Abdominal Pain

I have a patient with abdominal pain. How do I determine the cause?

Case Presentation: A 25-year-old female presents to the emergency department (ED)
with complaints of severe abdominal pain.
Abdominal Pain: is a subjective feeling of discomfort in the abdomen caused by nausea,
vomiting, or constipation.
Abdominal Pain: is an extremely common presenting symptom.

Causes
Gastrointestinal
Gastroduodenal
• Peptic ulcer
• Gastritis
• Malignancy
• Gastric volvulus

Intestinal
• Appendicitis
• Obstruction
• Diverticulitis (Fig. 1)
• Gastroenteritis
• Mesenteric adenitis
• Inflammatory bowel disease
• Intussusception
• Volvulus
• TB • (common in parts of the world where TB is endemic) rangulated hernia

Hepatobiliary
• Acute cholecystitis
• Chronic cholecystitis
• Cholangitis
• Hepatitis

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Pancreatic
• Acute pancreatitis
• Chronic pancreatitis
• Malignancy

Splenic
• Infarction
• Spontaneous rupture

Urinary Tract
• Cystitis
• Acute retention of urine
• Acute pyelonephritis
• Ureteric colic
• Hydronephrosis
• Tumour
• Pyonephrosis
• Polycystic kidney

Gynecological
• Ruptured ectopic pregnancy
• Torsion of ovarian cyst
• Ruptured ovarian cyst
• Salpingitis
• Severe dysmenorrhoea
• Mittelschmerz
• Endometriosis
• Red degeneration of a fibroid

Vascular
• Aortic aneurysm
• Mesenteric embolus
• Mesenteric angina (claudication)
• Mesenteric venous thrombosis
• Ischemic colitis
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• Acute aortic dissection

Peritoneum
• Secondary peritonitis
• Primary peritonitis

Abdominal Wall
• Strangulated hernia
• Rectus sheath hematoma
• Cellulitis

Retroperitoneum
• Retroperitoneal haemorrhage, e.g., anticoagulants

Referred Pain
• Myocardial infarction
• Pericarditis
• Testicular torsion
• Pleurisy
• Herpes zoster
• Lobar pneumonia
• Thoracic spine disease, e.g. disc, tumour

Medical Causes
• Hypercalcaemia
• Uraemia
• Diabetic ketoacidosis
• Sickle cell disease
• Addison’s disease
• Acute intermittent porphyria
• Henoch–Schönlein purpura

Type of Pain
1-Colic Pain
• Tension-type pain

• Associated with forceful peristaltic contractions

• Most characteristic type of pain arising from the viscera

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• Produced by an irritant substance, from infection or bacteria, or the body’s attempt to force its

luminal contents through an obstruction

2-Stretching Pain
• Tension-type pain

• Caused by acute stretching of an organ, such as the liver, spleen, or kidney, due to enlargement

• Patient is restless, moves about, and has difficulty getting comfortable

3-Ischemic Pain
• Intense, continuous pain

• Strangulation of bowel from obstruction is a common cause

4-Inflammatory Pain
• Visceral peritonitis
• Aching
• Patient lies still and does not want to move
• Pain may be referred from abdomen to other parts of the body via common neural pathways

Step 1: Data Acquisition (History & Physical Exam)

A- HISTORY
MEDICAL HISTORY IN GENERAL
Medical History: General
• Medical conditions and surgeries
• Allergies
• Current medications
• Bowel pattern
• LMP
SPECIFIC MEDICAL HISTORY: NDD
Medical History: Specific to Complaint
• Previous abdominal surgeries
• Pregnancies
• Miscarriages
• Abortions
• Recent use of new prescribed medications
• Recent use of over-the-counter medications, such as ibuprofen or Naprosyn
• Family history of cancer of the stomach, bowel, uterus, or ovaries

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B- PHYSICAL EXAM
A-GENERAL PHYSICAL EXAMINATION NDD
PHYSICAL EXAMINATION
Vital Signs
• Temperature
• Pulse
• Respiration
• Oxygen saturation (SpO2)
• Blood pressure (BP)
General Appearance
• Apparent state of health
• Appearance of comfort or distress
• Color
• Nutritional status
• Hygiene
• Match between appearance and stated age
• Difficulty with gait or balance
1-Abdominal Inspection
• SKIN: color, lesions, masses, or hernias
• SIZE/SHAPE: distention, shape, symmetry, surgical scars, hernias, pulsations
2-Abdominal Examination
• AUSCULTATION: for frequency, intensity, pitch of bowel sounds (BS), determine presence of bruits, friction rub
• RECTAL: if rectal bleeding or change in bowel habits; testing of stool as positive or negative
3-Pelvic Examination
• EXTERNAL: observe for redness or lesions
• INTROITUS: observe for discharge or lesions
• VAGINA: observe for presence or absence of rugae, discharge, bleeding, or odor
• CERVIX: inspect for lesions, discharge from os; note whether there is pain with motion of the cervix from side to side
• UTERUS: note size, shape, and position and whether there is any tenderness with movement
• OVARIES: note if palpable; if palpable, note whether they are enlarged, tender, or masses are present
• PERCUSSION: look for patterns of dullness and tympany
• PALPATION: locate masses or organomegaly, pulsations
a-Light palpation: tenderness, pain, presence of guarding, rigidity, and rebound tenderness
b- Deep palpation: locate masses or organomegaly, pulsations

B- SPECIFIC PHYSICAL EXAMINATION PH.E

General
-Is the patient lying comfortably? Is the patient lying still but in pain, e.g. peritonitis?
-Is the patient writhing in agony, e.g., ureteric or biliary colic?
-Is the patient flushed, suggesting pyrexia?

Pulse, temperature, respiration

Pulse and temperature are raised in inflammatory conditions. They may also be raised with impending infarction of bowel.
An increased respiratory rate might suggest chest infection referring pain to the
abdomen.

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Cervical lymphadenopathy
Associated with mesenteric adenitis.

Chest
Referred pain from lobar pneumonia.

Abdomen
■ Inspection. Does the abdomen move on respiration? Look for scars, distension, visible peristalsis (usually due to chronic

obstruction in patient with very thin abdominal wall). Check the hernial orifices. Are there any obvious masses, e.g. visible,
pulsatile mass to suggest aortic aneurysm?

■ Palpation. The patient should be relaxed, lying flat, with arms by side.

Be gentle and start as far from the painful site as possible. Check for guarding and rigidity. Check for masses, e.g. appendix
mass, pulsatile expansile mass to suggest aortic aneurysm. Carefully examine the hernial orifices. Examine the testes to
exclude torsion.

■ Percussion, e.g. tympanitic note with distension with intestinal obstruction; dullness over bladder due to acute retention.

■ Auscultation. Take your time (30–60 s); e.g. silent abdomen of peritonitis; high-pitched tinkling bowel sounds of intestinal

obstruction.

Rectal examination
Always carry out a rectal examination.

Vaginal examination
There may be discharge or tenderness associated with pelvic inflammatory disease. Examine the uterus and adnexa, e.g.
pregnancy, fibroids, ectopic pregnancy.

Step 2: Accurate Problem Representation Chief Complaint

HISTORY OF COMPLAINT NDD
Symptomatology
Ask about the following characteristics of each symptom using open-ended questions:
• Onset (sudden or gradual)
• Chronology
• Current situation (improving or deteriorating)
• Location
• Radiation
• Quality
• Timing (frequency, duration)
• Severity
• Precipitating and aggravating factors
• Relieving factors

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• Associated symptoms
• Effects on daily activities
• Previous diagnosis of similar episodes
• Previous treatments
• Efficacy of previous treatments

Step 3: DIAGNOSTIC EXAMINATION NDD

1-CBC with differential: High white blood cells (WBCs)
2-Quantitative pregnancy test: Done to rule out the possibility of a tubal/ectopic pregnancy
3-Wet mount (saline): If pH <4.5, wet mount reveals up to 3 to 5 WBCs/high power fi eld and
presence of epithelial cells and lactobacilli (may be physiological discharge) WBCs high in the
presence of a foreign body
4-Chlamydia and gonococcus (STI test): Common link to PID
5-Urinalysis and urine culture if UA shows leukocytes: Screens for infection
6-Pelvic and vaginal ultrasound: Examines margins of pelvic structures to determine size.
7-Culdocentesis: Determines hemoperitoneum (ruptured ectopic pregnancy from pelvic sepsis)

Step 4: HYPOTHESES NDD

DIFFERENTIAL DIAGNOSIS
1-Pelvic Inflammatory Disease.
2-Sexually Transmitted Disease.
3-Septic Abortion.
4-Ectopic Pregnancy.
5-Appendicitis.

Step 5: Diagnosis: for example, Pelvic inflammatory disease NDD