acute abdominal pain.ad 027 034 aug22 08

Background

HowtotreatHistory and examination

Investigation

Specific surgicalconditions

Non-generalsurgical causes ofabdominal pain

inside

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PATIENTS complaining of acuteabdominal pain make up at least 3%of all presentations to a general prac-tice and up to 10% of all presenta-tions to accident and emergencydepartments. These patients are oftendiagnostically challenging because ofthe multitude of potential diagnosesand the diversity of presentations.

Although most presentations are

assumed to have a surgical basis,medical diagnoses can mimic theacute abdomen and should at leastbe ruled out. Elderly patients or thosewith significant comorbidity or exces-sive body habitus are particularly dif-ficult to diagnose when the initialsymptoms and signs are non-specific.

The aim of assessing acute abdom-inal pain is to recognise patients who

need rapid transfer to an emergencydepartment for resuscitation and/orurgent surgical intervention, as wellas to triage those who will need hos-pitalisation for further investigationand definitive treatment. About one-third of patients who present withacute abdominal pain ultimately arediagnosed with non-specific abdominal pain.

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DR JULIA CRAWFORD, surgical registrar, department ofgastrointestinal surgery, RoyalNorth Shore Hospital, St Leonards, NSW.

The authors

DR THOMAS JARVIS, surgical registrar, department ofgastrointestinal surgery, RoyalNorth Shore Hospital, St Leonards, NSW.

DR THOMAS J HUGH, senior lecturer, University ofSydney and senior staffspecialist and upper GI andlaparoscopic surgeon,department of gastrointestinalsurgery, Royal North ShoreHospital and North Shore PrivateHospital, St Leonards, NSW.

AcuteABDOMINALPAIN

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How to treat – acute abdominal pain

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AS with any clinical presentation, acomprehensive history should betaken to determine the mode ofonset, duration, frequency, charac-ter, location and radiation of thepain, and any aggravating or reliev-ing factors. Often the history pro-vides more important informationfor subsequent management thanany single laboratory test. Further-more, a good history guides themost logical and appropriate inves-tigations.

In the past, diagnosis of acuteabdominal pain was largely basedon pattern recognition. Even in anera of easy access to diagnostictests, knowledge of these classicpresentations is still important.However, frustratingly, patientswith acute abdominal pain maypresent with atypical features thatmake pattern recognition unreli-able.

The onset and duration of thepresenting pain may give an indi-cation of the severity of the under-lying pathology. Sudden onset ofsevere pain usually indicates a cat-astrophic event such as a perfo-rated viscus or a rupturedaneurysm. Rapidly progressingpain that stays in one area of theabdomen suggests a specific diag-nosis such as biliary colic or severepancreatitis, depending on the loca-tion of the pain.

In contrast, pain that builds upgradually over several hours andthat begins as a slight or vague dis-comfort only, but soon localises toa specific area of the abdomen,suggests a subacute process char-acteristic of peritoneal inflamma-tion. As a general principle, anysevere acute abdominal pain thatlasts for more than a few hours islikely to be due to an underlyingsurgical pathology.

The location of the pain in theright or left side of the abdomenor in the epigastrium provides aguide to the likely diagnosis. Typi-cally, diffuse but localised epigas-tric pain suggests such diagnosesas pancreatitis or peptic ulcer dis-ease, while right upper-quadrant orright-sided back pain indicates bil-iary colic or acute cholecystitis.

Renal colic often begins as a dullflank pain but may radiate downinto the groin.

The classic presentation of acuteappendicitis involves a prodromalperiod of anorexia associated withvague peri-umbilical pain that

gradually moves to the right iliacfossa as localised peritonitis sets in.

It is helpful to try to describeabdominal pain as intermittent orcontinuous in nature or as dull orsharp in character. ‘Colicky’ symp-toms describe pain that occursintensely for a short period of timefollowed by a pain-free period.This is typical of obstruction of ahollow viscus by vigorous peristal-sis proximal to the site of theobstruction.

Large luminal obstruction suchas occurs in the colon may besevere but tolerable for long peri-ods of time. On the other hand,obstruction of a narrow lumentube such as the ureter or the smallbowel is frequently excruciatingand unbearable.

Continuous or constant abdomi-nal pain is invariably associatedwith peritoneal inflammation or,more worryingly, ischaemia. Whenthe intensity of the pain crescendosbut then does not settle betweenattacks, underlying ischaemia

should be suspected.A confusing misnomer is ‘biliary

colic’, which is used to describe thesymptoms associated with uncom-plicated gallstones. The gallblad-der lacks a strong muscularismucosa, so pain from anobstructed cystic duct is constantrather than colicky in nature.

Other descriptive terms used bysome patients included a ‘tearing’sensation that may indicate a dis-secting aneurysm, or a ‘burning’epigastric pain that may indicateeither acute gastritis or a pepticulcer. However, the diagnosis ofacute gastritis is relatively rare andshould only be made when therehas been a history of a toxic inges-tion such as excessive alcoholintake, recent heavy NSAID use ordeliberate or accidental ingestionof a caustic substance.

In contrast, patients with chronicgastritis are usually either asymp-tomatic or have subtle and vagueupper abdominal discomfort ratherthan acute abdominal pain.Chronic gastritis is divided intotype A (associated with perniciousanaemia), type B (mostly due toHelicobacter pylori infection) andtype C (due to chronic ingestion ofa toxin, such as an NSAID).

Patterns of radiation of theabdominal pain may also be help-ful. For example, acute pancreatitisor a ruptured abdominal aorticaneurysm frequently causes severeepigastric pain that radiatesthrough to the back. Anotherexample of radiating symptomsrelates to acute cholecystitis, whichoften presents as right upper-quad-rant discomfort extending aroundthe patient’s side rather thanstraight through to the back.

Any pathology that causes irri-tation of the diaphragm may resultin referred pain to the shoulder tip.This occurs because of innervationof the diaphragm by the fourth cer-vical nerve route, which also sup-plies the shoulder. Other examplesof referred pain include renal colicthat classically radiates from theloin into the tip of the genitalia,and small bowel colic that initiallypresents as peri-umbilical discom-fort because this area shares thesame spinal nerve root innervation(T10) as the small intestine.

A shift in the location of theabdominal pain with time reflectsprogression of the pathology. Forexample, the initial visceral or

peri-umbilical pain of early appen-dicitis (reflecting innervation fromT10) shifts to the right iliac fossaover several hours as localisedperitonitis develops.

A change in the nature of thepain may also signify progressionto a more sinister pathology. Forexample, a change from the gen-eralised cramping and intermittentabdominal pain of subacute small-bowel obstruction to a more con-stant and generalised pain raisesconcern about intestinalischaemia.

Identifying the factors that influ-ence the patient’s abdominal painmay also point towards the diag-nosis. For example, a patient maydescribe relief from severe abdomi-nal and back pain by leaning for-ward, and this often occurs inacute or chronic pancreatitis.

In the case of peritoneal inflam-mation from acute appendicitis,any movement such as coughing,straining or even travelling overthe bumps on the road during thecar trip to the hospital exacerbatesthe abdominal symptoms and is agood indicator of peritoneal irri-tation.

It may also be helpful to eluci-date whether there have been anyother associated symptoms. Thepresence of nausea, vomiting,anorexia or a change in bowelhabit frequently go hand in handwith acute abdominal pain. Thetemporal relationship of thesesymptoms to the pain may pointtowards a particular diagnosis.For example, intractable nauseamay precede the pain associatedwith obstruction of a narrowlumen tube such as the pancreaticduct.

Accompanying fevers, rigors orchills suggest an associated infec-tion and should help differentiatesuch diagnoses as ‘biliary colic’and renal colic from cholecystitisand pyelonephritis. In the lattertwo conditions, hospital admissionis usually required for pain reliefand IV antibiotics.

Any symptoms associated withvoiding or opening of the bowelsmay suggest a specific pathologybut it is worth remembering thatthese symptoms may just be sec-ondary to pain or anxiety. A his-tory of a change in the colour ofthe urine or stools should also besought and may be helpful at leastin excluding some diagnoses.

History

ExaminationIN an era of ready access tocomplex and expensive inves-tigations it is easy to forgetthat an accurate history,combined with a thoroughclinical examination, will fre-quently make the correctdiagnosis without the needfor any investigations.

We bemoan the lack of clin-ical acumen in junior doctors— and so we should, becausethese skills are now moreimportant than ever in decid-ing on the most appropriateand cost-effective investiga-tions to order. The consis-tently large numbers of litiga-

tion cases for delayed diagno-sis are a testament to this.

Also, the ‘end of the bed’assessment should not beunderestimated as a guide tothe severity of the acute pre-sentation. A patient may bejaundiced or pale, or may bemotionless in the case of peri-tonitis, or be rolling aroundin agony when the pain is dueto renal colic. Even a cursoryinspection may reveal signs ofdehydration, fever or tachyp-noea, suggesting a seriousacute abdominal problem thatwill prompt the need for earlyresuscitation and treatment.

Full exposure of theabdomen is critical to avoidmissing an obvious diagnosissuch as an obstructed inguinalor femoral hernia. The pres-ence of distension of theabdomen, scars from previousoperations or the presence ofany associated hernias shouldalso be noted. The patientshould be directed to liesupine with the arms placedby their sides and with theknees slightly flexed to relaxthe abdominal musculature.

The site of maximum painis often pointed out by thepatient and the abdominal

examination should start onthe opposite side to this.Alternatively, the patientshould be asked to cough asthis may highlight an area offocal tenderness, and theexamination can be tailoredaccordingly.

Diffuse abdominal rigidity(‘board-like’) suggests gener-alised peritoneal irritationwith subsequent involuntaryspasm of the abdominal wallmuscles. Rebound tenderness,indicating peritoneal irritation,can be elicited by withdrawingthe examining hand quicklyor, better still, by asking the

patient to cough and by gaug-ing their response.

The most likely diagnosescan at least be narroweddown by the specific region ofmaximal tenderness. Forexample, right upper-quad-rant pain with exacerbationof pain on palpation duringdeep inspiration (Murphy’ssign) usually indicates acutecholecystitis. Alternatively,focal epigastric tendernesswith radiation directlythrough to the back indicatespancreatitis. Loin pain radiat-ing into the groin is indicativeof renal pathology.

Abdominal X-ray of ischaemic small bowel secondary to adhesions.

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URINALYSIS is a simpleand readily available test thatmay yield important diagnos-tic information. The presenceof protein or blood in theurine often indicates an acuterenal tract pathology such asa renal calculus or nephritis.However, macroscopichaematuria can occur in non-renal pathologies such as aruptured abdominal aorticaneurysm. Similarly, pyuriamay also be present when aninflamed appendix lies adja-cent to the right ureter.Having said that, this test isstill very helpful because it isquick and simple to performand will, at least, exclude anysignificant urinary tractpathology.

A complete blood pictureincluding a check of thehaemoglobin, white cellcount, electrolytes, urea andcreatinine, liver functiontests (LFTs) and serum lipaselevel is important in narrow-ing down the cause of theacute abdominal pain.

A leucocytosis will be pre-sent in any infective condi-tion, whether bacterial orviral, and therefore shouldnot be used alone to makeor exclude a diagnosis of anacute abdominal problem.For example, the absence ofan elevated white cell countdoes not necessarily excludeearly acute cholecystitis,acute appendicitis or evencholangitis. Similarly, thewhite cell count may be ele-vated as a result of a viralinfection causing mesentericadenitis and consequentlyacute abdominal pain.

Regarding the diagnosis ofacute or chronic pancreati-tis, the serum amylase levelis less sensitive and less spe-cific than the serum lipaselevel, so only the latter testshould be used to excludethis diagnosis. Mild to mod-erate elevations in the serumamylase level may occur inthe presence of a perforatedpeptic ulcer, intestinalobstruction and even inmesenteric ischaemia.

In patients with suspectedacute appendicitis, the clini-cal history and physical signsare far more reliable thanchanges in the white cellcount. In most cases thisshould be a clinical diagno-sis, and any serological or

radiological investigationsshould only be used to sup-port the diagnosis.

Derangements in LFTs indi-cate hepatobiliary or pancre-atic pathology, and subsequentinvestigations should beordered accordingly. Assess-ment of electrolytes and renalfunction is essential in patientspresenting with acute abdomi-nal pain, to exclude dehydra-tion and to guide the need forfluid and electrolyte replace-ment. In patients with highepigastric or retrosternal chestpain, blood should be checked

for elevated troponin levelsand this should be done inconjunction with a restingECG.

RadiologyWith ready access to modernimaging such as ultrasound,CT or MRI, it is now uncom-mon, and often unhelpful, toorder a plain abdominal X-ray in patients who presentwith acute abdominal pain.

Having said that, if thereis a clinical suspicion, and aplain abdominal film is read-ily available, then this (per-

formed together with anerect CXR) may still be agood test to exclude free airunder the diaphragm as aresult of a perforated viscus.Also, if there is any sugges-tion of a respiratory compo-nent to the presentation,pneumonia should beexcluded by a CXR.

Abdominal ultrasound isone of the most useful diag-nostic tests for assessing acuteabdominal pain. It is cheap,readily available and non-invasive and is the investiga-tion of choice for examining

the gallbladder and biliarytract, as well as the pelvis.

Abdominal ultrasoundmay also be very helpful inthe diagnosis of acute appen-dicitis. Even if the appendixis not seen, the presence offocal tenderness associatedwith a good history and clin-ical signs may be enough evi-dence to clinch the diagnosisand justify surgical referral.

Having said that, ultrasoundof the abdomen is sometimeslimited by overlying gas-filledstructures, obesity and inabilityof the patient to tolerate the

investigation because of pain.Also, an abdominal ultrasoundis only as good as the operatorholding the probe, so experi-enced radiology practices willyield the best results.

CT scanning is now themodality of choice for investi-gating the patient with anacute abdomen. However theradiation exposure is muchgreater for a CT scan com-pared with a plain X-ray, andthere are concerns about radi-ation exposure with CT, espe-cially in children. Hence anultrasound scan is preferred asthe first choice in young chil-dren and in women who maybe pregnant.

Other than in remote ruralareas of Australia, CT scan-ning is readily available tomost general practices duringworking hours and is alsoavailable after hours in mostreasonably sized hospitals.Although the final result isstill dependent on the hard-ware and software of thescanner, in most cases a CTscan provides an accurateassessment of the intra-abdominal organs and usu-ally identifies the causativepathology. Having said that,a CT scan should only beused as an adjunct, and notas a substitute, for a thor-ough history and physicalexamination.

Also, when requesting a CTscan, it is helpful for the radi-ologist to have some basicclinical information about thepresentation — even a differ-ential diagnosis. They aremore likely to look critically atthe area of interest rather thanjust having a cursory inspec-tion if this information is pro-vided.

After referral to an accidentand emergency department,patients frequently endurelengthy delays while waitingfor results of investigations.This could be streamlined byarranging appropriate bloodtests, and imaging, if indicated,before the patient is sent to thehospital.

However, this should onlybe done if it does not cause anundue delay in receiving treat-ment. A legible letter from thereferring doctor indicatingwhat tests have been done andhow the results can beaccessed is extremely helpfulfor emergency room staff.

Investigation

Ultrasound showing acute appendicitis with no significant narrowing of the lumen duringcompression.


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Ultrasound showing acute cholecystitis with perforation.

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In patients withsuspected acuteappendicitis, theclinical historyand physicalsigns are farmore reliablethan changes inthe white cellcount.

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these patients should bereferred for consideration fora laparoscopic cholecystec-tomy.

The presence of a positiveMurphy’s sign, persistentabdominal pain despite anal-gesia, a leucocytosis or feversuggests acute cholecystitis.These patients should bereferred to hospital for IVantibiotics and considerationfor semi-urgent cholecystec-tomy.

The presence of recurrentabdominal pain and feversassociated with alteration inLFTs or a history of jaun-dice suggests cholangitis sec-ondary to choledocholithia-sis (Charcot’s triad). Ifpatients are acutely unwellthey will need urgent fluidresuscitation and IV antibi-otics and may also requireurgent endoscopic retrogradecholangiopancreatography(ERCP).

The presence of a stonein the common bile duct onultrasound, or the findingof abnormal LFTs, doesnot necessarily mandatereferral for a pre-cholecys-tectomy ERCP, as long asthe patient does not havesevere cholangitis. Manysurgeons are now happy toperform an operativecholangiogram at the timeof the cholecystectomy andto remove the stones fromthe common bile ductlaparoscopically during thesame procedure.

Acute pancreatitisThe two most commoncauses of pancreatitis in ourcommunity are gallstonesand excessive alcohol inges-tion. There are a myriad ofother less common causes,including viral illnesses,medications (eg, corticos-teroids, ACE inhibitors,frusemide, etc) and congeni-tal ductal abnormalities (seetable 1, page 31).

Patients typically presentwith sudden onset of severeepigastric pain radiatingthrough to the back. Thepain is often intolerablewithin 3-4 hours of the onsetof symptoms and may beassociated with nausea andvomiting.

Classic clinical signs ofsevere acute pancreatitisinclude Grey Turner’s sign(flank ecchymosis) andCullen’s sign (periumbilicalskin discolouration). Boththese clinical signs reflectsevere retroperitonealinflammation and mandateurgent hospital admissionfor IV fluid resuscitation andpossibly even acute surgicalintervention.

The diagnosis of acutepancreatitis is easily made bychecking for an elevatedwhite cell count, abnormalLFTs and an elevated serumlipase level. Definitive assess-ment of pancreatic perfu-sion, and the presence or

Acute abdominal emergencyLeaking or ruptured abdominal aortic aneurysmABDOMINAL aortic aneurysms are typically asymptomaticand may go undetected until a catastrophic complicationoccurs. However, there may be a short history of symptomssuggesting impending rupture, including new and persistentbackache or vague but deep-seated abdominal pain.

Just before rupture of the aneurysm, patients may experi-ence a sudden onset of severe abdominal or epigastric painradiating through to the back associated with pre-syncope,diaphoresis, nausea or tachycardia. If an intra-abdominalrupture occurs, there will be a catastrophic sudden haemor-rhage resulting in the rapid demise of the patient.

Patients whose abdominal aortic aneurysms are containedin the retroperitoneum have a chance of survival if diagnosisand treatment are instituted promptly. A leaking or rupturedabdominal aortic aneurysm is associated with high mortalityand requires urgent transfer to a hospital, where surgicalintervention offers the only chance of survival.

Perforated viscusIn the past, perforation of a peptic ulcer was a commonacute surgical emergency. However, with the dramatic fall inthe incidence of peptic ulceration in our community this isnow a rare acute surgical presentation.

More commonly, patients present with a perforated diver-ticulum secondary to diverticulitis. In this situation theremay have been a history of diverticulosis or of lower abdom-inal pain for several weeks before the acute presentation.

An acute contained perforation may present as focal peri-tonitis, while patients with an uncontained perforation ofeither the colon or a peptic ulcer will have generalised abdom-inal pain and board-like rigidity of the abdomen. This may beassociated with hypotension, tachycardia and tachypnoea,which are manifestations of systemic sepsis.

With acute perforation there may be referral of pain to theshoulder tip because of diaphragmatic irritation due to freeintra-abdominal fluid. Abdominal distension is due to theassociated ileus. Blood tests usually reveal a leucocytosis,and a plain abdominal X-ray and erect CXR will show freeintra-peritoneal gas in up to 80% of cases. These patientsobviously require urgent transfer for surgical intervention.

Subacute abdominal emergencyBiliary colic and acute cholecystitisCalculous disease of the biliary tract is one of the mostcommon causes of subacute abdominal pain. Gallstones occurcommonly in Western societies, particularly in women aged20-50. The traditional teaching that gallstones occur in thefive F’s (fair, fat, forty, fecund, and female) is a reasonablegeneralisation, but gallstones are certainly not confined to thisgroup of patients.

Classic symptoms of biliary colic include epigastric dis-comfort, often described as a ‘band-like’ pain across theupper abdomen and sometimes radiating around to the rightside of the back. About 40% of patients complain of referredpain to the interscapular or right shoulder area.

Low-grade nausea or anorexia is also a common presentingcomplaint and fatty-food intolerance is not always present.Most patients can decrease the frequency of their attacks ofbiliary colic by severely restricting their diet. This is becauseingestion of all types of food (particularly fatty food) stimu-lates contraction and emptying of the gallbladder.

Some patients present with atypical biliary symptoms. Thisoften leads to a delay in diagnosis or inappropriate investi-gations for other pathologies. High epigastric or low ret-rosternal pain may be confused with a possible cardiac cause.This often results in lengthy, but frequently unnecessary, car-diac investigations after presentation to the accident andemergency department.

Similarly, it is surprising how often patients are investigatedwith an upper endoscopy for what are, in retrospect, typicalbiliary symptoms. The yield from an upper endoscopy in anera when peptic ulcer disease is now uncommon is small. Amuch more logical approach might be to order a simple andreadily available biliary ultrasound as the first step, thenarrange an endoscopy if this study proves negative.

The presence of typical biliary symptoms in conjunctionwith the finding of gallstones is an indication for cholecys-tectomy. Focal tenderness over the gallbladder or evidence ofa thick-walled gallbladder suggests cholecystitis.

In those with atypical biliary pain and a negative biliaryultrasound, endoscopy is indicated to exclude other pathol-ogy. It is also helpful in excluding additional upper GIpathology when patients present with gallstones but withslightly atypical symptoms.

For patients with uncomplicated biliary colic, a strictlylow-fat diet may reduce the severity of biliary pain beforedefinitive treatment. In the absence of any contraindications

Specific surgical conditions

CT scan showing acute sigmoid diverticulitis.

Air under the diaphragm due to a perforated duodenal ulcer.

Calcified gallstones on plain abdominal X-ray.

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Non-general surgical causes of abdominal painGynaecological conditionsWOMEN of childbearing age whopresent with acute abdominal painmay have a gynaecological problem.Of these, ectopic pregnancy is themost serious acute pathology andaccounts for about 9% of all preg-nancy-related deaths. Abdominalpain, amenorrhoea and vaginalbleeding are the classic presentingfeatures.

There should be a high index ofsuspicion of this diagnosis in womenof childbearing age. A urinary (andpreferably serum) beta human chori-onic gonadotrophin test, togetherwith an urgent pelvic ultrasound, willmake the diagnosis.

Confirming pregnancy is alsoimportant in determining whethercertain medications or diagnostic X-ray procedures can be used, particu-larly in the early stages of pregnancy.

Other gynaecological causes ofacute abdominal pain include a rup-tured ovarian cyst, salpingitis, aspontaneous or threatened abortion,and ovarian torsion.

Renal conditionsA diagnosis of acute renal colic can oftenbe made clinically with a typical history ofsevere colicky flank pain radiating to thegroin. This diagnosis is supported by thepresence of blood on urinalysis. A spiralCT scan (without oral or IV contrast) isthe most useful investigation and will con-firm the diagnosis in most cases.

If the calculi are <5mm in diameter andthere is no urinary obstruction, there is a90% chance of spontaneous passage, andpatients can be safely treated conserva-tively. In the presence of larger calculi, orwhen there is obstructive sepsis, urgenturological intervention may be required.

In contrast with renal colic, patientswith pyelonephritis usually present withsigns of sepsis and with pain tending to bemore in the flank or lower back ratherthan the upper abdomen. Almost allpatients with pyelonephritis have haema-turia and pyuria on urinalysis.

Other non-surgical causes of abdomi-nal pain include:■ Acute hepatitis.■ Lower-lobe pneumonia.■ Pericarditis.

■ Congestive cardiac failure withhepatomegaly.

■ Diabetic ketoacidosis.

Should parenteral pain relief begiven to patients with acute abdominal pain before surgicalreview?In the past there has been confusionabout whether administration of analgesiamasks the signs of acute abdomen beforedefinitive surgical review. In fact there isno evidence that this is the case and, onthe contrary, appropriate pain relief mayactually assist in allowing a more thor-ough abdominal examination. A smalldose of IM, SC or even IV pethidine ormorphine is appropriate for patients withsevere acute abdominal pain.

Another common misconceptionrelates to the administration of narcoticanalgesia in the presence of pancreatitis orbiliary disease. Although the sphincter ofOddi in some patients is sensitive to nar-cotic analgesia (including morphine andcodeine), there is no evidence that thisform of analgesia increases the severityor risks of complications of pancreatitis.

Summary of causes of upper abdominal pain

Right upper-abdominal pain■ Cholecystitis■ Biliary colic■ Choledocholithiasis/cholangitis■ Hepatic abscess■ Retrocaecal appendicitis■ Hepatitis■ Right pyelonephritis■ Right renal calculi■ Hepatomegaly from chronic heart failure■ Right lower-lobe pneumonia■ Gastritis (acute)■ High-intestinal obstruction■ Inflammatory bowel disease of the duodenum

Epigastric pain■ Biliary colic■ Pancreatitis■ Peptic ulcer■ Acute MI■ Pericarditis

Left upper-abdominal pain■ Pancreatitis■ Left renal calculi■ Left pyelonephritis■ Splenomegaly■ Splenic abscess■ Splenic infarction■ Splenic artery aneurysm■ Gastritis (acute)■ Left lower-lobe pneumonia■ Diverticulitis■ High-intestinal obstruction■ Inflammatory bowel disease (proximal jejunal)


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Table 1: Causes of pancreatitis (in order

of frequency)

■ Gallstones(choledocholithiasis),alcohol

■ Idiopathic

■ Post-ERCP

■ Trauma

■ Drugs (including corticosteriods, frusemide,ACE inhibitors)

■ Hereditary

■ Hypercalcaemia

■ Developmentalabnormalities of the pancreas (eg, pancreasdivisum)

■ Hypertriglyceridaemia

■ Tumours (pancreaticductal obstruction)

■ Toxins

absence of complicationssuch as an acute fluid collec-tion or abscess, are deter-mined by a two-phase fine-cut pancreatic CT scan.

Severe acute pancreatitisresults in rapid dehydration,

and acute renal failure willdevelop unless IV fluid resus-citation is initiated promptly.In this setting it is sometimesnot possible to give an IVcontrast agent at the time ofthe CT scan.

Less common acute surgical conditionsNumerous other surgicalconditions that may result inan acute abdomen include amesenteric embolus, mesen-teric venous thrombosis,

hepatic abscess, splenicinfarct or splenic abscess.These conditions may pre-sent with subtle clinicalsymptoms and signs andultimately may only be diag-nosed by either CT or MRI.

CT scan showing a dilated common bile duct due to a large stone.

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What not to miss — the acute abdomen■ Haemorrhage, eg, ruptured abdominal aortic aneurysm,

haemorrhagic pancreatitis

■ Infection, eg, appendicitis, Meckel’s diverticulitis

■ Perforation, eg, perforated gastric or duodenal ulcer, perforated diverticulum, perforated colonic tumour

■ Obstruction, eg, incarcerated groin or incisional hernia

■ Ischaemia, eg, strangulated hernia, mesenteric thrombosis

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Lower chest painA PREVIOUSLY well 55-year-oldmale presented to his GP with acuteonset of what he described as chestpain. The onset of the pain wasabout two hours before presenta-tion and woke him from his sleep.

He described the severity of thepain as 10/10. His lower chest painwas constant and was accompaniedby sweating and nausea. There wasno radiation of the pain and noshortness of breath.

Just before presenting to his GPhe had one bile-stained vomit.There had been no recent changein his bowel habit. He had not beenable to alleviate the pain withsimple analgesia, and movementdid not exacerbate his pain. He hadbeen eating and drinking well upuntil that day although he had hada ‘heavy’ meal the night before.

The patient recalled a similarattack of pain about 18 monthspreviously, when he presented tothe accident and emergency depart-ment at his local hospital. On thatoccasion he had been investigatedwith a resting ECG and serial tro-ponin levels and had even gone onto have a stress ECG. All thesestudies were normal and no obvi-ous cardiac cause was identified.He had not been advised toundergo any further investigations.

At the time of presentation it wasclear that he had lower retroster-nal and epigastric discomfort andthere was a positive Murphy’s sign.His blood tests revealed a mild neu-trophilia and mildly elevated serumAST and GGT. An abdominalultrasound revealed a gallbladderthat had a slightly thickened walland contained multiple large stones.No dilatation of the biliary tree andno obvious choledocholithiasis wasseen.

He was referred to the accidentand emergency department for sur-gical review and subsequentlyunderwent an uneventful semi-

urgent laparoscopic cholecystec-tomy and operative cholangiogramthe following day.

An unusual presentationA 15-year-old boy was referred tothe accident and emergency depart-ment by his GP after he presentedwith right upper-quadrant pain oftwo days’ duration. This pain wasinitially generalised to both lowerquadrants of his abdomen but overthe preceding 12 hours had becomemore intense on the right hand side.

The patient was slightly nauseousand was not hungry but he did notlook particularly unwell and therewas no vomiting and no change inhis bowel habit. Examinationrevealed a slight tachycardia and alow-grade fever (37.8°C).

On palpation of his abdomenthere was moderate guarding in the

right upper quadrant and also somepercussion tenderness. He wasuncomfortable, with rigidity ondeep palpation in the right iliacfossa, but there were no palpablemasses.

A urinalysis showed micro-haematuria only, and all blood testswere within the normal range. ACT scan was arranged, as the diag-nosis was not obvious on physicalexamination. This revealed anacutely inflamed appendix with itstip lying just inferior to the hepaticflexure.

The patient underwent a laparo-scopic appendicectomy that sameday and a retrocaecal gangrenousappendix without perforation wasidentified and removed. Thepatient was discharged from thehospital without any complicationson the third postoperative day.


Further reading■ Goldman RD, et al. Analgesia

administration for acuteabdominal pain in the pediatricemergency department.Pediatric Emergency Care2006; 22:18-21.

■ Hewett P. How to treat: acutelower abdominal pain.Australian Doctor 14thFebruary 2003.

■ Jamieson GG. The Anatomy ofGeneral Surgical Operations,2nd edn. Churchill Livingstone,Adelaide, 2006.

■ Martinez JP, Mattu A.Abdominal pain in the elderly.Emergency Medicine Clinics ofNorth America 2006; 24:371-88.

■ Poulin EC, et al. Earlylaparoscopy to help diagnoseacute non-specific abdominalpain, Lancet 2000; 355:861–63.

■ Rosen MP, et al. Impact ofabdominal CT on the manage-ment of patients presenting tothe emergency department withacute abdominal pain.American Journal ofRoentgenology 2000;174:1391-96.

■ Shabbir J, et al. Administrationof analgesia for acute abdomi-nal pain sufferers in the acci-dent and emergency setting.European Journal of EmergencyMedicine 2001; 11:309-12.

■ Taylor S, Watt M. Emergencydepartment assessment ofabdominal pain: clinical indica-tor tests for detecting periton-ism. European Journal ofEmergency Medicine 2005;12:275-77.

■ Townsend CM, et al. SabistonTextbook of Surgery: TheBiological Basis of ModernSurgical Practice, 17th edn.Saunders Elsevier, Philadelphia,2004.

■ Urban BA, Fishman EK.Tailored helical CT evaluationof acute abdomen.Radiographics 2000; 20:725-49.

■ Wolfe JM, et al. Analgesicadministration to patients withan acute abdomen: a survey ofemergency medicine physicians.American Journal of EmergencyMedicine 2000; 18:250-53.

Online resources■ familydoctor.org (family health

information, from theAmerican Academy of Family Physicians): http://familydoctor.org/online/famdocen

■ virtualmedicalcentre.com: http://www.virtualchildshealth.com

Authors’ case studies

GP’s contributionCase studyND, 53, presented with a seven-dayhistory of abdominal discomfort,nausea and vomiting. Two days laterdiarrhoea with PR bleeding started,and he described what sounded likerigors.

Ulcerative colitis had been diag-nosed 30 years ago. It had been qui-escent for 10 years and he hadstopped taking sulfasalazine fiveyears ago. ND had not been on anymedications before the onset of this

illness and had not travelled to ruralareas or overseas.

He looked unwell but was afebrile,normotensive and had no tachycar-dia. The abdomen was soft, withonly mild tenderness of the leftabdomen and into the left iliac fossa.

Pathology revealed a haemoglobinlevel of 144g/L, white cell count11.0×109/L (normal differential) andmildly abnormal LFTs, with acholestatic picture. Stool and bloodcultures were negative. However, C-

reactive protein was 111mg/L(normal range 0-5).

ND was referred to a gastroen-terologist, who arranged admissionto hospital, where he was treatedwith IV hydrocortisone and metron-idazole. Sigmoidoscopy showedmoderately severe diffuse proctocol-itis. A CT scan of the abdomen andpelvis showed thickening of thedescending colon and sigmoid colon,with no evidence of intra-abdominal

DR MARG TAITPicnic Point, NSW

cont’d page 34

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An ultrasound of a gallbladder with a thick wall, with stones evident.

www.australiandoctor.com.au32 | Australian Doctor | 22 August 2008

AD_032___AUG22_08 14/8/08 3:14 PM



HOW TO TREAT Editor: Dr Wendy MorganCo-ordinator: Julian McAllan Quiz: Dr Wendy Morgan

Acute abdominal pain — 22 August 2008

INSTRUCTIONSComplete this quiz online and fill in the GP evaluation form to earn 2 CPD or PDP points. We no longer accept quizzesby post or fax. The mark required to obtain points is 80%. Please note that some questions have more than one correctanswer.

ONLINE ONLY

1. Which THREE statements aboutassessing patients with acute abdominalpain are correct?a) Continuous abdominal pain is invariably

associated with peritoneal inflammation orischaemia

b) Pathology irritating the diaphragm maycause referred pain to the shoulder tip,because both these structures areinnervated by the third cervical nerve

c) The patient should be directed to liesupine with the knees slightly flexed torelax the abdominal musculature

d) Rebound tenderness can be elicited byasking the patient to cough and thengauging their response

2. Which TWO statements aboutassessing patients with acute abdominalpain are correct?a) Patients should not be given

analgesia before surgical assessment, asthis may mask the signs of an acuteabdomen

b) Assessing electrolytes and renal functionis essential in patients presenting withacute abdominal pain

c) Narcotic analgesia should not be given topatients with biliary disease orpancreatitis, as this increases the risks ofcomplications

d) In patients with high epigastric pain, bloodshould be checked for elevated troponinlevels in conjunction with a resting ECG

3. Which ONE statement aboutradiological investigation of acuteabdominal pain is correct?a) A normal plain abdominal and erect CXR

rules out the diagnosis of a perforatedviscus

b) CT scanning is now the investigation ofchoice for examining the gallbladder andbiliary tract

c) The usefulness of abdominal ultrasound ininvestigating acute abdominal pain may belimited by obesity and overlying gas-filledstructures

d) Radiological assessment in cases of acute pancreatitis is best performed withultrasound

4. Which TWO statements aboutsuspected acute appendicitis are correct?a) It is worthwhile to enquire about

exacerbation of pain with coughing orstraining

b) The shift of pain from the initial peri-umbilical area to the right iliac fossa reflects development of localisedperitonitis

c) A raised white cell count will clinch thediagnosis in acute appendicitis

d) Abdominal ultrasound is not useful in thediagnosis of acute appendicitis

5. Which THREE statements aboutabdominal aortic aneurysms are correct?a) New and persistent backache could be a

warning of impending rupture of anabdominal aortic aneurysm

b) The presence of macrohaematuria rulesout an abdominal aortic aneurysm as thecause of the pain

c) Patients may experience sudden severeabdominal or epigastric pain radiatingthrough to the back just before rupture ofan abdominal aortic aneurysm

d) Symptoms and signs associated withrupture of an abdominal aortic aneurysminclude pre-syncope, diaphoresis, nauseaor tachycardia

6. Which THREE statements about aperforated viscus are correct?a) Perforation of a peptic ulcer is a common

acute surgical emergencyb) With acute perforation there may be

referral of pain to the shoulder tipc) Perforation of either the colon or a peptic

ulcer may present as focal peritonitisd) Hypotension, tachycardia and tachypnoea

associated with a perforated viscus areindicative of systemic sepsis

7. Ingrid, 40, presents with a history of intermittent upper-abdominaldiscomfort and nausea, especially after eating fatty foods. Which TWO statements about biliary colic are correct?a) The pain of biliary colic is classically

colicky rather than constant in natureb) About 40% of patients with biliary colic

complain of referred pain to theinterscapular or right shoulder area

c) For patients with upper abdominal painsuggestive of biliary colic, an ultrasoundscan would be the appropriate first-lineinvestigation

d) A low-fat diet is of no benefit in patientswith uncomplicated biliary colic

8. You refer Ingrid for an abdominalultrasound. However, while awaiting herappointment she has an acute attack ofright upper-abdominal pain, associatedwith fever. Which THREE statements arecorrect?a) Right upper-quadrant pain with

exacerbation of pain on palpation duringdeep inspiration (Murphy’s sign) usuallyindicates acute cholecystitis

b) Absence of a leucocytosis excludes adiagnosis of acute cholecystitis

c) Evidence of a thick-walled gallbladder on ultrasound scan suggests cholecystitis

d) Recurrent abdominal pain and feversassociated with alteration in LFTs orjaundice suggests cholangitis

9. Mark, 45, presents with acute, severeepigastric pain radiating through to theback, associated with nausea andvomiting. He has a previous history ofacute pancreatitis. Which THREEstatements about acute pancreatitis arecorrect?a) The two most common causes of

pancreatitis in the Australian communityare gallstones and excessive alcoholingestion

b) Flank ecchymosis and periumbilical skindiscoloration are signs of severe acutepancreatitis

c) Acute pancreatitis is easily diagnosed bychecking for an elevated serum amylaselevel

d) Severe acute pancreatitis requires urgentIV fluid resuscitation

10. Tom, 40, presents with acute left flankpain. You suspect acute renal colic. WhichTWO statements are correct?a) A typical presentation of acute renal colic

is of severe colicky flank pain that radiatesto the groin

b) If flank pain is associated with fevers orrigors, a diagnosis of pyelonephritisshould be suspected

c) Intravenous pyelography is the mostuseful investigation for renal colic and willconfirm the diagnosis in most cases

d) If renal calculi are <1cm in diameter thereis a 90% chance of spontaneous passage,and these patients can be safely treatedconservatively

www.australiandoctor.com.au/cpd/ for immediate feedback

How to Treat Quiz

CPD QUIZ UPDATEThe RACGP now requires that a brief GP evaluation form be completed with every quiz to obtain category 2 CPD or PDP points for the 2008-10 triennium. Youcan complete this online along with the quiz at www.australiandoctor.com.au. Because this is a requirement, we are no longer able to accept the quiz by postor fax. However, we have included the quiz questions here for those who like to prepare the answers before completing the quiz online.

or pelvic collections, and anormal liver.

After a week he was dis-charged on prednisone 50mgdaily and sulfasalazine 1g tds.Two days after discharge hecontacted the gastroenterolo-gist, as he felt more unwellwith unremitting diarrhoeaand PR bleeding. He wasreadmitted and a further sig-moidoscopy revealed a severepancolitis.

He had a subtotal colec-tomy and end ileostomy, as hehad not responded to medicalmanagement for this acuteexacerbation of ulcerative col-itis.

Questions for the authorsWhat are the common surgi-cal problems that can arisefrom ulcerative colitis?

These include acute toxicmegacolon, bleeding, perfora-tion, obstruction and malig-nant change.

What conditions other thanrenal colic can cause pain radi-ating from the loin to thegroin? (I have seen an ectopicpregnancy that was initiallythought to be pyelonephritis.)

This type of pain may becaused by any condition thatirritates the retroperitoneum,such as ectopic pregnancy orretrocaecal appendicitis.

When monitoring an abdomi-nal aortic aneurysm, what isthe critical size at whichsurgery should be considered?

The risk of rupture of anabdominal aortic aneurysmsignificantly increases foraneurysms >5.5cm diameter.

NEXT WEEK The next How to Treat looks at polycystic ovary syndrome — a frustrating experience for an increasing number of women, a complex syndrome for managing clinicians, and a rapidly advancingarea of research with important new information updates. The authors are Professor Helena Teede, director of research, Jean Hailes Foundation for Women’s Health, Clayton, school of public health,Monash University, and head of Diabetes Southern Health, Melbourne, Victoria; Dr Lisa Moran, senior research fellow and dietitian, Jean Hailes Foundation for Women’s Health, Clayton, Victoria; and Dr Amanda Deeks, deputy director research, research psychologist, Jean Hailes Foundation for Women’s Health, Clayton, Victoria.

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