6.4 Typical clinical features in patients with an ‘acute abdomen’

Condition History Examination

Acute appendicitis Nausea, vomiting, central abdominal pain that later shifts to

right iliac fossa

Fever, tenderness, guarding or palpable mass in right iliac

fossa, pelvic peritonitis on rectal examination

Perforated peptic

ulcer with acute

peritonitis

Vomiting at onset associated with severe acute-onset

abdominal pain, previous history of dyspepsia, ulcer disease,

non-steroidal anti-inflammatory drugs or glucocorticoid therapy

Shallow breathing with minimal abdominal wall movement,

abdominal tenderness and guarding, board-like rigidity,

abdominal distension and absent bowel sounds

Acute pancreatitis Anorexia, nausea, vomiting, constant severe epigastric pain,

previous alcohol abuse/cholelithiasis

Fever, periumbilical or loin bruising, epigastric tenderness,

variable guarding, reduced or absent bowel sounds

Ruptured aortic

aneurysm

Sudden onset of severe, tearing back/loin/abdominal pain,

hypotension and past history of vascular disease and/or high

blood pressure

Shock and hypotension, pulsatile, tender, abdominal

mass, asymmetrical femoral pulses

Acute mesenteric

ischaemia

Anorexia, nausea, vomiting, bloody diarrhoea, constant

abdominal pain, previous history of vascular disease and/or

high blood pressure

Atrial fibrillation, heart failure, asymmetrical peripheral

pulses, absent bowel sounds, variable tenderness and

guarding

Intestinal obstruction Colicky central abdominal pain, nausea, vomiting and

constipation

Surgical scars, hernias, mass, distension, visible

peristalsis, increased bowel sounds

Ruptured ectopic

pregnancy

Premenopausal female, delayed or missed menstrual period,

hypotension, unilateral iliac fossa pain, pleuritic shoulder-tip

pain, ‘prune juice’-like vaginal discharge

Suprapubic tenderness, periumbilical bruising, pain and

tenderness on vaginal examination (cervical excitation),

swelling/fullness in fornix on vaginal examination

Pelvic inflammatory

disease

Sexually active young female, previous history of sexually

transmitted infection, recent gynaecological procedure,

pregnancy or use of intrauterine contraceptive device, irregular

menstruation, dyspareunia, lower or central abdominal pain,

backache, pleuritic right upper quadrant pain (Fitz-Hugh–Curtis

syndrome)

Fever, vaginal discharge, pelvic peritonitis causing

tenderness on rectal examination, right upper quadrant

tenderness (perihepatitis), pain/tenderness on vaginal

examination (cervical excitation), swelling/fullness in fornix

on vaginal examination

The history • 99

6

It may indicate anxiety but sometimes occurs in an attempt to

relieve abdominal pain or discomfort, and accompanies GORD.

Normally, 200–2000 mL of flatus is passed each day. Flatus

is a mixture of gases derived from swallowed air and from

colonic bacterial fermentation of poorly absorbed carbohydrates.

Excessive flatus occurs particularly in lactase deficiency and

intestinal malabsorption.

Borborygmi result from movement of fluid and gas along the

bowel. Loud borborygmi, particularly if associated with colicky

discomfort, suggest small bowel obstruction or dysmotility.

Abdominal distension

Abdominal girth slowly increasing over months or years is usually

due to obesity but in a patient with weight loss it suggests

intra-abdominal disease. The most common causes of abdominal

distension are:

• fat in obesity

• flatus in pseudo-obstruction or bowel obstruction

• faeces in subacute obstruction or constipation

• fluid in ascites (accumulation of fluid in the peritoneal

cavity; Fig. 6.6), tumours (especially ovarian) or distended

bladder

• fetus

• functional bloating (fluctuating abdominal distension that

develops during the day and resolves overnight, usually

occurring in irritable bowel syndrome).

Altered bowel habit

Diarrhoea

Clarify what patients mean by diarrhoea. They may complain of

frequent stools or of a change in consistency of the stools. Normal

frequency ranges from three bowel movements daily to once

every 3 days. Diarrhoea is the frequent passage of loose stools.

Steatorrhoea is diarrhoea associated with fat malabsorption. The

stools are greasy, pale and bulky, and they float, making them

difficult to flush away.

‘Mechanical’ dysphagia is often due to oesophageal stricture

but can be caused by external compression. With weight loss,

a short history and no reflux symptoms, suspect oesophageal

cancer. Longstanding dysphagia without weight loss but

accompanied by heartburn is more likely to be due to benign

peptic stricture. Record the site at which the patient feels the

food sticking; this is not a reliable guide to the site of oesophageal

obstruction, however.

Nausea and vomiting

Nausea is the sensation of feeling sick. Vomiting is the expulsion

of gastric contents via the mouth. Both are associated with

pallor, sweating and hyperventilation.

Ask about:

• relation to meals and timing, such as early morning or late

evening