Pain may be absent in elderly, those on steroids, diabetics and may be difficult to assess in the very frail. Are they moribund in extremis then ABC and get help fast and in meantime get IV access, Oxygen, IV Crystalloids, Analgesia and send off bloods including lactate, FBC, U&E, Amylase, cross match if haemorrhage a concern. If bleeding and shocked get in two lines and consider O negative blood. If sepsis then IV antibiotics and fluids.
|Localisation by quadrants||Causes|
|RUQ|| cholecystitis, gallbladder empyema, hepatitis, liver abscess, duodenal ulcer, pneumonia, subphrenic abscess, hepatic flexure of colon.
|LUQ|| gastroenteritis, splenic disease (infarction/rupture), splenic flexure of colon, subphrenic abscess, perinephritis, acute pancreatitis.
|Epigastrium|| oesophageal/gastric disease (perforation, gastric ulcer or duodenal ulcer), ruptured AAA, acute pancreatitis, myocardial infarction, PE, pancreatic cancer.
|Right flank|| ureteric colic (loin to groin), pyelonephritis (renal angle), retrocaecal appendix, muscle strain, perinephric abscess.
|Periumbilical|| early appendicitis, small bowel disease - obstruction and inflammatory bowel disease, gastroenteritis, pancreatitis, ruptured AAA, ischaemic bowel.
|Left flank|| ureteric colic (loin to groin), pyelonephritis (renal angle), muscle strain, perinephric abscess.
|RIF|| appendicitis, mesenteric lymphadenitis, perforated duodenal ulcer, caecal obstruction, Meckel's diverticulum, ectopic pregnancy, ovarian pathology, terminal ileal disease (Crohn's/Yersinia pseudotuberculosis) or very rarely RLQ diverticulitis, biliary colic with low lying gallbladder, acute salpingitis.
|LIF|| sigmoidal diverticulitis, constipation, ectopic pregnancy, ovarian pathology, ischaemic colitis, rectal cancer, IBS, ulcerative colitis.
|Suprapubic|| cystitis, UTI, acute urinary retention, testicular torsion, pelvic inflammatory disease, ectopic pregnancy, uterine disease, diverticulitis.
|Cause ||Clues to Consider|
|Acute Cholecystitis||History of Gallstones, RIF pain, Murphy's sign, fever, jaundice if stone in common bile duct. Murphy's sign: palpation over RUQ causes acute severe pain stopping inspiration. |
|Acute Acalculous Cholecystitis||Rare. No gallstones seen. Usually unwell form other issues. May be in ITU. RIF pain, Murphy's sign, fever, jaundice perhaps. No stone on USS. |
|Acute Appendicitis||Poorly localised pain begins peri-umbilical and moves to RIF as becomes more peritonitis and sharper. Anorexia, Vomiting. Dry, furred tongue. Previous appendectomy excludes appendicitis. Tender and guarding RIF |
|Leaking abdominal aortic aneurysm (AAA)|| midline pulsatile expansile mass, low BP, may have lost a femoral pulse. |
|Peptic ulcer disease and perforation|| Increased risk if HP or use of NSAIDs, steroids. |
|Ectopic pregnancy||Consider in all fertile females. Can rapidly kill. A pregnancy test for all women of reproductive age. ? Ectopic pregnancy. |
|Bowel Ischaemia|| Older patient, high lactate, abdominal pain, melena, AF. May need resection of necrotic bowel. |
|Ascending Cholangitis||Jaundice, rigors, RUQ pain|
|Incarcerated or strangulated hernia||Tender abdomen with bowel obstruction and tender hernial orifices. |
|Spontaneous Bacterial Peritonitis|| bulging flanks, abdominal distension with shifting dullness. Bowel floats and ascites gravitates to lowest point. Consider SBP in liver disease. |
|Acute Diverticulitis|| left iliac fossa pain, older patient. |
|Pelvic inflammatory pain|| may have similar history, vaginal discharge, history of STIs. |
|Inflammatory bowel disease|| Crohn's disease predominantly a small bowel obstruction picture. Ulcerative colitis mainly a colitis picture. Watch for toxic megacolon. |
|Rectus Sheath / Abdominal wall haematoma|| on Warfarin or antithrombotics. Coughing. Localised tender. |
|Ureteric colic/renal stones|| renal angle to loin pain, restless, paroxysmal. Stone on CT KUB |
|Testicular torsion|| Moderate to severe abdominal pain but always examine for testicular pain which should then focus the cause. |
|Meckel's diverticulum|| pain in RIF. May perforate. Seen in adolescents and young adults. Can mimic appendicitis. |
|Mittelschmerz||ovulation mid-cycle pain. May need gynaecological consult |
|Myocardial infarction (diaphragmatic/inferior)|| ECG - ST/T changes and troponin. |
|Gastroenteritis|| vomiting and diarrhoea predominate with vague pain and tenderness; gradually settles. |
|Diabetic ketoacidosis || Raised WCC. ABG low pH. Ketones. Amylase can also go up in DKA.|
|Lower lobe pneumonia|| fever, breathless, chest signs, CXR signs may be delayed. |
|Pyelonephritis|| positive urinalysis, tender renal angle, female. |
|Addisonian crisis|| pale, pigmented creases and scars, low BP. |
|Sickle cell crisis|| Afro-Caribbean origin, similar past history, anaemia. Hyposplenism. |
|Herpes zoster|| rash may not be seen early on - pain affecting abdominal dermatome does not cross midline. |
|Acute porphyria||variegate and acute intermittent porphyria, hereditary coproporphyria. |
|Familial Mediterranean fever || Turkish/Middle Eastern. Mesenteric adenitis: viral type illness - younger patients. Mimics appendicitis.|
|Tabes dorsalis || as part of tertiary syphilis.|
|Bleeding|| Leaking Aortic aneurysm or Aortic dissection, Ectopic pregnancy, Retro peritoneal bleed, Severe GI bleed. Needs IV access, Transfusion and correction of coagulopathy. May need Massive transfusion protocol. Assess need for surgical intervention to stop bleeding. Endoscopy for Upper GI bleed.
|Perforated viscus|| Gastric ulcer and perforation, Colorectal perforation, Diverticular disease, Appendix. May need urgent laparotomy and IV antibiotics. IV fluids and close attention to electrolytes.
|Necrosis of viscus|| Severe (haemorrhagic ) pancreattis, Volvulus and infarcted bowel, Intussusception and infarct bowel, Strangulated bowel, Ischaemic colitis. May need urgent laparotomy and iV antibiotics. IV fluids and close attention to electrolytes.
|Sepsis|| Cholangitis and general sepsis, Abscess and sepsis. May need urgent laparotomy and IV antibiotics. IV fluids and close attention to electrolytes. Drainage of abscess.
|Medical causes||DKA, Acute MI, Porphyria, Lower lobe pneumonia. Management as per cause.