Abdominal Pain

Abdominal Pain

John Thompson MS FRCSED FRCSConsultant Surgeon

“The general rule can be laid down that the majority of severe abdominal pains which ensue in patients who have been previously fairly well, and which last as long as six hours, are caused by conditions of surgical import”.

Zachary Cope,1881-1974

History

Nature of pain/severity Onset Duration and evolution Site/radiation Exacerbating and relieving factors

History

Don’t miss anything Abdominal symptoms Urinary symptoms Cardiovascular risks Chest symptoms It’s not always in the abdomen

Examination

General appearance Observations (no value judgements) Don’t hold back on analgesia (but beware

junkies/Munchausen Syndrome) Look, listen then feel Guarding, rebound and Rovsing’s sign Repeated observation (MICLO)

Don’t forget “medical” causes

Lower lobe pneumonia Inferior MI Hypercalcaemia Psychiatric

Investigations

Urine for…..? FBC for…..? Amylase for…..? CRP for…..? Lactate for….? X-Rays for….?

Chest X Ray

Sub-diaphragmatic gas Mediastinal widening Lung mass Pulmonary oedema

Abdominal X-Ray: Air

In dilated bowel In biliary tree In Gallbladder On both sides of bowel

wall With fluid level

Fluid levels (gastric, multiple, single)

AXR: Calcification

Around pancreas In line of ureter Next to vertebrae Right upper quadrant Left upper quadrant

Ultrasound

FAST scan in emergency

Gallstones/pancreatitis/cholangitis

AAA Appendicitis Gynae

Laparoscopy

….. AND BIOPSY! Useful in younger

female Take the appendix out

and tell the patient Perforated duodenal

ulcer ?Perforated colon

(controversial)

CT scanning

RAAA Trauma Pancreatitis Elderly with possible

malignancy

A bit of embryology……

Vomiting

Once or twice intermittent Huge vomit infrequently then relief Frequent small volume Unremitting Nature of vomitus

Never let the skin stand between you and a diagnosis!

Abdominal Pain

Education

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