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Approach to acute abdominal pain

The same eight steps, every presentation: threats first, then the history and exam that discriminate, one honest sentence, a mechanism-grouped differential, and the tests read in order.

  1. Immediate threats

    • Peritonitis (rigid, silent abdomen) or free air: surgical review now, not after imaging
    • Pain out of proportion to the exam in a vasculopath or AF: mesenteric ischemia, lactate and CT angiogram
    • Pulsatile mass, syncope, or flank pain in the over-60s: ruptured aneurysm until excluded
    • Any woman of reproductive age is an ectopic until a pregnancy test says otherwise
    • Cullen or Grey Turner signs with shock: hemorrhagic pancreatitis

  2. History that discriminates

    • Site, radiation, and migration (periumbilical to right iliac fossa tells its own story)
    • Character and tempo: colicky (obstruction of a tube) versus constant (inflammation, ischemia)
    • Anorexia, vomiting and its content, bowels and flatus, urinary and gynecological symptoms
    • Alcohol, gallstones, prior surgery (adhesions), anticoagulants, steroids that mute the exam

  3. Examination

    • Look first: distension, scars, hernias at every orifice
    • Guarding and rebound localize; a silent rigid abdomen is a different disease than a tender noisy one
    • Bowel sounds, hernial orifices, and a rectal exam where bleeding or obstruction is in play
    • Vitals against the abdomen: shock with a soft abdomen points vascular or medical

  4. Problem representation

    Constant epigastric pain radiating to the back with vomiting in a drinker, amylase pending (points at pancreatitis) versus colicky central pain with distension, absolute constipation, and a virgin abdomen scar-free except a hernia (points at obstruction).

  5. Differential, by mechanism

    Surgical / hollow organ

    • Appendicitis
    • Obstruction
    • Perforation
    • Cholecystitis
    • Diverticulitis

    Vascular

    • Mesenteric ischemia
    • Ruptured AAA
    • Ectopic pregnancy

    Medical mimics

    • Inferior MI
    • DKA
    • Basal pneumonia
    • Hypercalcemia
    • Adrenal crisis

    Renal / gynecological

    • Renal colic
    • Pyelonephritis
    • Ovarian torsion
    • PID

  6. Investigations

    • Pregnancy test before radiation in any woman who could be pregnant
    • Lipase, lactate, glucose with ketones, calcium; ECG for the epigastric story
    • Erect CXR for free air; CT abdomen with contrast as the definitive map
    • Ultrasound first for biliary disease, aneurysm at the bedside, and gynecology

  7. Interpretation

    • Analgesia does not mask the diagnosis; withholding it is a myth that only masks compassion
    • A normal lipase with a classic story does not exclude ischemia; a normal lactate early does not either
    • The trend of the exam over hours is a test: book the review before leaving the bedside

  8. Next steps

    • Nil by mouth, IV fluids, analgesia and antiemetics while the map is drawn
    • Early surgical involvement for peritonism, obstruction, or free air; antibiotics per source
    • The medical mimics get medical treatment: do not let a surgical label delay an inferior ECG

Connected

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