Special Operations Forces Medical Handbook

3-1

PART 3: GENERAL SYMPTOMS

Symptom: Acute Abdominal Pain

COL (Ret) Peter McNally, MC, USA

Introduction: Acute abdominal pain is an internal response to a mechanical or chemical stimulus. The pain
can be separated into three categories: visceral (dull and poorly characterized), somatoparietal (more intense
and precisely localized) and referred (pain felt remote from the origin). The most important elements in the
evaluation of acute abdominal pain are the history and physical examination. Attention to the chronology and
description of the pain can often suggest the origin of acute abdominal pain. Acute abdominal pain caused by
blunt or penetrating trauma is covered on the SOF Medical CD-ROM.

Subjective: Symptoms
Listed on Table 3-1 are some of the most common causes of acute abdominal pain and their associated
symptoms. Some patients will voluntarily provide a typical description of the details about the onset, location,
and character of the pain. For others, the medic will have to ask pertinent questions (e.g., Where does it
hurt? How would you describe the pain?, etc.) to obtain the necessary information. Integrate past medical
and surgical history, family history and medications into the search for the origin of acute abdominal pain. If
the patient also has jaundice, constipation, diarrhea and vomiting, see the appropriate symptom section. GU
and GYN illnesses may present as abdominal pain, although they typically present as ank pain or pelvic pain
respectively. See the respective chapters for additional information.

Objective: Signs
Using Basic Tools: Temperature: Fever suggests infection or inammation, i.e., appendicitis, cholecystitis,
pancreatitis, diverticulitis, gastroenteritis or pelvic inammatory disease.
BP and Pulse: Pain typically causes a reex increase in heart rate and BP. If the BP < 90, consider causes
of blood or vascular uid loss, i.e., bleeding ulcer, pancreatitis (uid third spacing), gastroenteritis (diarrheal
losses). Signs of shock suggest rapid loss of blood, i.e., ruptured ectopic pregnancy, hemorrhaging ulcer or
ruptured abdominal aneurysm.
Inspection: Surgical scars may suggest small bowel obstruction. Assumption of the fetal or knee-chest
position by the patient may suggest pancreatitis or sickle cell crisis.
Palpation: The abdominal examination should start gently away from the site of discomfort. Localization of
pain in the RLQ suggests appendicitis or pelvic inammatory disease. Sudden inspiratory arrest during steady
palpation of the RUQ (Murphy’s Sign) suggests cholecystitis. Rebound tenderness and involuntary guarding
highly suggest peritonitis from bowel perforation.
Pelvic Examination: Severe cervical motion tenderness or a tender adnexal mass, coupled with fever,
suggests pelvic inammatory disease.
Extremities: Loss of lower extremity pulse(s) suggests abdominal aneurysm.
Rectal: Tarry, sticky, foul-smelling stool (melena) suggests bleeding ulcer. Bright red blood on rectal exam can
indicate torrential ulcer bleeding or ischemic colitis.
For further objective signs, see Table 3-2.
Using Advanced Tools: Lab: CBC for infection and anemia, and UA infection, stones, etc.

Assessment:
Differential Diagnosis: Self-limiting causes of abdominal pain are usually milder in severity and remit
either spontaneously within 24 hrs, or after administration of antacids, H-2 blockers, laxatives, etc. Examples
of common self-limiting causes of abdominal pain would include gastroesophageal reux, gastritis, intestinal
gas, constipation, etc. See discussion and Table 3-1 for other diagnoses to consider. Also include OB (labor),
GYN, GU causes of abdominal pain (see respective chapters in this book).