Abdominal pain is one of the most common presenting complaints in both emergency and elective surgical practice, encompassing a vast spectrum of conditions ranging from benign and self-limiting causes to life-threatening surgical emergencies. It is broadly classified as acute abdominal pain of sudden onset, often requiring urgent assessment or chronic/recurrent abdominal pain, which develops gradually over weeks to months. Pain may originate from intra-abdominal viscera (visceral pain: poorly localised, cramping and midline), from parietal peritoneal irritation (somatic pain: sharp, well-localised and worsened by movement), or may be referred pain perceived at a site distant from the pathology, such as shoulder tip pain from diaphragmatic irritation. The anatomical location of pain provides the critical first clue to the underlying diagnosis and guides the systematic clinical approach.
Symptoms & Localisation
The character and location of pain direct differential diagnosis:
Right upper quadrant: biliary colic, acute cholecystitis, hepatitis, liver abscess
Epigastric: peptic ulcer disease, acute pancreatitis, gastritis, GORD, myocardial infarction
Left upper quadrant: splenic pathology, gastric disease, left lower lobe pneumonia
Periumbilical: early appendicitis, small bowel obstruction, mesenteric ischaemia, aortic aneurysm
Right iliac fossa: acute appendicitis, ovarian pathology, ileocaecal Crohn's disease, renal colic
Left iliac fossa: diverticular disease, colorectal pathology, ovarian cysts, constipation
Suprapubic: urinary retention, cystitis, pelvic inflammatory disease, uterine pathology
Generalised: peritonitis, bowel perforation, intestinal obstruction, ischaemic bowel
Associated features further refine the diagnosis, vomiting preceding pain suggests a medical cause; pain preceding vomiting suggests a surgical one. Fever indicates infection or inflammation. Absolute constipation with distension points to obstruction.
Diagnosis
A thorough history and clinical examination remain the cornerstone of assessment. Investigations are directed by clinical findings: Full blood count, CRP, urea and electrolytes, LFTs, serum amylase and urinalysis are performed in all acute presentations. Erect chest X-ray excludes pneumoperitoneum. Abdominal X-ray identifies obstruction or calcification. Ultrasound is first-line for right upper quadrant pathology, suspected appendicitis in women and gynaecological causes. CT scan of the abdomen and pelvis with contrast is the definitive investigation for undifferentiated acute abdominal pain, providing the highest diagnostic accuracy across the widest range of conditions and guiding urgent surgical decision-making.
Treatment
Management is entirely dictated by the underlying diagnosis. Immediate priorities in acute abdominal pain follow an ABCDE resuscitation approach securing IV access, fluid resuscitation, analgesia, and empirical antibiotics when sepsis is suspected. Surgical intervention is required for perforation, obstruction, ischaemia, appendicitis and cholecystitis. Conservative management with close monitoring is appropriate for pancreatitis, renal colic and uncomplicated diverticulitis. Timely diagnosis and early specialist surgical involvement remain the most critical determinants of outcome in acute abdominal pain.