Approach to Abdominal Pain

Differential diagnosis

• On call diagnosis
  • Acute abdomen
    • Mesenteric ischaemia
    • Appendicitis
    • Perforated viscus
    • Ruptured abdominal aortic aneurysm
  • Hepatobiliary
    • Gallstones – biliary colic
    • Acute cholecystitis
    • Ascending cholangitis
    • Acute hepatitis
    • Malignancy with capsular stretch
    • Acute pancreatitis
    • Ascites / spontaneous bacterial peritonitis
    • Portal vein thrombosis
    • Splenic infarction
  • Upper GI
    • Peptic ulcer disease
    • Gastritis
    • Gastro-oesophageal reflux disease
  • Lower GI
    • Diverticular disease
    • Inflammatory bowel disease
    • Colonic obstruction
  • Renal
    • Renal colic
    • Pyelonephritis
    • APKD – ruptured cyst
  • Gynaecological
    • Torsion of ovarian cyst
    • Ectopic pregnancy
    • Ruptured ovarian cyst
    • Endometriosis
    • Pelvic inflammatory disease
    • Dysmenorrhoea
  • Metabolic
    • Diabetic ketoacidosis
  • Autoimmune
    • SLE with gut manifestations
    • Polyarteritis nodosa and mesenteric ischaemia
  • Malignancy
    • Gut lymphoma
    • Colonic malignancy causing obstruction
• PACES diagnosis
  • Porphyria
  • Familial Mediterranean fever

High yield questions

• SOCRATES
• Do you have fever?
• Have you noticed your skin is yellow?
• Have you noticed your urine is dark or that your stools are pale?
• Any pain when passing urine?
• Any blood in urine?
• Any diarrhoea?
• Any blood in stools?
• Any relation to meals?
• Any NSAID use?
• Does the pain go to the back?
• Is the pain made better by leaning forward?
• Any history of gallstones or alcohol use?
• Feel like you are going to the toilet a lot or drinking a lot of water?
• Any rash or joint pain?
• Any mental illnesses in the past?
• Any loss of weight / night sweats?
• Last menstrual period
• Contraceptive use
• Vaginal / penile discharge
• Irritable bowel syndrome:
  • Any bloating?
  • Any relief after passing motion?

Examination

• Pulse: regular / irregular
• Abdominal examination
  • Hepatomegaly / tender hepatomegaly
• Joints
  • Large joint oligoarthritis for inflammatory bowel disease
• Skin: rashes