Acute abdominal pain

abdominal painEvaluation of a patient with acute abdominal pain requires careful history, physical examination by skilled physician, in conjunction with selective diagnostic testing.  Common causes of upper abdominal pain are:

  1. Acid peptic disease.
  2. Acute cholecystitis.
  3. Acute pancreatitis.
  4. Myocardial ischaemia.
  5. Ketoacidosis.
These conditions can be differentiated on history, examination and proper investigations.

History

Onset:
  • If pain started within seconds then it may be due to perforation of peptic ulcer or infarction.
  • If pain is sudden in onset and accelerating then suspect biliary colic or pancreatitis.
  • If pain is gradual in onset and increasing in intensity over several hours then it may be due to acute cholecystitis.
Character of pain is also important.
Site: Pain due to acute cholecystitis is either in epigastrium or right hypochondrium.  Pain of acid peptic disease and pancreatitis is in epigastrium.
Associated Factors: Biliary colic is increased after taking fatty meals.
Radiation of Pain: Pain of acute pancreatitis radiating to back, pain of acute cholecystitis radiating to tip of right scapula.
Proper History of diabetes, coronary artery disease and drug intake such as NSAIDS, steroid intake should be asked.

Physical Examination

Overall appearance of the patient should be assessed.
Vitals should be noted.

Abdominal Examination
  • See the shape of abdomen,
  • Look for tenderness, guarding, rigidity (features of peritonitis), and tender mass suggestive of acute cholecystitis.
  • Note area of tenderness and rebound tenderness.
  • Murphy’s Sign:  It is usually present in biliary colic
  • Absent bowel sounds indicate paralytic ileus.

Investigations

  • CBC.
  • S/Electrolytes.
  • S/Creatinine and Blood Urea.
  • Liver Function Tests.
  • Pancreatic enzymes (Amylase and Lipase).
  • Urine Exam.
  • ECG.

Diagnostic Imaging

Plain abdominal film may show gas-fluid level (paralytic ileus) and free gas under diaphragm.
Abdominal Ultrasonography may reveal inflamed gallbladder or swollen pancreas etc.

Management

  • Keep the patient Pain-Free.
  • H2-Blockers to prevent Stress Ulcer.
  • Treat the Cause after Resuscitation.
  • Pass NG Tube and Foley’s Catheter if indicated
  • Resuscitate the patient with I/V Fluids if indicated
  • Consider I/V Antibiotics.
  • Surgery if indicated.
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