Abdominal pain
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Abdominal Pain
Abdominal pain is one of the most common clinical presentations, requiring careful history-taking and examination to distinguish urgent surgical/medical conditions from benign causes (Harrison's, p. 554).
Differential Diagnosis by Location
| Region | Key Diagnoses |
|---|---|
| Right subcostal (RUQ) | Hepatitis, cholecystitis, biliary colic |
| Epigastric | Peptic ulcer disease, pancreatitis, GERD, MI (referred) |
| Left subcostal (LUQ) | Splenic injury/infarct, gastric pathology |
| Right flank | Renal colic, ureteric stone, pyelonephritis |
| Periumbilical | Early appendicitis, bowel obstruction, aortic aneurysm |
| Left flank | Renal colic, ureteric stone, pyelonephritis |
| Right iliac fossa (RIF) | Appendicitis, ovarian cyst/torsion, ectopic pregnancy |
| Suprapubic / hypogastric | UTI, PID, ovarian cyst, bladder pathology |
| Left iliac fossa (LIF) | Diverticulitis, sigmoid volvulus, IBD |
Character of Pain
| Quality | Suggests |
|---|---|
| Colicky (waves) | Bowel obstruction, ureteric/biliary colic |
| Constant, severe | Peritonitis, mesenteric ischemia, pancreatitis |
| Burning | Peptic ulcer, GERD |
| Tearing/ripping | Aortic dissection/aneurysm |
| Onset: sudden ("thunderclap") | Perforated viscus, ruptured AAA, ectopic pregnancy |
Key Red Flags (Urgent/Surgical)
- Sudden onset, severe, or rapidly worsening pain
- Hemodynamic instability (tachycardia, hypotension)
- Peritoneal signs: guarding, rigidity, rebound tenderness
- Fever with localized tenderness
- Absent bowel sounds (ileus/obstruction)
- Pulsatile abdominal mass
- Pregnancy with acute pain (ectopic until proven otherwise)
Evaluation Approach
History:
- Onset, duration, character, severity (1–10)
- Location and radiation (e.g., to back: pancreatitis, AAA; to shoulder: diaphragmatic irritation)
- Aggravating/relieving factors (food, position, defecation)
- Associated symptoms: nausea, vomiting, diarrhea, fever, hematuria, dysuria, vaginal discharge, last menstrual period
Examination:
- Vital signs (fever, hypotension, tachycardia)
- Inspection, auscultation, percussion, palpation
- Special signs: Murphy's (cholecystitis), Rovsing's/McBurney's (appendicitis), psoas sign, obturator sign, Carnett's sign (wall vs. visceral)
Investigations (tailor to presentation):
| Test | Utility |
|---|---|
| FBC, CRP, ESR | Infection, inflammation |
| LFTs, lipase/amylase | Hepatobiliary, pancreatic |
| Urine dipstick / MC&S | UTI, renal colic, haematuria |
| Beta-hCG (women of reproductive age) | Ectopic pregnancy |
| AXR | Obstruction, perforation (free air under diaphragm) |
| Erect CXR | Free air (perforated viscus) |
| USS abdomen/pelvis | Gallstones, appendicitis, ovarian pathology, AAA |
| CT abdomen/pelvis | Gold standard for acute abdomen workup |
Broad Cause Categories
- Surgical (acute abdomen): appendicitis, cholecystitis, perforated ulcer, bowel obstruction, ischemia, ruptured AAA, ectopic pregnancy
- Medical: pancreatitis, hepatitis, IBD, IBS, pyelonephritis, diabetic ketoacidosis, Addisonian crisis
- Gynaecological: PID, ovarian torsion, ectopic pregnancy, endometriosis
- Referred pain: MI (epigastric), pleurisy, lower lobe pneumonia
- Functional: IBS, functional dyspepsia
Is there a specific aspect of abdominal pain you'd like to focus on — a particular diagnosis, age group, management algorithm, or something else?
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