Overview
Learning Objectives
By the end of this module you should be able to:
- Understand the epidemiology of abdominal pain in the UK ED
- Apply a structured, senior-level approach to the acute abdomen
- Classify pain by type (visceral, somatic, referred) and by anatomical region
- Recognise the five BIOPI categories of surgical emergency
- Identify never-miss diagnoses and dangerous diagnostic mimics
- Apply condition-specific management aligned to RCEM, NICE, and NHS England pathways
- Manage special populations: elderly, pregnant, immunocompromised
- Dispose patients safely and document to medico-legal standard
Guidance referenced RCEM
Section 1
Epidemiology
Who is the Patient? What Is the Risk?
5–10% of all UK ED presentations involve abdominal pain
- 14–40% ultimately require surgical intervention
- Most common final diagnosis: non-specific abdominal pain (NSAP) — 41–46%
- Misdiagnosis in elderly carries significantly higher mortality. Exact figures vary by source.
Approximate cause frequency (Brewer et al.; US dataset)
- NSAP 41–46% | Appendicitis 4–24% | Cholecystitis 2.5–9%
- Gastroenteritis 7% | UTI 3–5% | SBO 2.5–4% | Renal colic 1.5–4%
- Pancreatitis 1–2% | Diverticulitis 1–2% | AAA / Ectopic <1%
Clinical challenge
- 1 in 3 patients present atypically — this is the default, not the exception
- Scope includes surgical, vascular, gynaecological, retroperitoneal, and medical causes
Elderly (>65)
- Attenuated pain response, absent fever in sepsis, absent peritonism in perforation
- 2× more likely to require surgery — lowest threshold for CT and admission
Women of childbearing age
- Beta-hCG strongly recommended in every case — missed ectopic is a leading cause of maternal death (MBRRACE)
Immunocompromised
- HIV, solid organ transplant, haematological malignancy, anti-TNF / rituximab therapy
- Peritonism and fever may both be absent — rely on CT, not examination alone
Post-operative patients
- Adhesions dominate — risk of SBO, anastomotic leak, abdominal collection
Pregnancy
- Any trimester: pain anatomy distorted, USS / MRI preferred over CT in first trimester
Guidance referenced MBRRACE-UK
Section 2
Structured ED Assessment
The Acute Abdomen: Think Before You Scan
Definition: Sudden, severe abdominal pain requiring urgent ED evaluation
- Mortality rises with delay — identify haemodynamic compromise first, history second
Immediate resuscitation priorities
- ABCDE. Two large-bore IV cannulae. Bloods and IV fluids if shocked.
- Permissive hypotension in suspected vascular catastrophe (target SBP 70–80 until surgical haemostasis)
Ask five diagnostic questions (Sarikaya framework)
- WHO is this patient? (age, sex, PMH, medications, surgical history)
- WHAT are the probable diagnoses?
- WHY do you think that? (clinical reasoning)
- HOW do you prove it? (investigations)
- WHEN to call the surgeon?
SOCRATES
- Site — location at onset and now
- Onset — sudden (vascular) vs gradual (inflammatory)
- Character — colicky, constant, burning, tearing
- Radiation — back (AAA/pancreatitis), shoulder tip (diaphragmatic)
- Associated symptoms — nausea, vomiting, fever, PR bleed
- Timing — worse since onset = bad sign
- Exacerbating / relieving factors
- Severity — 0–10, change over time
Contextual history
- PMH: prior episodes, DM, AF, vascular disease, IBD, malignancy
- Surgical history: adhesions, hernias, stomas, prior aortic surgery
- Medications: NSAIDs, anticoagulants, steroids, immunosuppressants
- GYN/URO: LMP, PV bleeding/discharge, prior ectopic, IUD
- Social: alcohol, IV drug use, home situation, recent travel
Key timing questions
- Vomiting before or after pain? (SBO vs appendicitis vs Boerhaave)
- Change in bowel habit? Last flatus?
General
- Vital signs, GCS, perfusion, hydration
- Patient position: writhing (colic) vs still (peritonitis)
Inspection
- Distension, scars, hernial orifices (groin, umbilicus, incisions)
- Cullen’s / Grey Turner’s sign (retroperitoneal bleed — late)
Palpation
- Localise tenderness, masses, pulsatile AAA
- Peritonism: guarding, rigidity, rebound
- McBurney’s point, Murphy’s sign
- Psoas sign (retroperitoneal irritation)
Auscultation
- Tinkling (obstruction) vs silence (ileus/peritonitis)
Extra-abdominal exam — never omit
- Chest: bases (basal pneumonia mimics acute abdomen)
- Heart: new murmur, AF (SMA embolism risk)
- Groin: femoral hernia (missed strangulation)
- Genitalia / scrotal exam where indicated
Rectal examination
- Perform when clinically indicated: PR bleeding, melaena, pelvic mass, prostatic pathology
Vaginal examination
- Perform when clinically indicated and with consent: cervical excitation (PID/ectopic), adnexal mass, PV discharge
Section 3
Understanding Abdominal Pain
Visceral · Somatic · Referred
Visceral pain
- Poorly localised, midline, cramping or aching — organ distension, ischaemia, spasm
- Mediated via sympathetic fibres — bilges towards the corresponding spinal level
Somatic (parietal) pain
- Well-localised, sharp, exacerbated by movement — parietal peritoneum irritation
- Guarding and rigidity are somatic responses — serious sign
Referred pain
- Diaphragmatic irritation → shoulder tip (C3–5)
- Renal/ureteric pain → groin / anterior thigh
- Biliary pain → right scapula (T6–8)
Spinal level reference
- C3–5: liver, spleen, diaphragm | T5–9: stomach, gallbladder, pancreas
- T8–T10: small bowel | T10–L1: colon, kidney | S2–4: bladder, rectum
RUQ
- Cholecystitis / biliary colic, cholangitis, hepatitis / hepatic abscess, pancreatitis
- Renal colic (right), peptic ulcer disease, right basal pneumonia, PE / inferior MI
LUQ
- Gastritis / gastric ulcer, splenic pathology (rupture, infarct), pancreatitis (tail)
- Renal colic (left), left basal pneumonia / PE
RLQ
- Appendicitis, ovarian cyst / torsion, ectopic pregnancy, inguinal / femoral hernia
- Renal colic, IBD (Crohn’s), AAA (right extension), caecal volvulus / tumour
LLQ
- Diverticulitis, sigmoid volvulus / tumour, ovarian cyst / torsion, ectopic pregnancy
- Inguinal hernia, IBD (UC), AAA (left extension)
Epigastric
- Peptic ulcer / GORD, pancreatitis, perforated viscus, biliary disease
- Inferior MI — up to 30% of cases (do ECG first)
- Aortic dissection type A
Central / periumbilical
- Early appendicitis (pre-migration), small bowel obstruction, mesenteric ischaemia
- Aortic aneurysm, hernia (umbilical)
Suprapubic
- UTI / urinary retention, ectopic / pelvic pathology, PID, ovarian cyst / torsion
Diffuse
- Peritonitis (any cause — perforation, pancreatitis, ischaemia)
- IBD — acute severe colitis / toxic megacolon
- Mesenteric ischaemia (late), diabetic ketoacidosis (DKA) / metabolic, sickle cell crisis, adrenal crisis
Section 4
Investigations
Directed, Not Reflexive
Bloods (directed by presentation)
- FBC, U&E, LFT, CRP, amylase/lipase, coagulation, G&S
- Lactate: raised in ischaemia, sepsis, strangulation
- Troponin: if cardiac differential in epigastric pain
- Beta-hCG: recommended in all women of childbearing age
- Cortisol: if adrenal crisis suspected
Urinalysis
- Haematuria: renal colic, urothelial malignancy
- Do not diagnose UTI as cause of abdominal pain without senior review
ECG
- Mandatory in all epigastric and upper abdominal pain
- Right-sided leads (V4R) if inferior MI suspected
Imaging
- Erect CXR: free air (70–80% sensitivity for perforation)
- AXR: limited utility — bowel obstruction, volvulus, calcified AAA
- Bedside USS: AAA (first in any shock + abdominal pain >50)
- Formal USS: gallstones, ovarian pathology, ectopic, hepatic
- CT A/P with IV contrast: workhorse of abdominal emergency imaging
- CT KUB (non-contrast): renal colic — 96% sensitivity
- CT angiography: active GI bleeding, mesenteric ischaemia, EVAR
- MRI: pregnancy (2nd/3rd trimester), biliary (MRCP), spinal cord compression
There are no standard belly labs
- Directed approach only — investigations should answer a specific question
Section 5
The BIOPI Framework
Five Categories of Surgical Urgency
Five Major Categories of the Acute Abdomen
B
Bleeding or rupture of vessels or tumour
- AAA, splenic rupture, ectopic pregnancy, hepatic haematoma, retroperitoneal haemorrhage
- Hallmark: haemodynamic instability, anaemia. Bedside USS first. Activate MTP.
I
Ischaemia or Infarction
- Mesenteric ischaemia, renal infarction, testicular torsion
- Hallmark: pain out of proportion to examination. Lactate raised. CT angiography.
O
Obstruction
- SBO, LBO, sigmoid/caecal volvulus, biliary obstruction, ureteric obstruction
- Hallmark: distension, vomiting (early in SBO), absolute constipation. AXR + CT.
P
Perforation
- Peptic ulcer, appendix, diverticular, Boerhaave syndrome
- Hallmark: sudden onset, peritonism, free air on erect CXR. Urgent surgical referral.
I
Inflammation
- Appendicitis, cholecystitis, pancreatitis, diverticulitis, IBD
- Hallmark: fever, localised tenderness, raised WBC/CRP. CT for diagnosis.
Section 6
Things Never to Mix Up
Dangerous Mimics · Diagnostic Pitfalls
Dangerous Mimics: True Diagnosis vs Initial Misdiagnosis
| True Diagnosis | Commonly Misdiagnosed As |
|---|---|
| Ruptured AAA | Renal colic, lumbar strain, diverticulitis |
| Mesenteric ischaemia | Gastroenteritis, constipation, ileus, SBO |
| Ectopic pregnancy | PID, UTI, corpus luteum cyst, appendicitis |
| Inferior MI | GORD, epigastric pain, pancreatitis |
| Aortic dissection type A | Epigastric pain, MI, PE |
| Perforated viscus | PUD, pancreatitis, non-specific abdominal pain |
| Strangulated hernia | Ileus, small bowel obstruction |
| Sigmoid/caecal volvulus | Constipation, functional bloating |
| Adrenal crisis | Sepsis, shock of unknown cause |
| Appendicitis (elderly/pregnant) | UTI, gastroenteritis, musculoskeletal |
Never miss
AAA vs Renal Colic
- Both present with flank / back pain radiating to groin — misdiagnosis kills
- AAA: pulsatile mass, haemodynamic instability, collapse, known aneurysm on history
- Renal colic: haematuria, writhing in agitation, colicky, prior episodes, younger age
- Low threshold for bedside AAA ultrasound in all patients >50 with flank, back, or abdominal pain
- Do not assume renal colic in a patient >60 without first excluding AAA
- Patient with ‘renal colic’ who drops BP has an AAA until proved otherwise
- Do NOT send a haemodynamically unstable patient to CT without a surgeon present
- CT confirms AAA diagnosis but never delay surgery for CT in collapse
- Permissive hypotension (SBP 70–80), MTP activation, immediate vascular referral
Never miss
Ectopic Pregnancy vs Appendicitis
- Both: RIF pain, nausea, low-grade fever, raised WBC — clinically indistinguishable at first
- Ectopic rupture causes haemorrhagic shock and death
- RULE: Beta-hCG in every woman of childbearing age with abdominal pain — recommended in all cases.
- Positive beta-hCG + pain + haemodynamic compromise = ruptured ectopic until proved otherwise
- TVS ultrasound: intrauterine pregnancy, free fluid, adnexal mass, empty uterus
- Appendicitis in pregnancy: pain shifts superiorly — USS first, MRI if inconclusive
- MBRRACE UK 2023: missed ectopic remains a leading cause of direct maternal death
Never miss
Mesenteric Ischaemia vs Gastroenteritis
- Classic teaching: pain out of proportion to examination — soft abdomen despite severe pain
- Late disease: peritonism = dead bowel. High mortality if diagnosis delayed.
- Risk profile: age >60, AF, vascular disease, recent aortic intervention, cardiac emboli
- RULE: AF + acute abdominal pain = SMA embolism until proved otherwise
- Do not diagnose gastroenteritis in a patient >60 with vascular risk factors without excluding mesenteric ischaemia
- Lactate: raised but non-specific. CT angiography is diagnostic. Normal lactate does not exclude early mesenteric ischaemia.
- ECG strongly recommended — identify AF as embolic source
- Vascular and surgical emergency. Time is bowel.
Never miss
Inferior MI vs Epigastric / Upper GI Pain
- Inferior MI presents as epigastric pain, nausea, vomiting in up to 30% of cases
- Right ventricular MI: add right-sided leads (V4R) — ST elevation V4R is diagnostic
- Aortic dissection type A also presents with epigastric / chest pain: wide mediastinum on CXR
- RULE: ECG before attributing any epigastric or upper abdominal pain to a GI cause
- Beware the patient who says ‘indigestion’ but looks pale, diaphoretic, and unwell
- GTN, troponin, serial ECGs, cardiology involvement before any upper GI procedure
- Avoid performing OGD or NG tube in undiagnosed MI
Never miss
Sigmoid / Caecal Volvulus vs Constipation
- Sigmoid volvulus: elderly, institutionalised, psychiatric patients on constipating drugs
- AXR: ‘coffee bean’ or ‘omega loop’ sign, apex pointing to RUQ
- Caecal volvulus: younger patients, right-sided distension on AXR
- Both are surgical emergencies — perforation and ischaemia follow delay
- Do not discharge a distended patient with laxatives before obtaining imaging.
- Sigmoid volvulus: flexible sigmoidoscopy / CT-guided decompression first-line if no peritonism
- Caecal volvulus: surgery required in most cases — no endoscopic option
- Involve colorectal surgery before committing to any management plan
Guidance referenced MBRRACE-UK
Section 7
Condition-Based Management
Key Diagnoses · RCEM & NICE Aligned
Clinical features
- Central pain migrating to RIF (McBurney’s point)
- Anorexia, nausea, low-grade pyrexia
- Rovsing’s sign, psoas sign, Dunphy’s sign
- Atypical in elderly, pregnant, immunocompromised
- Alvarado score for risk stratification
- RIF tenderness is the most consistent clinical feature
- Fever is unreliable as a diagnostic feature
ED Management (NICE CKS Appendicitis)
- CT abdomen/pelvis if diagnosis unclear after clinical assessment
- USS first line in children and pregnant women
- NBM, IV fluids, analgesia — do not withhold opioids
- Early surgical referral for Alvarado ≥7
- NICE supports conservative antibiotics in uncomplicated cases
- Admit all with peritonism for operative planning
- Perforation risk increases significantly with delayed diagnosis
Small Bowel Obstruction (SBO)
- Causes: adhesions (65%), hernia, tumour, Crohn’s, gallstone ileus
- Colicky central pain, vomiting early, absolute constipation late
- AXR: central loops >3 cm, ‘stack of coins’ valvulae conniventes
- CT confirms cause, identifies strangulation, closed-loop obstruction
Strangulation = emergency surgery
- Fever + peritonism + raised lactate = ischaemia until proved otherwise
Management
- NG tube (free drainage), IV fluids, catheter, NBM
- Early surgical referral — urgent surgery if strangulation suspected
Large Bowel Obstruction (LBO)
- Causes: colorectal cancer 60%, sigmoid volvulus 20%, diverticular
- Distension dominant, vomiting late, absolute constipation
- AXR: peripheral large bowel >6 cm, caecum >9 cm = impending rupture
Causes
- Perforated peptic ulcer (most common surgical GI emergency)
- Perforated diverticular, appendix, tumour, Boerhaave syndrome
Presentation
- Sudden onset severe pain, rapid generalisation to peritonism
- Rigid ‘board-like’ abdomen — haemodynamic instability = sepsis with peritonitis
Management (NELA/RCS guidelines)
- Resuscitate: IV fluids, IV antibiotics as per local Trust antimicrobial guideline
- NG tube, urinary catheter, NBM, VTE prophylaxis when safe
- Urgent surgical referral — time-critical diagnosis
Diagnosis (NICE NG104)
- Epigastric pain radiating to back, nausea, vomiting, low-grade fever
- Amylase or lipase >3× upper limit of normal
- Causes: gallstones 45%, alcohol 35%, idiopathic, hypercalcaemia, drugs
Management
- IV fluids: aggressive early resuscitation — Hartmann’s preferred (NICE)
- Analgesia: IV opioids first-line, consider PCA
- Encourage oral intake as tolerated
- Do not give prophylactic antibiotics (NICE NG104)
- ERCP within 24–48h if gallstone pancreatitis + cholangitis
Biliary colic
- Episodic RUQ/epigastric pain after fatty meals, no fever, USS: gallstones
- Discharge with analgesia (diclofenac 75 mg IM), elective surgical referral
Acute cholecystitis (Tokyo Guidelines)
- Murphy’s sign positive, fever, raised WBC/CRP, persistent RUQ pain >6h
- IV antibiotics, IV fluids, surgical referral
- Early laparoscopic cholecystectomy within 1 week (NICE CG188)
Ascending cholangitis — LIFE-THREATENING
- Charcot’s Triad: fever + RUQ pain + jaundice
- Reynolds’ Pentad adds confusion + hypotension = septic shock
- Blood cultures, broad-spectrum IV antibiotics, IV fluids, urgent ERCP
- RULE: Ascending cholangitis = life-threatening emergency. Do not discharge.
Risk stratification (NICE CG141)
- Glasgow-Blatchford score (GBS): BUN, Hb, SBP, HR, syncope, melaena
- Pre-endoscopy GBS 0 = offer early discharge with outpatient endoscopy
- HR >100 + SBP <100 = haemodynamically significant bleed
ED Management
- 2 large-bore IV cannulae, FBC, clotting, crossmatch 4 units
- Restrictive transfusion: Hb <70 g/L (or <80 if active cardiac disease)
- Terlipressin 2 mg IV if variceal bleeding suspected
- Offer endoscopy immediately if haemodynamically unstable, within 24h for all others
Causes
- Diverticular disease (most common), angiodysplasia, colorectal cancer, ischaemic colitis, IBD
Key pitfalls
- Avoid attributing PR bleeding to haemorrhoids without excluding colorectal malignancy
- 15% of apparent LGIB is upper GI bleeding — OGD first if source not excluded
- CT angiography for active bleeding localises source for embolisation
Classification
- Irreducible: cannot reduce — contents trapped
- Incarcerated: contents obstructed — emergency
- Strangulated: vascular compromise + ischaemia = surgical emergency
ED decision making
- Tense, tender, erythematous hernia + systemic features = strangulated
- RULE: Do NOT attempt manual reduction of a strangulated hernia
- Femoral hernia: highest strangulation risk — frequently missed
Ectopic Pregnancy
- Positive beta-hCG + pain → transvaginal USS immediately
- Haemodynamic compromise = emergency surgical management
- Anti-D immunoglobulin if Rh-negative
Ovarian Torsion
- Sudden onset severe unilateral lower abdominal pain
- Normal Doppler does NOT exclude torsion
- Gynaecology review urgently — time = ovary
PID
- Bilateral pelvic pain, PV discharge, cervical excitation, fever
- BASHH guidelines: IM ceftriaxone + oral doxycycline + metronidazole 14 days
HELLP Syndrome
- RUQ pain + raised LFT + thrombocytopenia + hypertension
- Variant of severe pre-eclampsia — emergency obstetric involvement
Acute severe UC
- Truelove and Witts: >6 bloody stools/day + systemic upset
- IV hydrocortisone 100 mg QDS. CT to exclude perforation.
- Involve gastroenterology and colorectal surgery from day one
Toxic megacolon
- Transverse colon >6 cm on AXR + systemic toxicity
- Avoid antispasmodics and opioids — worsen distension
- Emergency surgical consultation — high mortality with delay
Abdominal Trauma
- Primary survey first (ATLS). Spleen: most commonly injured solid organ.
- Positive FAST + unstable = emergency laparotomy without CT
Guidance referenced NICE NG104 · NICE CG188 · BSG · BASHH · Tokyo Guidelines · NELA · RCS · ATLS
Section 8
Retroperitoneal Emergencies
High Mortality · Easily Missed · CT is Diagnostic
Key retroperitoneal structures
- Aorta / IVC, kidneys and ureters, adrenal glands
- Pancreas (body/tail), duodenum (2nd–4th parts)
- Ascending and descending colon, sympathetic chains
Clinical significance
- Retroperitoneal bleeding does NOT irritate peritoneum
- Examination frequently normal even in massive haemorrhage
- CT is definitive — bedside USS limited in retroperitoneum
Ruptured AAA
- Classic triad (pain + collapse + pulsatile mass) present in <50%
- Permissive hypotension: target SBP 70–80 until haemostasis
- Crossmatch 10 units RBC + FFP. Activate MTP.
- Immediate vascular surgery referral and theatre activation
Retroperitoneal haematoma
- Causes: pelvic fracture (most common traumatic), aortic rupture, anticoagulants
- Femoral neuropathy: groin + anterior thigh pain, hip flexion weakness
Renal Emergencies
- Renal colic: CT KUB 96% sensitivity. NSAIDs first-line (diclofenac 75 mg IM).
- Admit if: stone >10 mm, single kidney, infection, bilateral obstruction
Urosepsis with obstruction
- Infected hydronephrosis = urological emergency — high mortality without drainage
- Broad-spectrum IV antibiotics immediately + urology for nephrostomy within hours
Adrenal crisis (Addisonian)
- Hypotension + hyponatraemia + hyperkalaemia + hypoglycaemia
- Do NOT wait for cortisol result: hydrocortisone 100 mg IV immediately
Phaeochromocytoma crisis
- Paroxysmal hypertension, headache, diaphoresis, palpitations
- Do NOT give beta-blockers without prior alpha-blockade
Psoas abscess
- Back/flank pain, fever, hip flexion deformity (psoas sign)
- CT-guided or surgical drainage + IV antibiotics. Consider TB.
Necrotising fasciitis (Fournier’s gangrene)
- Perineal NF extending retroperitoneally — crepitus, gas on imaging
- Mortality >30%. Surgical debridement within 6h.
Section 9
Special Populations
Elderly · Pregnant · Immunocompromised
Why the elderly are different
- Attenuated pain response: minimal pain despite perforation, ischaemia, or obstruction
- Peritonism and fever frequently absent even in septic peritonitis
- Polypharmacy: NSAIDs mask pain, anticoagulants increase bleeding, steroids mask signs
High-risk diagnoses
- AAA: first consideration in any >65 with back, flank, or abdominal pain
- Mesenteric ischaemia: AF, post-MI, vascular disease — time is bowel
- Cholecystitis: higher complication rate — empyema, perforation
- Sigmoid volvulus: institutionalised, laxative-dependent patients
ED approach
- Lower threshold for CT. Discuss with seniors early. Err on the side of admission.
- Social history is clinical: who is at home, falls risk, baseline cognition
Establish gestational age and LMP before investigation
Differential by trimester
- First: ectopic pregnancy, miscarriage, corpus luteum cyst, UTI
- Second/third: placental abruption, preterm labour, HELLP syndrome, appendicitis
- Any trimester: ovarian torsion, biliary disease, appendicitis, PE
HELLP Syndrome (obstetric emergency)
- Haemolysis + Elevated LFTs + Low Platelets + hypertension
- Emergency obstetric involvement immediately
Non-negotiable
- Call obstetrics early. Your role is stabilisation and recognition.
- Anti-D immunoglobulin if Rh-negative in any bleeding or abdominal trauma
Who is immunocompromised in the ED?
- HIV/AIDS, solid organ transplant, haematological malignancy, active chemotherapy
- Long-term steroids, anti-TNF, rituximab, JAK inhibitors
Why presentations differ
- Fever may be absent even in severe sepsis
- Peritonism minimal or absent — examination cannot be relied upon
Key diagnoses
- Neutropenic enterocolitis (typhlitis): right-sided pain + fever + diarrhoea
- CMV colitis: bloody diarrhoea in HIV
Approach
- Broad-spectrum IV antibiotics promptly if sepsis suspected
- CT is strongly recommended — do not rely on examination alone
- Involve haematology / oncology / infectious diseases early
Guidance referenced NICE NG253
Section 10
ED Management & Disposition
Algorithms · Decision Points · Safety
Step 1: Immediate
- ABCDE — identify haemodynamic instability before detailed history
- Two IV cannulae, venous bloods, bedside USS in shock, ECG in epigastric pain
- IV access + analgesia (do not withhold opioids) + antiemetics
Step 2: Investigations
- Bloods: FBC, U&E, LFT, CRP, amylase/lipase, coagulation, lactate, G&S, beta-hCG
- Imaging: directed by clinical assessment — USS, CT, erect CXR
Step 3: Diagnosis & risk stratification
- Apply BIOPI framework: which category? Surgical urgency?
- Red flag present? Peritonism, haemodynamic instability, raised lactate
Step 4: Escalation
- Involve surgery, vascular, gynaecology, urology based on diagnosis
- Senior review if uncertain — serial examination and vital signs
Emergency theatre — do not delay
- Haemodynamically unstable: ruptured AAA, ruptured ectopic, dead bowel
- Positive FAST + instability, peritonitis with deterioration
Admission: ward / surgical assessment
- Peritonism, obstruction, pancreatitis, perforated viscus, ascending cholangitis
- Any diagnosis requiring IV antibiotics, fluids, or further investigation
- Uncertain diagnosis in high-risk patient (elderly, immunocompromised, pregnant)
Observation / short-stay
- Serial examination and serial bloods for evolving diagnosis
- Alvarado 4–6, mild pancreatitis stabilising, LGIB that has stopped
Discharge home with abdominal warnings
- Biliary colic, uncomplicated UTI, constipation — only after senior review
- Clear return instructions: specific symptoms, time window, route of return
- Document understanding and agreed return criteria
Section 11
Documentation & Safety Netting
Protect Your Patient. Protect Your Practice.
Every ED abdominal pain note must include
- Documented clinical reasoning: why you reached your working diagnosis
- Relevant negatives: what you considered and excluded
- Investigations: results reviewed, acted upon, and timeframe documented
- Reassessment: time of re-examination and clinical status
- Escalation: who you spoke to, at what time, and what was agreed
- Disposition: explicit rationale for discharge or admission
Safety netting — document explicitly
- What the patient was told to look out for (specify symptoms)
- Patient understood and was able to act on the advice
- Return pathway: which department, by when, under what circumstances
Never write
- ‘Pain not surgical’ without a documented examination and reasoning
- ‘NAD’ without listing what was examined
- ‘Discharged home well’ without documented safety netting
01
5–10% of ED attendances. Time-critical diagnoses kill when missed.
02
Vascular pathology first in every differential — AAA, mesenteric ischaemia, ectopic.
03
BIOPI framework: Bleeding, Ischaemia, Obstruction, Perforation, Inflammation.
04
1 in 3 present atypically — the presentation you expect is the minority.
05
ECG before attributing epigastric pain to any GI cause.
06
Beta-hCG in every woman of childbearing age — recommended in all cases.
07
Retroperitoneal bleeding is invisible on examination — CT is your diagnostic tool.
08
The elderly are different — attenuated signs, highest complication rate.
09
Document reasoning, negatives, safety net. Every encounter. Every time.
10
When in doubt: reassess, re-examine, escalate, and document the conversation.
Clinical Pearl
"The strongest clinicians know when to follow protocol and when to think beyond it."
Dr Joshua Igwe · FRCEM