Abdominal pain

Acute upper abdominal pain: step-by-step assessment

1

Free air on CXR?

Perform an erect CXR in all unwell patients

with acute upper abdominal pain; the presence of free air under the diaphragm(s) (see
Fig. 4.4) indicates perforation of a hollow
viscus. Secure IV access, cross-match for
blood, resuscitate with IV fluids and refer
immediately to surgery.
If the CXR fails to demonstrate free air or
is equivocal but clinical suspicion is high
e.g. sudden-onset severe pain with epigastric tenderness and guarding, consider an
abdominal CT, but first check amylase and
ECG as described in steps 2 and 3.
2

ECG evidence of ischaemia?

Acute coronary syndromes, particularly

inferior myocardial infarction (MI), may
present atypically with epigastric pain.
However, hypotension or severe bleeding
in patients with acute abdominal pathology
may provoke or exacerbate ischaemia in
patients with stable coronary artery disease;
in these circumstances, administration of
powerful antithrombotic agents may have
catastrophic consequences.
Perform an ECG in all patients.
Refer immediately to cardiology if there
are features of an ST elevation MI (see
Box 6.1, p. 49).
In patients with ST depression, evaluate
carefully for hypotension, sepsis,
hypoxia and bleeding before
attributing changes to an acute
coronary event.
In patients with non-specific T wave
changes (see Box 6.1, p. 49), measure
cardiac biomarkers to assist diagnosis
and continue to search for alternative
causes.
Seek cardiology input if there is any
diagnostic doubt.
3

Amylase >500U/L?

Measure serum amylase in any patient with

acute severe epigastric pain. Patients with
an amylase >3 the reference range are 95%
likely to have pancreatitis; levels >1000U/L
are considered diagnostic.

If amylase levels are normal or equivocal,

continue to suspect the diagnosis if the
history is characteristic and:
there has been a delay in presentation
OR
there is a history of alcoholism
especially if the patient has had
previous episodes of pancreatitis.
In these patients, consider contrast
CT to look for evidence of pancreatic
inflammation.
Once the diagnosis has been made, evaluate repeatedly for evidence of complications, e.g. shock, hypoxia (acute respiratory
distress syndrome, ARDS), disseminated
intravascular coagulation (DIC); calculate
the Glasgow prognostic criteria score (Box
4.2) or other validated prognostic score;
and monitor CRP. Manage all patients
with severe or high-risk acute pancreatitis
(shock, organ failure, Glasgow score 3 or
peak CRP >210mg/L) in a critical care unit.
Perform an abdominal USS to look for
gallstones; those with severe pancreatitis
may require urgent ERCP and stone extraction, especially if there is jaundice or a
dilated common bile duct (CBD). Consider
CT to assess the extent of pancreatic injury

Box 4.2 Modified Glasgow criteria* for

assessing prognosis in acute pancreatitis
Age >55 years
PaO2 <8 kPa (60mmHg)
WBC >15 109/L
Albumin <32g/L
Serum calcium <2.00mmol/L (8mg/dL)
(corrected)
Glucose >10mmol/L (180mg/dL)
Urea >16mmol/L (45mg/dL) (after
rehydration)
ALT >200U/L
LDH >600U/L
*Severity and prognosis worsen as the number of these factors
increases. More than three implies severe disease.

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