Generalised Abdominal Pain

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FieldsAppendicitis Abdominal Aortic Aneurysm Crohn's Disease Coeliac Disease Diabetic Ketoacidosis Large Bowel Obstruction Diverticulitis Ischaemic Bowel Lactose Intolerance GI Bleed Meckel's Diverticulum Ulcerative Colitis Small Bowel Obstruction Urinary Retention Testicular Torsion 
Age Rare in the very young and the very old Mean age 65 Typically aged 15-30 at first presentation Any age. Most common in infants and over 50's More common Increases with Age Increases with age Increases with age ●Common in adolescents-40yrs Increases with age Usually young children, can be any age Two peaks of incidence 15-30 (more common) and 55-65 All Ages Any Age. Most common in infants and over 50's Typically 11-30 years old. Occasionally Neontes 
Gender M = F M > F 5:1 F > M M = F F > M M = F M = F M = F M = F M > F M:F 2:1 Roughly Equal M = F M > F Men only! 
Typical Presentation A 12 year old boy is brought into A&E after sudden onset central abdominal pain and vomiting, without diarrhoea. Pain is exacerbated by movement. Tender RIF. An 65 year old man with a 20 pack year smoking history and type 2 diabetes presented to A&E with severe sudden onset epigastric pain which radiated to his back accompanied by testicular pain. A 20 year old woman presents to her GP with intermittent abdominal pain and diarrhoea. She has noticed that her clothes have become much loser. She has a 3 pack year smoking history. On examination, her abdomen is tender and painful red, raised lesions on the fronts of her shins. A 42 year old woman presents to her GP with chronic diarrhoea and weight loss, and diffuse intermittent abdominal pain. She has been feeling very tired and bloated. She thinks that that her symptoms may be worse when she eats white bread. Her sister suffers from similar symptoms. A 26 year old woman is taken to A&E after becoming increasingly drowsy and confused at work, with diffuse abdominal pain and vomiting. She has been thirsty with polyuria. She has been under the weather the past few days with a cold. A 75 year old man who has recently been diagnosed with colonic cancer presents with lower abdominal pain and an inability to pass faeces or wind. An 80 year old woman develops a fever and crampy left iliac fossa pain. On examination, she has a tender abdomen, and investigations reveal leukocytosis. A 72 year old gentleman presented with sudden RIF pain and atrial fibrillation. He is an ex-smoker and has a history of hypertension and 2 previous MIs. A 20 year old woman of African Caribbean origin visits her GP after experiencing abdominal bloating, flatulence and cramping and diarrheoa for several weeks. On examination she has loud bowel sounds. A 65 year old man with a history of peptic ulcer disease visited his GP complaining of several episodes of vomiting blood. He said he felt tired all of the time, and on examination he had pale mucous membranes and was tachycardic and hypotensive A 2 year old boy is brought to A&E with nausea and vomiting. He is very distressed, with diffuse abdominal tenderness and fresh rectal bleeding. Pain appears to be worse in his RIF. A 24 year old man presents to his GP with intermittent crampy abdominal pain and diarrhoea with blood and mucus. On examination, he has a tender, distended abdomen and some signs of inflammation in his eyes. A 60 year old woman with previous history of abdominal surgery presents with abdominal pain with vomiting. Bowels not open for 2 days. On examination she has hardly any bowel sounds. A 26 year old man presents to his GP with a painful lower abdomen and the inability to pass urine for >24 hours following a heavy night of drinking in the pub with his friends. He is sheepish about ilicit drug use. A 14 year old boy presents to A&E with acute onset pain in his scrotum and groin. He has a fever and has vomited once. Examination reveals swollen testes and testicular tenderness. 
Other Symptoms ● Classically central/ periumbilical pain which then becomes localised to the RIF ● Anorexia, ● vomiting ● Usually BNO since onset of symptoms, rarely diarrhoea● Sudden onset tearing epigastric pain in abdomen which radiates to back ● Groin, iliac fossa and testicular pain Diarrhoea and mucus without blood ● Fever ● malaise ● anorexia ● weight loss. ● Tiredness and malaise ● Diarrhoea/ steatorrhoea ● Bloating ● Weight loss ● Diffuse intermittent abdominal pain ● Abdominal pain Vomiting ● Polyuria ● Thirst ● Weight loss ● Weakness ● N&V ● Leg cramps ● Blurred vision ● Pain (lower abdomen) less severe than small bowel obstruction but constant ● Absolute constipation (no faeces or flatus) followed by faeculant vomiting ● 95% asymptomatic. ● Left iliac fossa pain ● nausea ● constipation ● rectal bleeding ● Fever ● AF & generalised abdominal pain ● Hyperactive Stage: RIF/ umbilical pain and rectal bleeding +/- N&V, diarrhoea and increased HR ● Paralytic Stage: Bloating, no further stools, tender abdomen ● Shock Phase: critically ill ● Abdominal bloating ● Abdominal cramps ● Flatulence ● Diarrhoea ● Nausea and vomiting ● Tired all the time (if chronic - see Iron Deficiency Anaemia). ● Medical emergency if acute ● Painless rectal bleeding ● Intestinal obstruction ● Volvulus and intussesception ● N&V ● abdominal cramps. ● Crampy abdominal pain ● Bloody diarrhoea and mucus ● Urgency ● Tenesmus ● Fever ● malaise ● anorexia. ● Colicky upper abdominal pain ● Vomiting followed by absolute constipation (no faeces or flatus) ● Painful bladder ● Sensation of bladder fullness ● Acute onset pain in one testes which makes walking uncomfortable ● Diffuse pain in scrotum, groin, lower abdomen or inguinal region ● N&V 
Pain ● Sudden onset ● Constant● Sudden onset ● Constant or intermittent● Chronic abdominal pain ● Relapsing and Remitting ● Intermittent ● Severity of pain correlates to digestion of prolamin (wheat, barley, rye, oat products) ● FH (esp 1st degree relative) ● Autoimmune diseases ● T1 DM ●thyroid disease ● AIH ● Addison’s ● IBS ● unexplained osteoporosis ● Down’s syndrome ● Turner’s syndrome ● infertility/recurrent miscarriage. ● Gradual drowsiness, vomiting and dehydration with diffuse abdominal pain ● Slower onset than small bowel obstruction ● Pain constant ● Slow onset crampy left iliac fossa pain ● Sudden onset constant severe RIF/ umbilical pain ● Followed by no abdo pain and shock ● Pain 30-120min after lactose ingestion Acute or sub-acute ● Sudden onset pain. No region is specific ● Gradual onset crampy abdo pain ● Chronic ● Intermittent ● Relapsing and remitting ● Faster onset than large bowel obstruction ● Pain intermittent ● Congenital abnormality ● Surgery/ trauma to bladder ● Prostate pathology/ carcinoma ● BPH ● Strictures ● UMN/ LMN disease ● Crohn’s disease ● DiverticulitisPancreatitis ● Anticholinergics ● Recent alcohol consumption ● Elicit or prescribed drug drug use (benzodiazepines, anticholinergics, opioids, antipsychotics, antidepressants, anticholingercs) ● Sudden onset of diffuse groin pain and pain in one of testes. 
Signs ● RIF guarding, rebound and percussion tenderness. ● Tender mass if appendix abscess. ● Tachycardia ● fever ● furred tongue ● pain exacerbated by movement ● pain on coughing ● foetor +/- flushing ● shallow breaths ● PR painful on right. ● Rosving’s sign ● Psoas sign ● Cope sign● Expansile mass in abdomen ● Shock ● Collapse ● Many will die before making it to the emergency department. ● Aphthous ulcerations ● abdominal tenderness ● RIF mass ● perianal abscesses/fistulae/skin tags ● anal/rectal structures. Also: ● Clubbing ● erythema nodosum ● pyoderma gangrenosum ● conjunctivitis ● episcleritis ● iritis ● large joint arthritis ● seronegative spondylarthropathy ● malnutrition ● Signs of anaemia – pallor etc. ● Low BMI ●SOB ● Kussmaul breathing ● Clinical evidence of dehydration, e.g. reduced skin turgor ● Hypotension ● Cold extremities/ peripheral cyanosis ● Tachycardia ● Hypothermia ● Increased RR ●Smell of acetone on breath ● Confusion/ drowsiness/ coma ● Non-tender abdomen ● Abdominal distension ● Loud borborygmi ● Rectum empty ● Tender colon +/- localised or generalised peritoneum ● Tender abdomen ● No bowel sounds with reduced motility ● Shock ● Metabolic acidosis ● Deyhdration ● Hypotension ● Rapid heart rate ● Confusion ● Loud borborygmi ● Signs of hypovolaemia/ shock ● Orthostatic hypotension ● Haematemesis/ malaena/ bloody stools ● Pale mucous membranes ● Tachycardia ● Tachypnoea ●Diffuse abdominal tenderness if perforation and peritonitis. ● Pain in RIF clinically indistinguishable from acute appendicitis in 30%. ● Fever ● tachycardia ● tender, distended abdomen. Also: ● Clubbing ● aphthous oral ulcers ● erythema nodosum ● pyoderma gangrenosum ● conjunctivitis ● episcleriti ● iritis ● large joint arthritis ● seronegative spondylarthropathy ● Tender abdomen if strangulation ● Palpable dilated loops of bowel ● Tinkling bowel sounds ● Shock +/- oliguria ● Loud borborygmi if large bowel obstruction ● Bladder distension ● Tender lower abdomen ● Swelling/ inflammation of one of testes ● Testicular tenderness ● Testes may lie high and transversely ● Fever ● Cremasteric reflex absent/ diminished 
Past Medical History ● None specific. Not previously had an appendicectomy! ● Hypertension ● Smoker ● DM ● Obesity ● High LDL ● Sedentary lifestyle ● FH aneurysmal and atheraosclerotic disease ● Previous aortic surgery ● Marfan’s/ CT disorder ● 3rd trimester pregnancy ● trauma ● Co-arctation of the aorta ● Smoker ● Exacerbated by NSAIDs ● Pain worse when stressed ● FH ● Chronic problem, intermittent pain ● New onset UTI/ flu-like illness/ pneumonia ● Hx recent surgery ● Hyperglycaemia ● Diabetes Mellitus – predominantly T1 ● Hx poor control of hyperglycaemia ● Pregnancy ● Stroke ● Cocaine use ● Hx change in bowel habit +/- rectal bleeding ● FH IBD/ colon cancer ● Strictures, e.g. diverticular disease, IBD, ischaemia, radiation ● Herniae (not as common as small bowel) ● Pseudo-obstruction ● Lack of dietary fibre ● Marphan’s/CT disorder ● Excessive alcohol/caffeine consumption ● Change in bowel habits ● Hypotension ● Hx atherosclerosis/ thromboembolism/ cardiomyopathy/ AAA repair ● Cardiac surgery ● Renal failure ● FH ● Severity of pain increases with amount of lactose consumed, e.g. after several glasses of milk ● IBD ● African/ Asian ● DH NSAIDs/ aspirin ● H. Pylori infection ● Hx PUD ● Haemorrhoids ● Ulcerative colitis ● Crohn’s disease ● Dyspepsia ● Liver disease ● Alcoholism ● FH ● Non-Smoker (smoking is a portective factor) ● Pain worse when stressed ● FH ● Hx change in bowel habit ● Hx adhesions ● Herniae ● Recent surgery ● Tumours ● Crohn’s ● Volvulus ● Ischaemia ● Intersusception ● TB ● Caecal carcinoma ● FH IBD ● Can be acute or chronic ● Medication history ● Bell-clapper deformity ● Large testicles ● Sudden change of temperature ● Undescended testes ● Previous testicular pain 
Bloods ● High WCC, ● High CRP ● High ESR ● If presentation is very early, may be nominally abnormal ● High WCC ● High CRP ●High ESR ● Low albumin (marker of activity) ● Low Hb ● Low serum iron, B12 and red cell folate if anaemia.● Mild anaemia ● folate deficiency ●, iron deficiency ● rarely B12 deficiency, MCV increased. Serology: ● IgA tTG antibodies positive but beware of false negatives ● IgA EMA less sensitive. ● Hyperglycaemia (but not always!) ● Ketones in blood ● Urinalysis: ketones and blood ● ABG: acidosis ● Urea and creatinine may indicate kidney impairment due to dehydration ● High CRP ● High WCC ● May have high serum amylase ● FBC: anaemia (esp if obstruction due to caecal carcinoma) ● U&E: Fluid & electrolyte imbalance, esp K+ ● High CRP ● Amylase ● High WCC ● High CRP ● High ESR ● MCV increased as B12 absorption decreased. ● High WCC ● High Hb ● High amylase ● Low bicarbonate ● High lactic acid – metabolic acidosis ● Blood glucose test every 10-15 minutes shows flat curve in individuals with lactose malabsorption ● Blood film: normocytic anaemia ● Low Hb ● Leykocytosis ● High WCC ● High CRP ● High ESR. ● Low albumin (marker of activity). ● Low serum iron, B12 and red cell folate if anaemia.● FBC: anaemia (esp if obstruction due to caecal carcinoma) ● U&E: Fluid & electrolyte imbalance, esp K+ ● High CRP ● Amylase ● U&E: assess renal function ● MSU: Associated infection/ tumour cells ● None specifically 
Imaging ● US: inflamed appendix +/- appendix mass. ● CT: more sensitive and specific ●FAST (USS) scan in A+E dept is often method of diagnosis of acute rupture ● AXR: calcification ● US: stages aneurysm ● CT: pre-op assessment to observe surrounding structures ● Colonoscopy/ barium enema: Skip lesion, cobblestoning ‘rose thorn’ ulcers, colon strictures with rectal sparing ● Capsule endoscopy: assesses disease ● MRI: detects small bowel disease and fistulae ● DEXA scan performed at diagnosis due to increased risk of osteoporosis. ● Radiology/ endoscopy used if complication such as lymphoma suspected.● CXR to exclude infection ● CT to exclude stroke if confusion/recurrent vomiting ● Supine AXR: peripheral gas shadows proximal to blockage (e.g. in caecum) but not in rectum. Haustra do not cross lumen’s width. ● Colonoscopy but beware perforation. ● Water-soluble contrast study shows level of obstruction. ● CT: dilated, fluid-filled bowel + transition zone at site of obstruction. ● CT permits diagnosis. ● US alternative. ●Plain films show vesical fistulae (air in bladder). ● Sigmoidoscopy, barium enema, colonoscopy used to confirm. ● Early AXR: gasless abdomen ● CT: simple imaging complications. ● Arteriography aids diagnosis ● Colonoscopy/ flexible sigmoidoscopy if diagnosis unclear● None specifically ● Endoscopy/ colonoscopy will reveal bleed ● CT angiography: reveals exact location of bleed ● Technetium-99m pertechnetate scan/ ‘Meckel scan’ detects gastric mucosa as ~50% of symptomatic Meckel’s diverticula have ectopic gastric/ pancreatic cells within them. ● Colonoscopy to look for peptic ulcers ● US demonstrates omphaloenteric duct remnants or cysts ● CT to visualise. ● AXR: mucosal thickening/islands, colonic dilatation ● Erect CXR: may show perforation. ● Sigmoidoscopy/ Colonoscopy: inflamed, friable mucosa, mucosal ulcers and crypt abscesses.● Supine AXR: Distended bowel >5cm, central gas shadows with valulae conniventes that completely cross the lumen. No gas in large bowel. ● Colonoscopy but beware perforation. ● Water-soluble contrast study shows level of obstruction. ● CT: dilated, fluid-filled bowel + transition zone at site of obstruction. ● Cystography: may show urethral valves and strictures ● IV urography: investigates kidneys, ureters and bladder ● Cytoscopy ● Doppler US: absent blood flow ● Often diagnosis is clinical and proceed straight to theatre without imaging 
Additional Investigations Can often be an emergency. Occasionally may go to laparoscopy without imaging. ● Duodenal biopsy gold standard: increased number of intraepithelial lymphocytes, crypt hyperplasia with chronic inflammatory cells in the lamina propria and villous atrophy. ● PR essential ● PR: pelvic abscess or CRC – chief DDx. ● Laparotomy: discovery of necrotic bowel necessary for diagnosis ● Biopsy if diagnosis in question ● Measurement of mucosal O2 tension ● MR oximetric measurements of superior mesenteric vein flow ● H breath test = most accurate. ● Stool acidity test to diagnose lactose intolerance in infants – acid stools if lactose intolerant. ●Intestinal biopsy confirms lactase deficiency following discovery of elevated hydrogen in breath test. ●Stool sugar chromatography is another confirmatory test. As above ● Rectal biopsy: inflammatory infiltrate, goblet cell depletion, glandular distortion. ● Never do barium enema during severe attack! ● PR essential ● Laparotomy: the only definitive diagnostic tool, but not to be undertaken lightly! ● Urodynamics: allows analysis of neurological problems and BPH. ● Surgical exploration mandatory unless torsion can be excluded. 
Full Article AppendicitisAbdominal Aortic AneurysmInflammatory Bowel DiseaseCoaeliac DiseaseDiabetesLarge Bowel ObstructionDiverticulitisMesenteric IschaemiaNot Available (Sorry!) - You could always write oneUpper GI bleedNot Available (Sorry!) - You could always write oneInflammatory Bowel DiseaseSmall Bowel ObstructionUrinary RetentionTesticular Torsion

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