Abdominal pain (acute/chronic)

The cause of this man's abdominal pain is probably not IBS.

Epidemiology

Differential Diagnosis

Acute

This can be split into anatomical bits.

• Epigastrium - pancreatitis, MI, gastric ulcer, perforated oesophagus
• Right Upper Quadrant - cholecystitis, chonlangitis, gallstones, duodenal ulcer, hepatitis, pyelonephritis, pneumonia, appendicitis
• Left Upper Quadrant - ruptured spleen, gastric ulcer, aortic aneurysm, bowel perforation, pyelonephritis, pneumonia
• Umbilicus - bowel obstruction, pancreatitis, aortic aneurysm, diverticulitis, gastroenteritis
• Lower Quadrants - (see pelvic pain), appendicitis, salpingitis, abdominal abscess, ruptured ectopic pregnancy, renal stones, strangulated hernia, mesenteric adenitis, Meckel's diverticulum, Crohn's, bowel perforation, PID

Chronic

Pancreatitis, ulcers, cholangitis, cholecystitis, aortic aneurysm, renal colic, irritable bowel syndrome, menorrhagia.

Clinical and Associated Features

Emergencies

Medical Emergencies - these conditions are medical emergencies presenting with abdominal pain. Scary stuff. Remember - acute abdominal pain is surgical until proven otherwise.

• Appendicitis - central abdominal pain moving to the right iliac fossa, fever, rebound tenderness (pain on removing pressure of palpation), tenesmus (feeling of needing to poo), nausea, vomiting, pressure in left IF (iliac fossa) makes pain worse in RIF. Untreated, has a very high mortality as it leads to peritonitis.
• Ruptured abdominal aortic aneurysm - pulsatile mass in the abdomen is the key, with hypotension
• Ectopic pregnancy - give a pregnancy test to any woman with acute abdominal pain. Usually presents as for a normal pregnancy. Pain in the lower abdomen, fever. If they start going into shock or becoming very unwell, this may be a sign of rupture.
• Intussusception - under age 1, redcurrant stools (late sign), sausage-shaped mass, drawing-up legs and arms, crying loudly and inconsolably. Needs surgery...NOOOOOOWWWWWW!
• Intestinal ischaemia - abdo pain, nausea, vomiting, diarrhoea, tachycardia, rectal bleeding, constipation

Acute

• Acute pancreatitis - sudden-onset severe upper abdominal pain radiating to the back, nausea, vomiting, peritonitis (central abdominal and shoulder tip pain), absent bowel sounds (severe in paralytic ileus), hypocalcaemia
• Peptic ulcer disease
  • Gastric ulcer - epigastric pain 15-30 minutes after eating, better after vomiting, weight loss, heartburn, haematemesis, melaena, lasts for 2 weeks at a time, 1-2 month cycles
  • Duodenal ulcer - epigastric (commonly nocturnal) pain 2-3 hours after eating, relieved by milk, made worse by anxiety, stress, and missing a meal; lasts for 1-2 months, 4-6 month cycles; weight gain due to milk intake; haematemesis, melaena.
• Perforated oesophagus - chest pain, dysphagia, tachycardia, tachypnoea, hypotension, sepsis
• Biliary tract disease - colicky right upper quadrant pain, nausea, vomiting, fever (occasionally jaundice and itching)
• Ruptured spleen - history of abdominal trauma, pallor, tachycardia, hypotension (postural), shoulder tip pain (Kehr's sign), guarding, abdominal rigidity, absent bowel sounds, abdominal distention
• Bowel obstruction - vomiting, abdominal distention, pain, constipation, peritonitis
• Perforation - pain (associated with where perforation is), tenderness, peritonitis, shock
• Renal stones - loin-to-groin pain, pain at the tip of the penis/in labia majorum, can lead to shock and peritonitis if infection develops, flank pain
• Gastroenteritis - poo everywhere, abdominal discomfort, vomiting, nausea, blood in stools (certain bugs),

Chronic

• IBS - diagnosis of exclusion, pain, diarrhoea, no cause found. Treated symptomatically.