30 types of abdominal disease treatment tablet injection all details management differential diagnosis and use investigation detail impression
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Now I have enough textbook context to provide a comprehensive answer. Let me compose the full clinical reference covering 30 abdominal diseases.
30 Abdominal Diseases — Complete Clinical Reference
Covering: Presentation · Investigations · Differential Diagnosis · Management (Tablets, Injections, Procedures)
HOW TO USE THIS GUIDE
Each condition includes:
- Clinical impression (key features)
- Investigations
- Differential diagnosis
- Tablets (oral drugs)
- Injections / IV drugs
- Other management
1. ACUTE APPENDICITIS
Clinical Impression: Periumbilical pain migrating to RIF, fever, nausea, Rovsing's/McBurney's sign positive, rebound tenderness.
Investigations: WBC (↑ neutrophilia), CRP, urinalysis, USS abdomen, CT abdomen with contrast (gold standard), β-hCG in females.
Differential Diagnosis: Mesenteric adenitis, Meckel's diverticulitis, ovarian cyst torsion, ectopic pregnancy, Crohn's ileitis, right-sided ureteric colic, PID.
| Route | Drug | Dose |
|---|---|---|
| Tablet | Ciprofloxacin + Metronidazole (mild/uncomplicated) | Cipro 500 mg BD + Metro 400 mg TDS × 7–10 days |
| IV | Piperacillin-Tazobactam | 4.5 g TDS |
| IV | Cefuroxime + Metronidazole | Cef 1.5 g TDS + Metro 500 mg TDS |
| IM/IV | Morphine or Tramadol (analgesia) | Morphine 0.1 mg/kg IV |
Management: Appendicectomy (laparoscopic preferred). Antibiotics alone for uncomplicated appendicitis (select cases). NPO, IV fluids, catheter.
2. ACUTE PANCREATITIS
Clinical Impression: Severe epigastric pain radiating to back, nausea, vomiting, Cullen's/Grey Turner's signs (haemorrhagic), elevated amylase/lipase >3× normal.
Investigations: Serum amylase, lipase, LFTs, calcium, triglycerides, glucose, FBC, CRP, USS (gallstones), CT abdomen (Balthazar scoring), MRCP.
Differential Diagnosis: Peptic ulcer perforation, acute cholecystitis, mesenteric ischaemia, aortic dissection, inferior MI.
| Route | Drug | Dose |
|---|---|---|
| Tablet | Omeprazole (PPI) | 40 mg OD |
| Tablet | Ursodeoxycholic acid (gallstone prevention) | 600 mg OD |
| IV | Hartmann's/Normal Saline (aggressive fluid resuscitation) | 250–500 mL/hr initially |
| IV/IM | Morphine sulfate | 5–10 mg q4h |
| IV | Meropenem (infected necrosis) | 1 g TDS |
| SC | Enoxaparin (DVT prophylaxis) | 40 mg OD |
Management: NPO → early enteral feeding (nasojejunal), analgesia, correct electrolytes. ERCP if biliary obstruction. Surgical necrosectomy if infected necrosis fails conservative care.
3. ACUTE CHOLECYSTITIS
Clinical Impression: RUQ pain, fever, Murphy's sign positive, post-fatty meal onset, jaundice if Mirizzi syndrome.
Investigations: FBC, LFTs, amylase, USS (gallstones, wall thickening, pericholecystic fluid), HIDA scan (if USS inconclusive).
Differential Diagnosis: Acute pancreatitis, peptic ulcer, hepatitis, right-lower pneumonia, Fitz-Hugh-Curtis syndrome.
| Route | Drug | Dose |
|---|---|---|
| Tablet | Amoxicillin-Clavulanate | 625 mg TDS × 7 days |
| Tablet | Ciprofloxacin + Metronidazole | 500 mg BD + 400 mg TDS |
| IV | Cefazolin | 1–2 g TDS |
| IV | Piperacillin-Tazobactam | 4.5 g TDS |
| IV/IM | Ketorolac or Morphine | Ketorolac 30 mg IV |
| IV | Metronidazole | 500 mg TDS |
Management: Laparoscopic cholecystectomy (within 72h preferred). Percutaneous cholecystostomy if high surgical risk.
4. PEPTIC ULCER DISEASE (PUD)
Clinical Impression: Epigastric burning pain (gastric ulcer: worse with food; duodenal ulcer: relieved by food), haematemesis, melaena.
Investigations: OGD (gold standard), H. pylori testing (CLO test, stool antigen, urea breath test), FBC, serum gastrin.
Differential Diagnosis: GORD, gastritis, pancreatitis, gallstones, gastric cancer, functional dyspepsia.
| Route | Drug | Dose |
|---|---|---|
| Tablet | Omeprazole (PPI) | 20–40 mg OD |
| Tablet | Lansoprazole | 30 mg OD |
| Tablet | H. pylori Triple Therapy: Amoxicillin + Clarithromycin + PPI | 1 g BD + 500 mg BD + PPI BD × 14 days |
| Tablet | H. pylori Quadruple Therapy: Bismuth + Tetracycline + Metronidazole + PPI | Standard 10–14 days |
| IV | Omeprazole infusion (acute bleed) | 80 mg bolus → 8 mg/hr × 72h |
| IV | Pantoprazole | 40 mg BD |
| Injection | Adrenaline 1:10,000 (endoscopic injection) | Local at bleeding site |
Management: Endoscopy + haemostasis for bleeding. Stop NSAIDs. Sucralfate 1 g QDS (mucosal protectant). Surgery (truncal vagotomy + pyloroplasty) if refractory.
5. GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD)
Clinical Impression: Heartburn, regurgitation, dysphagia, hoarseness, chronic cough, worse when supine.
Investigations: OGD + biopsy, 24-hour pH monitoring, oesophageal manometry, barium swallow.
Differential Diagnosis: PUD, oesophagitis, eosinophilic oesophagitis, achalasia, cardiac chest pain.
| Route | Drug | Dose |
|---|---|---|
| Tablet | Omeprazole | 20 mg OD (maintenance); 40 mg OD (acute) |
| Tablet | Pantoprazole / Rabeprazole | 40 mg OD |
| Tablet | Ranitidine (H2-blocker) or Famotidine | Famotidine 20 mg BD |
| Tablet | Domperidone (prokinetic) | 10 mg TDS before meals |
| Tablet | Metoclopramide | 10 mg TDS |
| Tablet | Alginate (Gaviscon) | 10 mL after meals |
Management: Lifestyle: head-of-bed elevation, weight loss, avoid triggers. Antireflux surgery (Nissen fundoplication) if refractory.
6. IRRITABLE BOWEL SYNDROME (IBS)
Clinical Impression: Abdominal cramps + altered bowel habit (constipation-dominant, diarrhoea-dominant, or mixed), bloating, no alarm features, Rome IV criteria.
Investigations: FBC, CRP/ESR (exclude IBD), coeliac serology, TSH, stool calprotectin, colonoscopy (if alarm features).
Differential Diagnosis: IBD (Crohn's, UC), coeliac disease, colorectal cancer, microscopic colitis, SIBO.
| Route | Drug | Dose |
|---|---|---|
| Tablet | Mebeverine (antispasmodic) | 135–200 mg TDS |
| Tablet | Hyoscine butylbromide (Buscopan) | 10–20 mg TDS/QDS |
| Tablet | Loperamide (diarrhoea-IBS) | 2–4 mg after loose stool (max 16 mg/day) |
| Tablet | Lactulose / Macrogol (constipation-IBS) | 15–30 mL BD |
| Tablet | Low-dose Amitriptyline | 10–50 mg nocte |
| Tablet | Rifaximin (SIBO-related) | 550 mg TDS × 14 days |
| Tablet | Mesalazine (post-infectious IBS) | 400–800 mg TDS |
Management: Low-FODMAP diet, probiotics, psychological therapy (CBT). Linaclotide (IBS-C) 290 mcg OD. Alosetron (IBS-D, women).
7. INFLAMMATORY BOWEL DISEASE — CROHN'S DISEASE
Clinical Impression: Chronic diarrhoea, abdominal pain, weight loss, perianal disease (fistulae, skin tags), skip lesions, transmural inflammation, string sign on imaging.
Investigations: FBC, CRP, ESR, stool calprotectin, OGD + colonoscopy + biopsy, CT enterography, MRI small bowel, ASCA antibodies.
Differential Diagnosis: UC, TB, IBS, lymphoma, Behçet's disease, NSAID enteropathy.
| Route | Drug | Dose |
|---|---|---|
| Tablet | Prednisolone (induction) | 40 mg OD tapering |
| Tablet | Budesonide (ileo-caecal) | 9 mg OD × 8 weeks |
| Tablet | Azathioprine (maintenance) | 2–2.5 mg/kg/day |
| Tablet | 6-Mercaptopurine | 1–1.5 mg/kg/day |
| Tablet | Methotrexate | 25 mg/week oral/SC |
| Tablet | Mesalazine (mild) | 2–4 g/day |
| SC Injection | Adalimumab (anti-TNF) | 160 mg → 80 mg → 40 mg EOW |
| IV Injection | Infliximab (anti-TNF) | 5 mg/kg at 0, 2, 6 weeks then q8w |
| IV | Hydrocortisone (severe flare) | 100 mg QDS |
| SC | Vedolizumab or Ustekinumab | Per schedule |
Management: Elemental diet (remission induction in paeds). Surgery: stricturoplasty, resection of refractory segments.
8. ULCERATIVE COLITIS (UC)
Clinical Impression: Bloody diarrhoea, mucus per rectum, urgency, tenesmus, diffuse continuous colonic inflammation from rectum proximally.
Investigations: FBC, ESR, CRP, stool MC+S, calprotectin, flexible sigmoidoscopy/colonoscopy + biopsy, AXR (toxic megacolon: colonic diameter >6 cm).
Differential Diagnosis: Crohn's disease, infective colitis, ischaemic colitis, microscopic colitis, CMV colitis.
| Route | Drug | Dose |
|---|---|---|
| Tablet | Mesalazine (5-ASA) | 2.4–4.8 g/day |
| Tablet | Sulfasalazine | 1–2 g BD |
| Tablet | Prednisolone (moderate-severe) | 40 mg OD tapering |
| Tablet | Azathioprine | 2–2.5 mg/kg/day |
| Enema/Suppository | Mesalazine enema | 1 g OD per rectum |
| IV | Hydrocortisone (severe UC) | 100 mg QDS |
| IV | Infliximab (acute severe, steroid-refractory) | 5 mg/kg |
| IV | Ciclosporin (steroid-refractory) | 2 mg/kg/day continuous infusion |
| SC | Vedolizumab | 300 mg at 0, 2, 6 weeks then q8w |
Management: Colectomy (panproctocolectomy ± ileal pouch) for refractory/fulminant disease or dysplasia.
9. LIVER CIRRHOSIS
Clinical Impression: Jaundice, spider naevi, palmar erythema, Dupuytren's, caput medusae, ascites, splenomegaly, asterixis, hepatic encephalopathy, variceal bleeding.
Investigations: LFTs, albumin, PT/INR, FBC, U&E, Child-Pugh/MELD score, USS + Doppler, liver biopsy, endoscopy (varices), AFP (HCC screen).
Differential Diagnosis: Acute liver failure, cardiac failure (congestive hepatomegaly), hepatic vein thrombosis (Budd-Chiari), NAFLD.
| Route | Drug | Dose |
|---|---|---|
| Tablet | Spironolactone (ascites) | 100–400 mg OD |
| Tablet | Furosemide | 40–160 mg OD |
| Tablet | Propranolol (variceal prophylaxis) | 40 mg BD (titrate to HR 55–60) |
| Tablet | Carvedilol | 6.25 mg BD |
| Tablet | Lactulose (encephalopathy) | 30–50 mL TDS (2–3 loose stools/day) |
| Tablet | Rifaximin (encephalopathy) | 550 mg BD |
| Tablet | Norfloxacin (SBP prophylaxis) | 400 mg OD |
| IV | Terlipressin (variceal bleed) | 2 mg q4h → 1 mg q4h |
| IV | Octreotide | 50 mcg bolus → 50 mcg/hr infusion |
| IV | Cefotaxime (SBP treatment) | 2 g TDS × 5 days |
| IV | Human Albumin (SBP/HRS) | 1.5 g/kg day 1, 1 g/kg day 3 |
Management: TIPS for refractory ascites/varices. Liver transplantation. Band ligation (endoscopic varices).
10. ACUTE LIVER FAILURE (ALF)
Clinical Impression: Jaundice, coagulopathy (INR >1.5), hepatic encephalopathy within 26 weeks of illness onset, no prior liver disease.
Investigations: LFTs, PT/INR, FBC, glucose, ABG, paracetamol levels, viral hepatitis serology, autoimmune panel, serum copper (Wilson's), USS liver.
Differential Diagnosis: Acute-on-chronic liver failure, sepsis, metabolic encephalopathy, Budd-Chiari.
| Route | Drug | Dose |
|---|---|---|
| IV | N-acetylcysteine (paracetamol OD) | 150 mg/kg over 1h → 50 mg/kg over 4h → 100 mg/kg over 16h |
| IV | Dextrose 10% (hypoglycaemia) | Continuous infusion |
| IV | Vitamin K | 10 mg OD |
| Tablet/NG | Lactulose | 30–50 mL TDS |
| IV | Mannitol (cerebral oedema) | 0.5–1 g/kg |
| IV | Terlipressin (HRS) | 1 mg q4h |
| IV | Broad-spectrum antibiotics (infection) | Piperacillin-tazobactam 4.5 g TDS |
Management: ICU. Liver transplant (King's College Criteria). Avoid sedatives, nephrotoxins.
11. ASCITES
Clinical Impression: Abdominal distension, shifting dullness, fluid thrill, peripheral oedema. SAAG ≥1.1 = portal hypertension.
Investigations: Diagnostic paracentesis (cell count, albumin, protein, culture), serum albumin (SAAG), USS, LFTs.
Differential Diagnosis: Cirrhosis, malignancy (peritoneal), cardiac failure, TB peritonitis, nephrotic syndrome, Meigs' syndrome.
| Route | Drug | Dose |
|---|---|---|
| Tablet | Spironolactone | 100 mg OD (up to 400 mg) |
| Tablet | Furosemide | 40 mg OD (up to 160 mg) |
| IV | Human Albumin (post large-volume paracentesis) | 6–8 g per litre removed |
Management: Low-sodium diet (<2 g/day). Large-volume paracentesis (>5 L). TIPS for refractory ascites.
12. SPONTANEOUS BACTERIAL PERITONITIS (SBP)
Clinical Impression: Fever, abdominal pain/tenderness, worsening encephalopathy in cirrhotic patient. Diagnostic: ascitic PMN >250/mm³.
Investigations: Ascitic tap (cell count, culture), blood cultures, FBC, CRP, creatinine.
Differential Diagnosis: Secondary peritonitis (perforated viscus), pancreatitis, tuberculous peritonitis.
| Route | Drug | Dose |
|---|---|---|
| IV | Cefotaxime | 2 g TDS × 5 days |
| IV | Piperacillin-Tazobactam | 4.5 g TDS |
| Tablet | Norfloxacin (primary/secondary prophylaxis) | 400 mg OD |
| Tablet | Ciprofloxacin (prophylaxis alternative) | 500 mg OD |
| IV | Human Albumin | 1.5 g/kg at diagnosis, 1 g/kg day 3 |
13. GASTROINTESTINAL BLEEDING (UPPER)
Clinical Impression: Haematemesis ("coffee ground"), melaena, dizziness, hypotension, PR bleeding (massive). Rockford/Glasgow-Blatchford scoring.
Investigations: FBC, clotting, group & save/crossmatch, LFTs, U&E (elevated urea:creatinine ratio), OGD within 24h.
Differential Diagnosis: PUD (most common), varices, Mallory-Weiss tear, Dieulafoy's lesion, gastric cancer, aortoenteric fistula.
| Route | Drug | Dose |
|---|---|---|
| IV | Omeprazole (PPI) | 80 mg bolus → 8 mg/hr × 72h |
| IV | Terlipressin (variceal) | 2 mg q4h |
| IV | Octreotide | 50 mcg/hr infusion |
| IV | Tranexamic acid | 1 g over 10 min (within 3h) |
| IV | Ceftriaxone (varices) | 1 g OD (infection prophylaxis) |
| IV | FFP, Platelets, pRBC | As per massive haemorrhage protocol |
Management: Resuscitation. OGD (adrenaline injection + haemoclip/thermal). Band ligation (varices). Sengstaken tube (rescue). Surgery if endoscopy fails.
14. LOWER GI BLEEDING
Clinical Impression: Bright red PR bleeding, haematochezia, often diverticular, angiodysplastic or haemorrhoidal. Older patients, painless typically.
Investigations: FBC, clotting, PR exam, rigid/flexible sigmoidoscopy, colonoscopy, CT angiography (active bleeding), radionuclide scan.
Differential Diagnosis: Haemorrhoids, diverticular disease, angiodysplasia, colorectal cancer, IBD, ischaemic colitis, polyps.
| Route | Drug | Dose |
|---|---|---|
| IV | Tranexamic acid | 1 g TDS |
| IV | Omeprazole | 40 mg BD |
| Topical | Haemorrhoidal cream (lidocaine + hydrocortisone) | Apply BD |
| IV/IM | Phytomenadione (Vitamin K) | 10 mg |
Management: Resuscitation, colonoscopic haemostasis. Interventional radiology (embolisation). Surgery (resection) if fails.
15. INTESTINAL OBSTRUCTION
Clinical Impression: Colicky abdominal pain, vomiting (faeculent), absolute constipation, abdominal distension, high-pitched "tinkling" bowel sounds. AXR: dilated loops, air-fluid levels.
Investigations: AXR, CT abdomen (identifies level/cause), FBC, U&E, serum lactate (strangulation).
Differential Diagnosis: Pseudo-obstruction (Ogilvie), ileus, volvulus, intussusception, constipation.
| Route | Drug | Dose |
|---|---|---|
| IV | Normal saline / Hartmann's (fluid resuscitation) | As per assessment |
| IV/IM | Morphine | 5–10 mg q4h |
| IV | Metoclopramide | 10 mg TDS |
| IV | Neostigmine (pseudo-obstruction) | 2 mg slow IV infusion |
| Tablet/Enema | Lactulose / Phosphate enema (functional) | Per rectum |
Management: NGT decompression ("drip and suck"). Surgical: adhesiolysis, resection ± stoma for obstruction not resolving. Endoscopic stenting for colorectal cancer.
16. ACUTE MESENTERIC ISCHAEMIA
Clinical Impression: Severe central abdominal pain "out of proportion to examination", atrial fibrillation history, acute onset, bloody diarrhoea late. Surgical emergency.
Investigations: Serum lactate (↑↑), FBC, ABG, CT angiography (gold standard), D-dimer, LDH.
Differential Diagnosis: Aortic dissection, strangulated obstruction, ruptured AAA, acute pancreatitis.
| Route | Drug | Dose |
|---|---|---|
| IV | Unfractionated heparin | 80 units/kg bolus → 18 units/kg/hr |
| IV | Piperacillin-Tazobactam | 4.5 g TDS |
| IV | Papaverine (intra-arterial, non-occlusive) | 30–60 mg/hr |
| IV | Morphine | 5–10 mg q4h |
Management: Emergency laparotomy (resection of infarcted bowel). Embolectomy / bypass. Anticoagulation. Second-look laparotomy at 24–48h.
17. DIVERTICULITIS
Clinical Impression: Left iliac fossa pain, fever, change in bowel habit, nausea. "Left-sided appendicitis." Complicated: abscess, perforation, fistula.
Investigations: FBC, CRP, USS/CT abdomen (wall thickening, pericolic fat stranding, abscess).
Differential Diagnosis: Colorectal cancer, IBD, ischaemic colitis, IBS, ovarian pathology.
| Route | Drug | Dose |
|---|---|---|
| Tablet | Amoxicillin-Clavulanate | 625 mg TDS × 7–10 days |
| Tablet | Ciprofloxacin + Metronidazole | 500 mg BD + 400 mg TDS |
| IV | Cefuroxime + Metronidazole | Cef 1.5 g TDS + Metro 500 mg TDS |
| IV | Piperacillin-Tazobactam (complicated) | 4.5 g TDS |
| IV/IM | Morphine | 5–10 mg q4h |
Management: Mild: oral antibiotics + clear fluids outpatient. Complicated: inpatient IV antibiotics ± CT-guided drainage of abscess. Surgery (Hartmann's procedure) for perforation/peritonitis.
18. COLORECTAL CANCER (CRC)
Clinical Impression: Change in bowel habit, rectal bleeding, weight loss, iron-deficiency anaemia, tenesmus, palpable mass, Dukes/TNM staging.
Investigations: FBC, CEA, colonoscopy + biopsy, CT chest/abdomen/pelvis (staging), MRI rectum, PET scan.
Differential Diagnosis: IBD, diverticular disease, haemorrhoids, ischaemic colitis, solitary rectal ulcer.
| Route | Drug | Dose |
|---|---|---|
| IV | 5-Fluorouracil (5-FU) + Leucovorin (FOLFOX) | Standard chemotherapy regimen |
| IV | Oxaliplatin (FOLFOX) | 85 mg/m² q2w |
| IV | Irinotecan (FOLFIRI) | 180 mg/m² q2w |
| IV | Bevacizumab (anti-VEGF) | 5 mg/kg q2w |
| IV | Cetuximab/Panitumumab (KRAS wild-type) | Per schedule |
| Tablet | Capecitabine (oral 5-FU prodrug) | 1250 mg/m² BD days 1–14 |
Management: Curative surgical resection (hemicolectomy, anterior resection, APR). Neoadjuvant chemoradiotherapy (rectal cancer). Palliative: stenting, colostomy.
19. HEPATOCELLULAR CARCINOMA (HCC)
Clinical Impression: Known cirrhosis, RUQ pain, weight loss, ↑ AFP, arterially enhancing liver lesion with portal venous washout on CT/MRI (LI-RADS 5).
Investigations: AFP, LFTs, USS liver (surveillance 6-monthly), triphasic CT/MRI liver, biopsy (if non-diagnostic imaging).
Differential Diagnosis: Cholangiocarcinoma, metastases, hepatic adenoma, focal nodular hyperplasia, haemangioma.
| Route | Drug | Dose |
|---|---|---|
| Tablet | Sorafenib (unresectable, first line) | 400 mg BD |
| Tablet | Lenvatinib (alternative first line) | 8–12 mg OD |
| IV | Atezolizumab + Bevacizumab (immunotherapy combo) | Per schedule |
| IV | Doxorubicin (TACE) | Intra-arterial via catheter |
Management: Resection (Child-Pugh A), liver transplant (Milan criteria), RFA (≤3 cm), TACE (intermediate), SBRT, sorafenib (advanced).
20. GALLSTONE DISEASE / CHOLEDOCHOLITHIASIS
Clinical Impression: Biliary colic (RUQ colicky pain → shoulder tip), Charcot's triad (jaundice + fever + RUQ pain = cholangitis), Reynold's pentad (+ shock + confusion = suppurative cholangitis).
Investigations: LFTs (↑ ALP, GGT, bilirubin), USS (cholelithiasis), MRCP (choledocholithiasis), ERCP (therapeutic).
Differential Diagnosis: Acute cholecystitis, pancreatitis, peptic ulcer, hepatitis, cholangiocarcinoma.
| Route | Drug | Dose |
|---|---|---|
| Tablet | Ursodeoxycholic acid (gallstone dissolution) | 8–15 mg/kg/day |
| Tablet | Ciprofloxacin + Metronidazole (cholangitis) | 500 mg BD + 400 mg TDS |
| IV | Piperacillin-Tazobactam | 4.5 g TDS |
| IV | Ceftriaxone | 2 g OD |
| IV/IM | Diclofenac or Tramadol (biliary colic) | Diclofenac 75 mg IM |
Management: ERCP + sphincterotomy + stone extraction. Laparoscopic cholecystectomy. Cholecystostomy if unfit for surgery.
21. INGUINAL/ABDOMINAL WALL HERNIA
Clinical Impression: Groin/abdominal swelling, cough impulse, reducible vs. irreducible vs. strangulated (severe pain, vomiting, no bowel sounds over hernia = emergency).
Investigations: Clinical diagnosis. USS if uncertain. CT abdomen if strangulation suspected.
Differential Diagnosis: Lymph node enlargement, hydrocele, femoral aneurysm, lipoma, undescended testis.
| Route | Drug | Dose |
|---|---|---|
| IV/IM | Morphine (strangulated) | 5–10 mg |
| IV | Antibiotics (pre-operative) | Cefazolin 2 g IV at induction |
Management: Elective: open (Lichtenstein) or laparoscopic (TAPP/TEP) repair with mesh. Emergency: immediate surgery + bowel resection if necrotic.
22. PERITONITIS
Clinical Impression: Generalised abdominal rigidity ("board-like"), guarding, rebound tenderness, absent bowel sounds, systemic sepsis. Cause: perforated viscus, SBP.
Investigations: FBC, CRP, lactate, AXR/erect CXR (free air = perforation), CT abdomen.
Differential Diagnosis: Acute abdomen (any cause), pseudo-peritonitis (DKA, Addisonian crisis, porphyria), pelvic peritonitis.
| Route | Drug | Dose |
|---|---|---|
| IV | Piperacillin-Tazobactam | 4.5 g TDS |
| IV | Meropenem (severe sepsis) | 1 g TDS |
| IV | Metronidazole | 500 mg TDS |
| IV/IM | Morphine | 5–10 mg q4h |
| IV | Noradrenaline (vasopressor, septic shock) | 0.1–0.3 mcg/kg/min |
Management: Emergency laparotomy. Washout + repair of perforation. ICU. Sepsis 6 bundle.
23. ABDOMINAL AORTIC ANEURYSM (AAA) — RUPTURED
Clinical Impression: Severe tearing back/flank pain, pulsatile abdominal mass, hypotension, classic triad. Mortality >50%. Immediate surgical emergency.
Investigations: Bedside USS (diagnostic), CT angiography (haemodynamically stable), FBC, crossmatch 10 units.
Differential Diagnosis: Renal colic, acute pancreatitis, mesenteric ischaemia, acute MI.
| Route | Drug | Dose |
|---|---|---|
| IV | Blood products (pRBC, FFP, platelets — 1:1:1 ratio) | Massive transfusion protocol |
| IV | Tranexamic acid | 1 g over 10 min |
| IV | Noradrenaline (permissive hypotension: SBP 70–80) | Vasopressor support |
Management: Emergency open surgery (EVAR if anatomy suitable). Haemostatic resuscitation. ICU post-op.
24. RENAL/URETERIC COLIC
Clinical Impression: Severe loin-to-groin colicky pain, haematuria, nausea. Pain "makes patient roll around." Urinalysis: blood ++ without infection.
Investigations: Urinalysis + MC+S, serum creatinine, calcium, urate, non-contrast CT KUB (gold standard), USS (first-line if pregnant).
Differential Diagnosis: AAA, appendicitis, ovarian cyst torsion, musculoskeletal.
| Route | Drug | Dose |
|---|---|---|
| Tablet | Diclofenac (NSAID) | 75 mg BD (if no contraindication) |
| Tablet | Tamsulosin (alpha-blocker, facilitates stone passage) | 0.4 mg OD × 4 weeks |
| IM | Diclofenac | 75 mg IM |
| IV/IM | Morphine | 5–10 mg q4h |
| IV | Ketorolac | 30 mg IV |
Management: Stones <5 mm: conservative + tamsulosin. Stones >10 mm / obstruction: ureteroscopy (URS) or ESWL. Nephrostomy if obstructed + infected (pyonephrosis = emergency).
25. ACUTE PYELONEPHRITIS
Clinical Impression: Fever, rigors, loin pain/tenderness, dysuria, frequency. Costovertebral angle tenderness.
Investigations: Urinalysis + MC+S, FBC, CRP, blood cultures, renal USS (exclude obstruction, abscess).
Differential Diagnosis: Pelvic inflammatory disease, appendicitis, renal calculus, diverticulitis.
| Route | Drug | Dose |
|---|---|---|
| Tablet | Ciprofloxacin | 500 mg BD × 7–14 days |
| Tablet | Co-amoxiclav | 625 mg TDS × 14 days |
| Tablet | Trimethoprim | 200 mg BD × 14 days |
| IV | Ceftriaxone (severe/admitted) | 1–2 g OD |
| IV | Gentamicin | 5 mg/kg OD (monitor levels) |
| IV | Ciprofloxacin | 400 mg BD |
Management: Oral antibiotics if mild. IV if severe/sepsis/unable to tolerate oral. Treat underlying obstruction. Drainage if abscess.
26. ECTOPIC PREGNANCY
Clinical Impression: Lower abdominal pain, amenorrhoea, positive β-hCG, vaginal bleeding. Rupture: peritonism, haemodynamic collapse, shoulder tip pain (diaphragmatic irritation).
Investigations: Serum β-hCG (serial), TVUSS (empty uterus, adnexal mass), FBC, group & save.
Differential Diagnosis: Threatened miscarriage, ovarian cyst torsion/haemorrhage, appendicitis, PID.
| Route | Drug | Dose |
|---|---|---|
| IM | Methotrexate (medical management, haemodynamically stable, unruptured) | 50 mg/m² single dose |
| IV/IM | Morphine | Analgesia |
| IV | Blood products | If haemorrhagic shock |
Management: Surgical (laparoscopic salpingectomy/salpingotomy) if ruptured or haemodynamically unstable. Anti-D immunoglobulin (RhD negative patients). Follow-up β-hCG monitoring post-methotrexate.
27. PELVIC INFLAMMATORY DISEASE (PID)
Clinical Impression: Lower abdominal pain, cervical motion tenderness (chandelier sign), adnexal tenderness, vaginal discharge, fever.
Investigations: Endocervical swabs (NAAT: gonorrhoea/chlamydia), FBC, CRP, pelvic USS (TOA), β-hCG (exclude ectopic).
Differential Diagnosis: Ectopic pregnancy, appendicitis, ovarian cyst torsion, endometriosis, UTI.
| Route | Drug | Dose |
|---|---|---|
| Tablet | Doxycycline + Metronidazole | Doxy 100 mg BD × 14 days + Metro 400 mg BD × 14 days |
| Tablet | Ofloxacin + Metronidazole | Oflo 400 mg BD + Metro 400 mg BD × 14 days |
| IV | Cefoxitin + Doxycycline (inpatient) | Cefoxitin 2 g QDS + Doxy 100 mg BD |
| IM | Ceftriaxone | 500 mg single dose (gonorrhoea) |
Management: Outpatient if mild. Inpatient if severe, pregnant, TOA, surgical emergency excluded. Drain TOA if ≥3 cm or not responding.
28. ABDOMINAL TUBERCULOSIS
Clinical Impression: Chronic abdominal pain, weight loss, night sweats, ascites (high protein), diarrhoea/constipation, ileocaecal mass.
Investigations: CXR, Mantoux/IGRA (QuantiFERON), ascitic fluid (lymphocytic, high protein, ADA >40 U/L), colonoscopy + biopsy (caseating granulomas), CT abdomen, PCR for TB.
Differential Diagnosis: Crohn's disease, colorectal malignancy, lymphoma, peritoneal carcinomatosis, amoebic abscess.
| Route | Drug | Dose |
|---|---|---|
| Tablet | Isoniazid (H) | 5 mg/kg/day (max 300 mg) |
| Tablet | Rifampicin (R) | 10 mg/kg/day (max 600 mg) |
| Tablet | Pyrazinamide (Z) | 25 mg/kg/day |
| Tablet | Ethambutol (E) | 15–20 mg/kg/day |
| Tablet | Pyridoxine (vitamin B6 with INH) | 10–25 mg OD |
Management: 2HRZE / 4HR (2 months intensive phase → 4 months continuation). Corticosteroids (prednisolone 40 mg) for TB peritonitis/obstruction. Surgery for intestinal obstruction or perforation.
29. HEPATITIS (VIRAL — B & C)
Clinical Impression: Jaundice, fatigue, RUQ discomfort, anorexia, dark urine, pale stools. Acute: self-limiting. Chronic: cirrhosis risk.
Investigations: HBsAg, HBeAg, anti-HBc, HBV DNA, HCV antibody, HCV RNA (PCR), LFTs, biopsy/Fibroscan.
Differential Diagnosis: Alcoholic hepatitis, autoimmune hepatitis, drug-induced liver injury, CMV/EBV hepatitis, Wilson's disease.
| Route | Drug | Dose |
|---|---|---|
| Tablet | Tenofovir alafenamide (HBV) | 25 mg OD |
| Tablet | Entecavir (HBV) | 0.5 mg OD (1 mg if prior lamivudine) |
| Tablet | Sofosbuvir + Velpatasvir (HCV pan-genotypic) | 1 tablet OD × 12 weeks |
| Tablet | Glecaprevir + Pibrentasvir (HCV 8 weeks) | 3 tablets OD × 8 weeks |
| SC Injection | Peginterferon alfa-2a (HBV/selected HCV) | 180 mcg/week × 48 weeks |
| Tablet | Ribavirin (with interferon) | Weight-based BD dosing |
Management: HCV cure rate >95% with DAAs. HBV: lifelong suppression with NAs. Liver transplant for end-stage. Screen household contacts / vaccinate.
30. ACUTE MESENTERIC LYMPHADENITIS
Clinical Impression: Children/young adults, central/RIF pain, fever, URTI prodrome, tender RIF lymph nodes. Mimics appendicitis but USS shows mesenteric nodes, normal appendix.
Investigations: FBC (lymphocytosis), CRP, USS abdomen (mesenteric lymph nodes >10 mm, normal appendix), throat swab (Yersinia/viral), Yersinia serology if suspected.
Differential Diagnosis: Acute appendicitis, Crohn's disease, infectious mononucleosis (EBV), TB lymphadenitis, lymphoma.
| Route | Drug | Dose |
|---|---|---|
| Tablet | Paracetamol (symptomatic) | 1 g QDS |
| Tablet | Ibuprofen | 400 mg TDS |
| Tablet | Ciprofloxacin (Yersinia confirmed) | 500 mg BD × 7–10 days |
| Tablet | Trimethoprim-Sulfamethoxazole (Yersinia) | 960 mg BD × 7 days |
Management: Usually self-limiting and resolves within 2–6 weeks. Analgesia, rest, fluids. Antibiotics only for bacterial cause (Yersinia enterocolitica). Reassess to exclude evolving appendicitis.
QUICK DIFFERENTIAL DIAGNOSIS MATRIX
| Location of Pain | Top Differentials |
|---|---|
| RUQ | Cholecystitis, Hepatitis, Choledocholithiasis, Fitz-Hugh-Curtis, Peptic ulcer, Subphrenic abscess |
| LUQ | Gastritis, Splenic infarct, Pancreatitis, Left pneumonia |
| Epigastric | PUD, GORD, Pancreatitis, Gastritis, MI (referred), Aortic dissection |
| RIF | Appendicitis, Crohn's, Mesenteric adenitis, Ectopic, Ovarian cyst, Ureteric colic |
| LIF | Diverticulitis, Sigmoid volvulus, IBD, Ectopic, Ovarian cyst |
| Central/Periumbilical | Early appendicitis, SBO, Mesenteric ischaemia, Aortic aneurysm, Gastroenteritis |
| Generalised | Peritonitis, Bowel perforation, SBP, Acute abdomen |
| Loin/Flank | Pyelonephritis, Renal colic, AAA (rupture), Retroperitoneal bleed |
KEY INVESTIGATION PRINCIPLES
| Test | When to Use |
|---|---|
| Erect CXR | Suspect perforation (free air under diaphragm) |
| CT Abdomen with contrast | Most acute surgical conditions (gold standard) |
| USS Abdomen | First-line for RUQ (gallstones), renal, pelvic |
| Serum Amylase/Lipase | Pancreatitis (lipase more specific) |
| Serum Lactate | Mesenteric ischaemia, sepsis, bowel necrosis |
| β-hCG | All women of reproductive age with abdominal pain |
| Calprotectin | IBD vs IBS differentiation |
| AXR | Obstruction, volvulus, toxic megacolon |
| MRCP/ERCP | Biliary tree pathology |
| Colonoscopy + biopsy | IBD, CRC, diverticular, TB |
COMMON ABDOMINAL DRUG CLASSES SUMMARY
| Class | Examples | Key Use |
|---|---|---|
| PPIs | Omeprazole, Pantoprazole | PUD, GORD, GI bleeding |
| Antispasmodics | Mebeverine, Hyoscine | IBS, colic |
| Aminosalicylates | Mesalazine, Sulfasalazine | IBD (UC/Crohn's) |
| Corticosteroids | Prednisolone, Hydrocortisone, Budesonide | IBD flares, TB peritonitis |
| Immunomodulators | Azathioprine, Methotrexate | IBD maintenance |
| Biologics | Infliximab, Adalimumab, Vedolizumab | IBD, refractory |
| Antibiotics | Ciprofloxacin, Metronidazole, Tazocin | Infections, peritonitis, SBP |
| Antivirals | Sofosbuvir, Entecavir, Tenofovir | Hepatitis B & C |
| Vasopressors | Terlipressin, Octreotide | Variceal bleed, hepatorenal |
| Diuretics | Spironolactone, Furosemide | Ascites, cirrhosis |
| Opioids | Morphine, Tramadol | Acute abdominal pain |
| Anti-TB | HRZE | Abdominal TB |
Sources: Yamada's Textbook of Gastroenterology 7e · Sleisenger and Fordtran's GI and Liver Disease · Sabiston Textbook of Surgery · Harrison's Principles of Internal Medicine 22e · Schwartz's Principles of Surgery 11e · GOLDMAN-CECIL Medicine
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