Systematic Approach

to Abdominal Pain
Dr Devinder Singh Bansi BM DM FRCP
Consultant Gastroenterologist
Imperial College Healthcare NHS Trust

What Do They Have?

As you go through this

presentation, think about each of
these cases:
An 18 mo old that suddenly
became inconsoleable from AP
while playing
A 20 yo man with 12 hours of
diffuse crampy AP that migrated to
RLQ that became sharp
78 yo woman with h/o chronic
steroid use with sudden sharp AP
and a rigid exam

Scale of the Problem

GI symptoms in primary care

7.1-9.6% of all primary consultations are with

regard to GI complaints

Gastric pain:
Regurgitation:
Abdominal pain:
Nausea:
Diarrhoea:
Constipation:

5.0
2.0
6.1
2.9
6.7
8.1

per 1000/yr

Thompson WG, Gut 2000: 46: 78-82

Scale of the Problem:

Abdominal pain in the general population

Community prevalence 15-20%

75% of these abdominal complaints
non-consulting
25% consulting

23.5% stay in primary care

1-2% referred to secondary care

Scale of the Problem:

Abdominal pain in general practice

578 cases of non-acute abdominal pain presenting to 11

general practices
Follow up 15 months
Females predominated in the younger age groups
80% visited GP <3 times during F/U
83% managed entirely in the practices
64% received a prescription
Only 20% were additionally investigated in anyway by the GP
Hardly any differences in dx between patients who had
complaints less than 1 week or more than 1 week before
presenting to their GP
Family Practice Vol 10: 4. 387-400

Scale of the Problem:

Prevalence of GI disease

Peptic ulcer:
Oesophagitis:
IBD:
1.5
GI cancer: 1.6

1.9 per 1000/yr

2.9

Functional dyspepsia:
GORD:
5.8
IBS:
10.5

12

80% of chronic GI disease has a functional background

Thompson WG . Gut 2000: 46: 78-82

Scale of the problem;

Acute abdominal pain

Acute abdominal pain is not

uncommon.
Approximately 5 admissions to the
MRI/day with acute abdominal pain
from a population base of 500,000.
1 case per GP per month for an
average list size of 2,000.

Acute Abdominal Pain

Approximately 6% of ED visits
Admission rates vary by
population, up to about 65% in
high risk elderly populations
Most common diagnosis is
NONSPECIFIC (ie, I dunno)
Use H+P, risk factors, and directed
studies to arrive at diagnosis
MUST rule out emergency
conditions

Acute Abdominal Pain

Causes in 10320 patients

Appendicitis
28%
Cholecystitis
10%
Small bowel obstruction 4%
Gynaecological 4%
Pancreatitis
3%
Renal colic
3%
Peptic ulcer
2%
Cancer
2%
No clinical diagnosis
34%
De Dombal, Scand J Gastroenterol 1988

Abdominal Pain Across

the Ages

Ages 0-2

Ages 2-12

Functional, appendicitis, GE, toxins

Teens to adults

Colic, GE, viral illness, constipation

Addition of genitourinary problems

Elderly

Beware of what seems like

everything!

Special Populations

Elderly/ nursing home patients

Immunocompromised

Post operative patients

Infants

Abdominal Pain in the Elderly

Diminished sensation of pain in the

elderly
Comorbid diseases
Polypharmacy
Combinations of above result in many
more vague, nonspecific presentations
Twice as likely to require surgery with
presentation over age 65
Social factors

Understanding the Types of

Abdominal Pain

Visceral

Somatic

Stretch fibers in capsules or walls

of hollow viscus that enter both
sides of spinal cord
Fibers dermatomally distributed
and enter unilaterally in the spinal
cord

Referred

Overlap of fibers from other

locations

Understanding the Types of

Abdominal Pain

Visceral
Crampy, achy, diffuse,
Poorly localized

Somatic
Sharp, lancinating
Well localized

Referred
Distant from site of generation
Symptoms, but no signs

Understanding the Types of

Abdominal Pain

Location, location, location

Organs and their corresponding
fiber entry to the spinal cord
C3-5 liver, spleen, diaphragm
T5-9 gallbladder, stomach,
pancreas, small intestine
T10-11 colon, appendix, pelvic
viscerat11-l1 sigmoid, renal
capsules, ureters, gonads
S2-4 - bladder

History Taking in Abdominal

Pain Presentations

OLD CARS
O- onset
L- location
D- duration
C- character
A-alleviating/aggravating factors
associated symptoms
R- radiation
S- severity

History Taking for Abdominal

Pain Presentations

PMH

PSH

Abx, NSAIDS, acid blockers, etc

GYN/URO

Adhesions, hernias, tumors

MEDS

Similar episodes in past

Other medical problems that increase disease
likelihood of problems (ex: DM and gastroparesis)

LMP, bleeding, discharge

Social

Tob/EtoH/drugs/home situation/agenda

Physical Exam in Abdominal

Pain Presentations

General appearance
Sick versus not sick
Mobile versus still
Obvious pain or discomfort
Doorway impression

Vital signs

Thats why theyre called vital

Physical Exam in Abdominal

Pain Presentations

Inspection

Distention, scars, bruises

Auscultation
Present, hyper, or absent
Actually not that helpful!

Palpation
Often the most helpful part of exam
Tenderness versus pain
Start away from painful area first
Guarding, rebound, masses

Physical Exam in Abdominal

Pain Presentations

Signs

Extra-abdominal exam

Iliopsoas
Murphys
Pelvic or scrotal exams
Lungs, heart
Remember its a patient, not a part

Rectal

Adds very little (despite the angst) beyond

gross blood or melena

Laboratory Testing

Everybody likes a CBC, but

Lacks sensitivity, no specificity
Little to no change in diagnostic
probabilities
Should not dramatically alter
approach (tender is still tender)

Laboratory Testing

Directed approach to lab studies

There are no standard belly labs
Pregnancy test in women of child
bearing age
Urine dipsticks

Imaging

Plain films

Free air, obstruction, air-fluid, FBs

Ultrasound
Rapid yes or no ED evaluations
Formal studies
May add doppler

Computed Tomography
Revolutionized acute care
Often better than we are!

Common Diagnoses by Quadrant

Management of
Abdominal Pain

Always right to start with ABCs

IV access
Fluid administration
Antiemetics
Analgesics
Directed testing and imaging
Re-evaluations
Antibiotics
Consultants

Surgeons, OB/GYN, urologists,

cardiologists, etc

Now How About Those Cases

18 mo old had classic presentation

of intussusception, and symptoms
may wax and wane; rectal would
be to look for current jelly stool. Air
enema for diagnosis and reduction.
Involve consultants early in the
course.

Now How About Those Cases

20 year old with classic

presentation of appendicitis, which
likely does not need CT scan. Most
do not present so simply, quite a
wide array of presentations.
General surgery consultation, pain
meds, IVF, and an operation would
all be good, but dont be shocked if
CT requested.

Now How About Those Cases

78 yo has perforated abdomen,

with age, multiple problems, and
chronic steroids risks for
perforation. Rapid resuscitation,
plain films to confirm free air,
antibiotics, pain medicine, and a
surgeon as fast as you can would
be good practice.

Pearls, Pitfalls and Myths

Do not restrict the diagnosis solely by

the location of the pain.
Consider appendicitis in all patients with
abdominal pain and an appendix,
especially in patients with the presumed
diagnosis of gastroenteritis, PID or UTI.
Do not use the presence or absence of
fever to distinguish between surgical
and medical causes of abdominal pain.
The WBC count is of little clinical value
in the patient with possible appendicitis.
Any woman with childbearing potential
and abdominal pain has an ectopic
pregnancy until her pregnancy test
comes back negative.
Pain medications reduce pain and
suffering without compromising
diagnostic accuracy.

An elderly patient with

abdominal pain has a high
likelihood of surgical disease.
Obtain an ECG in elderly
patients and those with cardiac
risk factors presenting with
abdominal pain.
A patient with appendicitis by
history and physical
examination does not need a
CT scan to confirm the
diagnosis; they need an
operation.
The use of abdominal
ultrasound or CT may help
evaluate patients over the age
of 50 with unexplained
abdominal or flank pain for the
presence of AAA.

Simplified rules for the diagnosis of

acute abdominal pain.

Think in terms of the area of the

pain.
Common conditions are common.
Disease prevalence changes with
age.
Different patterns of disease
between men and women.