Red flag symptoms: Abdominal pain

Distinguish serious causes from functional pain, writes Dr Tillmann Jacobi.

Abdominal pain is a common complaint, either as acute, chronic or chronic-recurrent pain. It can stem from a large variety of possible causes. It is essential to recognise and distinguish an acute surgical abdomen from abdominal pain due to medical or other causes.

Red flag symptoms
  • Possible pregnancy
  • Acutely systemically unwell
  • Dehydrated
  • Post trauma
  • Guarding or rebound tenderness
  • Abdominal distension
  • Unexplained weight loss
  • Post trauma

Causes
The most common systems involved in abdominal pain are the GI tract (constipation or obstruction, diverticulitis, appendicitis, IBS, gallbladder problems, pancreatitis, malignancy), the renal system (UTI, renal colic) and in females the gynaecological organs (ectopic pregnancy, miscarriage, ovarian cyst, pelvic inflammatory disease, endometriosis).

Diverticula in the sigmoid colon (Photograph: spl)

However, don't forget possible cardiac, pulmonary, vascular or endocrine emergencies, such as acute MI, pneumonia, abdominal aortic aneurism or diabetic ketoacidosis.

Rupture of the spleen after trauma can occur with a delay of several days or longer. Coeliac disease may present with recurrent, typically colicky pain.

There could be functional pain due to stress, which is common in children and anxious patients.

However, beware of displaced appendicitis in advanced pregnancy. The risk for atypical symptoms from fibroids or gallstones is also increased in pregnancy.

Age, sex, general health state and past history of the patient are useful to narrow down differential diagnoses for each case.

It is essential to establish a good history including the onset, area, quality and intensity of the pain as well as any associated symptoms. Patients may well volunteer aggravating or relieving factors and any changes of quality, frequency or severity of the pain since it started.

Examination
Examination, especially in acute abdominal pain, must include pulse and BP, as well as examining the area of the pain for guarding and/or rebound, bowel sounds, organomegaly, ascities or distension.

A urine dipstick, pregnancy test and a possible rectal and vaginal examination might be necessary. Consider a blood test with FBC, inflammatory markers, LFTs and U&Es if the pain is not too acute.

Abdominal X-ray is less likely to be helpful, but an ultrasound might confirm gallstones.

Management
The management of abdominal pain will depend on the history, the overall state of the patient and the findings during the examination. It could range from general advice and reassurance, or some symptomatic treatment and further investigations to an acute surgical, medical or gynaecological admission. Functional abdominal pain might require a careful long-term management approach with or without psychological input.

  • Dr Jacobi is a salaried GP in York

Possible causes

  • Constipation or obstruction
  • Irritable bowel syndrome
  • UTI
  • Pelvic inflammatory disease
  • Appendicitis
  • Gallbladder disease
  • Coeliac disease
  • Malignancy

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