Abdominal Pain 🤢
Clinical guide for assessing abdominal pain. History, examination, differential diagnosis, red flags, surgical abdomen, investigations, and management for on-call doctors.
📞 What to Ask / Orders to Make
- Current vitals and NEWS: fever, tachycardia, hypotension, hypoxia?
- Pain severity, onset (sudden vs gradual), and location.
- Vomiting, diarrhoea, constipation, absolute constipation (no flatus)?
- Any PV bleeding, pregnancy risk, or urinary symptoms?
- Ask nurse to get: IV access, urine dip ± β-hCG, ECG if epigastric/elderly.
- Keep NBM if surgical concern until you review.
🧾 History
- Onset, duration, and character (constant, colicky, sharp, dull, burning).
- Location and radiation (back, shoulder tip, groin, scapula).
- Associated symptoms: nausea, vomiting (bilious/faeculent?), fever, anorexia, bowel habit change, dysuria, PV bleeding/discharge.
- Last bowel movement and whether still passing flatus.
- Past abdominal surgery, known IBD, gallstones, diverticular disease, AAA, GORD, IHD.
- Medications: NSAIDs, steroids, anticoagulants, opioids; alcohol intake.
- LMP and contraception in people who can become pregnant.
🩺 Examination
- General: well vs septic/shocked; pallor, jaundice, diaphoresis, pain posture (still vs writhing).
- Vitals: HR, BP, RR, SpO₂, temp, CRT, GCS/confusion.
- Inspection: distension, scars, hernias, visible peristalsis, bruising (Cullen/Grey Turner).
- Palpation: start away from the painful area. Map tenderness by quadrant; note guarding, rigidity, rebound.
- Localising signs: Murphy’s (RUQ), McBurney’s / Rovsing’s (appendicitis), renal angle tenderness, pulsatile mass (AAA).
- Percussion: tympany (obstruction/gas), shifting dullness (ascites); light percussion tenderness suggests peritonism.
- Auscultation: absent, reduced, or high-pitched tinkling bowel sounds.
- Always check hernial orifices. PR if indicated (blood, mucus, mass, faecal loading). External genitalia if torsion possible.
- Chest and heart: lower lobe pneumonia, ACS, and AF with mesenteric ischaemia can present as abdo pain.
🧪 Investigations
- Bloods: FBC, U&E, LFTs, CRP, amylase/lipase; VBG/ABG with lactate if unwell or ischaemia suspected.
- Group & hold / crossmatch if bleeding, AAA, or likely theatre.
- Urinalysis ± MCS; pregnancy test if relevant.
- ECG in older patients or if epigastric/chest-associated pain.
- Erect CXR if perforation suspected (free air under diaphragm).
- AXR has limited value; consider only if obstruction or foreign body strongly suspected.
- Imaging directed by exam: USS (biliary, gynae, appendix in selected patients) or CT AP with senior/surgical input.
🔍 Differential by Location
- Always consider medical mimics: ACS, pneumonia, DKA, herpes zoster, and testicular/ovarian torsion.
RUQ
- Key differentials
- Cholecystitis, cholangitis, hepatitis, peptic disease, basilar pneumonia, pyelonephritis
Epigastric
- Key differentials
- Pancreatitis, peptic ulcer ± perforation, gastritis, ACS, aortic pathology
LUQ
- Key differentials
- Splenic pathology, gastritis/ulcer, pyelonephritis, pneumonia
RLQ
- Key differentials
- Appendicitis, mesenteric adenitis, Crohn’s, ovarian/torsion/ectopic, ureteric stone
LLQ
- Key differentials
- Diverticulitis, constipation, colitis, ovarian pathology, ureteric stone
Diffuse / central
- Key differentials
- Obstruction, perforation, mesenteric ischaemia, gastroenteritis, peritonitis, AAA rupture
Flank / back
- Key differentials
- Pyelonephritis, ureteric colic, AAA, pancreatitis, musculoskeletal
| Region | Key differentials |
|---|---|
| RUQ | Cholecystitis, cholangitis, hepatitis, peptic disease, basilar pneumonia, pyelonephritis |
| Epigastric | Pancreatitis, peptic ulcer ± perforation, gastritis, ACS, aortic pathology |
| LUQ | Splenic pathology, gastritis/ulcer, pyelonephritis, pneumonia |
| RLQ | Appendicitis, mesenteric adenitis, Crohn’s, ovarian/torsion/ectopic, ureteric stone |
| LLQ | Diverticulitis, constipation, colitis, ovarian pathology, ureteric stone |
| Diffuse / central | Obstruction, perforation, mesenteric ischaemia, gastroenteritis, peritonitis, AAA rupture |
| Flank / back | Pyelonephritis, ureteric colic, AAA, pancreatitis, musculoskeletal |
🚩 Red Flags / When to Escalate
- Haemodynamic instability, sepsis, or rising lactate.
- Peritonism (rigidity, rebound, silent abdomen) or suspected perforation/obstruction.
- Severe uncontrolled pain, or pain out of proportion to exam (think mesenteric ischaemia).
- Pulsatile abdominal mass, syncope, or back/flank pain in older patients (AAA).
- Possible ectopic pregnancy, ovarian/testicular torsion.
- Post-operative abdomen, or known IBD with acute severe flare.
💊 Initial Management
- ABC approach. Early senior/surgical discussion if acute abdomen, shock, or red flags.
- IV access, fluids if hypovolaemic or septic; keep NBM if surgical pathology possible.
- Analgesia early and adequately (paracetamol ± opioids).
- Avoid NSAIDs if perforation, bleeding risk, AKI, or likely surgery until discussed.
- Antiemetics as needed. NG tube if obstruction with significant vomiting/distension.
- Sepsis Six if infection/sepsis criteria met. PPI if peptic disease/UGIB concern.
- Document exam findings clearly (including hernias, PR if done) and your working diagnosis.
🔗 Related topics
Note Template
Ready-to-use clinical note structure
🕒 24 / 08 / 2026 — 19:11 ATRP re: abdominal pain Patient: [age] [sex] Admission Dx: [reason for admission] PMHx: [GI disease, surgeries, medications] 🧾 Hx: • Onset, duration, and character of pain • Location and radiation • Associated symptoms: [nausea, vomiting, diarrhoea, constipation, fever, urinary symptoms] • Last bowel movement and flatus • Appetite and oral intake • Medications and allergies 🩺 Exam: • General appearance: [well / septic / shocked] • Vitals: HR __ BP __ Temp __ RR __ SpO₂ __ CRT __ • Abdomen: inspection (distension/scars/hernias), tenderness location, guarding/rigidity/rebound, bowel sounds • Localising signs: [Murphy’s / McBurney’s / renal angles / pulsatile mass / none] • Hernial orifices: [clear / reducible / irreducible] • PR exam: [performed / deferred] — findings: [ ] • Chest/heart if relevant: [ ] 📋 Impression: Likely cause: [appendicitis / diverticulitis / obstruction / cholecystitis / pancreatitis / other] 📌 Plan: • NBM, IV fluids as indicated • Bloods: FBC, U&E, LFTs, amylase/lipase, CRP ± lactate • Urinalysis and β-hCG if applicable • Imaging: USS/CT as indicated (discuss with senior/surgery) • Analgesia (paracetamol ± opioids) • Escalate to senior / surgical review 👤 [Your Name], [Role] IMC: _______