Acute Abdominal Pain

Analgesia adequate pain relief will aid your diagnosis

o If pain is excruciating and not relieved by opioid analgesia, suspect a vascular
ischaemic event, e.g. ruptured AAA, mesenteric ischaemia
o A severe pain relieved by opioid analgesia suggests widespread inflammation, e.g.
pancreatitis, or generalised peritonitis from a viscus perforation
o If acute pain relieved by parental analgesia, suspect a less severe cause, e.g. biliary or
renal colic

ABCs
1. Ensure the patients airway is clear and stabilise the cervical spine
2. Assess the pts lungs, chest wall and diaphragm, administering oxygen if necessary
3. Assess the pts pulse, BP, and look for signs of shock
4. Determine the pts neurological status using the Glasgow Coma Scale
5. Expose the patient and perform physical examination
6. Take an Abdominal X-ray

After ABCDE these crucial investigations should be performed

1. ECG To monitor cardiac function
2. ABG To assess severity of shock and the pts degree of compensation
3. X-rays an erect chest and abdominal X-ray will aid your diagnosis
4. Urinary catheter to monitor fluid balance
INVESTIGATIONS
o Observation chart look for changes in pattern to indicate deterioration,
haemorrhage, shock, elevating fever or respiratory distress
o Baseline blood tests to assess vital organs
o UE, CRP, FBC, LFTs
o INR (if you suspect the pt will need a prompt intervention)
o Serum amylase & lipase
o Serum amylase elevated to 5x normal levels in the first 5 days after symptoms
begin = pancreatitis (normal: 40 140 U/L)
 o Elevated CRP < 200 mg/l in the first day indicates a severe attack
o Abdominal X-ray small/large bowel obstruction can be seen on a plain film of the
abdomen
o Large dilated loops of bowel with visible haustra = an obstruction in the large
bowel
o Erect Chest X-ray
o Perforation of the bowel causes air to enter the abdominal cavity
o On an erect CXR the air rises to the top can be seen under the diaphragm =
pneumoperitoneum

SUMMARY
- A patient presenting with acute abdominal pain, remember these essential steps
before you do a thorough clerking
o ABCDE always comes first
o Give analgesia helps with next steps and eases the pt
o Focused History and examination to rule out life threatening conditions
o Ensure vital organs are functioning and your pt is stable with simple
investigations

COMMON CONDITIONS
1. Peritonitis
2. Perforated peptic/duodenal ulcer
3. Acute pancreatitis
4. Cholecystitis & gall stone disease
5. Appendicitis
6. Bowel obstruction
7. Acute diverticulitis
PERITONITIS

Local peritonitis
- Inflammation of a single viscera e.g. appendicitis, diverticulitis & cholecystitis can
irritate the local parietal peritoneum
- This causes localised abdominal pain, tenderness & guarding, that begins after the
initial onset of visceral pain

- Treatment is for the underlying disease, but dont forget to monitor and correct fluid
balance, and provide analgesia
- Monitor for signs of complications or progression to generalised peritonitis

Generalised peritonitis
- Widespread inflammation of the peritoneal lining is a serious condition that requires
urgent surgical attention

Causes
1. Chemical irritation from perforated peptic or duodenal ulcer
2. Leaking bile from cholecystitis
3. Infection from ruptured appendix
4. Faecal matter from diverticulitis
5. Deterioration of local peritonitis from inflammatory condition

Clinical Presentation
- Severe abdominal pain, worse on movement
- Patient lies very still
- Tender abdomen with washboard rigidity, rebound tenderness, guarding, and absent
bowel sounds
- Hypovolaemic shock may occur
o Hypotension
o Weak, thready pulse
o Sinus tachycardia
o Tachypnoea
o Low urine output
o Cool clammy peripheries
o Hypothermia
o Confusion
o Weakness
o Thirst
Investigations:
- CT abdomen (determines the cause)
- Serum amylase (rule out pancreatitis)
Management:
- Resuscitate with IV fluids with careful fluid balance monitoring until a good urinary
output is maintained (NG tube, urinary catheter, IV fluids)
- Infuse IV Antibiotics
- Prompt laparotomy/laparoscopy (peritoneal wash-out, and treatment of the
underlying condition)
- Monitor for development of post-operative complications
o Suspect a peritoneal abscess formation if the pt develops
A swinging fever
Swelling
Raised White Cell Count
Increasing or sustained pain
Ultrasound/CT scan necessary, followed by percutaneous drainage or
laparotomy
- If treatment is delayed, peritonitis can rapidly deteriorate with further toxaemia,
septicaemia, and multi organ-failure.

Summary
Generalised peritonitis presents with
- Generalised pain & tenderness
- Rigid, distended abdomen
- Absent bowel sounds
Urgent resuscitation, ABX and peritoneal wash-out required.