4

Abdominal pain

Acute upper abdominal pain: step-by-step assessment

and look for evidence of complications, e.g.

infection, particularly in patients with persistent organ failure or a systemic inflammatory response.
4

Jaundice?

Organise an urgent abdominal USS for all

patients with acute upper abdominal pain
and jaundice to look for evidence of biliary
obstruction or hepatitis.
Assume biliary sepsis, at least initially, if
the patient is unwell with high fever
rigors or cholestatic jaundice (p. 177); give
IV antibiotics and, if the USS confirms a
dilated CBD, refer immediately to surgery
for biliary decompression.
Assess as described in Chapter 19 if
there are clinical or USS features of acute
hepatitis.
5

Inflammatory response?

At this stage, use the presence or absence of

a systemic inflammatory response (see Box
4.1) to narrow the differential diagnosis.
Arrange prompt abdominal USS to
confirm or exclude acute cholecystitis in
any patient with inflammatory features
accompanied by any of the following:
localised RUQ pain
direct tenderness to palpation in the
RUQ
positive Murphys sign (sudden arrest
of inspiration while taking a deep
breath during palpation of the
gallbladder).
In the absence of acute cholecystitis, the
USS may reveal an alternative cause for the
presentation, e.g. pyelonephritis, hepatitis,
subphrenic collection.
If none of these features is present, consider alternative disorders:
basal pneumonia if there is clinical or
CXR evidence of basal consolidation
(see Figs 12.3 and 12.4, pp. 116 and 117),
especially if accompanied by productive
cough or dyspnoea
gastroenteritis in patients with an acute
vomiting illness and no abdominal
guarding or rigidity (reassess regularly)
36

acute pyelonephritis if urinalysis is

positive for leucocytes/nitrites.
Otherwise, consider USS/CT to exclude
atypical presentations of acute appendicitis/
pancreatitis/cholecystitis, Crohns disease
or other acute inflammatory pathology.
6

Characteristics of biliary colic?

Biliary colic is a common cause of acute

severe upper abdominal pain in patients
who are otherwise well and do not exhi
bit evidence of a systemic inflammatory
response. Abdominal USS can assist the
diagnosis by demonstrating the presence
of gallstones. However, asymptomatic
gallstones are very common and so the
history is critical to making an accurate
diagnosis.
Look for the following suggestive
features:
onset of pain a few hours after a meal
(may waken the patient from sleep)
duration 6 hours followed by complete
resolution of symptoms
the main site is the epigastrium or RUQ
radiation to the back
constant, vague, aching or cramping
discomfort (it is not, strictly speaking,
colicky)
history of previous similar episodes.
Arrange abdominal USS only in patients
with a suggestive history. If the pain has
settled and LFTs are not deranged, USS
may be performed in the outpatient
department.
7

Consider other causes observation/

surgical review if any concern

Systemically well patients with an acute

vomiting illness and recent infectious
contact or ingestion of suspicious foodstuffs
are likely to have gastroenteritis.
Suspect acute gastritis if the patient
reports new-onset gnawing, burning or
vague epigastric discomfort mild tenderness especially if this is associated with
dyspeptic symptoms e.g. nausea, belching,
heartburn, or a history of recent alcohol
excess/NSAID use; consider peptic ulcer