Surgical Module: Acute Abdominal Pain

Activity 1
Causes of Acute Abdominal Pain:

Surgical
Peritonitis
Perforated viscus
Appendicitis
Bowel Obstruction
Cholecystitis
Ascending Cholangitis
PUD
Mesenteric Ischaemia
Ruptured AAA
Pancreatitis

Medical
Inflammatory Bowel
Diseases
Hepatitis
Endocrinological Crises
(Diabetes Keto,
Addison crisis,
hypercalcemia)
MI, Pulmonary infarct
Pneumonia
Pericarditis
Effusion/empyema
tuberculosis of
ileocecal junction

Gynaecological
Ectopic
Miscarriage
Endometriosis
PID
Tubo-ovarian abscess
Ovarian torsion

Surgical Module: Acute Abdominal Pain

Surgical Module: Acute Abdominal Pain

Activity 2
Somatic vs Visceral Pain- sharp vs dull, localised vs diffused, somatic nerve, visceral nerve
Localisation- paired organs vs unpaired organs
Different pain in:

Inflammation of parietal peritoneum

Obstruction of hollow viscera
Vascular compromise
Neurogenic causes
Metabolic abdominal crises
Referred pain from extraabdominal diseases
Arising from the abdominal wall

Surgical Module: Acute Abdominal Pain

Activity 3
Investigations:

Plain, upright, lateral decubitus- intestinal obstruction, perforation

Barium, water-soluble contrast
Peritoneal Lavage, FAST
Ultrasound, CT
Diagnostic Laparoscopy
Laparotomy

Surgical Module: Acute Abdominal Pain

Activity 5
S*, 43, female, Iban, referred from private polyclinic with complaint of RUQ pain of rapid onset for 2
days duration on 13/6. The pain started while she was working and was very severe (10/10). It was
constant and dull in nature. There was no radiation. It was not exacerbated by food/movement. Not
related to cough or breathing. No other exacerbating or alleviating factors.
It was associated with loss of appetite, vomiting x1 and loose stoolx2/7 with no PR bleed.
No fever. No pale stool, No dark-colour urine. No SOB, No chest pain. No dysuria, frequency,
hesitancy. No cough, runny nose, sore throat.
LMP: 8/6/14
1 past episode of similar abdominal pain about 2 months ago. Seen doctor at polyclinic. Found to
have cholelithiasis dx by USG. (April 2014)
PMHx and PSHx: Nil
Drug Hx: Nil
No allergies
FHx: no significance
SHx: factory worker, Lives w husband & children (3) (2 in jb, 1 in Sarawak), non smoker, no alcohol
O/E: alert, pink, not jaundice, good hydration
BP: 140/90 PR: 68 RR 18 T: 37 SPO2: 98% under RA
CVS: DRNM Lungs: Clear
Abd: +tender RUQ, +murphys sign, no mass palpable, Bowel sound+
DDx: (Hepatobiliary, GI, GU, Extraabdominal, Misc)

Acute Cholecystitis
Biliary colic
Cholangitis
CBD obstruction
Pancreatitis
Hepatitis, Hepatic Abscess/mass, Budd-Chiari
Subphrenic abscess
Gastric/duodenal, pancreatic, hepatic flexure
GU: nephrolithiasis, pyelonephritis, renal mass/ischemia/trauma
RLL pneumonia, effusion/empyema, CHFeffusion, hepatic congestion, MI, PI, pericariditis,
pleuritis
Mis: Zoster, trauma, costochondritis, Dengue, Ectopic, Fitz-Huge-Curtis syndrome

Surgical Module: Acute Abdominal Pain

Ix:

(UFEME, LFT/BUSE/Creat, GM, ECG, FBC)

Imaging: USG biliary system, EUS, CT, HIDA scan (hepatobiliary iminodiacetic acid), ERCP
Mgt:
-IV tramal 50mg TDS
-IV Augmentin 1.2g stat & tds
-NBM w IVD 4pint (2pint NS+ 2pint DS)
-KIV cholecystectomy