Abdominal Pain

Abdominal pain is a common complaint in general practice and can arise from a multitude of causes ranging from benign to life-threatening. The approach to abdominal pain involves a detailed understanding of potential causes, a thorough clinical assessment, appropriate differential diagnoses, and subsequent management.

Causes

Abdominal pain can be classified based on the underlying cause:

  • Gastrointestinal Causes:
    • Gastritis, peptic ulcers
    • Gastroenteritis
    • Inflammatory bowel diseases (Crohn’s disease, ulcerative colitis)
    • Irritable bowel syndrome (IBS)
    • Appendicitis
    • Diverticulitis
    • Constipation
    • Bowel obstruction
    • Colitis
    • Gallstones, cholecystitis
    • Pancreatitis
    • Hepatitis, liver abscess
  • Genitourinary Causes:
    • Urinary tract infection (UTI)
    • Pyelonephritis
    • Kidney stones
    • Ovarian cysts, torsion
    • Ectopic pregnancy
    • Endometriosis
    • Pelvic inflammatory disease (PID)
  • Vascular Causes:
    • Abdominal aortic aneurysm
    • Mesenteric ischemia
  • Other Causes:
    • Hernias
    • Trauma
    • Metabolic disorders
      • DKA
      • Hypercalcaemia (Hyperparathyroidism)
      • Addisons Disease
    • Psychogenic pain

Diagnosis

  • History:
    • SOCRATES-PT
      • Site
      • Onset
      • Character
      • Radiation
      • Associated
      • Time intensity
      • Exacerbating/Relieving
      • Severity
      • Patient Thinks
    • Nature, location, intensity, timing, and duration of pain.
    • Associated symptoms: nausea, vomiting, diarrhea, fever, urinary symptoms, menstrual history.
    • Aggravating and relieving factors.
    • Previous medical history, medications, surgeries.
  • Physical Examination:
    • Inspection, auscultation, percussion, and palpation of the abdomen.
    • Evaluation of rebound tenderness, guarding, and rigidity to assess peritoneal irritation.
    • Pelvic and rectal examinations in selected cases.
  • Laboratory Tests:
    • Full blood count (FBC), CRP, electrolytes, liver function tests, amylase, lipase, lactate.
    • Urinalysis.
    • Pregnancy test in women of childbearing age.
  • Imaging:
    • Ultrasound for gallbladder, liver, gynecological, and renal conditions.
    • Abdominal X-ray for obstruction, perforation.
    • CT scan for detailed assessment of abdominal organs.

Differential Diagnosis

  • Acute Appendicitis, Cholecystitis, Diverticulitis: Based on location and nature of the pain, fever, and imaging findings.
  • Gastroenteritis, IBS, Peptic Ulcer Disease: Considered in chronic or recurrent pain cases.
  • Ectopic Pregnancy, Ovarian Cyst/Torsion: In women with lower abdominal pain.
  • Urinary Tract Infection, Pyelonephritis, Kidney Stones: Especially with dysuria or flank pain.
  • Abdominal Aortic Aneurysm, Mesenteric Ischemia: In older patients or those with vascular disease.

Management

  • Pain Management: Analgesics as appropriate
  • Specific Treatments:
    • Antibiotics for infections like UTI, cholecystitis, diverticulitis
      • NB eTG advises trial of clear fluids for mild diverticulitis
    • IV fluids, bowel rest for gastroenteritis, pancreatitis, diverticulitis
    • Surgical intervention for appendicitis, obstructive causes, ectopic pregnancy.
  • Lifestyle Modifications: Dietary changes in IBS, gastritis.
  • Follow-Up: Regular monitoring for chronic conditions like IBS, inflammatory bowel disease.

Referral

  • Specialist Referral: For unexplained, persistent, or severe symptoms, and for specific conditions requiring specialized care (e.g., gastroenterologist, surgeon, gynecologist).
  • Emergency Referral: For signs of acute abdomen, such as severe, unremitting pain, peritonitis, hemodynamic instability, or suspicion of life-threatening conditions like ectopic pregnancy, bowel perforation, or aneurysm.

Conclusion

The approach to abdominal pain is multifaceted, involving a detailed patient history, thorough physical examination, judicious use of laboratory and imaging studies, and consideration of a broad differential diagnosis. Management depends on the underlying cause, ranging from conservative treatment to surgical intervention. Timely referral to appropriate specialties is crucial in cases of diagnostic uncertainty or severe underlying pathology.