4

Abdominal pain

Acute abdominal pain: step-by-step assessment

Features of intestinal obstruction?

Suspect intestinal obstruction if abdominal

pain is colicky and accompanied by vomiting, absolute constipation and/or abdominal distension. The predominant symptoms
will vary, depending on the site of obstruction; in high small bowel obstruction vomiting and pain are pre-eminent, whereas in
low colonic lesions constipation and distension are more pronounced. If any of these
features is present, perform an AXR (Fig.
4.5) to help confirm the diagnosis and estimate the level of the obstruction.
Examine for an incarcerated hernia
in any patient with suspected small bowel
obstruction. Consider further imaging and
rectal examination to confirm an obstructing lesion and differentiate from pseudoobstruction in patients with large bowel
obstruction.
Patients may be profoundly dehydrated
check U+E, provide adequate fluid
resuscitation, insert a large-bore nasogastric
tube and consider a urinary catheter.
Refer to surgery for further assessment
and management.
4

Unilateral loin or flank pain?

Suspect renal tract obstruction (usually due

to a calculus) if there is severe, colicky loin
pain (see above) that radiates to the groin
testes/labia. In contrast to peritonitis, renal
tract obstruction causes patients to be
32

Acute and/or bloody diarrhoea?

Recent onset of acute diarrhoea with cramping abdominal pain vomiting suggests
infective gastroenteritis. Suspect colitis
(infective, inflammatory or ischaemic) if the
patient has bloody diarrhoea with cramping lower abdominal pain tenesmus and
features of systemic inflammation (see Box
4.1). Always consider the possibility of
ischaemic colitis if the patient is elderly or
has known vascular disease/atrial fibrillation; if ischaemic colitis is suspected,
arrange a CT mesenteric angiogram. Otherwise, send stool for culture and assess as
described in Chapter 9.
5

Distended loops of small bowel Stomach

B
A

Very distended Distended low-lying

caecum
transverse colon

Fig. 4.5 Intestinal obstruction. A. Small bowel.

B. Large bowel.