EMQ: 20
Abdominal pain
a) Acute
appendicitis
b)
Diverticular disease
c) Abdominal
aortic aneurysm
d) Perforated
peptic ulcer
e) Crohn's
disease
f)
Ulcerative colitis
g) Acute
pancreatitis
h) Diverticulitis
i) Acute
viral hepatitis
j) Acute
cholecystitis
Match one of the options above to the most likely
scenario given below:
1) A 55-year-old male who has been taking antacids
for long standing dyspepsia, presents with severe upper abdominal pain that
has subsequently spread and become generalised. For the week prior to
admission he had used ibuprofen to ease pain in his right knee
On examination he is afebrile, pulse rate 120
beats per minute, BP 110/60. His abdomen does not move with respiration, it is
rigid. Percussion note over the right lower ribs is resonant and bowel sounds
are absent
Answer: d) perforated peptic ulcer
The history of dyspepsia should make one suspect a
peptic ulcer. The ingestion of ibuprofen should alert one to the possibility
of a complication.
The physical signs would suggest air under the
diaphragm and peritonitis.
2) A 76-year-old female presents with colicky
pain in the left iliac fossa. She also complains of rectal bleeding and
diarrhoea. She is febrile. A thickened mass is palpable in the left iliac
fossa. It is tender. The white cell count shows a neutrophilia.
Answer: h) diverticulitis
Pain in the left iliac fossa with diarrhoea and
rectal bleeding should make one suspect pathology in the left colon. A
palpable mass in this region should reinforce this suspicion. Tenderness would
suggest inflammation and the neutrophilia would also favour this.
3) A 27-year-old male presents with anorexia,
nausea, vomiting and fever of a few days duration. He has recently returned
from a holiday in the Far East. On examination he is febrile, has icteric
sclera and has tender hepatomegaly.
Answer: i) acute viral hepatitis
Fever, anorexia, nausea and vomiting of a few days
duration should make one suspect an infective aetiology. Travel to the Far
East would add weight to this suspicion. Jaundice would make one suspect that
the liver is the focus of the infection and tender hepatomegaly should make
one suspect inflammation of the liver.
4) A 35-year old male presents with sudden onset of epigastric pain
radiating to the back. The pain is severe and characterized as deep and
boring. Eating food worsens the pain and bending forward relieves the pain. On
examination the patient is febrile he has a tachycardia, and hypotension.
Abdominal examination reveals flank ecchymosis and umbilical ecchymosis. On
palpation there is epigastric tenderness with localized guarding and rebound,
Bowel sounds are sluggish.
Answer: g) acute pancreatitis
The history of abdominal pain following an alcoholic binge should alert one
to the possibility of pancreatitis. The increase in severity of the pain
following food and relief by bending forward is also in favour of this. The
systemic signs would favour this diagnosis. The ecchymoses would suggest
retroperitoneal haemorrhage in association with pancreatitis. The tenderness
in this region would be further evidence in favour of this diagnosis and the
sluggish bowel sounds would suggest associated ileus.
5) A 75-year-old male presents with central abdominal pain radiating
through to his back. On examination he is tachycardic and hypotensive and has
a pulsatile mass in the central abdomen with a systolic bruit audible over it
Answer: c) abdominal aortic aneurysm
In an elderly patient presenting with central abdominal pain radiating to
his back one of the possibilities is an aortic aneurysm. The features of a
pulsatile mass with a systolic bruit over it should make this possibility more
likely.
Revision Tip
Abdominal pain is an important symptom and one should
learn how to analyse it. The first step is to know the causes of abdominal
pain.
First read chapter 3 of ACES
for PACES and learn about the components of diagnosis and the
checklists that one may use to work out the components of diagnosis.
Use this to work out the causes of abdominal pain.
Use the lists on pages
286-287, 289 and 326 of ACES for PACES to guide you further
