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Acute abdominal pain

Acute abdominal pain is one of the commonest presentations encountered by both primary and emergency care physicians.1Stone R. Acute abdominal pain. Lippincotts Prim Care Pract. 1998;2(4):341-57.  2Cartwright SL Knudson MP. Evaluation of acute abdominal pain in adults.Am Fam Physician. 2008;77(7):971-8.   The condition is marked by sudden onset of pain that lasts for less than 24 hours in contrast to chronic cases wherein a long-standing intermittent or continuous pain is observed.3Abdullah M Firmansyah MA. Diagnostic approach and management of acute abdominal pain. Acta Med Indones. 2012 Oct;44(4):344-50.  4American Academy of Pediatrics Subcommittee on Chronic Abdominal Pain; North American Society for Pediatric Gastroenterology Hepatologyand Nutrition. Chronic abdominal pain in children. Pediatrics.2005;115(3):e370-81.   This nociceptive abdominal response can be seen in all age groups; however the severity of pain may vary in individual patients. While in some patients the pain can be benign and has a self-limiting course; in other cases it might be indicative of some underlying life-threatening condition necessitating appropriate emergency intervention and specialist care.5Ragsdale L Southerland L. Acute abdominal pain in the older adult. Emerg Med Clin North Am. 2011 May;29(2):429-48 x.  6Balachandran B Singhi S Lal S. Emergency management of acute abdomen in children. Indian J Pediatr. 2013;80(3):226-34.   7Murata A Okamoto K Mayumi T et al. Age-related differences in outcomes and etiologies of acute abdominal pain based on a nationaladministrative database. Tohoku J Exp Med. 2014;233(1):9-15.  8Cartwright SL Knudson MP. Diagnostic imaging of acute abdominal pain in adults. Am Fam Physician. 2015;91(7):452-9.  9Ditkofsky NG Singh A Avery L et al. The role of emergency MRI in the setting of acute abdominal pain. Emerg Radiol. 2014;21(6):61524.  10Falch C Vicente D Häberle H et al. Treatment of acute abdominal pain in the emergency room: a systematic review of the literature. Eur J Pain.2014;18(7):902-13.   The former – primary care – application however seems to reflect the majority of healthcare burden of abdominal pain given that most cases are benign and taken care of by the general practitioners.11Brekke M Eilertsen RK. Acute abdominal pain in general practice: tentative diagnoses and handling. A descriptive study. Scand J Prim Health Care.2009;27(3):137-40.  

Underlying causes of acute abdominal pain

Acute abdominal pain generally has a confusing differential diagnosis as it can originate from multiple organ systems – gastrointestinal gynecological urological vascular and musculoskeletal system – in the abdomen.12Brekke M Eilertsen RK. Acute abdominal pain in general practice: tentative diagnoses and handling. A descriptive study. Scand J Prim Health Care.2009;27(3):137-40.  13Cole E Lynch A Cugnoni H. Assessment of the patient with acute abdominal pain. Nurs Stand. 2006;20(39):67-75.  14Del Arco Galan C Parra Gordo ML Garcia-Casasola Sanchez G. Imaging tests in acute abdominal pain. Rev Clin Esp. 2008;208(10):520-4.   As such the exact cause of abdominal pain may sometimes be hard to delineate. This dilemma posed by such multitudinal pathophysiology underlying the disorder is further compounded by the variable intensity and nature of pain among different patients. Nevertheless the etiological spectrum of ‘acute abdominal pain’ can broadly encompass acute surgical causes intra- and extra-abdominal disorders systemic illnesses and more commonly functional abdominal pain. A diverse range of specific causes of acute abdominal pain have also been explored including acute appendicitis cholecystitis intestinal infection biliary colic acute diverticulitis bowel obstruction visceral perforation peptic ulcer disease pancreatitis peritonitis and renal colic.3Abdullah M Firmansyah MA. Diagnostic approach and management of acute abdominal pain. Acta Med Indones. 2012 Oct;44(4):344-50.  7Murata A Okamoto K Mayumi T et al. Age-related differences in outcomes and etiologies of acute abdominal pain based on a national administrative database. Tohoku J Exp Med. 2014;233(1):9-15.  15Agboola JO Olatoke SA Rahman GA. Pattern and presentation of acute abdomen in a Nigerian teaching hospital. Nigerian Medical Journal:Journal of the Nigeria Medical Association. 2014;55(3):266-270.   16Yang W-C Chen C-Y Wu H-P. Etiology of non-traumatic acute abdomen in pediatric emergency departments. World Journal of Clinical Cases : WJCC.2013;1(9):276-284.   17Boyd CA Riall TS. Unexpected Gynecological Findings during Abdominal Surgery. Current Problems in Surgery. 2012;49(4):195-251.   18Leung AK Sigalet DL. Acute abdominal pain in children. Am Fam Physician.2003;67(11):2321-6.   While some of these cited conditions may require treatment within 24 hour (urgent) many others are non-urgent requiring a less stringent course of action. Often the most common non-urgent diagnosis of acute abdominal pain made by general practitioners is non-specific abdominal pain labeled in up to one-fifth of patients (Figure 1).2Cartwright SL Knudson MP. Evaluation of acute abdominal pain in adults.Am Fam Physician. 2008;77(7):971-8.  11Brekke M Eilertsen RK. Acute abdominal pain in general practice: tentative diagnoses and handling. A descriptive study. Scand J Prim Health Care.2009;27(3):137-40.  

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Diagnosis of acute abdominal pain

Given the wide spectrum of underlying etiologies and differential diagnoses for acute abdominal pain it may seem rational not to find a uniform approach of diagnosis. Accordingly wide variations can be seen across diagnostic practices in different clinics which most often seem to be influenced by the clinical course of pain in individual patients and physicians’ approach towards it. As the initial constellation of complaints portrayed by patients can be highly non-specific there is difficulty in accurately identifying the underlying cause. Regardless it is repeatedly mentioned that an apposite approach to the diagnosis of acute abdominal pain should initiate with the clinical history and appropriate physical examination driven mainly by the pain location.

Typically a thorough pain related history should therefore be sought which includes information on the location character onset and intensity of pain. In first instance the site and character of pain can be predictive

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of the cause of acute abdomen (Table 1). Neverthelessfew additional and simple questions like where else the patients feel pain what makes the pain worse or better if it has changed over time and how and whether they have ever had it before may also be of help in narrowing down the possible etiology in individual case.3Abdullah M Firmansyah MA. Diagnostic approach and management of acute abdominal pain. Acta Med Indones. 2012 Oct;44(4):344-50.  19Macaluso CR McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. Int J Gen Med. 2012;5:789-797.   Subsequentlythe physical examination should consider both the common and more serious conditions of abdominal pain to facilitate clinical decisions according to the urgent and non-urgent need of the findings.20Kim JS. Acute Abdominal Pain in Children. Pediatric GastroenterologyHepatology & Nutrition. 2013;16(4):219-224.    21Gans SL Pols MA Stoker J et al; expert steering group. Guideline for the diagnostic pathway in patients with acute abdominal pain. Dig Surg.2015;32(1):23-31.    22Flasar MH Goldberg E. Acute abdominal pain. Med Clin North Am.2006;90(3):481-503.    23Moll van Charante E de Jongh TO. Physical examination of patients with acute abdominal pain. Ned Tijdschr Geneeskd. 2011;155:A2658.  

Laboratory testing such as C-reactive protein (CRP) and imaging methods may also be required in select cases to accurately establish the cause predicted by history and examination.24Mahler CW Boermeester MA Stoker J et al. Diagnostic modalities in diagnosis of adult patients with acute abdominal pain. Ned Tijdschr Geneeskd. 2004;148(50):2474-80.   Imaging is often infrequently required in primary care unless the work-up remains inconclusive for exact cause of pain or there is possibility of some serious pathology which might require urgent triage and intervention. The choice of imaging modality – ultrasonography radiography computed tomography and magnetic resonance imaging – is again mostly based on the location of the pain and the suspected pathology.3Abdullah M Firmansyah MA. Diagnostic approach and management of acute abdominal pain. Acta Med Indones. 2012 Oct;44(4):344-50.  8Cartwright SL Knudson MP. Diagnostic imaging of acute abdominal pain in adults. Am Fam Physician. 2015;91(7):452-9.  9Ditkofsky NG Singh A Avery L et al. The role of emergency MRI in the setting of acute abdominal pain. Emerg Radiol. 2014;21(6):61524.  

Management of acute abdominal pain

Similar to the diagnostic approach the definite treatment of acute abdominal pain also varies in accordance with the underlying cause and specific needs related to it. Nevertheless a uniform approach should equate whether the condition requires urgent intervention or not which again would be dependent on the organ system and the specialty involved. As many cases of acute abdominal pain might be non-urgent requiring no immediate intervention they may be treated conservatively in the primary care itself without any pressure of time.25Trentzsch H Werner J Jauch KW. Acute abdominal pain in the emergency department – a clinical algorithm for adult patients. Zentralbl Chir.2011;136(2):118-28.   Regardless one factor that remains consistently important across all settings and could influence subsequent course of clinical decisions is the need for effective analgesia to alleviate the symptom burden and elicit desired patients’ response. Most of the initial strategy is hence directed at successful alleviation of the pain. However it is important to consider that such a move does not challenge the underlying diagnosis/etiology of the pain.

Controversy of pre-diagnostic analgesia

As mentioned above pain therapy is invariably required in cases of acute abdominal pain; however using it prior to the definite diagnosis has remained contentious because of fear of affecting the underlying etiology/diagnosis.10Falch C Vicente D Häberle H et al. Treatment of acute abdominal pain in the emergency room: a systematic review of the literature. Eur J Pain.2014;18(7):902-13.   Many clinicians often delay the administration of opiate analgesics in emergency to prevent masking of the symptoms because it is considered that use of opiates can result in unwarranted influence on the reliability of physical examination by obscuring the symptoms and thus negatively affecting treatment decisions. The latter outcome is indeed undesirable especially given the possibility of missing an urgent diagnosis which might require urgent intervention to avoid complications.21Gans SL Pols MA Stoker J et al; expert steering group. Guideline for the diagnostic pathway in patients with acute abdominal pain. Dig Surg.2015;32(1):23-31.   26Ranji SR Goldman LE Simel DL et al. Do opiates affect the clinical evaluation of patients with acute abdominal pain? JAMA. 2006;296(14):1764-74.   27D’Ambrogio A Peloponissios N Blanc C et al. Does early analgesia interfere with diagnostic process in acute abdominal pain syndrome? Rev Med Suisse. 2006;2(70):1593-6.   Nevertheless uniformly following this concern in all cases and thus delaying analgesia also seems not rational since pain can be debilitating. As well there may be few other confounders such as concerns over analgesics’ side effects and lower physicians’ rating of pain in some cases which may add to inadequate or delayed pain therapy in patients.10Falch C Vicente D Haberle H et al. Treatment of acute abdominal pain in the emergency room: a systematic review of the literature. Eur J Pain.2014;18(7):902-13.   28Stork B Hofmann-Kiefer K. Analgesia as an important component of emergency care. Anaesthesist. 2009;58(6):639-48;quiz 649-50.   29   30Marinsek M Kovacic D Versnik D et al. Analgesic treatment and predictors of satisfaction with analgesia in patients with acute undifferentiated abdominal pain. Eur J Pain. 2007;11(7):773-8.   Anti-cholinergic drugs also often mask the physical symptoms of “acute abdomen” and have several associated side-effects thus interfering with the clinical decision making and outcomes. Overall the viewpoints thus clearly suggest the need to have drugs which provide effective analgesia while not affecting the clinical diagnosis.

Use of anti-inflammatory and antispasmodics in acute abdominal pain

Pre-diagnostic administration of analgesia could be appropriate in many cases of acute abdominal pain regardless of the etiology.31Schreyer N D’Ambrogio A Demartines N. Acute abdominal pain: what about analgesia. Rev Med Suisse. 2007;3(117):1647-50.   It is though prudent to select an analgesic that does not influence the underlying diagnoses. Drotaverine is one such agent that provides effective pain control in abdominal pain originating from different organ systems without masking the symptoms. Such a use of drotaverine is consistent with the objectives of spasmolytic treatment for acute abdominal pain that is (i) symptomatic treatment of spasm without being involved in disease pathogenesis; (ii) and spasmolytic drug may serve as part of causal therapy if spasm is the leading symptom/cause of an underlying disorder. Drotaverine may therefore be considered for use in most cases of acute abdominal pain without finalized diagnosis in favor of its property of not interfering with the association of correct diagnosis. In fact drotaverine has several favorable features which make it a preferred antispasmodic in acute abdominal pain (Box 1).32Blasko G. Pharmacology mechanism of action and clinical significance of a convenient antispasmodic agent-drotaverine. JAMA India-The physician update.1998;1(6):63-69.  

Use of drotaverine has powerful spasmolytic action on smooth muscle cells and it thus effectively relieves smooth muscle spasm of various organs. The effect has been evaluated in a variety of indications with smooth muscle spasm including suspected biliary intestinal and renal colic dysmenorrhea and prior to instrumental investigative procedures. Moreover the drug is welltolerated with no major side effects. These positive effects of drotaverine have been confirmed for over 35 years by its use in clinical studies on more than 10000 patients.33Rai RR Dwivedi M Kumar N. Efficacy and safety of drotaverine hydrochloride in irritable bowel syndrome: a randomized double-blind placebo-controlled study. Saudi J Gastroenterol. 2014;20(6):378-82.   34Romics I Molnár DL Timberg G et al. The effect of drotaverine hydrochloride in acute colicky pain caused by renal and ureteric stones.BJU Int. 2003;92(1):92-6.

The mechanism of action of drotaverine involves a selective inhibitory action on phosphodiesterase IV (PDE-IV) enzyme which per se seems functionally important in influencing the contractile activity of the smooth muscles. In addition it has mild Ca-channel blocking effect.35Aggarwal V. Drotaverine for recurrent abdominal pain in children. Indian Pediatr 2015;52:843-844   To potentiate the analgesic effectdrotaverine can also be used in combination with other analgesics like aceclofenac or mefenamic acid which have complimentary mechanisms of action.34Romics I Molnár DL Timberg G et al. The effect of drotaverine hydrochloride in acute colicky pain caused by renal and ureteric stones.BJU Int. 2003;92(1):92-6.   36Pareek A Chandurkar NB Patil RT et al. Efficacy and safety of aceclofenac and drotaverine fixed-dose combination in the treatment of primary dysmenorrhoea: a double-blind doubledummy randomized comparative study with aceclofenac. Eur J Obstet Gynecol Reprod Biol. 2010;152(1):86-90.   37Sharma JB Agarwal M Karmakar D et al. Evaluation of an effective and cheap analgesic protocol prior to intrauterine device insertion in a developing country. Int J Reprod Contracept Obstet Gynecol. 2015;4(4):1061-1065.   Such combinations provide a synergistic effect and could therefore prove highly effective in relieving acute spasmodic pain through their actions on several pain components including those related to spasm and where several inflammatory mediators are involved.38Ortiz MI Molina MAR Arai YCP et al. Analgesic drugs combinations in the treatment of different types of pain. Pain Research and Treatment 2012;Article ID 612519:2 pages.  

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Similar to drotaverine paracetamol also does not interfere with the correct diagnosis and can be combined to drotaverine if required.39Mousavi SM Paydar S Tahmasebi S et al. The effects of intravenous acetaminophen on pain and clinical findings of patients with acute appendicitis; a randomized clinical trial. Bulletin Of Emergency And Trauma 2016;2:22-26.   40Mahaparale S Telekone RS Raut RP et al. Simultaneous spectrophotometric determination of drotaverine hydrochloride and paracetamol in tablet.Indian J Pharm Sci. 2010;72(1):133-136.   Early administration of paracetamol in patients with acute abdominal pain of non-traumatic origin was found to provide effective analgesia; as well it did not interfere with diagnosis. In fact diagnostic accuracy of paracetamol was found to be equivalent to that of placebo.41Oguzturk H Ozgur D Turtay MG et al. Tramadol or paracetamol do not effect the diagnostic accuracy of acute abdominal pain with significant pain relief – a prospective randomized placebo controlled double blind study. Eur Rev Med Pharmacol Sci. 2012;16(14):1983-8.   Therefore similar to the drotaverine paracetamol may also be considered an agent of choice for acute mild to moderate undifferentiated abdominal pain.42Remington-Hobbs J Petts G Harris T. Emergency department management of undifferentiated abdominal pain with hyoscine butylbromide and paracetamol: a randomised control trial. Emerg Med J 2012;29:989-994.  

Conclusion

Acute abdominal pain is a frequent complaint encountered in primary care and emergency settings. The characteristics of pain are however often non-specific resulting in a broad and confusing differential diagnosis. A detailed clinical history and physical examination findings may help in making a diagnosis which could be supported by relevant investigations and imaging if required. Regardless prompt alleviation of pain is the main concern in most such cases during the initial management. The use of analgesics such as drotaverine and paracetamol appears advisable in such instances as they do not interfere with the association of underlying diagnosis. These drugs are effective in alleviating the pain and are well-tolerated. More importantly they can be given in almost all cases of acute abdominal pain without waiting for a final diagnosis. Furthermore drotaverine is also available in combination with aceclofenac mefenamic acid and paracetamol rendering highly effective combinations for patients with acute abdominal pain.

References

  1. Stone R. Acute abdominal pain. Lippincotts Prim Care Pract. 1998;2(4):341-57.
  2. Cartwright SL Knudson MP. Evaluation of acute abdominal pain in adults.Am Fam Physician. 2008;77(7):971-8.
  3. Abdullah M Firmansyah MA. Diagnostic approach and management of acute abdominal pain. Acta Med Indones. 2012 Oct;44(4):344-50.
  4. American Academy of Pediatrics Subcommittee on Chronic Abdominal Pain; North American Society for Pediatric Gastroenterology Hepatologyand Nutrition. Chronic abdominal pain in children. Pediatrics.2005;115(3):e370-81.
  5. Ragsdale L Southerland L. Acute abdominal pain in the older adult. Emerg Med Clin North Am. 2011 May;29(2):429-48 x.
  6. Balachandran B Singhi S Lal S. Emergency management of acute abdomen in children. Indian J Pediatr. 2013;80(3):226-34.
  7. Murata A Okamoto K Mayumi T et al. Age-related differences in outcomes and etiologies of acute abdominal pain based on a national administrative database. Tohoku J Exp Med. 2014;233(1):9-15.
  8. Cartwright SL Knudson MP. Diagnostic imaging of acute abdominal pain in adults. Am Fam Physician. 2015;91(7):452-9.
  9. Ditkofsky NG Singh A Avery L et al. The role of emergency MRI in the setting of acute abdominal pain. Emerg Radiol. 2014;21(6):61524.
  10. Falch C Vicente D Haberle H et al. Treatment of acute abdominal pain in the emergency room: a systematic review of the literature. Eur J Pain.2014;18(7):902-13.
  11. Brekke M Eilertsen RK. Acute abdominal pain in general practice: tentative diagnoses and handling. A descriptive study. Scand J Prim Health Care.2009;27(3):137-40.
  12. Flasar MH Cross R Goldberg E. Acute abdominal pain. Prim Care. 2006 Sep;33(3):659-84 vi.
  13. Cole E Lynch A Cugnoni H. Assessment of the patient with acute abdominal pain. Nurs Stand. 2006;20(39):67-75.
  14. Del Arco Galan C Parra Gordo ML Garcia-Casasola Sanchez G. Imaging tests in acute abdominal pain. Rev Clin Esp. 2008;208(10):520-4.
  15. Agboola JO Olatoke SA Rahman GA. Pattern and presentation of acute abdomen in a Nigerian teaching hospital. Nigerian Medical Journal:Journal of the Nigeria Medical Association. 2014;55(3):266-270.
  16. Yang W-C Chen C-Y Wu H-P. Etiology of non-traumatic acute abdomen in pediatric emergency departments. World Journal of Clinical Cases : WJCC.2013;1(9):276-284.
  17. Boyd CA Riall TS. Unexpected Gynecological Findings during Abdominal Surgery. Current Problems in Surgery. 2012;49(4):195-251.
  18. Leung AK Sigalet DL. Acute abdominal pain in children. Am Fam Physician.2003;67(11):2321-6.
  19. Macaluso CR McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. Int J Gen Med. 2012; 5:789-797.
  20. Kim JS. Acute Abdominal Pain in Children. Pediatric GastroenterologyHepatology & Nutrition. 2013;16(4):219-224.
  21. Gans SL Pols MA Stoker J et al; expert steering group. Guideline for the diagnostic pathway in patients with acute abdominal pain. Dig Surg.2015;32(1):23-31.
  22. Flasar MH Goldberg E. Acute abdominal pain. Med Clin North Am.2006;90(3):481-503.
  23. Moll van Charante E de Jongh TO. Physical examination of patients with acute abdominal pain. Ned Tijdschr Geneeskd. 2011;155:A2658.
  24. Mahler CW Boermeester MA Stoker J et al. Diagnostic modalities in diagnosis of adult patients with acute abdominal pain. Ned Tijdschr Geneeskd. 2004;148(50):2474-80.
  25. Trentzsch H Werner J Jauch KW. Acute abdominal pain in the emergency department – a clinical algorithm for adult patients. Zentralbl Chir.2011;136(2):118-28.
  26. Ranji SR Goldman LE Simel DL et al. Do opiates affect the clinical evaluation of patients with acute abdominal pain? JAMA. 2006;296(14):1764-74.
  27. D’Ambrogio A Peloponissios N Blanc C et al. Does early analgesia interfere with diagnostic process in acute abdominal pain syndrome? Rev Med Suisse. 2006;2(70):1593-6.
  28. Stork B Hofmann-Kiefer K. Analgesia as an important component of emergency care. Anaesthesist. 2009;58(6):639-48;quiz 649-50.
  29. Mills AM Shofer FS Chen EH et al. The association between emergency department crowding and analgesia administration in acute abdominal pain patients. Acad Emerg Med. 2009;16(7):603-8.
  30. Marinsek M Kovacic D Versnik D et al. Analgesic treatment and predictors of satisfaction with analgesia in patients with acute undifferentiated abdominal pain. Eur J Pain. 2007;11(7):773-8.
  31. Schreyer N D’Ambrogio A Demartines N. Acute abdominal pain: what about analgesia. Rev Med Suisse. 2007;3(117):1647-50.
  32. Blasko G. Pharmacology mechanism of action and clinical significance of a convenient antispasmodic agent-drotaverine. JAMA India-The physician update.1998;1(6):63-69.
  33. Rai RR Dwivedi M Kumar N. Efficacy and safety of drotaverine hydrochloride in irritable bowel syndrome: a randomized double-blind placebo-controlled study. Saudi J Gastroenterol. 2014;20(6):378-82.
  34. Romics I Molnár DL Timberg G et al. The effect of drotaverine hydrochloride in acute colicky pain caused by renal and ureteric stones.BJU Int. 2003;92(1):92-6.
  35. Aggarwal V. Drotaverine for recurrent abdominal pain in children. Indian Pediatr 2015;52:843-844
  36. Pareek A Chandurkar NB Patil RT et al. Efficacy and safety of aceclofenac and drotaverine fixed-dose combination in the treatment of primary dysmenorrhoea: a double-blind doubledummy randomized comparative study with aceclofenac. Eur J Obstet Gynecol Reprod Biol. 2010;152(1):86-90.
  37. Sharma JB Agarwal M Karmakar D et al. Evaluation of an effective and cheap analgesic protocol prior to intrauterine device insertion in a developing country. Int J Reprod Contracept Obstet Gynecol. 2015;4(4):1061-1065.
  38. Ortiz MI Molina MAR Arai YCP et al. Analgesic drugs combinations in the treatment of different types of pain. Pain Research and Treatment 2012;Article ID 612519:2 pages.
  39. Mousavi SM Paydar S Tahmasebi S et al. The effects of intravenous acetaminophen on pain and clinical findings of patients with acute appendicitis; a randomized clinical trial. Bulletin Of Emergency And Trauma 2016;2:22-26.
  40. Mahaparale S Telekone RS Raut RP et al. Simultaneous spectrophotometric determination of drotaverine hydrochloride and paracetamol in tablet.Indian J Pharm Sci. 2010;72(1):133-136.
  41. Oguzturk H Ozgur D Turtay MG et al. Tramadol or paracetamol do not effect the diagnostic accuracy of acute abdominal pain with significant pain relief – a prospective randomized placebo controlled double blind study. Eur Rev Med Pharmacol Sci. 2012;16(14):1983-8.
  42. Remington-Hobbs J Petts G Harris T. Emergency department management of undifferentiated abdominal pain with hyoscine butylbromide and paracetamol: a randomised control trial. Emerg Med J 2012;29:989-994.
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