Abdominal Pain Assessment

Points on History

• Consider recent trauma, medical and surgical history, and current medications, including antibiotics.
• Look for anorexia, weight loss, fever, constipation, diarrhea, and vomiting (with or without blood).
• Investigate dysuria, bites, travel history, family history, menstruation, and sexual activity or abuse.
• Identify rectal bleeding, poisoning, or exposure to toxins.
• Note pain onset, location (diffuse vs. localized), nature (colicky, sharp, burning), frequency, pattern, and severity.

Physical Examination

• Assess circulation and perfusion, hydration status, and body temperature
• Check level of consciousness and pain-free mobility.
• Identify signs of peritoneal irritation such as rebound tenderness, guarding, iliopsoas rigidity (psoas sign), pain with thigh rotation (obturator test), pain with jarring movements, abdominal wall rigidity, and reduced bowel sounds.
• Examine for jaundice, purpura, conjunctivitis, mucosal lesions, eschar from bites/stings, arthritis, hepatosplenomegaly, abdominal masses, ascites, hernias, testicular torsion, and perianal lesions.
• Determine the site of maximal pain or tenderness to suggest the source of pain.
• Epigastric pain may indicate foregut issues like gastroesophageal reflux, peptic ulcer disease, hepatitis, cholangitis, cholecystitis, or pancreatitis.
• Periumbilical pain is nonspecific and usually of midgut origin (e.g., early appendicitis, acute gastroenteritis, constipation).
• Lower abdominal pain may indicate hindgut issues, bladder problems, or referred pain/radiation.
• Check signs of intestinal obstruction via abdominal distention, vomiting (bile-stained or fecal), and visible peristalsis.

Investigations

• Conduct urine tests: dipstick with or without culture, and pregnancy test if relevant.
• Perform stool tests: MC&S and occult blood tests.
• Obtain blood samples for a full blood count and differential, blood sugar, renal function, C-reactive protein, erythrocyte sedimentation rate, alanine and aspartate transaminase, lipase, and malaria smear (if indicated).
• If ascites is present, conduct a fluid tap, document the appearance microscopically.
• Investigate: albumin, MC&S, TB, cell count, cytology, LDH, ADA, fungal culture, triglycerides (↑ in chylous ascites), lipase (↑ in pancreatic ascites), bilirubin (↑ in biliary ascites), and creatinine (↑ in urinary ascites).
• Use abdominal X-rays to detect: faecoliths in appendicitis, thickened bowel wall, pneumatosis intestinalis, free air, calcifications, pneumonia/pleural effusion, renal stones, and fractures.
• Utilize ultrasound for appendicitis, intussusception, gallbladder/biliary tract issues, renal pathology (hydronephrosis), pelvic masses, abscesses, pregnancy/ectopic pregnancy, and ovarian pathology.
• Use CT scans for blunt trauma.

Degree of Illness

• Mild: Minimal interference with activity, known benign cause (e.g., AGE).
• Moderate: Interference with activity, signs of bacterial infection, or history of abdominal surgery/NEC.
• Severe: Signs of peritonitis, intestinal obstruction, intussusception, altered mental status, or moderate to severe dehydration.
• Very Severe: Signs of sepsis/septic shock, poor peripheral perfusion, hypotension, or ARDS.
• Consider non-accidental injury with associated bruises, fractures, and unexplained injuries.

Peritonitis

• An inflammatory process of the peritoneal lining of the abdominal cavity.
• Primary (spontaneous) bacterial peritonitis occurs with infection with an intact gastrointestinal tract.
• Secondary bacterial peritonitis is from perforation of the gastrointestinal tract or postsurgical anastomotic leak.
• Catheter-related peritonitis occurs with indwelling foreign bodies.
• Diagnose based on fever, abdominal pain, and peritonism signs (rebound, guarding, decreased bowel sounds).
• Laboratory tests include full blood count, C-reactive protein, blood culture, and ascitic fluid analysis to distinguish primary from secondary peritonitis.