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 ABDOMINAL PAIN

 Acute abdominal pain: step-by-step assessment4

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3 Features of intestinal obstruction?

Suspect intestinal obstruction if abdominalpain is colicky and accompanied by vomit-ing, absolute constipation and/or abdomi-nal distension. The predominant symptomswill vary, depending on the site of obstruc-tion; in high small bowel obstruction vomit-ing and pain are pre-eminent, whereas inlow colonic lesions constipation and disten-sion are more pronounced. If any of thesefeatures is present, perform an AXR (Fig.4.5) to help confirm the diagnosis and esti-mate the level of the obstruction.

Examine for an incarcerated hernia

in any patient with suspected small bowelobstruction. Consider further imaging andrectal examination to confirm an obstruct-ing lesion and differentiate from pseudo-obstruction in patients with large bowelobstruction.

Patients may be profoundly dehydrated– check U+E, provide adequate fluidresuscitation, insert a large-bore nasogastrictube and consider a urinary catheter.

Refer to surgery for further assessmentand management.

4 Acute and/or bloody diarrhoea?

Recent onset of acute diarrhoea with cramp-ing abdominal pain ±  vomiting suggestsinfective gastroenteritis. Suspect colitis(infective, inflammatory or ischaemic) if thepatient has bloody diarrhoea with cramp-

ing lower abdominal pain±

  tenesmus andfeatures of systemic inflammation (see Box4.1). Always consider the possibility ofischaemic colitis if the patient is elderly orhas known vascular disease/atrial fibrilla-tion; if ischaemic colitis is suspected,arrange a CT mesenteric angiogram. Other-wise, send stool for culture and assess asdescribed in Chapter 9.

5 Unilateral loin or flank pain?

Suspect renal tract obstruction (usually dueto a calculus) if there is severe, colicky loinpain (see above) that radiates to the groin ± testes/labia. In contrast to peritonitis, renaltract obstruction causes patients to be

Fig. 4.5  Intestinal obstruction. A. Small bowel.B. Large bowel.

A

Distended loops of small bowel Stomach

Very distendedcaecum

Distended low-lyingtransverse colon

A

B