Approach to Abdominal Pain: A Guide for Resident Doctors

Introduction

Abdominal pain is one of the most common complaints in the emergency department (ED). It ranges from benign, self-limiting conditions to life-threatening emergencies. As a junior doctor, your role is to quickly identify red flags, perform a focused history and examination, request appropriate investigations, and initiate timely management.

History-Taking – Ask the Right Questions

A systematic history helps narrow down the differential diagnosis. Use the SOCRATES mnemonic to structure your pain assessment:

Pain-Specific Questions (SOCRATES)

·     Site – Where is the pain located? (e.g., RUQ, epigastric, periumbilical, etc.)

·     Onset – Sudden or gradual? (e.g., perforated viscus = sudden, appendicitis = gradual)

·     Character – Sharp, dull, colicky, burning? (e.g., biliary colic = intermittent, pancreatitis = constant, burning = reflux)

·     Radiation – Does it spread anywhere? (e.g., RUQ pain to right shoulder = gallbladder pathology, loin to groin = renal colic)

·     Associated symptoms – Nausea, vomiting, fever, diarrhea, jaundice, weight loss?

·     Timing – Is it continuous or intermittent? Worse at night or after meals?

·     Exacerbating/Relieving factors – Better with food (peptic ulcer), worse with fatty meals (gallbladder), worse on movement (peritonitis)?

·     Severity – Rate out of 10 (helps assess progression).

Key Additional History Questions

·     Gastrointestinal – Change in bowel habits? Blood in stool (melena or hematochezia)?

·     Genitourinary – Dysuria, hematuria, urinary retention?

·     Gynecological (Females) – Last menstrual period (LMP)? Pregnancy risk? Vaginal discharge?

·     Past Medical History – Previous surgeries (adhesions →obstruction)? History of gallstones or peptic ulcers?

·     Medications – NSAIDs (gastric ulcer), steroids (masking peritonitis), anticoagulants (risk of bleeding)?

·     Social History – Alcohol (pancreatitis, liver disease), recent travel (infectious diarrhea), IV drug use (hepatitis)?

Examination – What to Look For

General Inspection

·     Does the patient look unwell? Pale, diaphoretic, distressed?

·     Vital signs: Fever (infection), tachycardia (shock), hypotension (perforation, bleeding)?

Abdominal Examination

·     Inspection – Surgical scars, distension (obstruction, ascites), pulsations (AAA)?

·     Palpation

·     Tenderness: Localized (e.g., appendicitis) vs. generalized (peritonitis).

·     Rebound tenderness/Guarding – Suggests peritonitis.

·     Murphy’s sign (RUQ pain on inspiration) – Cholecystitis.

·     Rovsing’s sign (RLQ pain on LLQ palpation) – Appendicitis.

·     McBurney’s point tenderness – Appendicitis.

·     Psoas sign/Obturator sign – Retrocecal appendicitis.

·     Percussion

·     Dullness – Ascites (liver disease, malignancy).

·     Hyperresonance – Bowel obstruction.

·     Auscultation

·     Absent bowel sounds – Paralytic ileus or peritonitis.

·     High-pitched tinkling – Bowel obstruction.

·     Rectal & Pelvic Examination

·     PR exam: Blood (GI bleed, malignancy), hard stool (impaction).

·     Pelvic exam (in females): Cervical motion tenderness (PID), adnexal mass (ovarian pathology)

Investigations – Confirming the Diagnosis

Bedside Tests

·     Urinalysis – UTI, renal stones, pregnancy test in females.

·     ECG – Consider cardiac causes (inferior MI can mimic epigastric pain).

·     Capillary Blood Glucose – Diabetic ketoacidosis (DKA) as a cause of abdominal pain.

Blood Tests

·     FBC – Leukocytosis (infection, inflammation), anemia (GI bleed).

·     CRP – Elevated in infection/inflammation.

·     U&Es – Dehydration, AKI, electrolyte imbalances (especially in obstruction).

·     LFTs – Raised bilirubin (choledocholithiasis), ALP/GGT (biliary disease), AST/ALT (hepatitis).

·     Amylase/Lipase – Pancreatitis (3× upper limit of normal is significant).

·     ABG/VBG – Metabolic acidosis (ischemic bowel, sepsis, DKA).

·     Lactate – Elevated in ischemia/sepsis.

·     Coagulation Profile – If considering surgery or liver disease.

Imaging

·     Abdominal X-ray (AXR) – Bowel obstruction (dilated loops, air-fluid levels), perforation (free air under diaphragm).

·     Ultrasound (US) – Gallstones, cholecystitis, AAA, renal colic.

·     CT Abdomen (Gold Standard for undifferentiated pain)

1. CT with contrast – Appendicitis, diverticulitis, ischemic bowel.

2. CT without contrast – Renal stones.

·     MRI/MRCP – If suspecting biliary pathology but inconclusive ultrasound.

Management – What to Do Next?

General Supportive Measures

·     Resuscitation (if unstable): ABCDE approach.

·     IV access + Fluids: Especially in sepsis, pancreatitis, or dehydration.

·     Analgesia: Start with paracetamol ± opioids (avoid NSAIDs if peptic ulcer suspected).

·     Antiemetic: Ondansetron, metoclopramide.

·     NPO (Nil by Mouth): If suspecting bowel obstruction or surgical pathology.

Key Takeaways for Junior Doctors

·     Always rule out life-threatening causes first (AAA, ischemia, perforation).

·     A structured history (SOCRATES) + focused examinationnarrows the diagnosis.

·     Use bedside tests, labs, and imaging appropriately.

·     If in doubt, consult seniors and escalate early for surgical cases.

·     Treat symptomatically while waiting for definitive management.