Dr. Matthew Smith
Emergency Specialist

 Types of pain
Special Populations
Assessment

History
Examination
Investigations
Differential Diagnosis

Management - overview
Cases ( if time permits)

Types Of Pain
Visceral
Parietal Pain

Visceral Pain
Stretching of nerve
fibres of walls or
capsules of organs
Crampy
Dull

Achy

Often unable to lie still

Bilateral innervation

Parietal Pain
Parietal peritoneum irritated
Usually anterior abdominal wall
Localised to the dermatome superficial to the

site of painful stimulus

Course

Non specific

Visceral

Parietal

Localised tenderness
Guarding
Rigidity
Rebound

Referred Pain
Examples of referred pain?

Special Populations

Elderly
May lack physical findings despite having serious

pathology
As patients age increases diagnostic accuracy
declines
Risk of Vascular Catastrophes
Assume surgical cause until proven otherwise
30-40% of geris with abdo pain need surgery
Biliary tract Disease is the commonest cause
Age > 65 need to think of reasons not to CT!
Mortality is 7% in the over 80s - equivalent to AMI!

Elderly Patient think

Nasties!
AAA
Ischaemic Gut
Bowel Obstruction

Diverticulitis
Perforated Peptic
Ulcer

Cholecystitis
Appendicitis

Women of Childbearing Age

Must Ascertain whether PREGNANT
ALL WOMEN OF CHILDBEARING AGE WITH

ABDO PAIN NEED BHCG

Gravid uterus displaces intra-abdominal
organs making presentations atypical
Pregnant women still get common surgical
abdominal conditions

History
What are the key points of the abdominal

pain history?

History
HPC
Pain

Provocative
Palliative
Quality
Radiation
Symptoms associated with
Timing
Taken for the pain

Consultations/

Presentations

Associated Symptoms
Gastro intestinal
Genito-urinary
Gynaecologic

History
PMH

DM
HT
Liver Disease
Renal Disease
Sexually Transmitted Infections

PSH
Abdominal Surgery
Pregnancies
Deliveries/ Abortions/ Ectopics
Trauma

History
Meds
NSAIDs
Steroids
OCP/ Fertility Drugs
Narcotics
Immunosuppressants
Chemotherapy agent
ALLS
Contrast
Analgesic

High Yield Questions

Which came first pain or vomiting?
How long have you had the pain?
Constant or intermittent?
History of cancer, diverticulosis, gall

stones,Inflammatory BD?
Vascular history, HT, heart disease or AF?

Examination
Lots of information from the end of the bed
Distressed vs. non distressed
Lying still - peritonitis

Writhing Renal Colic

Vital Signs
NEVER ignore abnormal vital signs!

Always document as part of your assessment

Investigations
Bedside
UA
Blood?
Leucocyte Esterase and nitrites
Urine HCG
ECG anyone with upper abdominal pain or elderly

Bloods
ALL WOMEN OF CHILDBEARING AGE NEED BHCG
What are your differentials?
Avoid machine gun approach!

Radiology
CXR ?perforation
?Extra abdominal pathology
?Complications of intra-abdominal disease

Which of the following is NOT an indication for

plain abdominal imaging?
1. Bowel Obstruction
2. Constipation
3. Tracking Renal Calculi
4. Foreign Body

Other imaging
USS

Biliary Disease
Good for gynae complaints
Rule out Ectopic pregnancy
Appendicitis in children
No radiation

 CT is accurate for
diagnosis of

Renal colic
Appendicitis
Diverticulitis
AAA
Intraabdominal
Abscesses
Mesenteric Ischaemia
Bowel Obstruction

Avoid repeated CT
scans
Limit use in younger
patients
Avoid where possible in
pregnant females

Imaging

Dose (mSV)

CXR equivalents

Pelvic XR

0.6

Abdominal XR

0.7

CT abdo-pelvis

14

140

CT aortogram

24

240

Management
Resuscitate

Large bore access

N Saline bolus 20ml/kg x 2 if shocked
If bleeding think hypotensive resuscitation
All should be NBM until provisional diagnosis
Ensure normothermia

Maintenance fluids and fluid balance

Analgesia doesnt mask signs

Use a the pain scale

Morphine titrated to pain. Normally 0.1mg/Kg
Paracetamol adjunct
NSAIDs for renal colic

Correct Electrolytes
Thromboprophylaxis

Cases

Case 1
21 year old female
24 hour history of vague peri-umbilical
abdominal pain.
Moved down to the RIF.
Now constant and sharp.
Associated with 2x vomits and feels flushed
No appetite
Normal Bowels

What clinical signs may lead you to a

diagnosis of appendicitis?

Lie still
RIF tenderness
Rebound
Rovsigs sign
Psoas Sign

Imaging?

AXR rarely useful

USS
Not as good as CT
Good for female to exclude gynae pathology
If appendix is visualised is useful

CT

Only if there is doubt about diagnosis

Sensitivity up to 98%
High radiation dose
Diagnose other pathology if no appendicitis
Elderley

Management
NBM
Analgesia
Anti-emetic if necessary
Maintenance fluids
IVABs e.g. Ceftriaxone, Gentamicin and
Metronidazole
Surgical Referral

Case 2

40 yr old obese female

RUQ pain
Pain is constant
nausea, vomiting
fevers and chills

PMH Asthma
MEDS OCP
SH
Drinks 2 std / week
Smokes 20/day
Nil drugs

On Examination

Looks distressed.
Not jaundiced
T 38 C
P 120
BP 100/60
RR 20
Sats 98% RA
Tender in the RUQ and
Murphys positive.

What bloods will you order

on this patient?

 HB 138

EUC Normal

WCC 16.0

Bil 9

Neuts 12.4

Lymph 1.6

(<18)
ALP 450 (30-130)
GGT 320 (<60)
ALT 41 (5-55)
AST 30 (5-55)
Amylase 28 (<120)
Lipase 40 (<60)

Management

NBM
IVF
IV abs Ampicillin + Gentamicin
Analgesia +- anti emetic
Refer to surgeons

Case 3

52 yr old alcoholic
Constant epigastric pain radiating to the
back. Worsening over the past 2 days
Improved with sitting up and forwards
Nausea and vomiting
Bowels OK

PMH Chronic Airways Limitation

Alcoholic Gastritis
MEDS Thiamine 100 mg daily
SH Boarding house resident
Drinks 4 litres wine/day
Smokes 20/day

 Looks unwell and

dehydrated
T38.4C

P105
BP 130/70
RR 18

Sats 93% RA

 Reduced AE L base
Tender

Epigastrium and
RUQ
No guarding/
rebound

What blood tests will you

order?

Blood Results

Biochem
Na 129
K 4.0
Cr 62
Ur 8.0

Amylase 1080 (<120)

Lipase 950 (<60)

Bil 11 ( 18)
GGT 900 (<60)
ALP 200 ( < 140)
AST 300 (5-55)
ALT 250 (5-55)
LDH 800( 105-333)

Glucose 15
Alb 23
Ca (Corr) 2.0

Haem
HB 114
WCC 17
Coags Normal

What imaging will you perform

( if any)?

CXR

Imaging
CT

Confirms diagnosis
Identifies complications
Helps grade severity
Not always necessary in ED

USS
Poor visualisation of

pancreas
Good for looking at gall
stones/ biliary tree
dilatation

CXR
Look for complications
Pleural Effusion,

Atelectasis, ARDS

Management

O2
NBM
IVF
Analgesia
+-Antibiotics (controversial)
Correct Electrolytes
Thromboprophylaxis
IDC/Art-line/CVC depending on severity
Surgical Admit +_ ICU review

Causes

G all stones
E toh
T rauma
S teroids
M umps
A utoimmune
S corpion Bites
H yperlidaemia/hypercalcaemia/hypothermia
E RCP
D rugs

Case 4

27 yr old female
6/40
LIF constant severe sharp pain
Radiating to the back
Light bright red PV spotting
Feels light headed

PMH

IVF
Previous D+C x 2
Ovarian Cysts

MEDS Nil

SH Lives with partner

Non-smoker
Non-Drinker

On Examination

Looks unwell. Pale, diaphoretic, restless

P 150
BP 70/40
RR 26 Sats
98% RA
Tender and guarding in the LIF
PV
Bright red blood spotting
L adnexal tenderness ++

How do you manage this

patient?
Panic! ( dont!)
Call for senior help
Large bore IV access x 2 (16 G or larger)
Urgent Cross Match
Fluid resuscitation
Call O+G urgently
Needs OT immediately

Case 5

88 yr old female.
Peri-umbilical, colicky abdominal pain for 2 days
Abdominal distension
Vomits x 10
Reduced flatus and NOB for 2 days.
PMH

Cholecystectomy
appendectomy
TAH BSO
Hypertension

On examination

Looks distressed
Lying Still
T 37.5
P 110 sinus
BP 150/80
RR 18
Sats 98% RA
Abdomen

Distended
Generally tender
No guarding rebound or rigidity
High pitched bowel sounds

Investigations

Investigations
EUC/CMP/FBP
AXR
CXR
CT

Management
NBM
Fluid resuscitation
Monitor volume status may have large volume
shifts
Correct Electrolytes
Analgesia
NG if vomiting
IV Abs Amp+Gent+Met
Urgent Surgical consult for OT

Small Bowel
Adhesions
Hernias
Polyps

Lymphoma
Adenocarcinoma
Gall Stones

Inflammatory BD

Large Bowel
Almost never
adhesions or hernia
CARCINOMA

Diverticulitis
Sigmoid Volvulus
Faecal Impaction

Case 6
73 yr old male presents with sudden onset of central abdominal

pain radiating to the back. He also reports weakness to both legs

PMH

HT
Hypercholesterolemia
Current smoker 30/day

MEDS

Aspirin 100mg Daily

Perindopril 5 mg Daily
Atorvastatin 10 mg Daily

SH

Lives Alone
Fully independent with ADLS
Occasional alcohol

Examination

Distressed
P 130
BP 80/60
RR 26 Sats
99% RA
Abdomen
Non-distended
Generally tender

Reduced power 3/5 to

hip flexors

Bedside Ultrasound

9cm

Management of ruptured AAA

Senior help
ABC
Large Bore IV Access x 2
Hypotensive resuscitation
Analgesia
Ensure O neg available
Ensure normothermia
Urgent Vascular Consult
To OT

Last Case!

85 yr old male. Nursing home resident

Central Abdominal Pain
Sudden onset. Severe
PMH

MEDS

Dementia
MI

Clopidogrel 75 mg Daily
Metoprolol 25 mg BD
Perindopril 5 mg daily

SH

Mild dementia
Forgetful
Requires some assistance with bathing
and toileting
Feeds Self
Walks with frame
Non-smoker
Non-drinker

Examination

Looks dry and emaciated

P 120- 140
BP 110/70
RR 30
Sats 96% RA
T 37.4 C
Abdomen
Generally tender
No guarding rigidity or rebound

ECG

Differential?

ABG
pH 7.10
pCO2 15
P02 80
Bic 8
BE -15
Lactate 10.2

Management

02
NMB
IV access
IVF
Analgesia
IV abs
Urgent Surgical Consult
Urgent CT mesenteric angiogram
OT

Take Home Message

Exclude life threatening pathology
BHCG in female of child bearing age
Be mindful of radiation exposure
Beware of Abdominal pain in the Elderly
Never ignore abnormal vital signs

Mesenteric Ischaemia
Surgical Emergency
Small bowel has warm ischaemic time of 2-3
hours
Rapidly progresses to gangrene, septic shock
and death

Need high index of suspicion to diagnose it

Severe pain but little tenderness on examination

Case 7
40 yr old male presents with sudden onset of
severe R loin to groin pain. Excruciating

pain.Coming in waves. Feels nauseated and has

vomited x 2.
Patient is agitated, pacing around the room,
unable to sit still.
Screaming in pain.
P 120 sinus BP 160/80 T 37.0 C RR 18 Sats 99% RA
R renal angle tender

Differential Diagnosis?
Renal Colic
Pancreatitis
Cholecystitis
Appendicitis
Ruptured/leaking AAA

 UA
Erythrocytes ++++
No leucocytes
No nitrites

Investigations
UA
EUC
FBC
(other bloods if diagnosis unclear)
CT KUB

Management
Analgesia
NSAID e.g. PR indomethacin 100 mg 1st line
Morphine IV titrated to pain
IV fluids maintenance only
Observe

Who should we CT
CT
Ongoing pain
Impaired renal function
Fever
Diagnosis not clear

Indications for admission

Infection
Impaired Renal Function
Pain ongoing needing IV opiates
Stone > 5mm
Obstruction/hydronephrosis on CT
Stag horn Calculus on CT

ECG
What does the ECG show?
1. Sinus Tachycardia
2. VT
3. VF
4. Rapid Atrial Fibrillation
5. No idea!

ECG