Abdominal pain

Abdominal assessment

Do first

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

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

  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL
  • 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

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

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 
  • 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