ABCs
- Ensure stability
- Consider O₂ if hypoxic or distressed
- Secure IV access
- Start fluid resuscitation if hypotensive
- Check heart rate, BP, temp, RR, SpO₂ and RBS
- Disability (Pain) use OPQRST
- Onset: Sudden (perforation?) vs gradual
- Provocation: What worsens or relieves?
- Quality: Sharp, dull, colicky?
- Radiation: Back (pancreatitis, dissection), shoulder (diaphragmatic irritation)
- Severity: Rate the pain
- Timing: Constant or intermittent?
- Examine for distension, tenderness, rebound, guarding, scars
- Still patient = peritonitis, restless = colicky pain (e.g., stones)
Red Flags – Escalate If
- Peritonitis signs: guarding, rigidity, rebound
- Hemodynamic instability
- High lactate or severe acidosis (think mesenteric ischemia)
- Persistent vomiting (→ bowel obstruction)
- Pain worsening despite analgesia
HPI & EXAMINATION
| Symptom / Sign | Clues |
|---|---|
| Radiates to back | Pancreatitis, PUD, dissection |
| Shoulder tip pain | Splenic rupture, gallbladder |
| Constipation, distension | Obstruction |
| Vomiting | Obstruction, pancreatitis |
| Jaundice | Hepatobiliary cause |
| Recent surgery | Adhesions, ileus |
| Alcohol, NSAIDs | Pancreatitis, ulcers |
Targeted Signs
- Murphy’s – Cholecystitis
- McBurney’s / Rovsing’s / Psoas – Appendicitis
- Rectal exam – GI bleed, ischemia
- Pelvic exam – PID, ectopic pregnancy
| Category | Tests | Why |
|---|---|---|
| Baseline | CBC, CRP | Infection, inflammation |
| U&E, Creatinine | Dehydration, AKI, baseline before contrast | |
| RBS | Hypo/hyperglycemia, DKA | |
| Cause-Specific | LFTs, Lipase | Hepatobiliary or pancreatic source |
| Lactate | Suspect mesenteric ischemia | |
| Troponin, ECG | Epigastric pain = rule out MI | |
| Urine β-hCG | All women of reproductive age | |
| Urinalysis | Infection, hematuria (e.g., stones) | |
| Pre-intervention | Coagulation panel | If bleeding risk, liver disease, or before procedure |
| Group & crossmatch | Suspected rupture, bleeding, or surgery |
MANAGEMENT
- NPO – if surgical cause or pancreatitis suspected
- IV Fluids – for hypotension, vomiting, pancreatitis
- Analgesia:
- IV Paracetamol 1 g
- Avoid NSAIDs if perforation or renal impairment
- Antiemetics
- Ondansetron 4–8 mg IV PRN
- Nasogastric Tube (NGT) – if bowel obstruction suspected
- Constipation – Lactulose 15–30 mL, Movicol sachet, or enema STAT
| Condition | Empiric Choice |
|---|---|
| Peritonitis, cholangitis, diverticulitis | Pip-Tazo or Ceftriaxone + Metronidazole |
| Intra-abdominal sepsis | Ampicillin + Gentamicin + Metronidazole |
| Diagnosis | Key Steps |
|---|---|
| Pancreatitis | IV fluids, analgesia, monitor lipase, bowel rest |
| AAA rupture | Permissive hypotension, CT angio, urgent surgery |
| Appendicitis | NPO, IV fluids, abx, surgical consult |
| Obstruction | NPO, NGT, IV fluids, surgical input |
| Cholangitis | IV abx, IV fluids, early ERCP/surgery |
| Diverticulitis | IV fluids, abx, bowel rest, surgery if perforated |
| Gastroenteritis | Hydration, antiemetics, stool studies if severe |
| Mesenteric ischemia | IV fluids, lactate, abx, anticoagulate, urgent surgery |
| Nephrolithiasis | IV fluids, analgesia, tamsulosin, urology if needed |
| PUD | IV PPI, H. pylori eradication, surgery if perforated |
| Perforation | IV fluids, abx, urgent imaging + surgical referral |
| Ruptured ectopic | Gyn/surgical emergency, IV fluids, transfuse if needed |