APPROACH TO ABDOMINAL PAIN IN

EMERGENCY DEPARTMENT

Dr. Aneeq Nayer Khan

LEADING PRINCIPLES
 One of the most common presenting compains in ED.
 Around 7 million annual visits in US.
 Around in 40% of the cases, cause is not determined.
 First and foremost, identify patients requiring resuscitation and urgent
treatment (mainly associated with hypovolemia and/or septic shock).
 Less obvious but equally important, patients requiring urgent treatment with
no clinical evidence of shock (e.g; ruptured abdominal aortic aneurysms.
 Key is good history and physical examination.
HISTORY
 THE PAIN
• Site, severity, radiation, shift, character (constant, intermittent/colicky), timing,
aggravating and relieving factors (food, position, inspiration).
 VOMITING
• Record anorexia & nausea.
• Nature/contents of vomiting e.g; projectile, blood, bile, food content, number
of episodes, duration etc.

• Pain before vomiting suggests surgical etiology

whereas vomiting before pain is likely non-surgical.
 BOWEL HABITS
• Constipation, diarrhea, last bowel movement. Always ask if any PR bleed.
 OTHER SYMPTOMS
• Abdominal pain can be due to Urological, Repiratory, Cardiovascular or
Gynecological disorders. Always essential to ask for symptoms like dysuria,
LMP, vaginal discharge, burning mictration, fever, chills, pain elsewhere etc.
• Analgesia that patient have already tried?
 PAST HX
• Both medical & surgical hx.
• Preferably obtaining old medical record.
• Note the medications.
PHYSICAL EXAMINATION
 Record/check vital signs (including RBS). Observe patient lying on bed to
check signs of distress.
 Inspect for surgical scars, masses, markings (e.g; bruising), hernial orifices.
 Unnecessary and unkind to attempt elicit rebound terderness as
tenderness on percussion is ample evidence of peritonitis.
 PR/PV exam if necessary (but always recommended in US guidelines).
 Examine testes for masses/tenderness. Pelvic exam is important & may yield
evidence of salpingitis, cervicitis, ovarian problems. (US guidelines)
ESSENTIALS OF ABDOMINAL EXAMINATION

 Palpation should begin in RUQ LUQ LEFT LOWER & finally RLQ.
 However, order should be changed to begin with area further away from pain
(painful area to be examined last).
 Pelvic/PR/PV exam should always be performed with a chaperone
irrespective of the gender of the patient and physician.
QUADRANT CLUES
RUQ LUQ RLQ LLQ

COMMON: COMMON: COMMON: COMMON:

• Biliary Colic • Gastritis • Appendicitis • Sigmoid diverticulitis
• Acute Cholecystitis • Pancreatitis • Regional enteritis • Regional enteritis
• Acute Pancreatitis • Ureteral stone • Ureteral stone
• Cecal diverticulitis • PID
• PID • Ovarian cyst
• Ovarian cyst
UNCOMMON: UNCOMMON: UNCOMMON: UNCOMMON:
• Perforated duodenal • MI • Ruptured ectopic • Ruptured ectopic
ulcer • Left lower lobe pregnancy pregnancy
• Acute heaptitis pneumonia • Ovarian torsion • Ovarian torsion
• Retrocecal appendix • Mesenteric adenitis • Mesenteric adenitis
• MI • Meckel’s diverticulum • Meckel’s diverticulum
• Right lower lobe • Endometriosis • Endometriosis
pneumonia • Psos abscess
• Hepatic Abscess
 IMPORTANT: DKA may present as diffused abdominal pain.

Although rare, it is important to recognize and treat immediately.

 NO CAUSE OF PAIN FOUND
• Many patients get better without definite cause being identified (NON-
SPECIFIC ABDOMINAL PAIN)
• May be reasonable to discharge some patients specially if blood tests &
urinalysis are normal.
• Obtain senior review if patient is > 70 years old before discharge due to
relatively high incidence of important missed pathology (e.g; ruptured aortic
aneurysm)
• Counsel and provide appropriate advice about when to return if symptoms
recur/worsen.
 CANCER CAUSING ABDOMINAL PAIN
• Unexplained abdominal pain with altered bowel habits in patients > 50 years
of age may be caused by cancer specially of large bowel (mainly due to
transient or partial bowel obstruction).
• Ask about previous episodes of pain, weight loss, change in bowel habits.
• If no indication for admission, consider refering to surgical clinic for
investigations and further evaluation.
INVESTIGATIONS
 Assessment/Evaluation usually depends mainly on “good history and
physical examination”.
 In many patients, lab tests are not remarkably significant to establish
diagnosis or have any remarkable effect on initial management.
 While in many other patients, labs will be required to narrow down or confirm
the diagnosis.
 In some circumstances, tests will be ordered because the consultants you
are involving will require them specially those patients requiring admission
(irrespective of the test utility, be polite and obtain the test asked for unless it
it likely to harm the patient).
 URINALYSIS
• To rule out UTI and urinary stones

 BLOOD TESTS
• Consider CBC, U & E, Amylase, LFT, CRP, cultures, coagulation profile and
cross matching depending upon patient complains, Hx and examination.
• If clearly unwell, check ABGs and Lactate.
• Lipase is more sensitive and specific if pancreatitis is suspected.
• If STD suspected, be sure to send cultures for chlamydia and gonococcus
(GC).
 PREGNANCY TEST
• Always perform urine pregnancy test on all the women of child-bearing age
presenting with abdominal pain (to rule out ectopic pregnancy).
 ECG
• Especially in patients aged > 55 years old or patients who may be suffering from
an atypical presentation of acute medical problem (most notably MI).
 ERECT CXR
• Can help exclude chest pathology which may mimic abdominal conditions (e.g:
CCF, Basal pneumonia)
• It may also reveal free gas under diaphragm.
 ABDOMINAL X-RAY
• Are NOT routinely indicated.
• Specific indications if suspicion of Intestinal Obstruction, Toxic megacolon,
sigmoid volvulus & GI perforation.
 ULTRASOUND
• Reveals gallstones, free peritoneal fluid, urinary stones, aortic aneurysms.
 CT SCAN
• May be helpful in diagnosis of certain cases (e.g; acute appendicitis in less
straight-forwad cases).

 IF REQUIRED TO ORDER TEST THAT IS TIME TAKING,

LET THE PATIENT KNOW IN ADVANCE
TREATMENT
 Treat shock first by urgent resuscitation, IV fluids (caution if aneurysm
suspected), full monitoring (including urinary output via urinary catheter).
 Prompt resucitaion and provision of analgesia are integral components in
serious abdominal pain.
 Traditional belief that analgesia should not be given because it might mask a
serious problem is INCORRECT & CRUEL.
 Most appropriate form of analgesia is usually IV opioid (e.g; morphine,
fentanyl etc) IV Paracetamol.
 According to US guidelines, IV Antiemetics (e.g; metoclopromide) and IV
fluids alone will help relieve pain in large group of non-specific causes.
 All the other treatment is mainly symptomatic e.g; Antiemetics (e.g;
metoclopramide, ondansetron), PPI (e.g; omeprazole) which should be given
if required or inicated.
 ANTIBIOTICS should be given to the patients early who are found to be
septic or suspected with peritonitis, perforated viscus.
 Adopt a low threshold for seeking senior help as it can be difficult to decide if
admission is needed.
GASTROENTERITIS/FOOD POISONING
 DIARRHOEA & VOMITING
• Diarrhoea is the usual presenting symptom but may be due to other conditions
(e.g; Antibiotics induced, rectal tumor and even constipation if there is
overflow around obstructed stool).
• Diarrhoea and vomiting both is usually caused by pathogen (bacteria, viruses,
toxins).
• Source is usually contaminated food or water (mainly due to under-cooking
and poor storage).
 FOOD POISONING
• Is a notifiable disease (immediate notification by telephone is necessary if
outbreak is suspected).
• The food eaten, incubation period and symptoms may suggest the toxin
involved.
• CO poisoning may cause malaise and vomiting in several family members
and can be misdiagnosed as FP.
• Ensure the patients with diarrhoea are flagged and isolated to
avoid/decrease infection spread.
• In case of histamine fish poisoning (scombroid fish poisoning), it is important
to tell the patient that posioning is caused by improper handling and storage
(not an allergic reaction) so patient would not have to avoid eating fish in
future.
CAUSE INCUBATION FOOD
Staph. Aureus 1-6 hr Meat, milk
Bacillus cereus 1-16 hr Rice
Salmonella 6-48 hr Meat, eggs
E. Coli 1-2 days Any food
E. Coli VTEC O157 1-2 days Meat, milk
Campylobacter 1-3 days Meat, milk
Shigella 1-3 days Any food
Vibrio parahem 2-3 days Seafood
Cholera 12 hours to 6 days Water, seafood
Rotavirus 1-7 days
Histamine fish poisoning <1 hr Fish
Ciguatera fish poisoning 1-6 hr (rarely 30 hr) Fish from tropical coral reef
Paralytic shellfish poisoning 30min to 10hr Shellfish
Mushrooms <24hr Mushrooms
 ASSESSMENT & TREATMENT POINTERS

• Type of food ingested? Took any medications?

• Duration of symptoms, frequency and desccription of stool and vomit.
• Travel history and occupation (especially if food handler).
• Document other symptoms (abdominal pain, fever etc).
• Assess the degree of dehydration (especially in children). Traditionally classified
as Mild (<5%), Moderate (5-10%) and Severe (>10%). Evidence of severe
dehydration includes weakness, confusion, shock, and low urine output.
• Stool culture is unnecessary in most cases but obtain if patient is systemically
unwell, blood or pus in stool, immunocompromised, recent hospitalization, has
had antibiotics or PPI, has been abroad, food handler.
• Antiemetic drugs are helpful.
• Antibiotics only in special circumstances as viral causes are not helped.
Occasionally helpful in traveller’s diarrhoea.
• Antidiarrhoeal drugs (e.g; loperamide) are contraindicated in children and
rarely needed in adults as they may aggravate nausea and vomiting and
occasionally cause ileus. However may provide symptomatic relief in mild
to moderate diarrhoea (avoid if blood in stools/possible Shigella infection).
PITFALLS
 Steroids, NSAIDS, Obesity may render physical signs less obvious.
 In elderly patients with peritoneal irritation, it may difficicult to elicit guarding
due to low musculature.
 Beta blockade may mask the signs of shock.
 Absense of fever doesn’t exclude infection (esp. immunocompromised
patient).
 TLC may be normal in established peritonitis/sepsis.
 Amylase may be normal in pancreatitis as well as it can be moderately raised
in acute cholecystitis, perforated peptic ulcer and mesenteric infarction.
REFERENCES

 Oxford handbook of Emergency Medicine.

 American College of Emergency Medicine.

 Society for American Emergency Medicine (SAEM)