Abdominal Pain

Abdominal pain is one of the most common reasons for referral to medical and surgical teams in the NHS.
Some causes are benign, while others are time-critical and life-threatening.

This guide focuses on how doctors should think clinically when assessing abdominal pain on the ward and on-call.

What does this topic cover?

This is not a list to memorise.
It is a framework for thinking safely and logically when reviewing a patient with abdominal pain.

The key question is always:

Is this patient sick?
And could this be surgical?

How does abdominal pain present?

Patients may describe:

  • Localised pain (e.g. RUQ, epigastric, RIF)
  • Generalised abdominal pain
  • Colicky pain
  • Constant severe pain
  • Pain radiating to back or shoulder
  • Pain associated with vomiting or diarrhoea

Associated symptoms matter:

  • Fever
  • Vomiting
  • Constipation or diarrhoea
  • Jaundice
  • GI bleeding
  • Weight loss
  • Urinary symptoms

The story often gives you the diagnosis before the bloods do.

First priority = assess stability

Before thinking about diagnoses, always assess:

  • NEWS score
  • BP and heart rate
  • Oxygen saturations
  • Temperature
  • Mental state
  • Urine output

Red flags:

  • Hypotension
  • Tachycardia
  • Confusion
  • Guarding / rigidity
  • Severe uncontrolled pain
  • Rising lactate

These patients need urgent senior review.

Think anatomically (simple and practical)

This makes abdominal pain much easier to approach.

Epigastric pain:

  • Acute pancreatitis
  • Gastritis / peptic ulcer disease
  • Upper GI bleed
  • Biliary colic
  • Myocardial infarction (always consider)

Right upper quadrant (RUQ):

  • Gallstones / biliary colic
  • Cholecystitis
  • Cholangitis
  • Hepatitis
  • Liver congestion

Right lower quadrant (RIF):

  • Appendicitis
  • Crohn’s flare
  • Constipation
  • Ovarian pathology (in women)

Left lower quadrant (LIF):

  • Diverticulitis
  • Constipation
  • Colitis

Generalised abdominal pain:

  • Gastroenteritis
  • Peritonitis
  • Bowel obstruction
  • Ischaemic bowel
  • DKA
  • Sepsis

On the ward, always ask

Could this be surgical?

Because missing a surgical abdomen is one of the biggest on-call risks.

Always consider surgical causes if there is:

  • Severe pain
  • Guarding or rigidity
  • Rebound tenderness
  • Persistent vomiting
  • No bowel movements + distension
  • Haemodynamic instability

If unsure → discuss early with seniors or surgical team.

Immediate assessment on the ward (what juniors should actually do)

When reviewing a patient with abdominal pain:

Do early:

  • Full A–E assessment
  • Examine the abdomen properly
  • Check bowel movements
  • Check urine output
  • Bloods: FBC, U&E, LFTs, CRP, amylase
  • VBG/ABG + lactate if unwell
  • Urinalysis
  • Pregnancy test in women of childbearing age

Practical steps:

  • Analgesia (do not withhold while assessing)
  • Antiemetics if needed
  • IV fluids if dehydrated
  • Keep NBM if surgical cause possible

Imaging (real-world approach)

  • Ultrasound → gallstones, biliary pathology, ascites
  • CT abdomen → obstruction, perforation, severe inflammation
  • AXR → limited value but may help in obstruction

Don’t order scans blindly — use clinical suspicion.

When to escalate

Escalate urgently if:

  • Severe pain not controlled
  • Guarding or peritonism
  • Hypotension
  • Tachycardia
  • Rising lactate
  • AKI
  • NEWS ≥5
  • Concerned nursing staff

These patients often need:

  • Senior review
  • Surgical input
  • Urgent imaging
  • HDU/ICU if unstable

Common mistakes juniors make

  • Focusing only on blood results
  • Ignoring a concerning abdominal exam
  • Delaying escalation while waiting for scans
  • Underestimating persistent pain
  • Forgetting pregnancy test
  • Forgetting that MI can present as epigastric pain

Take-home concept

Abdominal pain is not about memorising differentials.
It is about assessing severity, thinking anatomically, recognising red flags, and escalating early when concerned.