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Acute abdomen: Difference between revisions

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Acute abdomen is the name of the clinical presentation involving acute onset abdominal pain. There’s a large number of conditions which can cause acute abdomen, and so knowing the differential diagnosis and investigations to distinguish them is important. The presence of typical risk factors, gender, and age for a specific cause can also help the diagnosis, and so knowing these is important as well. It’s important to remember that atypical presentations exist, of course. These patients should be examined systematically to identify the underlying cause.
'''Acute abdomen''' is the name of the clinical presentation involving acute onset abdominal pain. There’s a large number of conditions which can cause acute abdomen, and so knowing the differential diagnosis and investigations to distinguish them is important. The presence of typical risk factors, gender, and age for a specific cause can also help the diagnosis, and so knowing these is important as well. It’s important to remember that atypical presentations exist, of course. These patients should be examined systematically to identify the underlying cause.


== Life-threatening conditions ==
== Life-threatening conditions ==
It’s important to recognise or exclude life-threatening conditions, including AAA rupture, mesenteric ischaemia, GI perforation, ectopic pregnancy, etc.
It’s important to recognise or exclude life-threatening conditions.
{| class="wikitable"
{| class="wikitable"
!Disorder
!Disorder
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!Typical findings
!Typical findings
|-
|-
!Abdominal aortic aneurysm rupture
![[Abdominal aortic aneurysm]] rupture
|Elderly male patient with cardiovascular risk factors, especially hypertension or known AAA
|Elderly male patient with cardiovascular risk factors, especially hypertension or known AAA
|Triad of severe acute abdominal pain, pulsatile abdominal mass, haemodynamic instability
|Triad of severe acute abdominal pain, pulsatile abdominal mass, haemodynamic instability
|-
|-
!Mesenteric ischaemia
![[Mesenteric ischaemia]]
|Elderly patient with cardiovascular risk factors or atrial fibrillation
|Elderly patient with cardiovascular risk factors or [[atrial fibrillation]]
|“Pain out of proportion to the physical examination” (severe pain but normal physical examination), often peritonitic
|“Pain out of proportion to the physical examination” (severe pain but normal physical examination), often peritonitic
|-
|-
!Gastrointestinal perforation
![[Gastrointestinal perforation]]
|Elderly patient with known ulcer or GI disease, recent abdominal surgery
|Elderly patient with known ulcer or GI disease, recent abdominal surgery
|Severe, diffuse abdominal pain, often peritonitic
|Severe, diffuse abdominal pain, often peritonitic
|-
|-
!Acute bowel obstruction
!Acute bowel obstruction ([[ileus]])
|Patient with recent abdominal surgery or known hernia
|Patient with recent abdominal surgery or known hernia
|Abdominal distension, vomiting, absence of flatus
|Abdominal distension, vomiting, absence of flatus
|-
|-
!Ruptured ectopic pregnancy
!Ruptured [[ectopic pregnancy]]
|Any female of childbearing age
|Any female of childbearing age
|Amenorrhoea, abdominal pain, vaginal bleeding, positive hCG
|Amenorrhoea, abdominal pain, vaginal bleeding, positive hCG
|-
|-
!(Inferior) Myocardial infarction
!(Inferior) [[Acute myocardial infarction|Myocardial infarction]]
|Older patient with diabetes
|Older patient with diabetes
|Epigastric pain
|Epigastric pain
|-
|-
!Aortic dissection
![[Aortic dissection]]
|Elderly male patient with cardiovascular risk factors, especially hypertension
|Elderly male patient with cardiovascular risk factors, especially hypertension
|Tearing/ripping pain, associated symptoms of downstream ischaemia
|Tearing/ripping pain, associated symptoms of downstream ischaemia
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!Typical findings
!Typical findings
|-
|-
!Cholecystitis
![[Acute calculous cholecystitis|Cholecystitis]]
| rowspan="3" |Patient with the 6 Fs
| rowspan="3" |Patient with the 6 Fs
|Steady, severe RUQ or epigastric pain, positive Murphy sign
|Steady, severe RUQ or epigastric pain, positive Murphy sign
|-
|-
!Cholelithiasis
![[Gallstone disease|Cholelithiasis]]
|Intense, dull, constant RUQ or epigastric discomfort, sweating, nausea, vomiting
|Intense, dull, constant RUQ or epigastric discomfort, sweating, nausea, vomiting
|-
|-
!Cholangitis
![[Cholangitis]]
|Charcot’s triad of fever, RUQ abdominal pain, jaundice
|Charcot’s triad of fever, RUQ abdominal pain, jaundice
|-
|-
!Acute pancreatitis
![[Acute pancreatitis]]
|Patient with alcoholism, 6Fs, known hypertriglyceridaemia
|Patient with alcoholism, 6Fs, known hypertriglyceridaemia
|RUQ or epigastric pain, band-like radiation to the back, nausea, vomiting
|RUQ or epigastric pain, band-like radiation to the back, nausea, vomiting
|-
|-
!Hepatitis
![[Hepatitis]]
|IV drug user, paracetamol intoxication, recent travel abroad
|IV drug user, paracetamol intoxication, recent travel abroad
|RUQ pain, liver tenderness, elevated liver enzymes
|RUQ pain, liver tenderness, elevated liver enzymes
|-
|-
!Lower lobe pneumonia
!Lower lobe [[pneumonia]]
|–
|–
|Basal crepitations, coughing, dyspnoea
|Basal crepitations, coughing, dyspnoea
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!Typical findings
!Typical findings
|-
|-
!Peptic ulcer disease/gastritis
![[Peptic ulcer disease]]/[[gastritis]]
|Smoking, NSAID use, known H. pylori
|Smoking, NSAID use, known H. pylori
|Epigastric/LUQ pain, indigestion, reflux symptoms
|Epigastric/LUQ pain, indigestion, reflux symptoms
|-
|-
!Acute pancreatitis
![[Acute pancreatitis]]
|Patient with alcoholism, gallstone risk factors, or known hypertriglyceridaemia
|Patient with alcoholism, gallstone risk factors, or known hypertriglyceridaemia
|RUQ or epigastric pain, band-like radiation to the back, nausea, vomiting
|RUQ or epigastric pain, band-like radiation to the back, nausea, vomiting
|-
|-
!Abdominal aortic aneurysm rupture
![[Abdominal aortic aneurysm]] rupture
|Elderly male patient with cardiovascular risk factors, especially hypertension or known AAA
|Elderly male patient with cardiovascular risk factors, especially hypertension or known AAA
|Triad of severe acute abdominal pain, pulsatile abdominal mass, haemodynamic instability
|Triad of severe acute abdominal pain, pulsatile abdominal mass, haemodynamic instability
|-
|-
!Lower lobe pneumonia
!Lower lobe [[pneumonia]]
|–
|–
|Basal crepitations, coughing, dyspnoea
|Basal crepitations, coughing, dyspnoea
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!Typical findings
!Typical findings
|-
|-
!Peptic ulcer disease/gastritis
![[Peptic ulcer disease]]/[[gastritis]]
|Smoking, NSAID use, known H. pylori
|Smoking, NSAID use, known H. pylori
|Epigastric/LUQ pain, indigestion, reflux symptoms
|Epigastric/LUQ pain, indigestion, reflux symptoms
|-
|-
!Splenic infarct/rupture
![[Splenic infarct]]/[[rupture]]
|Recent abdominal trauma
|Recent abdominal trauma
|Tender/enlarged spleen
|Tender/enlarged spleen
|-
|-
!Lower lobe pneumonia
!Lower lobe [[pneumonia]]
|–
|–
|Basal crepitations, coughing, dyspnoea
|Basal crepitations, coughing, dyspnoea
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!Typical findings
!Typical findings
|-
|-
!Acute appendicitis
![[Acute appendicitis]]
|Young adult, previously healthy
|Young adult, previously healthy
|Pain originating periumbilically, later migrating to the McBurney point. Tenderness. Positive Rovsing, psoas, or obturator sign.
|Pain originating periumbilically, later migrating to the McBurney point. Tenderness. Positive Rovsing, psoas, or obturator sign.
|-
|-
!Inflammatory bowel disease
![[Inflammatory bowel disease (Crohn disease and ulcerative colitis)|Inflammatory bowel disease]]
|Young adult, known history of GI complaints
|Young adult, known history of GI complaints
|Local peritonitis, mildly elevated inflammatory parametres
|Local peritonitis, mildly elevated inflammatory parametres
|-
|-
!Ruptured ectopic pregnancy
!Ruptured [[ectopic pregnancy]]
|Any female of childbearing age
|Any female of childbearing age
|Amenorrhoea, abdominal pain, vaginal bleeding, positive hCG
|Amenorrhoea, abdominal pain, vaginal bleeding, positive hCG
|-
|-
!Ovarian torsion
![[Ovarian torsion]]
|Known ovarian cyst or tumour
|Known ovarian cyst or tumour
|Unilateral lower abdominal or pelvic pain, nausea/vomiting, palpable adnexal mass
|Unilateral lower abdominal or pelvic pain, nausea/vomiting, palpable adnexal mass
|-
|-
!Testicular torsion
![[Testicular torsion]]
|Young male (teenager)
|Young male (teenager)
|Testicular and lower abdominal pain, swollen and tender testis, horisontal testicle
|Testicular and lower abdominal pain, swollen and tender testis, horisontal testicle
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!Typical findings
!Typical findings
|-
|-
!Diverticulitis
![[Diverticular disease (diverticulosis and diverticulitis)|Diverticulitis]]
|Elderly patient
|Elderly patient
|Low-grade fever, nausea/vomiting, recent change in bowel habits
|Low-grade fever, nausea/vomiting, recent change in bowel habits
|-
|-
!Ruptured ectopic pregnancy
!Ruptured [[ectopic pregnancy]]
|Any female of childbearing age
|Any female of childbearing age
|Amenorrhoea, abdominal pain, vaginal bleeding, positive hCG
|Amenorrhoea, abdominal pain, vaginal bleeding, positive hCG
|-
|-
!Ovarian torsion
![[Ovarian torsion]]
|Known ovarian cyst or tumour
|Known ovarian cyst or tumour
|Unilateral lower abdominal or pelvic pain, nausea/vomiting, palpable adnexal mass
|Unilateral lower abdominal or pelvic pain, nausea/vomiting, palpable adnexal mass
|-
|-
!Testicular torsion
![[Testicular torsion]]
|Young male (teenager)
|Young male (teenager)
|Testicular and lower abdominal pain, swollen and tender testis
|Testicular and lower abdominal pain, swollen and tender testis
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!Typical findings
!Typical findings
|-
|-
!Diabetic ketoacidosis
![[Diabetic ketoacidosis]]
|Young patient without known T1D, or patient with known T1D and poor compliance, recent stress/infection
|Young patient without known T1D, or patient with known T1D and poor compliance, recent stress/infection
|Polyuria, neurological symptoms, dehydration, fruity odour, Kussmaul breathing
|Polyuria, neurological symptoms, dehydration, fruity odour, Kussmaul breathing
|-
|-
!Porphyria attack
![[Porphyria]] attack
|Known porphyria, recent drug change or infection
|Known porphyria, recent drug change or infection
|Brown or reddish urine
|Brown or reddish urine
|-
|-
!Mesenteric ischaemia
![[Mesenteric ischaemia]]
|Elderly patient with cardiovascular risk factors or atrial fibrillation
|Elderly patient with cardiovascular risk factors or atrial fibrillation
|“Pain out of proportion to the physical examination” (severe pain but normal physical examination), often peritonitic
|“Pain out of proportion to the physical examination” (severe pain but normal physical examination), often peritonitic
|-
|-
!Acute bowel obstruction
!Acute bowel obstruction ([[ileus]])
|Patient with recent abdominal surgery or known hernia
|Patient with recent abdominal surgery or known hernia
|Abdominal distension, vomiting, absence of flatus
|Abdominal distension, vomiting, absence of flatus
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!Typical findings
!Typical findings
|-
|-
!Ureteric colic/nephrolithiasis
!Ureteric colic/[[nephrolithiasis]]
|History of stone disease
|History of stone disease
|Colicky pain, flank pain, haematuria
|Colicky pain, flank pain, haematuria
|-
|-
!Pyelonephritis
![[Pyelonephritis]]
|Women, pregnancy, known urinary tract obstruction
|Women, pregnancy, known urinary tract obstruction
|Tender costovertebral angle on percussion, fever, chills, UVI symptoms
|Tender costovertebral angle on percussion, fever, chills, UVI symptoms
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=== Routine investigations ===
=== Routine investigations ===
Initial management involves performing routine investigations, including blood test (WBCs, <abbr>CRP</abbr>, Hb, amylase/lipase, liver function tests, electrolytes), obtaining IV access and providing fluids if necessary, and analgesia.
Initial management involves performing routine investigations, including blood test ([[WBC|WBCs]], <abbr>[[CRP]]</abbr>, [[Hb]], [[amylase]]/[[lipase]], [[Liver function test|liver function tests]], electrolytes), obtaining IV access and providing fluids if necessary, and analgesia.


To exclude ectopic pregnancy and atypical presentation of myocardial infarction, serum hCG should be measured in all females of childbearing age and an ECG should be obtained in all patients, or at least the elderly ones.
To exclude ectopic pregnancy and atypical presentation of myocardial infarction, serum [[hCG]] should be measured in all females of childbearing age and an [[ECG]] should be obtained in all patients, or at least the elderly ones.


=== Analgesia ===
=== Analgesia ===
Many are afraid of giving strong analgesics which may mask physical examination findings and interfere with the diagnosis, but multiple high-quality studies (RCTs) have disproved this<ref>https://pubmed.ncbi.nlm.nih.gov/12517545/</ref><ref>https://pubmed.ncbi.nlm.nih.gov/8959160/</ref><ref>https://pubmed.ncbi.nlm.nih.gov/16953529/</ref><ref>https://pubmed.ncbi.nlm.nih.gov/17032990/</ref><ref>https://pubmed.ncbi.nlm.nih.gov/21249672/</ref>. Therefore, there’s no good reason patients shouldn’t be relieved of their pain, usually with strong analgesics like morphine or oxycodone.
Many are afraid of giving strong analgesics which may mask physical examination findings and interfere with the diagnosis, but multiple high-quality studies (RCTs) have disproved this<ref>https://pubmed.ncbi.nlm.nih.gov/12517545/</ref><ref>https://pubmed.ncbi.nlm.nih.gov/8959160/</ref><ref>https://pubmed.ncbi.nlm.nih.gov/16953529/</ref><ref>https://pubmed.ncbi.nlm.nih.gov/17032990/</ref><ref>https://pubmed.ncbi.nlm.nih.gov/21249672/</ref>. Therefore, there’s no good reason patients shouldn’t be relieved of their pain, usually with strong analgesics like [[morphine]] or [[oxycodone]].


=== History and physical examination ===
=== History and physical examination ===
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