Author: Melissa Crooks / Editor: Charlotte Davies / Codes: CAP1, HAP1 / Published: 31/07/2018
It’s your second day on the ‘shop floor’ and your next patient is handed over as a 51-year-old man who has been brought in by ambulance with sudden onset generalised abdominal pain and vomiting. You have a spidey sense something is wrong, what next?
Abdominal pain is common in the ED, accounting for 5-10% of presentations and the differentials are incredibly wide ranging. The key to narrowing down potential diagnoses lies in a systematic approach, an efficient yet comprehensive history and thorough examination. Most of these patients will be discharged from the department, but a small percentage of them will be referred to the surgical team.
When assessing a patient presenting with abdominal
pain I keep this diagram in mind which, along with sex and age, helps to identify the important and common causes of their symptoms.
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You’ve learnt about many of the common abdominal diagnoses in medical school – here’s a few tips about how to manage the import and immediately life-threatening in the ED
The classic history of sudden onset abdominal pain radiating to the back is not always the case. Always have AAA in mind, especially in the over 50s presenting with abdominal pain and features of shock. ED seniors are always keen to perform a bedside ultrasound to rule this out (note this is different from a FAST scan which aims to identify free fluid in the abdomen following trauma). It’s good to observe as many bedside ultrasound scans as you can, as it gives you a good amount of practice, and refreshes your anatomy knowledge.
Simple gallstones present frequently with right upper quadrant pain. The mainstay of managing these patients is an accurate diagnosis and analgesia. In most departments if they are pain free and have normal liver function tests they can go home. If they’re in lots of pain, many departments will want you to refer before blood results come back.
Patients with pain and fever may have an infected cholangitis. This should be treated aggressively with antibiotics and surgical referral. They are mostly Murphy’s positive (not always) but the elderly present bizarrely. This is why RCEM has a guideline
saying all old people with abdominal pain should be discussed with a senior.
This is probably one of the main worries of many of our patients, “do I have appendicitis?” Appendicitis is a triad of anorexia, migratory pain, fevers and vomiting.
When examining a patient in whom you suspect appendicitis remember the anatomy and special tests:
- McBurney’s point 2/3rds from umbilicus to ASIS
- Blumberg’s sign rebound tenderness over McBurneys point
- Rovsing’s sign if palpation of the left lower quadrant results in increased pain in the right lower quadrant it may indicate appendicitis
- Psoas sign pain on right hip extension indicates inflamed retro-caecal appendix
- Obturator sign pain on rotation of right flexed hip indicates irritation of the obturator internus muscle
To be thorough, or even just as an easy way to remember the salient signs and symptoms, you can use the Alvarado scoring system. A score of 6 indicates appendicitis is more likely. This is really useful as it helps us to differentiate appendicitis from gynae causes if it’s just RIF pain, appendicitis is unlikely!
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This is most commonly left lower quadrant pain with change in bowel habit and fever. Most of these need admission to the surgeons, if their observations are abnormal you don’t even need to wait for bloods! The surgeons will ask for a PR exam so do one as part of your initial assessment. If the patient is well, have a chat with your senior and they may be able to go home with oral antibiotics, or with no antibiotics.
This is one of the “don’t miss” diagnoses, that’s often really tricky to make. If you have a patient with AF, who is elderly with pain out of proportion despite analgesia and high lactate, think”could this be ischaemic bowel”. There have been cases of ischaemic bowel presenting with a normal lactate but always think of this in a patient with an isolated high lactate the pain often doesn’t fit any pattern. Remember CT isn’t 100% sensitive.
We all know the symptoms of bowel obstruction. If you think it’s obstruction, a CT may be more useful than an x-ray, especially in small bowel obstruction where x-ray is only about 50% sensitive. Depending on your department, ED may organise the CT or you may refer to your surgeons, and depending on your surgeons they may or may not mandate an AXR first! If you don’t think they’re obstructed but you do think they’re constipated, please don’t request an abdominal x-ray, especially in young people!
Most often presents with severe epigastric pain and vomiting so start treatment in these patients quickly, at least analgesia, IV fluids and anti-emetics.
Amylase peaks at approximately twelve hours and a diagnosis of pancreatitis can be made when it is 2-3 above the upper limit of normal. But if you’re still suspicious with a normal amylase speak to your senior, and then the surgeons!
Blood gas your surgical team will often ask you to do an ABG to score the patient. A VBG is just as good and in most emergency departments we do the diagnostic tests and the accepting team does the prognostic test!
Constipation is a diagnosis of exclusion, especially in the elderly. Think carefully about how you’ll treat it, your colleagues will not think much of you if you admit everyone to CDU for enemas when theyve got perfectly good toilets they could poo in at home. There’s no guidelines on how to treat constipation in adults but some thoughts based on the paediatric literature are here.
Non-specific abdominal pain
You’ll see a lot of this in the ED they come in with pain, fit no pattern, bloods normal (if done), tummy soft. Clearly they don’t need to need a surgeon or a gynaecologist. Practice what you’ll say to these patients something like; “there’s nothing acutely wrong with your tummy. The best thing to do is watch, wait and see what happens. If the pain persists attend your GP for review”. Always, always safety net with the GP.
Sometimes patients will have non specific pain but they’ll need referral because their pain is so severe. Refer honestly to the surgeons or gynaecologists and see what surprises the investigations reveal.
They are in pain, prescribe them analgesia and reassess!
Always keep in mind the diagnoses you dont want to miss e.g. the ruptured AAA and ischaemic bowel
What surgeons will invariably ask for:
Lactate, lactate, lactate!
Pregnancy test and urine dip
Previous imaging e.g. ultrasound in RUQ pain/suspected pancreatitis, previous colonoscopy if your main differential is diverticulitis and any previous CT scans
When did the patient last eat and drink, especially in the acute abdomen that may require emergency surgery
Group and save clotting, again in those that may require emergency surgery
Not all abdominal pain needs to be admitted. Up to 80% of patients are discharged with non-specific abdominal pain, and are often pain free within 2 weeks.
You may not have a specific diagnosis when referring but offer differentials.
If you’re not sure if they’ll need surgery it’s best to keep them nil by mouth until the surgical team review or check when referring.
Diagnoses like appendicitis / diverticulitis do not require abdominal x-rays. (unless it helps to rule out another differential).
Abdominal pain can be gynaecological (ectopic / ovarian torsion / tube-ovarian abscess), urological (testicular torsion / renal colic) and even medical! (think DKA and pyelonephritis).