Renal/Ureteric colic

Clinical features Investigations Management

Sudden onset severe UFR – Pain relief -
pain predominantly red Diclofenac sodium
Loin to groin (or cells suppositories (if not
vice versa) radiation X ray KUB – after contraindicated)
– may radiate to bowel preparation Pethidine if no
upper thigh, penis, USS KUB response to above
scrotum Adequate fluid intake
Associated with Follow up – necessary
vomiting (if stone detected).
Moves about in pain Refer to a specialized
May have associated unit
urinary symptoms
Examination
Minimal signs
May have tenderness
in the iliac fossa,
lumbar region and/or
renal angle

UTI

Clinical features Investigations Management

Commonly seen in UFR – >5 pus cells particularly if pyo
females (in uncentrifuged nephrosis is
Pain – unilateral/ urine) suspected (Is an
bilateral/supra Urine for culture emergency)
pubic/ loins and ABST Increased intake of
Lower urinary tract X ray KUB – fluids orally
symptoms – USS KUB – Analgesics –
frequency, burning Diclofenac sodium
sensation, fever Antibiotics –
(with chills) Nitrofurantoin /
Examination Nalidixic acid/ Co
Tenderness in the trimoxazole
area of pain May need to
Febrile change the
antibiotic
according the
ABST report
Specialist opinion
is necessary for all
males (first
episode) and
females with
repeated episodes
of UTI
Biliary colic

Clinical features Investigations Management

Right USS – gall stones. Admit
hypochondrial or Distended GB, Nil orally
epigastric pain X ray abdomen – IV fluids
Radiation to back may show calcified Buscopan
(or shoulder tip) gall stones Diclofenac sodium
Nausea / vomiting thick wall / Pethidine
Not a typical colic Liver profile – may Usually settles
(diagram) be altered with conservative
History of fat FBC – for evidence management
intolerance, of infection May progress to
flatulent dyspepsia UFR – to exclude cholecystitis
Mild jaundice renal pathology Refer to surgical
No fever unit
Examination
Tenderness in right
hypochondrium

Gastritis

Clinical features Investigations Management

Burning epigastric S Amylase UGIE – If age over
pain ECG – to exclude 40 years or
Distension – after myocardial symptoms are
meals infarction recurrent
NSAID intake, Antacids – should
food intolerance, have prompt
alcohol, steroids response
History of H2 receptor
gastroesophageal antagonists (H2RA)
reflux OR Proton pump
disease (GERD), inhibitors (PPI)
dyspeptic should be given (if
symptoms severe, these may
Localized be commenced
tenderness only intravenously)
Myocardial If symptoms are
infarction may recurrent, refer to a
mimic the specialised unit
clinical features
of gastritis
Irritable bowel syndrome

Clinical features Investigations Management

Periodic pain ESR, Stools FR, Reassure
Associated with faecal occult blood Symptomatic
bowel symptoms May need – Double treatment – (eg –
Examination contrast barium antispasmodics for
Patient not ill enema, colics)
Exclude – colonoscopy Identify and avoid
inflammatory (electively) precipitating factors
bowel disease, (eg. Milk)
intestinal
obstruction

5.1. Intestinal colic

Clinical features Investigations Management

Sudden onset pain X ray abdomen Nil orally
Site – circum supine AP – NG tube – if
umbilical (small distended bowel vomiting or gross
bowel) or loops distension+
hypogastrium USS – if mass is IV fluids – type,
(large bowel) suspected volume, rate
Vomiting U&E depending on level
Diarrhoea (in RBS of dehydration
gastroenteritis) FBC Catheter – if close
Constipation monitoring is
Abdominal needed
distension Surgical referral is
Dehydration – mandatory (except
level should be in patients having
assessed gastroenteritis)
Lumps, ascites, If evidence of
scars of previous possible
laparotomy strangulation of
Hernial orifices bowel – urgent
need to be checked surgical referral is
(particularly for Indicated.
femoral hernia in
females)
DER – empty
rectum, tumour,
hard faeces
Cholecystitis

Clinical features Investigations Management

Right Ultra sound scan Nil orally
hypochondrial or of abdomen IV fluids
epigastric pain – FBC Diclofenac sodium
may be referred to LFT suppositories
the right shoulder / X ray of GB area Pethidine (if pain is
back (particularly if severe)
Hyperaesthesia in USS is not Monitor – for
the region of the available) evidence of
inferior angle of CXR – erect PA peritonitis
right scapula (Boas (to exclude basal Antibiotics –
sign) pneumonia / ciprofloxacin or
Vomiting perforated peptic cefuroxime IV
Fever ulcer) (if diabetic/immuno
Low grade icterus Amylase (to compromised – add
may be present exclude metronidazole)
Murphy’s sign pancreatitis) Early surgical
UFR referral –
particularly if
deteriorating

Pancreatitis

Clinical features Investigations Management

Sudden onset Serum Amylase Nil orally
Severe pain (four fold rise) IV fluids
Epigastric – CXR – PA (to NG tube
predominantly exclude a Analgesics –
Radiates to back perforated viscus) Pethidine
Vomiting Late presentation – Antibiotics – broad
Pain reduced when Serum lipase spectrum (if severe
bending forwards If confirmed – need attack)
History of alcohol, to assess severity Look out for
gall stones FBC complications (eg.
Examination LDH MODS) in severe
Ill looking – in Blood urea cases
pain RBS Obtain surgical
Tenderness, Blood gas opinion
guarding and Serum calcium May need
marked rigidity in US Scan laparotomy – if
the epigastrium CT – if severe diagnosis is in
Free fluid may be doubt
present
Liver dullness
present
Acute appendicitis

Clinical features Investigations Management

Circumumbilical pain UFR – to exclude Nil orally
– later shifting to RIF UTI IV fluids
Anorexia WBC/DC – Analgesics –
Nausea / Vomiting neutrophil Diclofenac sodium
Fever (low grade – leucocytosis suppositories
unless perforated) Urine for HCG – Monitor – pulse,
Examination in females to BP, respiration
Maximum exclude ectopic Broad spectrum
tenderness/guarding/ pregnancy antibiotics should
rigidity in the iliac USS abdomen – be given after
fossa particularly in confirming the
Tenderness and females – when diagnosis
guarding would be diagnosis is in Definitive
generalized if doubt treatment -
appendix has Laparoscopy – in appendicectomy
perforated females when
diagnosis is in
doubt

Perforated viscus

Clinical features Investigations Management

Sudden onset CXR PA – erect (if Nil orally
severe pain patient cannot be kept NG Tube
Generalized erect , X ray IV fluids
History of peptic abdomen lateral Analgesics –
ulcer disease/ decubitus view) Pethidine or
NSAID ingestion/ Serum Amylase (to Morphine
diverticular exclude Pancreatitis) Antibiotics –
disease/ bowel FBC broad spectrum
malignancy U&E plus
Examination RBS metronidazole
Febrile Monitor – Pulse,
Board like rigidity BP, resp, UOP
Absent bowel Optimize before
sounds surgery
Free fluid Definitive
Impaired liver treatment -
dullness surgery
Strangulated hernia

Clinical features Investigations Management

Previous history of FBC Nil orally
hernia RBS IV fluids
Symptoms and ECG (if >40 years Analgesics –
signs of intestinal of age) Narcotic
obstruction Avoid forceful
preceding the manipulation
persistent severe Needs surgery
pain If the patient is to
Examination be transferred for
Irreducible hernia surgery, place an
– tender ice pack on hernia,
Tachycardia elevate foot end

Torsion of testis

Clinical features Investigations Management

Age – infants, 7 – Doppler Immediate surgery
15 years examination – if
Sudden onset doubtful, time
lower abdominal permits
pain (may not UFR
point to testis)
Vomiting
Examination
Tender testis -
lying high /
horizontal
Abdomen - soft