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Acute Abdominal Pain

Acute Abdominal Pain

  1. Notify for symptoms like bloating and tightness.

  2. Abdominal pain.

  3. Re-evaluation.

If unstable:

  • Check for tachycardia, hypotension, signs of hypoperfusion, and signs of dehydration.

  • If not stable, proceed to resuscitation.

If stable:

  • Conduct a focused history and physical examination.

  • Proceed with focused investigations.

  • Determine if surgery consultation is needed.

  • If not, proceed with definite medical treatment.

  • Supportive treatment.

[1] Recognizing Impending Shock, Resuscitate

  • Signs and symptoms of shock, especially tachycardia and narrow pulse pressure.

[2] Resuscitation:

  • Evaluate ABCs and resuscitate as needed.

  • Cardiac monitoring: BP, HR, SpO2, ± urine output monitoring (via Foley catheter).

  • Lab tests: Electrolytes, BUN/Cr, CBC with platelet count, coagulation tests, blood typing, crossmatch if hemorrhage is suspected, LFT if hepatobiliary cause is suspected, urinalysis (for KUB system).

  • If GI bleed is present, refer to the GI bleed section.

  • Consider blood transfusion.

  • If infection or sepsis is suspected, perform hemoculture and administer empirical antibiotics.

[3] Focused History Taking and Physical Examination:

  • Take a detailed history, including any accompanying symptoms and physical examination, focusing on past medical history (especially hepatobiliary), surgical history (check for surgical scars), history of nausea/vomiting, alcohol consumption, UTI symptoms, NPO status, and examination of the groin area (rule out inguinal hernia with/without complications).

  • For females with lower abdominal pain, always consider OB/GYN causes and perform a urine pregnancy test in women of childbearing age.

  • Always rule out surgical causes.

  • If a surgical condition is suspected, consult surgery urgently.

  • Signs of peritonitis include rigidity, involuntary guarding, rebound tenderness (weaker signs than guarding), or if the patient prefers to lie still to avoid pain.

  • Pain out of proportion (severe pain without signs) suggests an ischemic cause.

  • Abrupt onset of severe pain or change in pain location (referred pain).

  • Abdominal pain occurring before fever or vomiting.

  • Bilious vomiting.

  • Sudden onset of pallor (acute anemia) may indicate GI bleeding.

[4] Focused Investigation:

Laboratory Tests and Suspected Conditions:

  • Amylase, Lipase: More specific for Pancreatitis.

  • Serum β-HCG, Urine pregnancy test: Pregnancy, ectopic/molar pregnancy.

  • Platelet count, Coagulogram: GI bleed, coagulopathy, chronic liver disease.

  • Electrolytes: Dehydration, electrolyte imbalance.

  • Glucose: DKA, pancreatitis.

  • Hemoglobin/HCT: GI bleeding.

  • Lactate: Mesenteric ischemia, sepsis.

  • Liver function tests: Cholangitis, hepatitis, liver abscess, cholelithiasis.

  • Renal function tests: Dehydration, AKI, CKD.

  • Urinalysis: UTI, ureteric colic, pyelonephritis.

  • ECG & Troponin: MI.

  • Stool Exam: Inflammatory or infectious diarrhea.

  • Acute Abdomen Series: Bowel obstruction, ileus, bowel perforation (pneumoperitoneum indicates surgical intervention), gallstone (10%), kidney stone (90%).

  • Ultrasound: Cholecystitis, cholangitis, pancreatitis, liver abscess, intra-abdominal fluid collection, gynecologic conditions.

  • CT Abdomen: Uncertain diagnosis.

[5] Supportive Treatment:

  1. Anti-acid drug: Omeprazole (20 mg) 1 tablet orally before meals or, if severe, Omeprazole (40 mg) IV stat.

  2. Anti-spasmodic drug: Hyoscine [Buscopan] 10 mg 1 tablet orally three times daily, or Hyoscine 20 mg IV stat.

  3. Anti-emetics: Ondansetron 4 mg IV as needed every 4 hours; max 32 mg/day (Side Effect: headache), Metoclopramide 10 mg IV (Side Effect: extrapyramidal symptoms, EPS).

  4. Analgesics: Morphine for severe pain 3-5 mg IV as needed every 4-6 hours.

  5. Antibiotics: In cases of peritonitis or sepsis due to intra-abdominal infection, an empirical regimen of Ceftriaxone 2 g IV once daily + Metronidazole 500 mg IV every 8 hours.

Common Pitfalls:

  • Failure to perform a pregnancy test or consider pregnancy-related causes.

  • Overlooking aortic dissection or MI.

  • Not recognizing that DKA can often present with abdominal pain.

  • Omission of PR, PV, examination of the inguinal area when necessary.

  • Being misled by lab values within the normal range that mask the diagnosis, despite clinical indications (over-reliance on lab values).

  • Elderly and immunocompromised patient groups with unclear clinical presentations.

Life-Threatening Conditions:

  • Ruptured or expanding aortic aneurysm.

  • Aortic dissection/MI.

  • Bowel perforation.

  • Mechanical bowel obstruction.

  • Acute mesenteric ischemia.

  • Acute pancreatitis.

  • Acute cholangitis.

  • Ruptured ectopic pregnancy.

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