Acute abdominal pain is any abdominal pain of less than 7-10 days duration. It is the commonest cause of pain on surgical wards.
- appendicitis 25%
- diverticular disease 2%
- perforated ulcer 2%
- non-specific abdominal pain (NSAP) 45%
- cholecystitis 10%
- bowel obstruction 4%
- pancreatitis 2%
- renal colic 4%
- dyspepsia 5%
- (pelvic inflammatory disease (PID) 5%)
The causes of acute abdominal pain, however, are most conveniently considered stratified according to age:
young children
- intussusception
- urinary tract infection
- hernia
older children
- intussusception
- acute appendicitis
Other differentials for intussusception:
- gastroenteritis causing ileus
- other causes of intestinal obstruction
- constipation
- haemolytic uraemic syndrome
Other differentials for acute appendicitis:
- mesenteric lymphadenitis
- Henoch-Schönlein Purpura
- Sickle Cell Anaemia
- Meckel’s Diverticulum
- Cystic Fibrosis
- Renal Tract disorders
- Liver / biliary tract disease
- Pancreatitis
- Pneumonia
- Miscellaneous – other abdominal pain in childhood
- medication-related
- torsion testis
- peptic ulcer disease
- reflux oesophagitis
young adult males
- trauma
- Crohn’s disease
- ethanol
young adult females
- urinary tract infection
- pelvic inflammatory disease
- ovarian cyst
- ectopic pregnancy
- abortion
elderly
- increased mortality of ∼ 7% (cf. 0.1% young adult)
- lower diagnostic accuracy ∼ 30%
- ∼ 10% > 50 years old have a malignancy – colon (Europe, Nth Am.), liver (tropics)
- ∼ 10% > 70-year old have vascular cause – mesenteric insufficiency, aortic aneurysm, AMI
- perforation (half from colon and the other half from appendix or PUD) occurs more quickly and more frequently in > 50 year old → generalised peritonitis
How to recognise common causes of abdominal pain – short list of symptoms helpful in diagnosing common conditions:
acute appendicitis
- pain shifting to right lower quadrant (RLQ)
- pain aggravated by movement, cough
- nausea, vomiting, anorexia
- flushing (despite normal body temperature)
- local tenderness RLQ
- rebound and guarding
- tender on right side during PR examination
Heuristic (rule-of-thumb) based on above criteria:
-
- 0-1: home
- 2: observe
- 3: surgical admit and review
- 4: OR
cancer in elderly presenting with (masquerading as) abdominal pain
- > 60 years old
- pain > 48 hours
- pain getting worse
- recent change in bowel habit
- dysuria, increased frequency
- abdominal distension
- abdominal mass
General guide to house-surgeon decision making:
- should patient be admitted?
- to which service should be the admission?
- should patient be operated upon?
- any other management necessary?
