mcleaod 40

27 ABDOMINAL PAIN Differential diagnosis 4 of uncertain physical signs, e.g. mild localised abdominal tenderness, reinforcing suspicion of local peritonitis. In patients without a clear cause for pain, these features may suggest the need for admission and further investigation. By the same token, the absence of these features can, when used correctly, help to exclude im- portant inflammatory pathology. Finally, recognising and grading the presence of a systemic inflammatory response are central to the assessment of illness severity. Note that the significance of an individ- ual result depends on the clinical context, particularly with respect to CRP. In general, the higher the result, the greater the extent of systemic inflammation. A marginal rise in CRP e.g. <30 mg/L, does not provide compelling evidence of a major inflammatory process. However, if the test is being used to help ‘rule out’ a condition, then it is safer to regard any limit above the upper range of normal as elevated. Chronic/episodic abdominal pain Chronic abdominal pain is very common and challenging to assess. Most younger patients will have a functional disorder, e.g. IBS, but careful evaluation ± targeted investigation is required to exclude organic pathology. In older patients with new, persistent abdominal pain, the priority is to exclude underlying malignancy. cavity. The presence of fever, ↑CRP or ↑WBC with neutrophilia suggests that the patient is mounting an acute systemic inflammatory response (Box 4.1) and may thereby contribute to the diagnostic process. In some patients, the presence of inflammatory features may assist the interpretation Fig. 4.1 Regions of the abdomen. See text for typical sites of pain. 8 9 7 5 2 4 6 1 3 Fig. 4.2 Abdominal pain. Perception of visceral pain is localised to the epigastric, umbilical or suprapubic region, according to the embryological origin of the affected organ. Foregut – pain localises to epigastric area Midgut – pain localises to periumbilical area Hindgut – pain localises to suprapubic area *The significance of the result depends on the clinical context – see text. Box 4.1 Indicators of systemic inflammation • Fever (>38°C) • ↑CRP (>10 mg/L*) • WBC >11 × 10 9 /L or <4 × 10 9 /L

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7/23/2019 mcleaod 40

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ABDOMINAL PAIN

Differential diagnosis4

of uncertain physical signs, e.g. mild local-ised abdominal tenderness, reinforcingsuspicion of local peritonitis. In patientswithout a clear cause for pain, these fea-tures may suggest the need for admissionand further investigation. By the sametoken, the absence of these features can,when used correctly, help to exclude im-portant inflammatory pathology. Finally,recognising and grading the presence of asystemic inflammatory response are centralto the assessment of illness severity.

Note that the significance of an individ-ual result depends on the clinical context,particularly with respect to CRP. In general,the higher the result, the greater the extentof systemic inflammation. A marginal risein CRP e.g. <30 mg/L, does not providecompelling evidence of a major inflamma-tory process. However, if the test is beingused to help ‘rule out’ a condition, then it issafer to regard any limit above the upperrange of normal as elevated.

Chronic/episodicabdominal pain

Chronic abdominal pain is very commonand challenging to assess. Most youngerpatients will have a functional disorder,e.g. IBS, but careful evaluation ± targetedinvestigation is required to exclude organicpathology. In older patients with new,persistent abdominal pain, the priority is

to exclude underlying malignancy.

cavity. The presence of fever, ↑CRP or↑WBC with neutrophilia suggests that thepatient is mounting an acute systemic in-flammatory response (Box 4.1) and maythereby contribute to the diagnostic process.In some patients, the presence of inflamma-tory features may assist the interpretation

Fig. 4.1 Regions of the abdomen. See text for

typical sites of pain.

4 6

1 3

Fig. 4.2 Abdominal pain. Perception of visceral pain is localised to the epigastric, umbilical or

suprapubic region, according to the embryological origin of the affected organ.

Foregut – pain localisesto epigastric area

Midgut – pain localises

to periumbilical area

Hindgut – pain localisesto suprapubic area

*The significance of the result depends on the clinical context– see text.

Box 4.1 Indicators of systemic inflammation