Abdominal pain

• Many causes of abdominal pain can be life-threatening
• Always consider heart pain and pneumonia — these can be felt in upper abdomen
• In females always consider PID, ectopic pregnancy or miscarriage
• Give pain relief early if BP adequate. Person will be more relaxed and assessment more accurate

Abdominal assessment

Do first

• Remember Life support — DRS ABC
• For initial assessment — see Acute assessment of abdominal pain
• In females
• Always ask about contraception, last menstrual period
• Do urine pregnancy test. If negative — could still be early ectopic pregnancy or miscarriage

Ask

Pain

• Where is the pain. What area did it start
• Where does it go
• Does cough increase pain
• What does it feel like — stabbing or throbbing. Is it deep or just under the skin
• How long does it last. What makes it better/worse
• Why does the person think they have it. Have they had this pain before 

Nausea, vomiting, diarrhoea

• Is vomit green (bile indicates obstruction)
• Are they passing wind. When did they last open their bowels — constipation
• Do they have diarrhoea. How often does it occur
• Is there blood in the vomit or faeces

Other Symptoms

• Fever (feeling hot and cold)
• Cough
• Chest pain
• Shoulder tip pain
• Is appetite good or bad
• Pain or burning with urination

Men

• Discharge from penis — potential STI
• Painful/tender testicles — see Testicular pain

Women

• Vaginal discharge or bleeding
• Last menstrual period, contraception
• Deep pain with sex

Past Medical History

• Abdominal operations
• Pancreatitis
• Ectopic pregnancies
• Heart problems
• High BP
• Kidney stones
• Gallstones
• History of trauma

Medications

• Pain killers, especially NSAIDS
• Other medicines

Alcohol and other drugs

• How much do they normally drink, when did they last have a drink, how much did they drink
• Smoking
• Other drugs

Look

• Pallor — pale lips, tongue, inner eyelids
• Jaundice — yellow eyes or skin
• Rash — consider shingles
• Bruising, other signs of injury
• Masses (lumps)
• Distended abdomen (abdomen swollen), rigid, or moving with breathing

Listen with stethoscope

• Centre of abdomen for bowel sounds
• May be more than usual, less than usual, none
• Are they loud, splashing, tinkling like water in a cave — consider obstruction
• Chest for crackles, wheezing, bronchial (harsh breath sounds) — consider pneumonia

Feel

• Percuss and Palpate
• Start as far from painful area as possible — get more information if you palpate and percuss most painful area last
• Gently feel all areas of abdomen, including sides and behind kidneys for tenderness, hardness, organ enlargement, masses
• Watch person’s face 

• Abdomen soft or hard like wood — rigid, guarding OR very tender
• Does it hurt more in one part of the abdomen
• Does feeling or tapping in one part cause pain in another part of abdomen
• Check for tenderness or sharp pain when percuss — you tap your finger over painful area — percussion tenderness
• Check for rebound tenderness — tell person what you are going to do
• Press gently on sore area for 15 seconds, take hand away suddenly
• Watch person’s face for pain when you take hand away
• Check hernias — groin for swellings. Are they hard, soft or tender
• Hard, tender hernias are strangulated — urgent medical consult
  
• Check genitals (private parts) for males
• Swollen scrotum — hernia, hydrocele, cancer
• Tenderness — orchitis, epididymitis (infected testes or cord), torsion (twisted testicle)

Check

• U/A, pregnancy test
• If upper abdominal pain, right upper quadrant, or chest pain — do ECG
• Repeat ECG after 30–60 minutes to see if pattern changes

Do

• Based on history and physical assessment consider possible cause of pain
• See following pages for more information about common causes

Mild pain

• Mild abdominal pain may not need hospitalisation if a cause is identifiable and pain settles with analgesia — see pain relief

Moderate-severe pain

• If person has
  
• REWS 3 or more in children OR 5 or more in adults 
• Pain not responding to analgesia (pain relief)
• Appears very unwell
• Medical consult
• Keep nil by mouth
• Insert IV cannula
• POC Tests — electrolytes, Hb, WBC
• Take blood cultures before giving antibiotics
• IV antibiotics if infection/sepsis suspected
• Give adequate pain relief
• Consider IV fluids
• Consider oxygen
• Consider antiemetic for nausea and vomiting
• Consider urinary catheter

Upper abdominal or epigastric pain

• Usually caused by irritation of stomach or oesophagus — gastritis, reflux, indigestion
• Can be gastric/peptic ulcer, pancreatitis, gall bladder disease, pneumonia, heart disease
• Can be diabetic ketoacidosis. If high BGL — check ketones
• Common presentation of heart attack — do ECG, see Chest pain

Gastritis, reflux, indigestion

• May be history of gastritis, reflux or indigestion
• Loss of appetite
• Pain linked to hunger or eating certain foods
• Abdomen soft — may have mild tenderness
• Temp, pulse, RR, BP, O₂ sats usually normal
• Normal ECG

Do

• Give antacids (aluminium and magnesium salts) OR omeprazole oral — adult 20mg for 7 days AND review
  
• Advise person not to drink alcohol
• If pain continues for more than a few days with this treatment — medical consult about treatment and tests. Could be gastric/peptic ulcer or caused by some medicines

Right upper quadrant pain

• Usually caused by gall bladder disease — but may be heart attack pneumonia, uncomplicated gall stones or hepatitis (liver disease)

Gall bladder disease — infected and/or obstructed

• Suspect if very tender under right ribs
• If fever, pulse more than 100 beats/min, systolic BP less than 100mmHg, O₂ sats less than 90%, yellow skin or eyes (jaundice), bilirubin on U/A — ascending cholangitis (infected bile duct)
• Pain — moderate or severe. Usually constant

Do

• Medical consult AND consider sepsis
• Give amoxicillin OR ampicillin IV — adult 2g, child 50mg/kg/dose up to 2g — doses — single dose
  
• If allergy to penicillin — medical consult for ceftriaxone IV — adult 1g, child 50mg/kg/dose up to 1g — doses — single dose

AND give gentamicin IV — doses — single dose

AND give metronidazole IV — adult 500mg, child 12.5mg/kg/dose up to 500mg — doses — single dose

Lower abdominal pain

• Many possible causes — can be hard to tell apart. Consider
• Appendicitis
• Strangulated or stuck (incarcerated) hernia

Men

• Twisted testicle
• Infected testes

Women

• PID — common serious cause of lower abdominal pain in non-pregnant women aged 15–35 years, often missed, can cause serious problems
• Ectopic pregnancy

Could also be

• UTI
• Constipation
• Diverticulitis

Appendicitis

• Right lower area pain — may start as central pain
• Usually nausea, vomiting, loss of appetite — may be absent, especially if elderly
• May have percussion tenderness, guarding, rebound tenderness
• Usually mild fever (37.8–38°C), fast pulse

• If you suspect appendicitis — medical consult

Lower abdominal pain — women

Check

• Dates and results of last STI check and cervical screening
• History of UTIs, STIs, PID, ectopic pregnancy
• Childbirth, miscarriage, termination of pregnancy in last 6 weeks
• IUD

Ask

• Deep pain when having sex
• Vaginal loss — fluid, blood, colour, amount
• Leave pad in place
• If pregnant — contractions (baby pains), baby movements

Do

• If recent childbirth, miscarriage, termination of pregnancy — consider endometritis
• If less than 20 weeks pregnant — consider miscarriage, ectopic pregnancy
• If very unwell — consider ruptured ectopic pregnancy, septic abortion
• If more than 20 weeks pregnant — consider labour, preterm labour, placental abruption, intrauterine infection

Generalised abdominal pain

• 3 common causes — gastroenteritis, bowel obstruction (blocked gut), constipation
• 3 uncommon but very dangerous causes — generalised peritonitis, torn or ruptured abdominal aortic aneurysm, intestinal ischaemia

Ruptured abdominal aortic aneurysm

• Almost always fatal
• Usually elderly, history of high BP — may have known aneurysm
• Pain in central abdomen — may go through to back
• May feel pulsating mass — sometimes only after morphine has dulled pain
• Syncope (person may lose and regain consciousness)
• Person becomes very pale with fast pulse, falling BP, fast breathing

Do not

• Do not push IV fluids without medical consult — unless person becoming confused or drowsy

Do

• Give morphine for pain
• Repeat every 3 minutes until comfortable

Gastroenteritis

• Often fever, may have fast pulse, normal BP
• Often nausea and vomiting before pain starts
• Diarrhoea
• Mild/moderate crampy pain
• May have mild abdominal tenderness

Do not

• Do not assume abnormal observations are caused by dehydration

Do

Child — see Diarrhoea

Adult

• Can give pain relief
• Can give ORS
• If vomiting prevents oral intake — can give normal saline IV — 10mL/kg up to 1L
• If severe nausea — medical consult about antiemetic

• If no improvement after 2 hours
  
• Medical consult
• Do POC Test — venous blood gas, electrolytes 

Bowel obstruction (blocked gut)

• Usually fast pulse, may be low BP
• Nausea and vomiting, often after pain starts
• Cramping pain, swollen belly 
• Tender abdomen, sometimes guarding 
• May have diarrhoea to start with then no faeces
• May have increased or sometimes tinkling bowel sounds

Do

• Urgent medical consult 
• Give pain relief — usually morphine
• Put in nasogastric tube
• Put in IV cannula
• Run normal saline
• Give antiemetic to stop vomiting — do not give metoclopramide

Constipation

• Always looks well — no fever, normal pulse and BP
• Mild lower abdominal pain, usually crampy
• Small amount and/or hard faeces, may be some diarrhoea (overflow)
• Abdomen may be hard — with or without passing wind
• Usually little nausea or vomiting

Do

• Give dietary advice — high fibre and lots of water
• Can give bulking laxative (eg lactulose) or laxative (eg senna)
• If not better in a few days — medical follow-up

One-sided (flank/loin) pain

• Usually kidney problems. Felt in back or side between ribs and pelvis
• Consider pyelonephritis 

Renal Colic (kidney stone)

• Severe unilateral (one-sided) flank pain may go into groin or testicle
• No fever. Sometimes fast pulse
• Blood in urine
• Vomiting common
• Usually no urinary symptoms
• Often past history of kidney stones

Check

• If U/A positive for blood — send urine for MC&S

Do

• Give pain relief — usually moderate or severe pain
• Give antiemetic to stop vomiting
• If no better after 6 hours OR if fever develops — urgent medical consult
• Must have FBC, UEC, renal ultrasound after first episode
• Monitor urine for stones passing