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Acute History and
examination
ABDOMINAL
Investigation
Specific surgical
conditions
PAIN
Non-general
surgical causes of
abdominal pain
The authors
DR JULIA CRAWFORD,
surgical registrar, department of
gastrointestinal surgery, Royal
North Shore Hospital,
St Leonards, NSW.
DR THOMAS JARVIS,
surgical registrar, department of
gastrointestinal surgery, Royal
North Shore Hospital,
St Leonards, NSW.
DR THOMAS J HUGH,
History
AS with any clinical presentation, a should be suspected. peri-umbilical pain of early appen-
comprehensive history should be A confusing misnomer is ‘biliary dicitis (reflecting innervation from
taken to determine the mode of colic’, which is used to describe the T10) shifts to the right iliac fossa
onset, duration, frequency, charac- symptoms associated with uncom- over several hours as localised
ter, location and radiation of the plicated gallstones. The gallblad- peritonitis develops.
pain, and any aggravating or reliev- der lacks a strong muscularis A change in the nature of the
ing factors. Often the history pro- mucosa, so pain from an pain may also signify progression
vides more important information obstructed cystic duct is constant to a more sinister pathology. For
for subsequent management than rather than colicky in nature. example, a change from the gen-
any single laboratory test. Further- Other descriptive terms used by eralised cramping and intermittent
more, a good history guides the some patients included a ‘tearing’ abdominal pain of subacute small-
most logical and appropriate inves- sensation that may indicate a dis- bowel obstruction to a more con-
tigations. secting aneurysm, or a ‘burning’ stant and generalised pain raises
In the past, diagnosis of acute epigastric pain that may indicate concern about intestinal
abdominal pain was largely based either acute gastritis or a peptic ischaemia.
on pattern recognition. Even in an ulcer. However, the diagnosis of Identifying the factors that influ-
era of easy access to diagnostic acute gastritis is relatively rare and ence the patient’s abdominal pain
tests, knowledge of these classic should only be made when there may also point towards the diag-
presentations is still important. has been a history of a toxic inges- nosis. For example, a patient may
However, frustratingly, patients tion such as excessive alcohol describe relief from severe abdomi-
with acute abdominal pain may intake, recent heavy NSAID use or nal and back pain by leaning for-
present with atypical features that deliberate or accidental ingestion ward, and this often occurs in
make pattern recognition unreli- of a caustic substance. acute or chronic pancreatitis.
able. In contrast, patients with chronic In the case of peritoneal inflam-
The onset and duration of the gastritis are usually either asymp- mation from acute appendicitis,
presenting pain may give an indi- tomatic or have subtle and vague any movement such as coughing,
cation of the severity of the under- upper abdominal discomfort rather straining or even travelling over
lying pathology. Sudden onset of than acute abdominal pain. the bumps on the road during the
severe pain usually indicates a cat- Chronic gastritis is divided into car trip to the hospital exacerbates
astrophic event such as a perfo- type A (associated with pernicious the abdominal symptoms and is a
rated viscus or a ruptured anaemia), type B (mostly due to good indicator of peritoneal irri-
aneurysm. Rapidly progressing Helicobacter pylori infection) and tation.
pain that stays in one area of the type C (due to chronic ingestion of It may also be helpful to eluci-
abdomen suggests a specific diag- a toxin, such as an NSAID). date whether there have been any
nosis such as biliary colic or severe Patterns of radiation of the other associated symptoms. The
pancreatitis, depending on the loca- abdominal pain may also be help- presence of nausea, vomiting,
tion of the pain. Abdominal X-ray of ischaemic small bowel secondary to adhesions. ful. For example, acute pancreatitis anorexia or a change in bowel
In contrast, pain that builds up or a ruptured abdominal aortic habit frequently go hand in hand
gradually over several hours and gradually moves to the right iliac aneurysm frequently causes severe with acute abdominal pain. The
that begins as a slight or vague dis- fossa as localised peritonitis sets in. epigastric pain that radiates temporal relationship of these
comfort only, but soon localises to It is helpful to try to describe through to the back. Another symptoms to the pain may point
a specific area of the abdomen, abdominal pain as intermittent or example of radiating symptoms towards a particular diagnosis.
suggests a subacute process char- continuous in nature or as dull or relates to acute cholecystitis, which For example, intractable nausea
acteristic of peritoneal inflamma- sharp in character. ‘Colicky’ symp- often presents as right upper-quad- may precede the pain associated
tion. As a general principle, any toms describe pain that occurs rant discomfort extending around with obstruction of a narrow
severe acute abdominal pain that intensely for a short period of time the patient’s side rather than lumen tube such as the pancreatic
lasts for more than a few hours is followed by a pain-free period. straight through to the back. duct.
likely to be due to an underlying This is typical of obstruction of a Any pathology that causes irri- Accompanying fevers, rigors or
surgical pathology. hollow viscus by vigorous peristal- tation of the diaphragm may result chills suggest an associated infec-
The location of the pain in the sis proximal to the site of the in referred pain to the shoulder tip. tion and should help differentiate
right or left side of the abdomen obstruction. This occurs because of innervation such diagnoses as ‘biliary colic’
or in the epigastrium provides a Large luminal obstruction such of the diaphragm by the fourth cer- and renal colic from cholecystitis
guide to the likely diagnosis. Typi- as occurs in the colon may be vical nerve route, which also sup- and pyelonephritis. In the latter
cally, diffuse but localised epigas- severe but tolerable for long peri- plies the shoulder. Other examples two conditions, hospital admission
tric pain suggests such diagnoses ods of time. On the other hand, of referred pain include renal colic is usually required for pain relief
as pancreatitis or peptic ulcer dis- obstruction of a narrow lumen that classically radiates from the and IV antibiotics.
ease, while right upper-quadrant or tube such as the ureter or the small loin into the tip of the genitalia, Any symptoms associated with
right-sided back pain indicates bil- bowel is frequently excruciating and small bowel colic that initially voiding or opening of the bowels
iary colic or acute cholecystitis. and unbearable. presents as peri-umbilical discom- may suggest a specific pathology
Renal colic often begins as a dull Continuous or constant abdomi- fort because this area shares the but it is worth remembering that
flank pain but may radiate down nal pain is invariably associated same spinal nerve root innervation these symptoms may just be sec-
into the groin. with peritoneal inflammation or, (T10) as the small intestine. ondary to pain or anxiety. A his-
The classic presentation of acute more worryingly, ischaemia. When A shift in the location of the tory of a change in the colour of
appendicitis involves a prodromal the intensity of the pain crescendos abdominal pain with time reflects the urine or stools should also be
period of anorexia associated with but then does not settle between progression of the pathology. For sought and may be helpful at least
vague peri-umbilical pain that attacks, underlying ischaemia example, the initial visceral or in excluding some diagnoses.
Examination
IN an era of ready access to tion cases for delayed diagno- Full exposure of the examination should start on patient to cough and by gaug-
complex and expensive inves- sis are a testament to this. abdomen is critical to avoid the opposite side to this. ing their response.
tigations it is easy to forget Also, the ‘end of the bed’ missing an obvious diagnosis Alternatively, the patient The most likely diagnoses
that an accurate history, assessment should not be such as an obstructed inguinal should be asked to cough as can at least be narrowed
combined with a thorough underestimated as a guide to or femoral hernia. The pres- this may highlight an area of down by the specific region of
clinical examination, will fre- the severity of the acute pre- ence of distension of the focal tenderness, and the maximal tenderness. For
quently make the correct sentation. A patient may be abdomen, scars from previous examination can be tailored example, right upper-quad-
diagnosis without the need jaundiced or pale, or may be operations or the presence of accordingly. rant pain with exacerbation
for any investigations. motionless in the case of peri- any associated hernias should Diffuse abdominal rigidity of pain on palpation during
We bemoan the lack of clin- tonitis, or be rolling around also be noted. The patient (‘board-like’) suggests gener- deep inspiration (Murphy’s
ical acumen in junior doctors in agony when the pain is due should be directed to lie alised peritoneal irritation sign) usually indicates acute
— and so we should, because to renal colic. Even a cursory supine with the arms placed with subsequent involuntary cholecystitis. Alternatively,
these skills are now more inspection may reveal signs of by their sides and with the spasm of the abdominal wall focal epigastric tenderness
important than ever in decid- dehydration, fever or tachyp- knees slightly flexed to relax muscles. Rebound tenderness, with radiation directly
ing on the most appropriate noea, suggesting a serious the abdominal musculature. indicating peritoneal irritation, through to the back indicates
and cost-effective investiga- acute abdominal problem that The site of maximum pain can be elicited by withdrawing pancreatitis. Loin pain radiat-
tions to order. The consis- will prompt the need for early is often pointed out by the the examining hand quickly ing into the groin is indicative
tently large numbers of litiga- resuscitation and treatment. patient and the abdominal or, better still, by asking the of renal pathology.
Investigation
URINALYSIS is a simple In patients with investigation because of pain.
and readily available test that Also, an abdominal ultrasound
may yield important diagnos-
suspected acute is only as good as the operator
tic information. The presence appendicitis, the holding the probe, so experi-
of protein or blood in the clinical history enced radiology practices will
urine often indicates an acute and physical yield the best results.
renal tract pathology such as CT scanning is now the
a renal calculus or nephritis. signs are far modality of choice for investi-
However, macroscopic more reliable gating the patient with an
haematuria can occur in non- than changes in acute abdomen. However the
renal pathologies such as a radiation exposure is much
ruptured abdominal aortic
the white cell greater for a CT scan com-
aneurysm. Similarly, pyuria count. pared with a plain X-ray, and
may also be present when an there are concerns about radi-
inflamed appendix lies adja- ation exposure with CT, espe-
cent to the right ureter. cially in children. Hence an
Having said that, this test is ultrasound scan is preferred as
still very helpful because it is the first choice in young chil-
quick and simple to perform dren and in women who may
and will, at least, exclude any be pregnant.
significant urinary tract Other than in remote rural
pathology. areas of Australia, CT scan-
A complete blood picture ning is readily available to
including a check of the most general practices during
haemoglobin, white cell working hours and is also
count, electrolytes, urea and Ultrasound showing acute cholecystitis with perforation. available after hours in most
creatinine, liver function reasonably sized hospitals.
tests (LFTs) and serum lipase Although the final result is
level is important in narrow- still dependent on the hard-
ing down the cause of the ware and software of the
acute abdominal pain. scanner, in most cases a CT
A leucocytosis will be pre- scan provides an accurate
sent in any infective condi- assessment of the intra-
tion, whether bacterial or abdominal organs and usu-
viral, and therefore should ally identifies the causative
not be used alone to make pathology. Having said that,
or exclude a diagnosis of an a CT scan should only be
acute abdominal problem. used as an adjunct, and not
For example, the absence of as a substitute, for a thor-
an elevated white cell count ough history and physical
does not necessarily exclude examination.
early acute cholecystitis, Also, when requesting a CT
acute appendicitis or even scan, it is helpful for the radi-
cholangitis. Similarly, the ologist to have some basic
white cell count may be ele- clinical information about the
vated as a result of a viral presentation — even a differ-
infection causing mesenteric ential diagnosis. They are
adenitis and consequently more likely to look critically at
acute abdominal pain. the area of interest rather than
Regarding the diagnosis of just having a cursory inspec-
acute or chronic pancreati- tion if this information is pro-
tis, the serum amylase level Ultrasound showing acute appendicitis with no significant narrowing of the lumen during vided.
is less sensitive and less spe- compression. After referral to an accident
cific than the serum lipase and emergency department,
level, so only the latter test radiological investigations for elevated troponin levels formed together with an the gallbladder and biliary patients frequently endure
should be used to exclude should only be used to sup- and this should be done in erect CXR) may still be a tract, as well as the pelvis. lengthy delays while waiting
this diagnosis. Mild to mod- port the diagnosis. conjunction with a resting good test to exclude free air Abdominal ultrasound for results of investigations.
erate elevations in the serum Derangements in LFTs indi- ECG. under the diaphragm as a may also be very helpful in This could be streamlined by
amylase level may occur in cate hepatobiliary or pancre- result of a perforated viscus. the diagnosis of acute appen- arranging appropriate blood
the presence of a perforated atic pathology, and subsequent Radiology Also, if there is any sugges- dicitis. Even if the appendix tests, and imaging, if indicated,
peptic ulcer, intestinal investigations should be With ready access to modern tion of a respiratory compo- is not seen, the presence of before the patient is sent to the
obstruction and even in ordered accordingly. Assess- imaging such as ultrasound, nent to the presentation, focal tenderness associated hospital.
mesenteric ischaemia. ment of electrolytes and renal CT or MRI, it is now uncom- pneumonia should be with a good history and clin- However, this should only
In patients with suspected function is essential in patients mon, and often unhelpful, to excluded by a CXR. ical signs may be enough evi- be done if it does not cause an
acute appendicitis, the clini- presenting with acute abdomi- order a plain abdominal X- Abdominal ultrasound is dence to clinch the diagnosis undue delay in receiving treat-
cal history and physical signs nal pain, to exclude dehydra- ray in patients who present one of the most useful diag- and justify surgical referral. ment. A legible letter from the
are far more reliable than tion and to guide the need for with acute abdominal pain. nostic tests for assessing acute Having said that, ultrasound referring doctor indicating
changes in the white cell fluid and electrolyte replace- Having said that, if there abdominal pain. It is cheap, of the abdomen is sometimes what tests have been done and
count. In most cases this ment. In patients with high is a clinical suspicion, and a readily available and non- limited by overlying gas-filled how the results can be
should be a clinical diagno- epigastric or retrosternal chest plain abdominal film is read- invasive and is the investiga- structures, obesity and inability accessed is extremely helpful
sis, and any serological or pain, blood should be checked ily available, then this (per- tion of choice for examining of the patient to tolerate the for emergency room staff.
absence of complications and acute renal failure will Less common acute hepatic abscess, splenic
such as an acute fluid collec- develop unless IV fluid resus- surgical conditions infarct or splenic abscess.
tion or abscess, are deter- citation is initiated promptly. Numerous other surgical These conditions may pre-
mined by a two-phase fine- In this setting it is sometimes conditions that may result in sent with subtle clinical
cut pancreatic CT scan. not possible to give an IV an acute abdomen include a symptoms and signs and
Severe acute pancreatitis contrast agent at the time of mesenteric embolus, mesen- ultimately may only be diag-
results in rapid dehydration, the CT scan. teric venous thrombosis, nosed by either CT or MRI.
Table 1: Causes of
pancreatitis (in order
of frequency)
■ Gallstones
(choledocholithiasis),
alcohol
■ Idiopathic
■ Post-ERCP
■ Trauma
■ Drugs (including
corticosteriods, frusemide,
ACE inhibitors) Summary of causes of upper abdominal pain
■ Hereditary Right upper-abdominal pain
■ Cholecystitis
■ Hypercalcaemia ■ Biliary colic
■ Choledocholithiasis/cholangitis
■ Developmental
■ Hepatic abscess
abnormalities of the
■ Retrocaecal appendicitis
pancreas (eg, pancreas
■ Hepatitis
divisum)
■ Right pyelonephritis
■ Hypertriglyceridaemia ■ Right renal calculi
Epigastric pain
■ Biliary colic
■ Peptic ulcer
■ Acute MI
Gynaecological conditions Renal conditions ■ Congestive cardiac failure with ■ Pericarditis
WOMEN of childbearing age who A diagnosis of acute renal colic can often hepatomegaly.
present with acute abdominal pain be made clinically with a typical history of ■ Diabetic ketoacidosis. Left upper-abdominal pain
may have a gynaecological problem. severe colicky flank pain radiating to the ■ Pancreatitis
Of these, ectopic pregnancy is the groin. This diagnosis is supported by the Should parenteral pain relief be ■ Left renal calculi
most serious acute pathology and presence of blood on urinalysis. A spiral given to patients with acute ■ Left pyelonephritis
accounts for about 9% of all preg- CT scan (without oral or IV contrast) is abdominal pain before surgical ■ Splenomegaly
nancy-related deaths. Abdominal the most useful investigation and will con- review? ■ Splenic abscess
pain, amenorrhoea and vaginal firm the diagnosis in most cases. In the past there has been confusion ■ Splenic infarction
bleeding are the classic presenting If the calculi are <5mm in diameter and about whether administration of analgesia ■ Splenic artery aneurysm
features. there is no urinary obstruction, there is a masks the signs of acute abdomen before ■ Gastritis (acute)
There should be a high index of 90% chance of spontaneous passage, and definitive surgical review. In fact there is ■ Left lower-lobe pneumonia
suspicion of this diagnosis in women patients can be safely treated conserva- no evidence that this is the case and, on ■ Diverticulitis
of childbearing age. A urinary (and tively. In the presence of larger calculi, or the contrary, appropriate pain relief may ■ High-intestinal obstruction
preferably serum) beta human chori- when there is obstructive sepsis, urgent actually assist in allowing a more thor- ■ Inflammatory bowel disease (proximal jejunal)
onic gonadotrophin test, together urological intervention may be required. ough abdominal examination. A small
with an urgent pelvic ultrasound, will In contrast with renal colic, patients dose of IM, SC or even IV pethidine or
make the diagnosis. with pyelonephritis usually present with morphine is appropriate for patients with
Confirming pregnancy is also signs of sepsis and with pain tending to be severe acute abdominal pain. What not to miss — the acute abdomen
important in determining whether more in the flank or lower back rather Another common misconception
■ Haemorrhage, eg, ruptured abdominal aortic aneurysm,
certain medications or diagnostic X- than the upper abdomen. Almost all relates to the administration of narcotic
haemorrhagic pancreatitis
ray procedures can be used, particu- patients with pyelonephritis have haema- analgesia in the presence of pancreatitis or
larly in the early stages of pregnancy. turia and pyuria on urinalysis. biliary disease. Although the sphincter of ■ Infection, eg, appendicitis, Meckel’s diverticulitis
Other gynaecological causes of Other non-surgical causes of abdomi- Oddi in some patients is sensitive to nar- ■ Perforation, eg, perforated gastric or duodenal ulcer,
acute abdominal pain include a rup- nal pain include: cotic analgesia (including morphine and perforated diverticulum, perforated colonic tumour
tured ovarian cyst, salpingitis, a ■ Acute hepatitis. codeine), there is no evidence that this ■ Obstruction, eg, incarcerated groin or incisional hernia
spontaneous or threatened abortion, ■ Lower-lobe pneumonia. form of analgesia increases the severity
■ Ischaemia, eg, strangulated hernia, mesenteric thrombosis
and ovarian torsion. ■ Pericarditis. or risks of complications of pancreatitis.
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Acute abdominal pain answer.
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1. Which THREE statements about b) CT scanning is now the investigation of 6. Which THREE statements about a c) Evidence of a thick-walled gallbladder
assessing patients with acute abdominal choice for examining the gallbladder and perforated viscus are correct? on ultrasound scan suggests cholecystitis
pain are correct? biliary tract a) Perforation of a peptic ulcer is a common d) Recurrent abdominal pain and fevers
a) Continuous abdominal pain is invariably c) The usefulness of abdominal ultrasound in acute surgical emergency associated with alteration in LFTs or
associated with peritoneal inflammation or investigating acute abdominal pain may be b) With acute perforation there may be jaundice suggests cholangitis
ischaemia limited by obesity and overlying gas-filled referral of pain to the shoulder tip
b) Pathology irritating the diaphragm may structures c) Perforation of either the colon or a peptic 9. Mark, 45, presents with acute, severe
cause referred pain to the shoulder tip, d) Radiological assessment in cases of ulcer may present as focal peritonitis epigastric pain radiating through to the
because both these structures are acute pancreatitis is best performed with d) Hypotension, tachycardia and tachypnoea back, associated with nausea and
innervated by the third cervical nerve ultrasound associated with a perforated viscus are vomiting. He has a previous history of
c) The patient should be directed to lie indicative of systemic sepsis acute pancreatitis. Which THREE
supine with the knees slightly flexed to 4. Which TWO statements about statements about acute pancreatitis are
relax the abdominal musculature suspected acute appendicitis are 7. Ingrid, 40, presents with a correct?
d) Rebound tenderness can be elicited by correct? history of intermittent upper-abdominal a) The two most common causes of
asking the patient to cough and then a) It is worthwhile to enquire about discomfort and nausea, especially pancreatitis in the Australian community
gauging their response exacerbation of pain with coughing or after eating fatty foods. Which are gallstones and excessive alcohol
straining TWO statements about biliary colic ingestion
2. Which TWO statements about b) The shift of pain from the initial are correct? b) Flank ecchymosis and periumbilical skin
assessing patients with acute abdominal peri-umbilical area to the right iliac a) The pain of biliary colic is classically discoloration are signs of severe acute
pain are correct? fossa reflects development of localised colicky rather than constant in nature pancreatitis
a) Patients should not be given peritonitis b) About 40% of patients with biliary colic c) Acute pancreatitis is easily diagnosed by
analgesia before surgical assessment, as c) A raised white cell count will clinch the complain of referred pain to the checking for an elevated serum amylase
this may mask the signs of an acute diagnosis in acute appendicitis interscapular or right shoulder area level
abdomen d) Abdominal ultrasound is not useful in the c) For patients with upper abdominal pain d) Severe acute pancreatitis requires urgent
b) Assessing electrolytes and renal function diagnosis of acute appendicitis suggestive of biliary colic, an ultrasound IV fluid resuscitation
is essential in patients presenting with scan would be the appropriate first-line
acute abdominal pain 5. Which THREE statements about investigation 10. Tom, 40, presents with acute left flank
c) Narcotic analgesia should not be given to abdominal aortic aneurysms are correct? d) A low-fat diet is of no benefit in patients pain. You suspect acute renal colic. Which
patients with biliary disease or a) New and persistent backache could be a with uncomplicated biliary colic TWO statements are correct?
pancreatitis, as this increases the risks of warning of impending rupture of an a) A typical presentation of acute renal colic
complications abdominal aortic aneurysm 8. You refer Ingrid for an abdominal is of severe colicky flank pain that radiates
d) In patients with high epigastric pain, blood b) The presence of macrohaematuria rules ultrasound. However, while awaiting her to the groin
should be checked for elevated troponin out an abdominal aortic aneurysm as the appointment she has an acute attack of b) If flank pain is associated with fevers or
levels in conjunction with a resting cause of the pain right upper-abdominal pain, associated rigors, a diagnosis of pyelonephritis
ECG c) Patients may experience sudden severe with fever. Which THREE statements are should be suspected
abdominal or epigastric pain radiating correct? c) Intravenous pyelography is the most
3. Which ONE statement about through to the back just before rupture of a) Right upper-quadrant pain with useful investigation for renal colic and will
radiological investigation of acute an abdominal aortic aneurysm exacerbation of pain on palpation during confirm the diagnosis in most cases
abdominal pain is correct? d) Symptoms and signs associated with deep inspiration (Murphy’s sign) usually d) If renal calculi are <1cm in diameter there
a) A normal plain abdominal and erect CXR rupture of an abdominal aortic aneurysm indicates acute cholecystitis is a 90% chance of spontaneous passage,
rules out the diagnosis of a perforated include pre-syncope, diaphoresis, nausea b) Absence of a leucocytosis excludes a and these patients can be safely treated
viscus or tachycardia diagnosis of acute cholecystitis conservatively
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