‘medical’ Causes of Acute Abdominal Pain
| Site of pain | Pathologies to consider | Comment |
|---|---|---|
| Right upper quadrant | Right basal pneumonia (Chapters 62, 63) Pulmonary embolism Hepatic congestion due to congestive heart failure Alcoholic hepatitis (Chapter 78) Viral hepatitis Acute gonococcal perihepatitis (Fitz-Hugh-Curtis syndrome) Liver abscess Budd-Chiari syndrome Portal vein thrombosis | Always listen for basal lung signs (pleural rub, crackles) Fitz-Hugh-Curtis syndrome usually presents with right upper quadrant pain (which may radiate to the shoulder) and minimal pelvic signs. Think of Budd-Chiari syndrome in patients with acute or chronic upper abdominal pain, hepatomegaly and deranged liver enzymes. |
| Epigastric | Acute gastritis Peptic ulcer disease Gastro-oesophageal reflux disease Acute inferior myocardial infarction (Chapter 45) Acute pericarditis (Chapter 53) Aortic dissection (Chapter 50) Acute pancreatitis (Chapter 79) | Pain in the distal oesophagus related to reflux oesophagitis can be difficult to distinguish from epigastric pain from gastric causes. An ECG should always be performed in patients with acute upper abdominal pain. |
| Left upper quadrant | Left basal pneumonia Pulmonary embolism Splenic infarction Splenic abscess | Splenic causes are relatively uncommon but should be considered in patients with haemoglobinopathies and in procoagulant states. |
| Lower abdomen | Ileitis:
Ureteric obstruction or stones In women:
| Ovarian cysts are commonly encountered on ultrasound and may not be the cause of pain. Always consider other causes such as appendicitis or ileitis. |
| Central or diffuse | Viral or bacterial gastroenteritis (Chapter 22) Acute inflammatory bowel disease (Chapter 76) Spontaneous bacterial peritonitis Diabetic ketoacidosis (Chapter 83) Acute adrenal insufficiency (Chapter 90) Aortic dissection (Chapter 50) Acute intermittent porphyria Vaso-occlusive crisis of sickle cell disease (Chapter 104) Henoch-Schonlein purpura (colicky pain with arthralgia, pupruric rash on buttocks and legs and sometimes bloody diarrhoea) Retroperitoneal haemorrhage (complicating anticoagulant therapy, bleeding disorder, leaking abdominal aortic aneurysm or vertebral fracture) | Crohn's disease can present with acute abdominal pain with minimal preceding symptoms. Spontaneous bacterial peritonitis can occur in patients with relatively mild ascites. Acute intermittent porphyria is rare but should be considered if recurrent unexplained generalized pain. |