ACUTE ABDOMEN258 Surgical Emergencies
(iii) Otherwise pain tends to localize over the organ affected, provided
there is peritoneal involvement, with radiation to a shoulder tip if
the diaphragm is irritated, e.g. by cholecystitis or a ruptured spleen.
3 Look for associated features such as:
(i) Nausea and vomiting:
(a) pain tends to precede the nausea and vomiting in the surgical
acute abdomen
(b) a medical condition such as gastroenteritis or gastritis is
more likely if the nausea and vomiting precede the pain.
(ii) Fever and rigors:
(a) a low-grade pyrexia is usual in appendicitis or diverticulitis
(b) a high fever and rigors suggest cholecystitis, cholangitis,
diffuse peritonitis, pyelonephritis or acute pelvic
inflammatory disease (salpingitis).
4 Check the temperature, pulse, blood pressure and respiratory rate.
5 Inspect for visible peristalsis and distension, palpate for local tenderness,
guarding and masses, percuss for free gas, and listen for increased or absent
bowel sounds. Examine the hernial orifices, particularly in cases of intesti-
nal obstruction.
6 Perform a rectal examination, external genitalia examination in male
patients, and consider a vaginal examination in female patients.
7 Insert an i.v. cannula and send blood for FBC, U&Es, LFTs, blood sugar and
lipase/amylase.
(i) Their true discriminatory value in differentiating between the
various conditions is limited, apart from the lipase/amylase.
8 Test the urine for sugar, blood, protein, bile and urobilinogen, and send for
microscopy and culture in suspected UTI.
(i) Perform a -hCG pregnancy test in females with abdominal pain.
9 Record an ECG.
10 Plain and special radiology.
Only request radiologic investigation for the following specific indications:
(i) An erect CXR – to look for evidence of pulmonary disease, a
secondary pleural reaction from intra-abdominal disease and free
gas under the diaphragm indicating a perforation.
(ii) Erect and supine abdomen films – to look at the gas pattern for
obstruction or volvulus, splenic shadow, renal outlines and psoas
shadows, and for calcification and opacities.
(iii) Upper abdominal ultrasound to confirm biliary colic or cholecystitis.
(iv) Lower abdominal ultrasound to confirm an AAA or ureteric colic.
(v) Pelvic ultrasound – to look for a gynaecological cause (remember
to do the -hCG first).
(vi) CT scan
(a) with i.v. contrast for a suspected aortic aneurysm, provided
the patient is haemodynamically stable