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Acute abdominal pain

Medicine > Cardiovascular

Differential Diagnosis Schema 🧠

Gastrointestinal

  • Acute appendicitis: Periumbilical pain migrating to the right iliac fossa, associated with nausea and vomiting.
  • Cholecystitis: Right upper quadrant pain, often triggered by fatty meals, may radiate to the shoulder or back.
  • Peptic ulcer disease: Epigastric pain, possibly relieved by eating or antacids.
  • Pancreatitis: Epigastric pain radiating to the back, often with a history of alcohol or gallstones.
  • Diverticulitis: Left lower quadrant pain, usually with a history of constipation or previous episodes.

Genitourinary

  • Renal colic: Flank pain radiating to the groin, often associated with haematuria.
  • Ectopic pregnancy: Lower abdominal pain, vaginal bleeding, history of missed periods.
  • Pelvic inflammatory disease: Lower abdominal pain, associated with vaginal discharge, fever, and dyspareunia.
  • Ovarian torsion: Sudden onset unilateral lower abdominal pain, often with nausea.

Vascular

  • Abdominal aortic aneurysm: Sudden severe central abdominal pain, often radiating to the back, possible pulsatile mass.
  • Mesenteric ischemia: Severe, diffuse abdominal pain, disproportionate to examination findings, often in elderly patients with cardiovascular disease.

Other

  • Diabetic ketoacidosis: Diffuse abdominal pain, polyuria, polydipsia, and vomiting, often in a known diabetic.
  • Herpes zoster: Localised pain with a dermatomal distribution, often followed by a vesicular rash.
  • Referred pain (e.g., myocardial infarction): Epigastric pain, may be associated with exertion and not relieved by antacids.

Key Points in History 🥼

Onset and Duration

  • Sudden onset: May suggest perforation, vascular event, or torsion.
  • Gradual onset: Often seen in inflammatory conditions such as appendicitis or diverticulitis.

Pain Character

  • Colicky pain: Typically seen in renal colic, biliary colic, or intestinal obstruction.
  • Sharp, localised pain: Suggestive of peritoneal irritation (e.g., appendicitis).
  • Dull, diffuse pain: Common in early appendicitis, gastroenteritis, or mesenteric ischemia.

Associated Symptoms

  • Fever: Often indicates an infectious or inflammatory process such as cholecystitis or diverticulitis.
  • Nausea and vomiting: Common in almost all causes of acute abdominal pain, especially in obstructive or inflammatory conditions.
  • Change in bowel habits: Diarrhoea may suggest gastroenteritis; constipation may be seen in bowel obstruction.

Background

  • Past medical history: Previous abdominal surgeries may suggest adhesions; a history of diverticulosis increases the risk of diverticulitis.
  • Drug history: NSAIDs may be linked to peptic ulcers; recent antibiotics could suggest Clostridium difficile infection.
  • Family history: Family history of inflammatory bowel disease may be relevant.
  • Social history: Alcohol use may be associated with pancreatitis.

Possible Investigations 🌡️

Laboratory Tests

  • Full blood count: Elevated white cell count may indicate infection or inflammation.
  • Urea and electrolytes: Assess renal function and electrolyte balance, especially in dehydration or renal colic.
  • Amylase/lipase: Raised levels suggest pancreatitis.
  • Liver function tests: Elevated bilirubin or transaminases may indicate hepatobiliary disease.
  • Urinalysis: Haematuria may be seen in renal colic; ketones in diabetic ketoacidosis.
  • Pregnancy test: Essential in women of childbearing age to rule out ectopic pregnancy.

Imaging

  • Ultrasound: First-line for biliary, renal, and gynaecological causes.
  • CT scan: High sensitivity for a wide range of conditions, including appendicitis, diverticulitis, and renal colic.
  • X-ray: Useful in bowel obstruction (look for air-fluid levels), perforation (free air under diaphragm).

Special Tests

  • ECG: Essential in older patients to rule out myocardial infarction presenting as epigastric pain.
  • Endoscopy: Consider in suspected peptic ulcer disease or upper gastrointestinal bleed.

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Cardiovascular