Abdominal pain questions:

Where –> system involved

What –> pathology

How –> functional limitation

Why –> aetiology

  1. Patient’s age
  2. SOCRATES – site, onset, character, radiation, associated symptoms, time course, exacerbating/relieving factors, and severity.

Character:

Onset:

  • constant pain rather than intermittent = worse

Location: correlate with organs potentially affected

Radiation: started centrally and migrated to RIF = appendicitis

Duration: shorter duration = worse

Exacerbating/relieving factors:

  • sitting forward = pancreatitis
  • not moving around, lying rigid = peritonism

Associated Sx:

  • nausea and vomiting à if vomiting follows pain = worse
  • others covered below

Previous episodes (no prior episodes = worse); ask about testing (endoscopy)

  1. Specific questions –
  • HoPC:

· Nausea and vomiting? Contents of vomit?

· Diarrhoea/constipation?

· Blood in stool? In toilet bowl?

· Normal urinary function?

· Jaundice? Who noticed it?

· Fatigue?

· Anorexia?

· Weight loss?

· Fever?

· PMH:

· Smoker?

· Diverticulosis? (diverticulitis)

· Gallstones? (choledocholithiasis)

· Ulcers? (GI)

· Pancreatitis? (GI)

· Heart attack? Other heart problems? (IHD)

· Hypertensive? (IHD)

· Lipid profile? (IHD)

· Diabetic? (IHD)

· Trauma? (pancreas)

· Previous surgery? To abdomen? (cholecystectomy, pancreatectomy)

· Previous gastroscopy/colonoscopy?

· Medication:

· NSAIDs? Aspirin? Alcohol? –> all potential causes of gastritis

· Antibiotics/steroids? –> may mask infection

· Alcohol consumption? (pancreas, liver)

· Any recent changes to medications?

· FH:

· Cancer?

· Cardiac disease?

  1. Questions to ask all the time:

· Smoker? Alcohol?

· Appetite?

· Weight loss?

· Any recent changes to medications?

· Allergies?

· Diabetic?

Causes by location of pain:

(a) LUQ

  • Gastritis
  • Pancreatitis
  • Splenic rupture
  • AMI
  • Left lower lobe pneumonia

(b) LLQ

  • Diverticulitis
  • Ruptured ectopic pregnancy
  • Renal colic
  • Twisted ovarian cyst
  • Leaking aneurysm
  • PID

(c) RUQ

  • Cholecystitis etc.
  • Hepatitis
  • Hepatic abscess
  • Perforated duodenal ulcer
  • AMI
  • Right lower lobe pneumonia

(d) RLQ

  • Appendicitis
  • Meckel’s diverticulitis
  • Ruptured ectopic pregnancy
  • Renal colic
  • Twisted ovarian cyst
  • Leaking aneurysm
  • PID

Differential Diagnoses:

(a) Life-threatening

· Ruptured ectopic pregnancy à women of childbearing age; risk factors include PIF, STDs, intrauterine contraceptive device. Sharp, severe localised pain rarely on midline. May be shocked if there is haemorrhage. b-HCG and transvaginal US.

· Ruptured/leaking AAA –> risk factors include CAD, hypertension, DM, smoking. Epigastric pain radiating to back/groin. May be shocked. Plain abdo X-Ray and Spiral CT.

· Mesenteric ischaemia –> risk factors include IHD, DM, hypertension. 70% mortality. Colicky pain. CT/MRI/angiography.

· Bowel obstruction –> History of previous abdominal surgery. Vomiting, colicky pain, distention and constipation (initially diarrhoea). Increased bowel sounds. Plain abdo X-Ray.

· Perforated bowel –> History of peptic ulcer disease/diverticulosis. Acute onset epigastric pain (peptic ulcer) common; may localise due to walling off, or spread. Localised/generalised peritonitis. Decreased bowel sounds, fever and tachycardia. Plain abdo X-Ray shows free gas below diaphragm.

· Pancreatitis –> serum amylase/lipase, US and CT.

(b) Common

· Peptic Ulcer –> all age groups; assoc/w H. pylori, NSAIDs, Aspirin, smoking and alcohol. Epigastric pain 1-3 hours after food that’s relieved by food/antacids. Pain can awake patient at night. If perforation, presentation will be more severe. Give PPI, then gastroscopy and blood test for H. pylori.

· Acute appendicitis –> most common young adulthood. Umbilical pain that migrates to RIF over hours. If perforation, peritonitis and more severe systemically. Assoc/w low-grade fever and anorexia. WCC.

· Choledocholithiasis/cholecystitis/ascending cholangitis –> most common 30-50. RUQ pain that radiates to R. subscapular area. May be associated with fever and peritonitis (cholecystitis/cholangitis), jaundice and nausea and vomiting (all). WCC, amylase and US.

· Renal colic –> most common 30-40. Loin to groin pain, very severe. Assoc/w nausea and vomiting. Urinalysis (haematuria) and IV pyelography.

· Diverticulitis –> more common with age. LIF pain associated with fever, nausea and vomiting and change in bowel habit. Plain abdo XRay and barium enema.

· Acute gastroenteritis –> may be seen in multiple family members. Non-specific abdominal pain that follows nausea and vomiting, and assoc/w watery diarrhoea and fever. This is the last diagnosis after process of elimination.

· Important extra-abdominal causes:

    • DKA
    • MI
    • Pneumonia
    • PE
    • Sickle cell crisis
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