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1.key points in history & clinical examination

2.select most appropriate tests

3.determine differential diagnosis

4.identify diseases with high mortality

Facts :

• 70% of diagnoses can be made based on history alone.
• 90% of diagnoses can be made based on history and physical exam.
• expensive tests often confirm what is found during the history and physical.examn

Abdominal pain is pain that is felt in the abdomen. The abdomen is an anatomical area that is bounded by the lower margin of the ribs above, the pelvic bone (pubic ramus) below, and the flanks on each side

• For Evaluation of Pain, Abdomen is divided into four quadrants:
• right upper quadrant
• right lower quadrant
• left upper quadrant
• left lower quadrant
• and three central areas:
• epigastric
• periumbilical
• suprapubic

Causes of pain in each Quadrant are

Epigastric pain

PUD

GERD

MI

AAA-abdominal aortic aneurysm

Pancreatic pain

Gallbladder and common bile duct obstruction

Right upper quadrant pain

Acute cholecystitis and biliary colic

Acute hepatitis or abscess

Hepatomegaly due to CHF

Perforated duodenal ulcer

Herpes zoster

Myocardial ischemia

Right lower lobe pneumonia

Left upper quadrant pain

Acute pancreatitis

Gastric ulcer

Gastritis

Splenic enlargement, rupture or Infarction

Myocardial ischemia

Left lower lobe pneumonia

Right lower quadrant pain

Appendicitis

Regional enteritis

Small bowel obstruction

Leaking aneurysm

Ruptured ectopic pregnancy

PID

Twisted ovarian cyst

Ureteral calculi

Hernia

Left lower quadrant pain

Diverticulitis

Leaking aneurysm

Ruptured ectopic pregnancy

PID

Twisted ovarian cyst

Ureteral calculi

Hernia

Regional enteritis

Periumbilical pain

Disease of transverse colon

Gastroenteritis

Small bowel pain

Appendicitis

Early bowel obstruction

Diffuse pain

Generalized peritonitis

Acute pancreatitis

Sickle cell crisis

Mesenteric thrombosis

Gastroenteritis

Metabolic disturbances

Dissecting or rupturing aneurysm

Intestinal obstruction

Psychogenic illness

Referred pain

• pneumonia (lower lobes)
• inferior myocardial infarction
• pulmonary infarction

Types of abdominal pain

Visceral

– originates in abdominal organs covered by peritoneum

Colic

–crampy pain

Parietal

– from irritation of parietal peritoneum

Referred

-Produced by pathology in one location felt at another location

• pain from hollow viscera
• crampy/paroxismal
• often poorly localized
• related to peristalsis
• patient writhing on exam table
• pain from peritoneal irritation
• steady/constant
• often localized
• patient lies still with knees up

Types and mechanisms

Types and mechanisms

1. The pain associated with inflammation of the parietalperitoneum is steady and aching, and worsened by changes in the tension of peritoneum caused by pressure or positional change. It is often accompanied by tension of the abdominal muscles contracting to relieve such tension.
2. The pain associated with obstruction of a hollow viscus is often intermittent or “colicky“
3. The pain associated with abdominal vascular disturbances (thrombosisor embolism) can be sudden or gradual in onset, and can be severe or mild. Pain associated with the rupture of an abdominal aortic aneurysm may radiate to the back, flank, or genitals.
4. Pain that is felt in the abdomen may be “referred” from elsewhere (g., a disease process in the chest may cause pain in the abdomen), and abdominal processes can cause radiated pain elsewhere (e.g., gall bladderpain—in cholecystitis or cholelithiasis—is often referred to the shoulder).

History                                         organic                                  functional

Pain character                               acute, persistent pain                     less likely to change

Increasing in intensity

Pain localization                           sharply localized                               various locations

Pain in relation to sleep              awakens at night                                  no affect

Pain in relation to

Umbilicus                                   further away                                       at umbilicus

Associated symptoms                fever, anorexia,

vomiting, wt loss,

anemia, elevated esr

headache, dizziness,

multiple system complaints

Psychological stress                               none reported                               present

Work-up of abdominal Pain

History

• Onset of pain

Qualitative description

Intensity

Frequency

Location -does it go anywhere (referred)?

Duration

Aggravating and relieving factors

The history of abdominal pain is a critical element in the evaluation. Note the following:

Understanding Abdominal Pain: When to Suspect Surgical Causes

Mode of onset, progression, character, and severity of abdominal pain can help differentiate between surgical and nonsurgical causes. Sudden, severe, or explosive pain that’s continuous, progressive, and lasts more than 6 hours generally points to a surgical etiology. In contrast, gradual onset, mild to moderate intensity, intermittent pain that resolves or improves within 6 hours usually signals a nonsurgical condition.

Pain from hollow, tubular structures—like the ureter, intestines, biliary ducts, or fallopian tubes—can be continuous or colicky. The narrower the structure involved, the more intense the pain. If you or someone you know is dealing with this kind of persistent, intense discomfort, it may be time to consult the Best Laparoscopic Surgeon in Gachibowli for accurate diagnosis and timely intervention.

Activity at pain onset also offers clues. Pain that begins during rest or sleep often suggests a surgical problem. If pain follows physical exertion or eating, it tends to be nonsurgical.

Pain location and migration matter. The farther from the umbilicus the pain localizes, the more likely it’s surgical.

• Epigastric pain = issues with the foregut (stomach, duodenum, biliary tract, pancreas, spleen)

• Periumbilical pain = midgut problems (jejunum, ileum, appendix, proximal colon)

• Hypogastric pain = hindgut or pelvic organs (distal colon, reproductive organs, bladder)

Pain that shifts location, like in appendicitis—starting periumbilically and moving to the right lower quadrant—suggests that inflammation has reached the parietal peritoneum and requires urgent evaluation.

Associated symptoms can provide further clarity. In surgical conditions, pain typically comes before nausea, vomiting, and anorexia. In nonsurgical conditions, those symptoms often precede the pain. Vomiting, especially in obese patients, is a red flag. Anorexia in an athlete—especially an obese one—is not common and should be taken seriously.

Fever is common, but fever with chills more often points to infections outside the surgical abdomen—like in the urinary or respiratory tracts.

Constipation can occur in both types, but obstipation (no gas or stool) strongly indicates a surgical issue. On the other hand, diarrhea with cramping typically suggests a nonsurgical cause like gastroenteritis or IBD.

Always ask what aggravates the pain first. Movement, coughing, or walking—especially downstairs—can irritate the peritoneum, suggesting surgical concern. Relief with posture change points to musculoskeletal pain. Relief after a bowel movement suggests a nonsurgical gastrointestinal cause.

Menstrual history and reproductive status are key in women. Abdominal pain is more frequent in women due to a broader range of potential genitourinary causes. Among sexually active women, surgical issues like ectopic pregnancy or ovarian torsion must be ruled out. Pain following an abnormal period may signal ectopic pregnancy. Bilateral pain with fever but without nausea or vomiting soon after a period often indicates pelvic inflammatory disease.

In men, abdominal pain may stem from seminal vesiculitis, prostatitis, or urethritis. However, men with abdominal pain have a higher chance of surgical disease, making prompt evaluation critical.

Certain medications and supplements—like NSAIDs, erythromycin, potassium, and salt tablets—can irritate the stomach and cause pain.

History matters: previous episodes, similar symptoms in family or peers, known food intolerances, allergies, sudden training or diet changes, or recent travel to high-risk areas suggest nonsurgical causes.

In any scenario where a surgical cause is suspected, it’s crucial to consult the Best Laparoscopic Surgeon in Gachibowli to ensure fast, minimally invasive care and avoid complications.

Work-up

Physical examination

Inspection

Inspection is always an important first step in any physical examination. Look at the abdominal contour and note any asymmetry. Record the location of scars, rashes, or other lesions.
Position – patient should be supine and the bed or examination table should be flat. The patient’s hands should remain at his/her sides with his/her head resting on a pillow. If the head is flexed, the abdominal musculature becomes tensed and the examination made more difficult. Allowing the patient to bend her knees so that the soles of her feet rest on the table will also relax the abdomen.

Lighting – adjusted so that it is ideal.

Draping – patient should be exposed from the pubic symphysis below to the costal margin above – in women to just below the breasts. Some surgeons would describe an abdominal examination being from nipples to knees.

Auscultation

Unlike other regions of the body, auscultation comes before percussion and palpation (the sounds may change after manipulation). Record bowel sounds as being present, increased, decreased, or absent

Percussion

Dullness

Resonance

Obliteration of liver dullness

Palpation

Begin with light palpation. At this point you are mostly looking for areas of tenderness. The most sensitive indicator of tenderness is the patient’s facial expression.

Look for Guarding -rebound tenderness and Rigidity

Rectal exam : Look for

Empty balloned rectum in Obstruction

Tender anterior wall  in Pelvic Peritonotis

Mucus /blood on finger in Intususception

Pelvic exam Look For

Tenderness of fornices in Salpingitis

Tender movements of cervix in Pregnancy

Fullness of douglas pouch in Pelvic Abscess

Work-up

Laboratory tests

1. Labs and Diagnostic Studies
   1. Urinalysis
   2. Complete Blood Count(CBC)
      1. Leukocytosislags other findings in elderly
   3. Electrocardiogram
   4. Pulseoximetry
   5. Serum Phosphate (increased in Mesenteric Ischemia)
   6. Liver Function Tests
   7. Blood Cultures
   8. Amylase
      1. Pancreatitis(Lipase preferred)
      2. Bowel Obstruction
      3. Bowel perforation or peptic ulcer perforation
      4. Mesenteric Ischemia
   9. LipaseIndications
      1. Pancreatitis
      2. Bowel Obstruction
      3. Duodenal Ulcer
   10. Arterial Blood Gas
2. Imaging: Protocol
   1. Directed imaging where specific cause is suggested
   2. Initial non-specific radiology studies
      1. Chest XRayfindings
         1. Abdominal free air
         2. Congestive Heart Failure
         3. Pneumonia
      2. Kidney, Ureter, Bladder plain XRay (KUB) findings
         1. Small Bowel Obstruction
         2. Incarcerated Hernia
         3. Appendicitis
         4. Large Bowel Obstruction
         5. Diverticulitis
         6. Volvulus
         7. Mesenteric Ischemia

Contrast studies -barium (upper and lower Gi series)

Ultrasound

CT Scanning with & without Contrast

Endoscopy

Sigmoidoscopy, colonoscopy

Diagnostic Laparoscopy