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Article author: Dr Mihai Mavru. Primary surgeon - Caritas University Hospital Bucharest, Romania.
 

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Acute abdominal pain (AAP) is one of the most common clinical problems physicians have to face. This is just one possible explanations for the ever renewed interest in the subject, as proved by the longevity of classical textbooks such as Cope's and Mondor's.

Whether the presentation is conspicuous or dramatic, the diagnosis of AAP often proves elusive. The definition, to start with, has many variances. For the purpose of this brief overview we will use "pain less than 48 hours from onset and severe enough to warrant medical attention".

Diagnostic modalities such as CT and ultrasound became prominent in recent years and computer aided diagnosis of AAP is more than three decades old. All these have produced an abundant literature on the subject which is out of the scope of the present text.

Sound judgment and clinical skills are of utmost importance whenever we face this clinical entity. In the following lines we will focus on a few clinical tips to aid in the diagnosis of AAP, baring in mind the non-experts in the field.

No place for haste

First, there is no need to, and indeed no place for, haste in the management of AAP. Once lethal conditions that require immediate intervention, such as aortic dissection, acute mesenteric ischemia or acute myocardial infarction have been reasonably ruled out, the time-honored method of assessing the condition by watchful waiting should be strongly considered. Repeated physical exams at 15 minute intervals can yield better results than rushing the patient to the radiology department; but this is, of course, subject to local policies.

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The site of pain is of utmost importance

The site of pain at the onset and at the presentation are of utmost importance in diagnosing AAP.
While the abdomen might be, as it was once called, a magic box for the clinician, the site of pain usually gives useful hints as to what lies inside and to what course of action our investigations should take. Differential diagnosis tables are often structured according to these criteria, and for a good reason.

Rigidity does not necessarily mandate surgery

Extra-abdominal sources of abdominal pain should be kept in mind, such as the thorax, pelvis, the abdominal wall, as well as the metabolic and neurogenic conditions that might mimic intra abdominal pathology. It is indeed rare but very embarrassing to subject or refer someone to a blank laparotomy or laparoscopy only to later notice a basal pneumonia or pleurisy that was overlooked on the chest films in the first place.

Guarding does not necessarily mandate surgery either

Guarding is, as everyone knows an even less specific sign for intraperitoneal pus than rigidity. It is found also in conditions such as severe bowel inflammation or enterocolitis. It is more deceitful than rigidity, so one should use the old trick of distracting the patient's attention when trying to elicit it, say by asking precise questions: "Did you through up? What was the character of your vomit? etc" . One should not be surprised when the abdomen becomes soft in such circumstances. Guarding should always be corroborated with tenderness of the peritoneal cul-de-sac at the pelvic examination.

Light analgesia is not contraindicated even if acute abdomen is considered

There are many sound studies showing that the administration of analgesics to patients with acute abdominal pain effectively relieves pain while not altering the ability of physicians to accurately evaluate and treat patients.

The diagnosis might be exceedingly difficult in extremes of age

One should be very careful when making the diagnosis of nonspecific abdominal pain in the elderly. In these often stoic individuals mild complaints might hide surgical conditions.

Make use but not abuse of laparoscopy

While laparoscopy in intraperitoneal emergencies might offer a definitive diagnosis to most and cure to many, with little discomfort to patients, it is an invasive technique that carries a specific morbidity that should be always taken into account.

The diagnosing of AAP is an exciting one. It can provide intellectual stimulation for clinicians of all ages and much reward when timely action leads to uneventful recovery of the patients.

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