As part of your approach to abdominal pain, you shall consider the need for an urgent attention if patients present with abdominal pain as part of the following context:
- Peritonitis suggested by guarding rebound tenderness or rigidity of the abdomen, for example, guarding, rebound tenderness or appendicitis, perforation
- Jaundice, for example, gallstone, hepatitis
- Fever>38ºC suggests significant sepsis, for example, pelvic inflammatory disease, pyelonephritis
- No stool or flatus for last 24 hours with nausea or vomiting suggests bowel obstruction
- In a patient on anti-retroviral treatment (ART), the combination of abdominal pain, nausea, vomiting, fatigue, sore muscles or difficulty breathing may suggest lactic acidosis
- No urine passed for the last 12 hours and swelling suggest acute urinary retention
- A pregnant women may have serous problems such as pregnancy-induced hypertension or pyelonephritis
- A patient with chest pain may have referred pain to the abdomen and a serious problem in the chest such as myocardial infarction or pneumonia, lower abdominal pain with recent termination of pregnancy/miscarriage/delivery or vaginal bleeding.
Gathering Information
Have the patient indicated the site of the pain and relate to the anatomy and function of the organs that are found in the abdominal cavity, where they are situated and their nerve supply.
The location of acute abdominal pain may be associated with the following causes:
Location Likely pathology
Right upper quadrant Gallbladder disease, lower lobe pneumonia, hepatic disease
Epigastrium Dyspepsia, peptic ulcer, perforation, pancreatitis, referred pain (for example, myocardial infarction, pneumonia)
Left upper quadrant and umbilical area Small bowel obstruction, early appendicitis, mesentric ischaemia, mesentric adenitis (TB), gastro-enteritis, lower lobe pneumonia
Right or left flank Ureteric colic, pyelonephritis, leaking abdominal aortic aneurysm
Suprapubic Cystitis, acute urinary retension, pelvic appendicitis
Right iliac fossa Diverticulitits, carcinoma of sigmoid colon, ulcerativ colitis, constipation, ovarian cyst, salpingitis, ectopic pregnancy
Groin Irreducible hernia
The mnemonic PQRST can help recall further key information in the history:
- P: Precipitating/palliating/provoking factors. Peritonitis is worse with movement so the patient lies still. Ureteric colic is unaffected by movement and the patient may move about trying to relieve the pain. Food may relieve a duodenal ulcer, but worsen a gastric ulcer. Fatty foods may worsen biliary colic, hot and spicy food may worsen dyspepsia and peptic ulcers, and milk may relieve dyspepsia, but worsen biliary colic due to the fat content. Pain on swallowing may be related to esophageal pathology, while pain 30-60 minutes after eating may be related to gastric pathology. Likewise, pain with defecation may be related to the lower gastrointestinal tract, pain on micturation to the genito-urinary tract and pain with menses to the reproductive tract.
- Q: Quality/quantity of pain. Burning sensation is usually felt if there is pathology within the gastrointestinal tract or on the skin. A stabbing pain may indicate peritoneal irritation (including free blood/fluid), a cramp-like and ‘colicky’ pain indicates pathology of a hollow viscus, whereas a dull and constant aching pain may indicate a tumour or space occupying lesion. The pain may appear to radiate ot another place. For example, pain in retro-peritoneal structures such as the pancreas or aorta may be experienced as back pain. Pain from the diaphragm may radiate to the shoulder tip and from the gallbladder to the tip of the scapula. Ovarian pain may radiate to the sacro-iliac region.
- R: Related factors. Ask about other symptoms of the gastrointestinal tract (for example, vomiting, diarrhea, constipation, worms, hematemesis, melena, dysphagia) or genito-urinary tract (for example, dysuria, menses, vaginal discharge). In a patient with weight loss, fever, night sweats and HIV, consider abdominal TB. In a patient with unexplained weight loss, consider cancer. In a patient with difficulty breathing and leg swelling, consider heart failure. It needs to be kept in mind that referred pain may present as abdominal pain. Cardiac pathology or pneumonia may present as upper abdominal pain. It is common for patients to present with vague lower abdominal pain when they would like to discuss issues of infertility, sexuality or relationship difficulties.
- S: Severity of the pain. Ask the patient to rate the severity on a scale of one to ten and also watch how they react during the consultation and examination.
- T: Time course and treatment. Consider the duration and whether it is intermittent or persistent pain and the use of or response to any medication. Abdominal pain may change over time. For example, appendicitis starts as a colicky central pain that later localizes to the right iliac fossa with the onset of peritonitis. Colic may last seconds (intestinal), minutes (ureteric), or 20 minutes (gallbladder). Dyspepsia may be caused by aspirin or NSAIDs.
Examination
Examination includes attention to the patient’s general appearance (sweating, pallor, position, behaviour), vital signs (temperature, pulse, blood pressure, respiratory rate), abdomen (nine quadrants), and may include a rectal and vaginal examination.
Investigations
Investigations will depend on the differential diagnoses being considered, and may include:
Complete blood count: anemia, infection
Urea and electrolytes: renal function, dehydration
Liver function tests: gallbladder, biliary or hepatic problems
Amylase: pancreatitis
Urinalysis: hematuria in ureteric colic and infection, leucocytes and nitrites in infection
pregnancy test
Erect chest X-ray: to look for free gas under the diaphragm or lower lobe pneumonia; note that 30% of acute perforations are not visible on the erect chest X-ray
Abdominal X-ray for signs of obstruction, free gas, calculi or gas in the biliary tree
Abdominal ultrasound can examine most organs
Scopes of upper or lower GIT
CT scanning, barium or gastro-grafin studies, laparotomy and laparoscopy may have a place at the referral hospital.