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Information ⬇

Author: Simon Anderson

Acute surgical causes of abdominal pain are typically due to gastro-intestinal obstruction, peritonitis or vascular emergencies.

Priorities ⬆ ⬇

  1. If the patient has severe abdominal pain and is shocked (systolic BP <90 mmHg, tachycardia, cool peripheries), the likely diagnosis is generalized peritonitis, mesenteric infarction, acute severe pancreatitis or ruptured abdominal aortic aneurysm (Table 21.1). The patient will need:
    • Vigorous fluid resuscitation, initially via a peripheral IV line and then guided by measurement of the central venous pressure (Chapter 116), with monitoring of the urine output by bladder catheter.
    • Antibiotic therapy: start cefotaxime 1–2g 6-hourly IV + metronidazole 500 mg 8-hourly IV.
    • An urgent surgical opinion. If there are obvious signs of a ruptured abdominal aortic aneurysm (painful aortic pulsation and hypotension), emergency laparotomy is needed, before any radiological examination.
  2. History needs to establish the characteristics of the abdominal pain, and the patient's other medical problems (Table 21.2):
    • When and how did the pain start – gradually or abruptly?
    • Where is the pain felt, and has it moved since its onset?
    • How severe is the pain?
    • Has there been vomiting, and when did vomiting begin in relation to the onset of the pain?
    • Has the patient had previous abdominal surgery and if so what for?
    • Women of childbearing age should be asked about their pregnancy and menstrual history (last menstrual period, last normal menstrual period, previous menstrual period, cycle length) and use of contraception. A pregnancy test should be done. Establish if there has been vaginal discharge or bleeding, dyspareunia or dysmenorrhea.
  3. As well as a careful examination of the abdomen (Table 21.2), you should:
    • Check the temperature, pulse, JVP and blood pressure.
    • Listen to the heart and over the lung bases.
    • Give oxygen if the patient has severe pain, is breathless, or if oxygen saturation by pulse oximetry is <94%.
    • Put in an IV cannula and take blood for urgent investigations (Table 21.3).
    • Relieve severe pain with morphine 5–10 mg IV plus an antiemetic, for example prochlorperazine 12.5 mg IV.
    • Start an infusion of crystalloid, at a rate determined by the volume status of the patient.
    • Arrange appropriate imaging (Table 21.3).

Further Management ⬆ ⬇

Further management will be determined by the results of investigations and surgical assessment. ‘Medical’ causes of abdominal pain are summarized in Table 21.4.

Further Reading ⬆

Bhangu A, Søreide K, Di Saverio S, Hansson Assarsson J, Thurston Drake F. (2015) Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet 386, 1278–1287.

Clair DG, Beach JM. (2016) Mesenteric ischemia. N Engl J Med 374, 959–968.

Gans SL, Pols MA, Stoker J, Boermeester MA, on behalf of the expert steering group (2015) Guideline for the diagnostic pathway in patients with acute abdominal pain. Dig Surg 32, 23–31. http://www.karger.com/Article/FullText/371583.

Lankisch PG, Apte M, Banks P.A. (2015) Acute pancreatitis. Lancet 386, 85–96.

Badger SA, Harkin DW, Blair PH, Ellis PK, Kee F, Forster R. (2016) Endovascular repair or open repair for ruptured abdominal aortic aneurysm: a Cochrane systematic review. BMJ Open 6, e008391. DOI: 10.1136/bmjopen-2015-008391