Questionnaire/history:

Small (adhesions (65-75%), inguinal/femoral hernia, Crohn's disease, malignancy, vovulus) or large (malignancy 60%, diverticular disease, volvulus) bowel obstruction?

- Intermittent crampy abdominal pain?

- Nausea/vomiting?

- Decreased or absent bowel function?

- Absence of flatus?

- History of surgery?

Acute cholecystitis?

- History of gallstones or biliary colic?

- Intense right upper quadrant (RUQ) pain?

- Right shoulder or inter-scapular (referred) pain?

- Nausea/vomiting?

- Fever?

Perforated gastric or duodenal ulcer?

- Upper abdominal pain worse after eating?

- Loss of appetite?

- Nausea/vomiting?

- Use of non-steroidal anti-inflammatory drugs (NSAIDs)?

- History of blood in the stool (melena)?

- Sudden onset of severe upper abdominal pain?

- Pain may be referred to shoulders from diaphragmatic irritation?

- Fever?

Appendicitis?

- Constant severe pain, often periumbilical initially with migration to the right lower quadrant or right flank pain?

- Pain may initially improve after rupture?

- Nausea/vomiting?

- Anorexia?

- Diarrhoea?

- Fever?

Ruptured ectopic pregnancy?

- Vaginal bleeding (not always)?

- Usually unilateral pelvic pain?

- Missed/late last menstrual period?

- Previous ectopic pregnancy (risk of recurrence 18.5%)?

- Tubal surgery?

- PID?

- Fertility treatment?

- Pregnancy with IUD in situ?

Acute pancreatitis?

- Acute onset, constant, severe mid-abdominal or epigastric pain, often radiating to back?

- Nausea/vomiting?

- Anorexia?

- Alcohol?

- Gallstones?

- Blunt abdominal trauma?

- Surgery?

- Hypertriglyceridaemia?

- Hypercalcaemia?

- Drugs (eg sulphonamides, tetracyclines, oestrogens, steroids)?

Ruptured aortic aneurysm?

- Severe abdominal pain radiating to back, blank, groin?

- Nausea/vomiting?

- Leg may have discolouration or pain in lower extremities due to ischaemia?

- Age > 60 years in men, > 70 years in females?

- Family history or abdominal aortic aneurysm (AAA)?

- European origin?

- Smoker or ex-smoker?

- Hypertension?

- Hyperlipidaemia?

- Established vascular disease?

Acute mesenteric ischaemia (AMI)?

- Severe central pain out of proportion?

- After 5-6 hour pain-free period because of infarction of the bowel and its nerve endings before bowel gangrene resulting in peritonitis, sepsis and multi-organ failure?

- > 75 (50) years

- Atrial fibrillation and other embolic sources?

- Ischaemic heart disease (IHD) or peripheral vascular disease (PVD)?

- Smoking?

- Hypertension?

- Diabetes?

- Hyperperistalsis leading to diarrhoea?

Acute diverticulitis?

- Persistent, severe left lower quadrant (LLQ) pain?

- Anorexia?

- Nausea/vomiting?

- Frank per rectum (PR) bleeding?

- Lower fibre diet?

- Obesity?

- Increased red meat intake?

- Low physical activity?

- Smoking?

- Excess alcohol and caffeine consumption?

- Steroids?

- Non-steroidal anti-inflammatory drugs (NSAIDs)?

- Fever?

Past medical history?

Current medication?

Known drug allergies?

Examination:

Blood pressure (BP)?

Pulse?

Temperature?

Small or large bowel obstruction?

- Distended, tympanic abdomen?

- Tenderness +/- guarding?

- High-pitched bowel sounds?

Acute cholecystitis?

- Fever?

- RUQ tenderness?

- Murphy's signs (RUQ tenderness with arrest of inhalation on palpation)?

- Palpable gallbladder (30-40%)?

- Localised guarding?

- Jaundice (10%)?

Perforated gastric or duodenal ulcer?

- Peritoneal signs with guarding and rebound tenderness?

Appendicitis?

- Fever?

- Tachycardia?

- Right lower quadrant (RLQ) tenderness with guarding and rebound tenderness?

- Rigid abdomen?

- Psoas sign (RLQ pain on right thigh extension)?

- Appendix retrocaecal/retrocolic: maybe right groin pain and tenderness/rigidity being absent due to protection from overlying caecum

- Appendix subcacecal/pelvis: maybe suprapubic pain and urinary frequency, maybe tenesmus (rectal irritation), urine dipstick may show leucocytes/blood

Ruptured ectopic pregnancy?

- Guarding and rebound tenderness?

- Rigid abdomen?

- Tachycardia?

- Hypotension?

- Vaginal bleeding on speculum exam?

- Shock?

Ruptured aortic aneurysm?

- Tachycardia

- Hypotension?

- Pulsatile abdominal mass?

- Lower extremity pulse deficit?

- Limb numbness?

- Confusion or loss of consciousness?

Acute mesenteric ischaemia (AMI)?

- Often abdominal exam initially normal?

- Rigid abdomen with guarding, rebound tenderness?

- Hypotension?

Acute diverticulitis:

- Fever?

- Tachycardia?

- LLQ tenderness, guarding, rebound, rigid abdomen?

Investigations:

Blood test (FBC, U&E, LFT, amylase)?

Plain abdominal x-ray?

Erect CXR (air under diaphragm?)?

Management:

IV access and fluid resuscitation if tachycardic or hypotensive?

Careful fluid resuscitation if suspected AAA (target BP 80-90 mmHg)?

If hypovolaemic schock with suspected haemoperitoneum resuscitatation with 2 L isotonic fluids?

Considered oxygen, eg if suspected ruptured AAA or bowel ischaemia

Analgesia

Urgent surgical or gynaecological assessment

Reference(s):

BMJ Best Practice: Assessment of acute abdomen