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How to treat
Pull-out section
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Acute
ABDOMINAL
PAIN
Background
PATIENTS complaining of acute
abdominal pain make up at least 3%
of all presentations to a general prac-
tice and up to 10% of all presenta-
tions to accident and emergency
departments. These patients are often
diagnostically challenging because of
the multitude of potential diagnoses
and the diversity of presentations.
Although most presentations are
3 : 2 1 PM
w w w. a u s t r a l i a n d o c t o r. c o m . a u
assumed to have a surgical basis,
medical diagnoses can mimic the
acute abdomen and should at least
be ruled out. Elderly patients or those
with significant comorbidity or exces-
sive body habitus are particularly dif-
ficult to diagnose when the initial
symptoms and signs are non-specific.
The aim of assessing acute abdom-
inal pain is to recognise patients who
inside
History and
examination
Investigation
Specific surgical
conditions
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,
senior lecturer, University of
Sydney and senior staff
specialist and upper GI and
need rapid transfer to an emergency laparoscopic surgeon,
department for resuscitation and/or department of gastrointestinal
urgent surgical intervention, as well surgery, Royal North Shore
as to triage those who will need hos- Hospital and North Shore Private
pitalisation for further investigation Hospital, St Leonards, NSW.
and definitive treatment. About one-
third of patients who present with
acute abdominal pain ultimately are
diagnosed with non-specific
abdominal pain.
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How to treat – acute abdominal pain

History
AS with any clinical presentation, a
comprehensive history should be
taken to determine the mode of
onset, duration, frequency, charac-
ter, location and radiation of the
pain, and any aggravating or reliev-
ing factors. Often the history pro-
vides more important information
for subsequent management than
any single laboratory test. Further-
more, a good history guides the
most logical and appropriate inves-
tigations.
In the past, diagnosis of acute
abdominal pain was largely based
on pattern recognition. Even in an
era of easy access to diagnostic
tests, knowledge of these classic
presentations is still important.
However, frustratingly, patients
with acute abdominal pain may
present with atypical features that
make pattern recognition unreli-
able.
The onset and duration of the
presenting pain may give an indi-
cation of the severity of the under-
lying pathology. Sudden onset of
severe pain usually indicates a cat-
astrophic event such as a perfo-
rated viscus or a ruptured
aneurysm. Rapidly progressing
pain that stays in one area of the
abdomen suggests a specific diag-
nosis such as biliary colic or severe
pancreatitis, depending on the loca-
tion of the pain.
In contrast, pain that builds up
gradually over several hours and
that begins as a slight or vague dis-
comfort only, but soon localises to
a specific area of the abdomen,
suggests a subacute process char-
acteristic of peritoneal inflamma-
tion. As a general principle, any
severe acute abdominal pain that
lasts for more than a few hours is
likely to be due to an underlying
surgical pathology.
The location of the pain in the
right or left side of the abdomen
or in the epigastrium provides a
guide to the likely diagnosis. Typi-
cally, diffuse but localised epigas-
tric pain suggests such diagnoses
as pancreatitis or peptic ulcer dis-
ease, while right upper-quadrant or
right-sided back pain indicates bil-
iary colic or acute cholecystitis.
Renal colic often begins as a dull
flank pain but may radiate down
into the groin.
The classic presentation of acute
appendicitis involves a prodromal
period of anorexia associated with
vague peri-umbilical pain that
Abdominal X-ray of ischaemic small bowel secondary to adhesions.
gradually moves to the right iliac
fossa as localised peritonitis sets in.
It is helpful to try to describe
abdominal pain as intermittent or
continuous in nature or as dull or
sharp in character. ‘Colicky’ symp-
toms describe pain that occurs
intensely for a short period of time
followed by a pain-free period.
This is typical of obstruction of a
hollow viscus by vigorous peristal-
sis proximal to the site of the
obstruction.
Large luminal obstruction such
as occurs in the colon may be
severe but tolerable for long peri-
ods of time. On the other hand,
obstruction of a narrow lumen
tube such as the ureter or the small
bowel is frequently excruciating
and unbearable.
Continuous or constant abdomi-
nal pain is invariably associated
with peritoneal inflammation or,
more worryingly, ischaemia. When
the intensity of the pain crescendos
but then does not settle between
attacks, underlying ischaemia
should be suspected.
A confusing misnomer is ‘biliary
colic’, which is used to describe the
symptoms associated with uncom-
plicated gallstones. The gallblad-
der lacks a strong muscularis
mucosa, so pain from an
obstructed cystic duct is constant
rather than colicky in nature.
Other descriptive terms used by
some patients included a ‘tearing’
sensation that may indicate a dis-
secting aneurysm, or a ‘burning’
epigastric pain that may indicate
either acute gastritis or a peptic
ulcer. However, the diagnosis of
acute gastritis is relatively rare and
should only be made when there
has been a history of a toxic inges-
tion such as excessive alcohol
intake, recent heavy NSAID use or
deliberate or accidental ingestion
of a caustic substance.
In contrast, patients with chronic
gastritis are usually either asymp-
tomatic or have subtle and vague
upper abdominal discomfort rather
than acute abdominal pain.
Chronic gastritis is divided into
type A (associated with pernicious
anaemia), type B (mostly due to
Helicobacter pylori infection) and
type C (due to chronic ingestion of
a toxin, such as an NSAID).
Patterns of radiation of the
abdominal pain may also be help-
ful. For example, acute pancreatitis
or a ruptured abdominal aortic
aneurysm frequently causes severe
epigastric pain that radiates
through to the back. Another
example of radiating symptoms
relates to acute cholecystitis, which
often presents as right upper-quad-
rant discomfort extending around
the patient’s side rather than
straight through to the back.
Any pathology that causes irri-
tation of the diaphragm may result
in referred pain to the shoulder tip.
This occurs because of innervation
of the diaphragm by the fourth cer-
vical nerve route, which also sup-
plies the shoulder. Other examples
of referred pain include renal colic
that classically radiates from the
loin into the tip of the genitalia,
and small bowel colic that initially
presents as peri-umbilical discom-
fort because this area shares the
same spinal nerve root innervation
(T10) as the small intestine.
A shift in the location of the
abdominal pain with time reflects
progression of the pathology. For
example, the initial visceral or
peri-umbilical pain of early appen-
dicitis (reflecting innervation from
T10) shifts to the right iliac fossa
over several hours as localised
peritonitis develops.
A change in the nature of the
pain may also signify progression
to a more sinister pathology. For
example, a change from the gen-
eralised cramping and intermittent
abdominal pain of subacute small-
bowel obstruction to a more con-
stant and generalised pain raises
concern about intestinal
ischaemia.
Identifying the factors that influ-
ence the patient’s abdominal pain
may also point towards the diag-
nosis. For example, a patient may
describe relief from severe abdomi-
nal and back pain by leaning for-
ward, and this often occurs in
acute or chronic pancreatitis.
In the case of peritoneal inflam-
mation from acute appendicitis,
any movement such as coughing,
straining or even travelling over
the bumps on the road during the
car trip to the hospital exacerbates
the abdominal symptoms and is a
good indicator of peritoneal irri-
tation.
It may also be helpful to eluci-
date whether there have been any
other associated symptoms. The
presence of nausea, vomiting,
anorexia or a change in bowel
habit frequently go hand in hand
with acute abdominal pain. The
temporal relationship of these
symptoms to the pain may point
towards a particular diagnosis.
For example, intractable nausea
may precede the pain associated
with obstruction of a narrow
lumen tube such as the pancreatic
duct.
Accompanying fevers, rigors or
chills suggest an associated infec-
tion and should help differentiate
such diagnoses as ‘biliary colic’
and renal colic from cholecystitis
and pyelonephritis. In the latter
two conditions, hospital admission
is usually required for pain relief
and IV antibiotics.
Any symptoms associated with
voiding or opening of the bowels
may suggest a specific pathology
but it is worth remembering that
these symptoms may just be sec-
ondary to pain or anxiety. A his-
tory of a change in the colour of
the urine or stools should also be
sought and may be helpful at least
in excluding some diagnoses.

Examination
IN an era of ready access to
complex and expensive inves-
tigations it is easy to forget
that an accurate history,
combined with a thorough
clinical examination, will fre-
quently make the correct
diagnosis without the need
for any investigations.
We bemoan the lack of clin-
ical acumen in junior doctors
— and so we should, because
these skills are now more
important than ever in decid-
ing on the most appropriate
and cost-effective investiga-
tions to order. The consis-
tently large numbers of litiga-
tion cases for delayed diagno-
sis are a testament to this.
Also, the ‘end of the bed’
assessment should not be
underestimated as a guide to
the severity of the acute pre-
sentation. A patient may be
jaundiced or pale, or may be
motionless in the case of peri-
tonitis, or be rolling around
in agony when the pain is due
to renal colic. Even a cursory
inspection may reveal signs of
dehydration, fever or tachyp-
noea, suggesting a serious
acute abdominal problem that
will prompt the need for early
resuscitation and treatment.
Full exposure of the examination should start on patient to cough and by gaug-
abdomen is critical to avoid the opposite side to this. ing their response.
missing an obvious diagnosis Alternatively, the patient The most likely diagnoses
such as an obstructed inguinal should be asked to cough as can at least be narrowed
or femoral hernia. The pres- this may highlight an area of down by the specific region of
ence of distension of the focal tenderness, and the maximal tenderness. For
abdomen, scars from previous examination can be tailored example, right upper-quad-
operations or the presence of accordingly. rant pain with exacerbation
any associated hernias should Diffuse abdominal rigidity of pain on palpation during
also be noted. The patient (‘board-like’) suggests gener- deep inspiration (Murphy’s
should be directed to lie alised peritoneal irritation sign) usually indicates acute
supine with the arms placed with subsequent involuntary cholecystitis. Alternatively,
by their sides and with the spasm of the abdominal wall focal epigastric tenderness
knees slightly flexed to relax muscles. Rebound tenderness, with radiation directly
the abdominal musculature. indicating peritoneal irritation, through to the back indicates
The site of maximum pain can be elicited by withdrawing pancreatitis. Loin pain radiat-
is often pointed out by the the examining hand quickly ing into the groin is indicative
patient and the abdominal or, better still, by asking the of renal pathology.

28 | Australian Doctor | 22 August 2008 www.australiandoctor.com.au

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Investigation
URINALYSIS is a simple
and readily available test that
may yield important diagnos-
tic information. The presence
of protein or blood in the
urine often indicates an acute
renal tract pathology such as
a renal calculus or nephritis.
However, macroscopic
haematuria can occur in non-
renal pathologies such as a
ruptured abdominal aortic
aneurysm. Similarly, pyuria
may also be present when an
inflamed appendix lies adja-
cent to the right ureter.
Having said that, this test is
still very helpful because it is
quick and simple to perform
and will, at least, exclude any
significant urinary tract
pathology.
A complete blood picture
including a check of the
haemoglobin, white cell
count, electrolytes, urea and
creatinine, liver function
tests (LFTs) and serum lipase
level is important in narrow-
ing down the cause of the
acute abdominal pain.
A leucocytosis will be pre-
sent in any infective condi-
tion, whether bacterial or
viral, and therefore should
not be used alone to make
or exclude a diagnosis of an
acute abdominal problem.
For example, the absence of
an elevated white cell count
does not necessarily exclude
early acute cholecystitis,
acute appendicitis or even
cholangitis. Similarly, the
white cell count may be ele-
vated as a result of a viral
infection causing mesenteric
adenitis and consequently
acute abdominal pain.
Regarding the diagnosis of
acute or chronic pancreati-
tis, the serum amylase level
is less sensitive and less spe-
cific than the serum lipase
level, so only the latter test
should be used to exclude
this diagnosis. Mild to mod-
erate elevations in the serum
amylase level may occur in
the presence of a perforated
peptic ulcer, intestinal
obstruction and even in
mesenteric ischaemia.
In patients with suspected
acute appendicitis, the clini-
cal history and physical signs
are far more reliable than
changes in the white cell
count. In most cases this
should be a clinical diagno-
sis, and any serological or
Pa ge 1 8 / 1 4 / 0 8 ,
In patients with
suspected acute
appendicitis, the
clinical history
and physical
signs are far
more reliable
than changes in
the white cell
count.
radiological investigations
should only be used to sup-
port the diagnosis.
Derangements in LFTs indi-
cate hepatobiliary or pancre-
atic pathology, and subsequent
investigations should be
ordered accordingly. Assess-
ment of electrolytes and renal
function is essential in patients
presenting with acute abdomi-
nal pain, to exclude dehydra-
tion and to guide the need for
fluid and electrolyte replace-
ment. In patients with high
epigastric or retrosternal chest
pain, blood should be checked
3 : 2 1 PM
Ultrasound showing acute cholecystitis with perforation.
Ultrasound showing acute appendicitis with no significant narrowing of the lumen during
compression.
for elevated troponin levels
and this should be done in
conjunction with a resting
ECG.
Radiology
With ready access to modern
imaging such as ultrasound,
CT or MRI, it is now uncom-
mon, and often unhelpful, to
order a plain abdominal X-
ray in patients who present
with acute abdominal pain.
Having said that, if there
is a clinical suspicion, and a
plain abdominal film is read-
ily available, then this (per-
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formed together with an
erect CXR) may still be a
good test to exclude free air
under the diaphragm as a
result of a perforated viscus.
Also, if there is any sugges-
tion of a respiratory compo-
nent to the presentation,
pneumonia should be
excluded by a CXR.
Abdominal ultrasound is
one of the most useful diag-
nostic tests for assessing acute
abdominal pain. It is cheap,
readily available and non-
invasive and is the investiga-
tion of choice for examining
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the gallbladder and biliary
tract, as well as the pelvis.
Abdominal ultrasound
may also be very helpful in
the diagnosis of acute appen-
dicitis. Even if the appendix
is not seen, the presence of
focal tenderness associated
with a good history and clin-
ical signs may be enough evi-
dence to clinch the diagnosis
and justify surgical referral.
Having said that, ultrasound
of the abdomen is sometimes
limited by overlying gas-filled
structures, obesity and inability
of the patient to tolerate the
22 August 2008 | Australian Doctor |
investigation because of pain.
Also, an abdominal ultrasound
is only as good as the operator
holding the probe, so experi-
enced radiology practices will
yield the best results.
CT scanning is now the
modality of choice for investi-
gating the patient with an
acute abdomen. However the
radiation exposure is much
greater for a CT scan com-
pared with a plain X-ray, and
there are concerns about radi-
ation exposure with CT, espe-
cially in children. Hence an
ultrasound scan is preferred as
the first choice in young chil-
dren and in women who may
be pregnant.
Other than in remote rural
areas of Australia, CT scan-
ning is readily available to
most general practices during
working hours and is also
available after hours in most
reasonably sized hospitals.
Although the final result is
still dependent on the hard-
ware and software of the
scanner, in most cases a CT
scan provides an accurate
assessment of the intra-
abdominal organs and usu-
ally identifies the causative
pathology. Having said that,
a CT scan should only be
used as an adjunct, and not
as a substitute, for a thor-
ough history and physical
examination.
Also, when requesting a CT
scan, it is helpful for the radi-
ologist to have some basic
clinical information about the
presentation — even a differ-
ential diagnosis. They are
more likely to look critically at
the area of interest rather than
just having a cursory inspec-
tion if this information is pro-
vided.
After referral to an accident
and emergency department,
patients frequently endure
lengthy delays while waiting
for results of investigations.
This could be streamlined by
arranging appropriate blood
tests, and imaging, if indicated,
before the patient is sent to the
hospital.
However, this should only
be done if it does not cause an
undue delay in receiving treat-
ment. A legible letter from the
referring doctor indicating
what tests have been done and
how the results can be
accessed is extremely helpful
for emergency room staff.
29
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How to treat – acute abdominal pain

Specific surgical conditions

Acute abdominal emergency these patients should be
Leaking or ruptured abdominal aortic aneurysm referred for consideration for
ABDOMINAL aortic aneurysms are typically asymptomatic a laparoscopic cholecystec-
and may go undetected until a catastrophic complication tomy.
occurs. However, there may be a short history of symptoms The presence of a positive
suggesting impending rupture, including new and persistent Murphy’s sign, persistent
backache or vague but deep-seated abdominal pain. abdominal pain despite anal-
Just before rupture of the aneurysm, patients may experi- gesia, a leucocytosis or fever
ence a sudden onset of severe abdominal or epigastric pain suggests acute cholecystitis.
radiating through to the back associated with pre-syncope, These patients should be
diaphoresis, nausea or tachycardia. If an intra-abdominal referred to hospital for IV
rupture occurs, there will be a catastrophic sudden haemor- antibiotics and consideration
rhage resulting in the rapid demise of the patient. for semi-urgent cholecystec-
Patients whose abdominal aortic aneurysms are contained tomy.
in the retroperitoneum have a chance of survival if diagnosis The presence of recurrent
and treatment are instituted promptly. A leaking or ruptured abdominal pain and fevers
abdominal aortic aneurysm is associated with high mortality associated with alteration in
and requires urgent transfer to a hospital, where surgical LFTs or a history of jaun-
intervention offers the only chance of survival. dice suggests cholangitis sec-
ondary to choledocholithia-
Perforated viscus sis (Charcot’s triad). If
In the past, perforation of a peptic ulcer was a common patients are acutely unwell
acute surgical emergency. However, with the dramatic fall in they will need urgent fluid
the incidence of peptic ulceration in our community this is resuscitation and IV antibi-
now a rare acute surgical presentation. otics and may also require
More commonly, patients present with a perforated diver- urgent endoscopic retrograde
ticulum secondary to diverticulitis. In this situation there cholangiopancreatography
may have been a history of diverticulosis or of lower abdom- (ERCP).
inal pain for several weeks before the acute presentation. The presence of a stone
An acute contained perforation may present as focal peri- in the common bile duct on
tonitis, while patients with an uncontained perforation of Air under the diaphragm due to a perforated duodenal ulcer. ultrasound, or the finding
either the colon or a peptic ulcer will have generalised abdom- of abnormal LFTs, does
inal pain and board-like rigidity of the abdomen. This may be not necessarily mandate
associated with hypotension, tachycardia and tachypnoea, referral for a pre-cholecys-
which are manifestations of systemic sepsis. tectomy ERCP, as long as
With acute perforation there may be referral of pain to the the patient does not have
shoulder tip because of diaphragmatic irritation due to free severe cholangitis. Many
intra-abdominal fluid. Abdominal distension is due to the surgeons are now happy to
associated ileus. Blood tests usually reveal a leucocytosis, perform an operative
and a plain abdominal X-ray and erect CXR will show free cholangiogram at the time
intra-peritoneal gas in up to 80% of cases. These patients of the cholecystectomy and
obviously require urgent transfer for surgical intervention. to remove the stones from
the common bile duct
Subacute abdominal emergency laparoscopically during the
Biliary colic and acute cholecystitis same procedure.
Calculous disease of the biliary tract is one of the most
common causes of subacute abdominal pain. Gallstones occur Acute pancreatitis
commonly in Western societies, particularly in women aged The two most common
20-50. The traditional teaching that gallstones occur in the causes of pancreatitis in our
five F’s (fair, fat, forty, fecund, and female) is a reasonable community are gallstones
generalisation, but gallstones are certainly not confined to this and excessive alcohol inges-
group of patients. tion. There are a myriad of
Classic symptoms of biliary colic include epigastric dis- other less common causes,
comfort, often described as a ‘band-like’ pain across the including viral illnesses,
upper abdomen and sometimes radiating around to the right medications (eg, corticos-
side of the back. About 40% of patients complain of referred teroids, ACE inhibitors,
pain to the interscapular or right shoulder area. frusemide, etc) and congeni-
Low-grade nausea or anorexia is also a common presenting tal ductal abnormalities (see
complaint and fatty-food intolerance is not always present. table 1, page 31).
Most patients can decrease the frequency of their attacks of Patients typically present
biliary colic by severely restricting their diet. This is because CT scan showing acute sigmoid diverticulitis. with sudden onset of severe
ingestion of all types of food (particularly fatty food) stimu- epigastric pain radiating
lates contraction and emptying of the gallbladder. through to the back. The
Some patients present with atypical biliary symptoms. This pain is often intolerable
often leads to a delay in diagnosis or inappropriate investi- within 3-4 hours of the onset
gations for other pathologies. High epigastric or low ret- of symptoms and may be
rosternal pain may be confused with a possible cardiac cause. associated with nausea and
This often results in lengthy, but frequently unnecessary, car- vomiting.
diac investigations after presentation to the accident and Classic clinical signs of
emergency department. severe acute pancreatitis
Similarly, it is surprising how often patients are investigated include Grey Turner’s sign
with an upper endoscopy for what are, in retrospect, typical (flank ecchymosis) and
biliary symptoms. The yield from an upper endoscopy in an Cullen’s sign (periumbilical
era when peptic ulcer disease is now uncommon is small. A skin discolouration). Both
much more logical approach might be to order a simple and these clinical signs reflect
readily available biliary ultrasound as the first step, then severe retroperitoneal
arrange an endoscopy if this study proves negative. inflammation and mandate
The presence of typical biliary symptoms in conjunction urgent hospital admission
with the finding of gallstones is an indication for cholecys- for IV fluid resuscitation and
tectomy. Focal tenderness over the gallbladder or evidence of possibly even acute surgical
a thick-walled gallbladder suggests cholecystitis. intervention.
In those with atypical biliary pain and a negative biliary The diagnosis of acute
ultrasound, endoscopy is indicated to exclude other pathol- pancreatitis is easily made by
ogy. It is also helpful in excluding additional upper GI checking for an elevated
pathology when patients present with gallstones but with white cell count, abnormal
slightly atypical symptoms. LFTs and an elevated serum
For patients with uncomplicated biliary colic, a strictly lipase level. Definitive assess-
low-fat diet may reduce the severity of biliary pain before ment of pancreatic perfu-
definitive treatment. In the absence of any contraindications Calcified gallstones on plain abdominal X-ray. sion, and the presence or

30 | Australian Doctor | 22 August 2008 www.australiandoctor.com.au

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absence of complications
such as an acute fluid collec-
tion or abscess, are deter-
mined by a two-phase fine-
cut pancreatic CT scan.
Severe acute pancreatitis
results in rapid dehydration,
and acute renal failure will
develop unless IV fluid resus-
citation is initiated promptly.
In this setting it is sometimes
not possible to give an IV
contrast agent at the time of
the CT scan.
Less common acute
surgical conditions
Numerous other surgical
conditions that may result in
an acute abdomen include a
mesenteric embolus, mesen-
teric venous thrombosis,
hepatic abscess, splenic
infarct or splenic abscess.
These conditions may pre-
sent with subtle clinical
symptoms and signs and
ultimately may only be diag-
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

■ Hepatomegaly from chronic heart failure

■ Tumours (pancreatic
■ Right lower-lobe pneumonia
ductal obstruction)
■ Gastritis (acute)
■ Toxins ■ High-intestinal obstruction
CT scan showing a dilated common bile duct due to a large stone.
■ Inflammatory bowel disease of the duodenum

Epigastric pain
■ Biliary colic

Non-general surgical causes of abdominal pain ■ Pancreatitis

■ 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
with an urgent pelvic ultrasound, will
make the diagnosis.
Confirming pregnancy is also
important in determining whether
certain medications or diagnostic X-
ray procedures can be used, particu-
larly in the early stages of pregnancy.
Other gynaecological causes of
acute abdominal pain include a rup-
tured ovarian cyst, salpingitis, a
spontaneous or threatened abortion,
and ovarian torsion.
urological intervention may be required.
In contrast with renal colic, patients
with pyelonephritis usually present with
signs of sepsis and with pain tending to be
more in the flank or lower back rather
than the upper abdomen. Almost all
patients with pyelonephritis have haema-
turia and pyuria on urinalysis.
Other non-surgical causes of abdomi-
nal pain include:
■ Acute hepatitis.
■ Lower-lobe pneumonia.
■ Pericarditis.
ough abdominal examination. A small
dose of IM, SC or even IV pethidine or
morphine is appropriate for patients with
severe acute abdominal pain. What not to miss — the acute abdomen
Another common misconception
■ Haemorrhage, eg, ruptured abdominal aortic aneurysm,
relates to the administration of narcotic
haemorrhagic pancreatitis
analgesia in the presence of pancreatitis or
biliary disease. Although the sphincter of ■ Infection, eg, appendicitis, Meckel’s diverticulitis
Oddi in some patients is sensitive to nar- ■ Perforation, eg, perforated gastric or duodenal ulcer,
cotic analgesia (including morphine and perforated diverticulum, perforated colonic tumour
codeine), there is no evidence that this ■ Obstruction, eg, incarcerated groin or incisional hernia
form of analgesia increases the severity
■ Ischaemia, eg, strangulated hernia, mesenteric thrombosis
or risks of complications of pancreatitis.

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AD_032___AUG22_08 Page 6 14/8/08 3:14 PM

How to treat – acute abdominal pain

Authors’ case studies Further reading

Lower chest pain
A PREVIOUSLY well 55-year-old
male presented to his GP with acute
onset of what he described as chest
pain. The onset of the pain was
about two hours before presenta-
tion and woke him from his sleep.
He described the severity of the
pain as 10/10. His lower chest pain
was constant and was accompanied
by sweating and nausea. There was
no radiation of the pain and no
shortness of breath.
Just before presenting to his GP
he had one bile-stained vomit.
There had been no recent change
in his bowel habit. He had not been
able to alleviate the pain with
simple analgesia, and movement
did not exacerbate his pain. He had
been eating and drinking well up
until that day although he had had
a ‘heavy’ meal the night before.
The patient recalled a similar
attack of pain about 18 months
previously, when he presented to
the accident and emergency depart-
ment at his local hospital. On that
occasion he had been investigated
with a resting ECG and serial tro-
ponin levels and had even gone on
to have a stress ECG. All these
studies were normal and no obvi-
ous cardiac cause was identified.
He had not been advised to
undergo any further investigations.
At the time of presentation it was
clear that he had lower retroster-
nal and epigastric discomfort and
there was a positive Murphy’s sign.
His blood tests revealed a mild neu-
trophilia and mildly elevated serum
AST and GGT. An abdominal
ultrasound revealed a gallbladder
that had a slightly thickened wall
and contained multiple large stones.
No dilatation of the biliary tree and
no obvious choledocholithiasis was
seen.
He was referred to the accident
and emergency department for sur-
gical review and subsequently
underwent an uneventful semi-
An ultrasound of a gallbladder with a thick wall, with stones evident.
urgent laparoscopic cholecystec-
tomy and operative cholangiogram
the following day.
An unusual presentation
A 15-year-old boy was referred to
the accident and emergency depart-
ment by his GP after he presented
with right upper-quadrant pain of
two days’ duration. This pain was
initially generalised to both lower
quadrants of his abdomen but over
the preceding 12 hours had become
more intense on the right hand side.
The patient was slightly nauseous
and was not hungry but he did not
look particularly unwell and there
was no vomiting and no change in
his bowel habit. Examination
revealed a slight tachycardia and a
low-grade fever (37.8°C).
On palpation of his abdomen
there was moderate guarding in the
■ Goldman RD, et al. Analgesia
administration for acute
abdominal pain in the pediatric
emergency department.
Pediatric Emergency Care
2006; 22:18-21.
■ Hewett P. How to treat: acute
lower abdominal pain.
Australian Doctor 14th
February 2003.
■ Jamieson GG. The Anatomy of
General Surgical Operations,
2nd edn. Churchill Livingstone,
Adelaide, 2006.
■ Martinez JP, Mattu A.
Abdominal pain in the elderly.
Emergency Medicine Clinics of
North America 2006; 24:371-
88.
■ Poulin EC, et al. Early
laparoscopy to help diagnose
acute non-specific abdominal
pain, Lancet 2000; 355:861–63.
■ Rosen MP, et al. Impact of
abdominal CT on the manage-
ment of patients presenting to
the emergency department with
acute abdominal pain.
American Journal of
Roentgenology 2000;
174:1391-96.
■ Shabbir J, et al. Administration
right upper quadrant and also some of analgesia for acute abdomi-
percussion tenderness. He was nal pain sufferers in the acci-
uncomfortable, with rigidity on dent and emergency setting.
deep palpation in the right iliac European Journal of Emergency
fossa, but there were no palpable Medicine 2001; 11:309-12.
masses. ■ Taylor S, Watt M. Emergency
A urinalysis showed micro- department assessment of
haematuria only, and all blood tests abdominal pain: clinical indica-
were within the normal range. A tor tests for detecting periton-
CT scan was arranged, as the diag- ism. European Journal of
nosis was not obvious on physical Emergency Medicine 2005;
examination. This revealed an 12:275-77.
acutely inflamed appendix with its ■ Townsend CM, et al. Sabiston
tip lying just inferior to the hepatic Textbook of Surgery: The
flexure. Biological Basis of Modern
The patient underwent a laparo- Surgical Practice, 17th edn.
scopic appendicectomy that same Saunders Elsevier, Philadelphia,
day and a retrocaecal gangrenous 2004.
appendix without perforation was ■ Urban BA, Fishman EK.
identified and removed. The Tailored helical CT evaluation
patient was discharged from the of acute abdomen.
hospital without any complications Radiographics 2000; 20:725-
on the third postoperative day. 49.
■ Wolfe JM, et al. Analgesic

administration to patients with

GP’s contribution
Case study
ND, 53, presented with a seven-day
history of abdominal discomfort,
nausea and vomiting. Two days later
diarrhoea with PR bleeding started,
and he described what sounded like
rigors.
Ulcerative colitis had been diag-
DR MARG TAIT
nosed 30 years ago. It had been qui-
Picnic Point, NSW
escent for 10 years and he had
stopped taking sulfasalazine five
years ago. ND had not been on any
medications before the onset of this
illness and had not travelled to rural
areas or overseas.
He looked unwell but was afebrile,
normotensive and had no tachycar-
dia. The abdomen was soft, with
only mild tenderness of the left
abdomen and into the left iliac fossa.
Pathology revealed a haemoglobin
level of 144g/L, white cell count
9
11.0×10 /L (normal differential) and
mildly abnormal LFTs, with a
cholestatic picture. Stool and blood
cultures were negative. However, C-
reactive protein was 111mg/L
(normal range 0-5).
ND was referred to a gastroen-
terologist, who arranged admission
to hospital, where he was treated
with IV hydrocortisone and metron-
idazole. Sigmoidoscopy showed
moderately severe diffuse proctocol-
itis. A CT scan of the abdomen and
pelvis showed thickening of the
descending colon and sigmoid colon,
with no evidence of intra-abdominal
cont’d page 34
an acute abdomen: a survey of
emergency medicine physicians.
American Journal of Emergency
Medicine 2000; 18:250-53.
Online resources
■ familydoctor.org (family health
information, from the
American Academy of
Family Physicians):
http://familydoctor.org/online/
famdocen
■ virtualmedicalcentre.
com: http://www.
virtualchildshealth.com

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AD_ 0 3 4 _ _ _ AUG2 2 _ 0 8 . P DF Pa ge
How to treat – acute abdominal pain
from page 32
or pelvic collections, and a
normal liver.
After a week he was dis-
charged on prednisone 50mg
daily and sulfasalazine 1g tds.
Two days after discharge he
contacted the gastroenterolo-
gist, as he felt more unwell
with unremitting diarrhoea
and PR bleeding. He was
readmitted and a further sig-
moidoscopy revealed a severe
pancolitis.
He had a subtotal colec-
tomy and end ileostomy, as he
had not responded to medical
management for this acute
exacerbation of ulcerative col-
itis.
Questions for the authors
What are the common surgi-
cal problems that can arise
from ulcerative colitis?
How to Treat Quiz
Acute abdominal pain
— 22 August 2008
1. Which THREE statements about
assessing patients with acute abdominal
pain are correct?
a) Continuous abdominal pain is invariably
associated with peritoneal inflammation or
ischaemia
b) Pathology irritating the diaphragm may
cause referred pain to the shoulder tip,
because both these structures are
innervated by the third cervical nerve
c) The patient should be directed to lie
supine with the knees slightly flexed to
relax the abdominal musculature
d) Rebound tenderness can be elicited by
asking the patient to cough and then
gauging their response
2. Which TWO statements about
assessing patients with acute abdominal
pain are correct?
a) Patients should not be given
analgesia before surgical assessment, as
this may mask the signs of an acute
abdomen
b) Assessing electrolytes and renal function
is essential in patients presenting with
acute abdominal pain
c) Narcotic analgesia should not be given to
patients with biliary disease or
pancreatitis, as this increases the risks of
complications
d) In patients with high epigastric pain, blood
should be checked for elevated troponin
levels in conjunction with a resting
ECG
3. Which ONE statement about
radiological investigation of acute
abdominal pain is correct?
a) A normal plain abdominal and erect CXR
rules out the diagnosis of a perforated
viscus
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can complete this online along with the quiz at www.australiandoctor.com.au. Because this is a requirement, we are no longer able to accept the quiz by post
or fax. However, we have included the quiz questions here for those who like to prepare the answers before completing the quiz online.
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34 | Australian Doctor | 22 August 2008
1 8 / 1 4 / 0 8 , 3 : 2 4 PM
These include acute toxic
megacolon, bleeding, perfora-
tion, obstruction and malig-
nant change.
What conditions other than
renal colic can cause pain radi-
ating from the loin to the
groin? (I have seen an ectopic
pregnancy that was initially
thought to be pyelonephritis.)
This type of pain may be
caused by any condition that
irritates the retroperitoneum,
such as ectopic pregnancy or
retrocaecal appendicitis.
When monitoring an abdomi-
nal aortic aneurysm, what is
the critical size at which
surgery should be considered?
The risk of rupture of an
abdominal aortic aneurysm
significantly increases for
aneurysms >5.5cm diameter.
b) CT scanning is now the investigation of
choice for examining the gallbladder and
biliary tract
c) The usefulness of abdominal ultrasound in
investigating acute abdominal pain may be
limited by obesity and overlying gas-filled
structures
d) Radiological assessment in cases of
acute pancreatitis is best performed with
ultrasound
4. Which TWO statements about
suspected acute appendicitis are
correct?
a) It is worthwhile to enquire about
exacerbation of pain with coughing or
straining
b) The shift of pain from the initial
peri-umbilical area to the right iliac
fossa reflects development of localised
peritonitis
c) A raised white cell count will clinch the
diagnosis in acute appendicitis
d) Abdominal ultrasound is not useful in the
diagnosis of acute appendicitis
5. Which THREE statements about
abdominal aortic aneurysms are correct?
a) New and persistent backache could be a
warning of impending rupture of an
abdominal aortic aneurysm
b) The presence of macrohaematuria rules
out an abdominal aortic aneurysm as the
cause of the pain
c) Patients may experience sudden severe
abdominal or epigastric pain radiating
through to the back just before rupture of
an abdominal aortic aneurysm
d) Symptoms and signs associated with
rupture of an abdominal aortic aneurysm
include pre-syncope, diaphoresis, nausea
or tachycardia
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6. Which THREE statements about a
perforated viscus are correct?
a) Perforation of a peptic ulcer is a common
acute surgical emergency
b) With acute perforation there may be
referral of pain to the shoulder tip
c) Perforation of either the colon or a peptic
ulcer may present as focal peritonitis
d) Hypotension, tachycardia and tachypnoea
associated with a perforated viscus are
indicative of systemic sepsis
7. Ingrid, 40, presents with a
history of intermittent upper-abdominal
discomfort and nausea, especially
after eating fatty foods. Which
TWO statements about biliary colic
are correct?
a) The pain of biliary colic is classically
colicky rather than constant in nature
b) About 40% of patients with biliary colic
complain of referred pain to the
interscapular or right shoulder area
c) For patients with upper abdominal pain
suggestive of biliary colic, an ultrasound
scan would be the appropriate first-line
investigation
d) A low-fat diet is of no benefit in patients
with uncomplicated biliary colic
8. You refer Ingrid for an abdominal
ultrasound. However, while awaiting her
appointment she has an acute attack of
right upper-abdominal pain, associated
with fever. Which THREE statements are
correct?
a) Right upper-quadrant pain with
exacerbation of pain on palpation during
deep inspiration (Murphy’s sign) usually
indicates acute cholecystitis
b) Absence of a leucocytosis excludes a
diagnosis of acute cholecystitis
c) Evidence of a thick-walled gallbladder
on ultrasound scan suggests cholecystitis
d) Recurrent abdominal pain and fevers
associated with alteration in LFTs or
jaundice suggests cholangitis
9. Mark, 45, presents with acute, severe
epigastric pain radiating through to the
back, associated with nausea and
vomiting. He has a previous history of
acute pancreatitis. Which THREE
statements about acute pancreatitis are
correct?
a) The two most common causes of
pancreatitis in the Australian community
are gallstones and excessive alcohol
ingestion
b) Flank ecchymosis and periumbilical skin
discoloration are signs of severe acute
pancreatitis
c) Acute pancreatitis is easily diagnosed by
checking for an elevated serum amylase
level
d) Severe acute pancreatitis requires urgent
IV fluid resuscitation
10. Tom, 40, presents with acute left flank
pain. You suspect acute renal colic. Which
TWO statements are correct?
a) A typical presentation of acute renal colic
is of severe colicky flank pain that radiates
to the groin
b) If flank pain is associated with fevers or
rigors, a diagnosis of pyelonephritis
should be suspected
c) Intravenous pyelography is the most
useful investigation for renal colic and will
confirm the diagnosis in most cases
d) If renal calculi are <1cm in diameter there
is a 90% chance of spontaneous passage,
and these patients can be safely treated
conservatively
HOW TO TREAT Editor: Dr Wendy Morgan
Co-ordinator: Julian McAllan
Quiz: Dr Wendy Morgan