Abdominal Pain
Abdominal pain is a sensory experience arising from visceral, parietal, or referred stimuli affecting structures within or related to the abdominal cavity, serving as a clinical indicator of a wide range of gastrointestinal, genitourinary, vascular, and systemic disorders.
History Taking: Abdominal Pain (腹痛)
Before you dive into questions, set the scene. Greet the patient, confirm their identity, and gain consent. In an OSCE, a smooth opening buys you rapport marks.
Practical phrasing: "Hello, my name is Dr ___. Can I confirm your name and date of birth? I understand you're having some tummy pain — I'd like to ask you some questions about it so we can figure out what's going on. Is that okay?"
Cantonese: 你好，我係___醫生。可唔可以確認你嘅姓名同出生日期？我知道你肚痛，我想問你幾個問題了解下情況，可以嗎？
2. Presenting Complaint — The SOCRATES Framework
This is the meat of your history. For abdominal pain, every letter of SOCRATES carries high diagnostic yield. Don't just ask the question — understand why it matters. [1] [2]
"Can you point with one finger to where the pain is worst?" (你可唔可以用一隻手指指住邊度最痛？)
| Region | Key Differentials |
|---|---|
| RUQ | Cholecystitis, cholangitis, hepatitis, liver abscess, basal pneumonia, subphrenic abscess [1] [3] |
| Epigastric | PUD, gastritis, pancreatitis, GERD, MI, gastric outlet obstruction [1] [2] |
| LUQ | Splenic pathology, pancreatitis, basal pneumonia, MI [1] |
| Periumbilical | Early appendicitis, SBO, mesenteric ischaemia, ruptured AAA, gastroenteritis [1] [2] |
| RLQ | Appendicitis, Crohn's, caecal CA, ectopic pregnancy, ovarian torsion, ureteric colic, strangulated hernia [1] [4] |
| LLQ/LIF | Diverticulitis, sigmoid CA, IBD, ovarian pathology, ectopic pregnancy, ureteric colic [1] [4] |
| Hypogastric | LBO, colorectal CA, UTI, AROU, PID, ectopic pregnancy [1] |
| Diffuse/non-specific | Gastroenteritis, constipation, generalised peritonitis, ruptured viscus, intra-abdominal haemorrhage, DKA, hypercalcaemia, herpes zoster, porphyria [1] [2] |
Why this matters: The site immediately narrows your differential by 70%. A pain that migrates (e.g. periumbilical → RIF) is classic for appendicitis. [1]
"When did the pain start? Did it come on suddenly or gradually?" (幾時開始痛？係突然間痛定係慢慢痛起嚟？)
Onset timing is one of the most discriminating features in acute abdomen: [1] [2]
- Within seconds: Perforation (e.g. PPU), haemorrhage (e.g. ruptured AAA), infarction (e.g. MI, mesenteric occlusion) [1] [2]
- Within minutes: Inflammatory (appendicitis, pancreatitis), colic (biliary, ureteric, IO), ischaemia (mesenteric ischaemia, strangulated IO, volvulus) [1]
- Over hours: Inflammatory (cholecystitis), obstruction (non-strangulated IO, urinary retention), mechanical (ectopic pregnancy, perforating tumours) [1]
Why this matters: A catastrophic, "thunderclap" onset = surgical emergency until proven otherwise. Gradual onset buys you investigation time.
"Can you describe the pain for me? Is it sharp, dull, cramping, burning, or like something squeezing?" (你可唔可以形容下痛嘅感覺？係刺痛、鈍痛、絞痛、灼熱痛、定係好似有嘢夾住咁？)
Three fundamental pain characters: [1]
| Character | Mechanism | Examples |
|---|---|---|
| Constant pain | Inflammation, infiltration, ischaemia, infarction | Peritonitis, pancreatitis, mesenteric ischaemia |
| Colicky pain | Hyperperistalsis against obstruction | IO (true colic with pain-free intervals), ureteric colic; biliary "colic" is actually constant with exacerbations, no true pain-free periods |
| Stretching pain | Prolonged obstruction of outflow | Urinary retention, chronic large bowel obstruction |
Biliary 'Colic' Is a Misnomer
Biliary colic is NOT true colic — it is severe, constant pain with painful exacerbations but no complete pain-free periods. This is a common OSCE pitfall. True colic (complete remissions between episodes) is seen in intestinal obstruction and ureteric colic. [1]
"Does the pain spread anywhere else?" (痛有冇去到其他地方？)
Key radiation patterns: [1]
- Back: Pancreatitis, AAA, aortic dissection, posterior peptic ulcer
- Shoulder tip (Kehr's sign): Haemoperitoneum (ruptured ectopic, splenic rupture) — diaphragmatic irritation referred via phrenic nerve (C3–5)
- Scapular spine / right shoulder: Gallbladder pathology
- Loin to groin: Ureteric colic (renal stone)
- Testicles to flank: Testicular torsion
- Flanks: Pyelonephritis, retroperitoneal haematoma, AAA
Why this matters: Radiation patterns are pathognomonic clues. Shoulder-tip pain + hypotension in a young woman = ruptured ectopic until proven otherwise.
2.5 Associations (伴隨症狀)
- Nausea/vomiting: Timing relative to pain is crucial
- Haematemesis / coffee-ground vomitus → UGIB (PUD, gastritis, oesophagitis)
- Heartburn / acid regurgitation → GERD
- Dysphagia → oesophageal pathology
- Dysuria, frequency, haematuria → UTI, ureteric colic [1]
- Urinary retention → AROU
- Chest pain / dyspnoea → basal pneumonia, MI [1]
Why this matters: Abdominal pain is never just about the abdomen. Missing an MI presenting as epigastric pain, or a basal pneumonia presenting as upper abdominal pain, is a classic exam trap.
"Is the pain constant, or does it come and go?" (痛係持續定係一陣一陣？)
- Constant → ulcers, peritonitis
- Colicky with pain-free remissions → intestinal, renal, (misleadingly called) biliary colic
- Steady increase then constantly severe → biliary colic, pancreatitis
- Progressive → appendicitis, diverticulitis
- Catastrophic onset → ruptured AAA, PPU [1]
"Is there anything that makes the pain better or worse?" (有冇咩會令到痛加重或者減輕？)
| Factor | Significance |
|---|---|
| Worsened by movement, relieved by staying still | Peritonitis — patient lies completely still [1] [2] |
| Relieved by movement / rolling around | Colic (ureteric, intestinal) [1] |
| Relieved by vomiting | IO, gastric ulcer [1] |
| Relieved by eating | Duodenal ulcer [1] |
| Worsened by eating / fatty meals | Gastric ulcer, pancreatitis, biliary colic [2] |
| Relieved by sitting up and leaning forward | Pancreatitis, CA pancreas [1] [2] |
| Worsened by lying flat | GERD [1] |
"On a scale of 0 to 10, where 0 is no pain and 10 is the worst pain you've ever had, how bad is it?" (由0到10分，0分係完全唔痛，10分係你經歷過最痛，你覺得幾痛？)
- Also ask about functional limitation: "Does it stop you from sleeping / working / eating?"
- Agonising pain out of proportion to clinical signs is a hallmark of mesenteric ischaemia — a critical diagnosis to recognise [1]
After SOCRATES, do a brief but directed systems review. Many of these overlap with associated symptoms above but serve as a safety net:
- Cardiovascular: Chest pain, palpitations, syncope (MI, AAA)
- Respiratory: Cough, SOB, pleuritic pain (basal pneumonia, PE)
- Neurological: Dermatomal pain / vesicles (herpes zoster) [4]
- MSK: Back pain (referred from AAA, pancreatitis; or lumbar spine pathology) [7]
- Skin: Rash, vesicles (herpes zoster), bruising (Cullen's/Grey Turner's sign in context)
4. Background History
"Do you have any medical conditions?" (你有冇其他疾病？)
Ask specifically about:
- Previous similar episodes — recurrent adhesive obstruction, biliary colic
- RF for AAA / mesenteric ischaemia: peripheral vascular disease, CAD, AF, hypertension [1]
- RF for bowel obstruction / perforation: previous cancer, PUD, previous abdominal surgery [1]
- Medical conditions mimicking surgical abdomen: DKA, porphyria, sickle cell crisis, Addisonian crisis [1] [2]
- Gallstone risk factors (5 F's): Fair, Fat, Female, Fertile, Forty [3]
- IBD, diverticular disease, polyps (risk for colorectal CA)
- HBV carrier status / cirrhosis (risk for HCC) [1]
"Have you ever had any operations?" (你有冇做過手術？)
- Previous abdominal or pelvic surgery — #1 cause of SBO is adhesions [1] [5] [6]
- Hernia repair history
- Any gynaecological procedures (IUD insertion → PID risk) [4]
Why this matters: An abdominal scar in a patient with colicky pain and vomiting = adhesive SBO until proven otherwise.
"Are you on any regular medications? Any allergies?" (你有冇食緊藥？有冇藥物敏感？)
Key medications to ask about: [1] [2] [5]
- NSAIDs / Aspirin / Bisphosphonates → PUD, perforation
- Corticosteroids → may mask signs of inflammation; also PUD risk
- Antibiotics → may mask peritonitis; can cause pseudomembranous colitis (C. diff)
- Opioids / anti-cholinergics / CCBs / iron → constipation, pseudo-obstruction [5]
- Anticoagulants → intra-abdominal haemorrhage, retroperitoneal haematoma
- OCP → risk of mesenteric venous thrombosis
Steroids Can Kill You Quietly
Corticosteroids mask peritoneal signs. A patient on long-term steroids may have a perforated viscus with minimal tenderness or guarding. Always maintain a high index of suspicion. [1]
"Do you smoke? Do you drink alcohol?" (你有冇食煙？有冇飲酒？)
- Smoking (幾時開始？每日幾多支？) — risk factor for PUD, AAA, colorectal CA, mesenteric ischaemia
- Alcohol (飲咩酒？幾多？幾密？) — quantify in units; risk factor for pancreatitis, liver disease, gastritis
- Travel history (最近有冇去旅行？) — amoebic liver abscess, infectious gastroenteritis
- Diet (飲食習慣？) — fatty food intake (biliary colic), fibre intake (diverticular disease/constipation)
- Occupation — exposure to chemicals, stress
- Sexual history (if relevant, especially in females) — STD risk → PID [4]
"Before this pain, how were you managing day to day? Could you walk independently?" (痛之前你日常生活點？行得到路嗎？)
This is critical for surgical decision-making — a frail patient with multiple comorbidities may not tolerate a major laparotomy.
5. Focused Differentiating Questions by Region
- "Did you eat a fatty meal before the pain started?" (痛之前有冇食油膩嘢？) — History of fatty food ingestion ≥1 hour before onset suggests biliary colic / cholecystitis [3]
- "Have you noticed your skin or eyes turning yellow?" (有冇發覺皮膚或者眼白變黃？) — jaundice → cholangitis, CBD stone, Mirizzi syndrome [3]
- "Any fevers or rigors?" — Charcot's triad (fever + jaundice + RUQ pain) = cholangitis [3]
- "Any cough or shortness of breath?" — basal pneumonia mimicking RUQ pain
- "Does eating make the pain better or worse?" — GU: worsened; DU: relieved [1]
- "Does the pain go through to your back?" — pancreatitis, posterior PUD [1]
- "Does sitting forward help?" — pancreatitis [1] [2]
- "Any chest tightness, jaw pain, or arm pain?" — MI can present as epigastric pain
- "Have you had a large alcohol binge or fatty meal recently?" — pancreatitis [1]
- "Did the pain start around your belly button and move to the right side?" (痛有冇由肚臍附近移去右邊？) — migratory pain classic for appendicitis (50%) [1] [4]
- "Have you lost your appetite?" — anorexia in ~75% of appendicitis, before onset of pain [1]
- "When was your last period?" (你最後一次月經幾時？) — MUST ask every female of reproductive age [1] [4]
- "Any vaginal discharge?" — PID [4]
- "Any blood in urine or pain going to the groin?" — ureteric colic [1]
- "Cardinal symptoms of IO: colicky pain, vomiting, abdominal distension, absolute constipation" — ask about all four [1] [5] [6]
- "Are you still passing gas?" (你仲有冇放屁？) — inability to pass flatus = complete obstruction [5] [6]
- "Do you have any heart conditions like AF?" — risk for mesenteric embolism [1]
- "Are you diabetic? When did you last check your blood sugar?" — DKA presenting as abdominal pain [1] [2]
These are the life-threatening causes of acute abdomen that you must actively consider: [2]
| Diagnosis | Key Clues |
|---|---|
| Perforated viscus (e.g. PPU) | Sudden severe epigastric pain, board-like rigidity, lies still [1] |
| Ruptured AAA | Elderly smoker, sudden central/back pain, shock [1] |
| Acute mesenteric ischaemia | Pain out of proportion to signs, AF/vascular disease history [1] |
| Acute intestinal obstruction | Colicky pain, vomiting, distension, absolute constipation [1] [5] [6] |
| Severe acute pancreatitis | Epigastric → back, leaning forward, gallstones/alcohol [1] |
| Ruptured HCC | Known HBV/cirrhosis, sudden RUQ pain, shock [1] |
| DKA | Known DM, polyuria, polydipsia, diffuse abdominal pain [1] [2] |
| Acute MI | Elderly, DM (silent MI), epigastric pain, SOB, diaphoresis [1] |
| Addisonian crisis | Chronic steroid use, acute illness, hypotension, confusion [2] |
| Ruptured ectopic pregnancy | Female of reproductive age, amenorrhoea, unilateral lower abdominal pain, shock [1] [4] |
Immediately escalate if any of the following are present: [1] [2]
- Haemodynamic instability (tachycardia, hypotension, shock)
- Signs of peritonism — board-like rigidity, rebound tenderness, guarding
- Pain disproportionate to physical findings — mesenteric ischaemia
- Signs of sepsis — fever, rigors, confusion, tachycardia
- Evidence of GI bleeding — haematemesis, melaena, significant PR bleeding
- Acute urinary retention
- Positive pregnancy test + abdominal pain — ectopic until proven otherwise
- Background of immunosuppression / steroids — symptoms may be masked
- Age > 55 with new-onset abdominal pain + constitutional symptoms — high suspicion for malignancy [2]
Common OSCE Mistakes
- Forgetting to ask LMP in females — ectopic pregnancy is a life-threatening diagnosis that is easily missed. Ask every single time.
- Not asking about medications — NSAIDs causing PUD, steroids masking peritonitis, opioids causing constipation/pseudo-obstruction.
- Assuming biliary colic is "true colic" — biliary colic does NOT have pain-free intervals; this is a favourite viva question. [1]
- Ignoring extra-abdominal causes — MI, basal pneumonia, PE, herpes zoster, DKA can all present as abdominal pain. [1] [4]
- Not screening for surgical history — adhesions from prior surgery are the #1 cause of SBO in developed countries. [5] [6]
- Describing pain location vaguely — always get the patient to point with one finger.
- Forgetting hernial orifices — a strangulated inguinal/femoral hernia is an easily missed cause of IO. [4]
- Not asking about passage of flatus — distinguishes complete from incomplete obstruction. [5] [6]
Viva Pearls
- "Pain before vomiting" = likely surgical cause (appendicitis); "Vomiting before pain" = likely medical cause (gastroenteritis). [1]
- Mesenteric ischaemia: "pain out of proportion to signs" — the abdomen is soft early on despite agonising pain. This classic phrase is highly examinable. [1]
- Murphy's sign (catching breath on RUQ palpation during inspiration) = cholecystitis. Severe jaundice in the context of cholecystitis should raise suspicion for cholangitis, CBD obstruction, or Mirizzi syndrome. [3]
- PPU: pain and guarding may decrease after 4–6 hours as acid is diluted, but peritonitis is still progressing — don't be fooled by the "silent interval." [1]
- In IO: vomiting occurs early in high SBO (profuse, rapid dehydration) but late in LBO; distension is central in SBO but pronounced and lower in LBO. [5]
- Appendicitis: nausea/vomiting occurs after pain onset; anorexia is present before pain onset in ~75%. [1]
- PID: onset is gradual, lower abdominal, often bilateral, with purulent vaginal discharge preceding pain by days, associated with dyspareunia and cervical excitation tenderness (Chandelier sign). [4]
Scenario: You are presenting to the surgical registrar on call.
"Thank you for taking my call. I'd like to refer Mr Chan, a 65-year-old gentleman, who presented to QMH A&E approximately 6 hours ago with acute abdominal pain.
Regarding his history of presenting illness: Mr Chan reports sudden onset of severe, constant epigastric pain that began approximately 6 hours ago after dinner. The pain rapidly reached maximum intensity within minutes and has since spread to involve the entire abdomen. He rates the pain 9 out of 10. The pain is worsened by any movement and he has been lying completely still. He reports associated nausea and two episodes of non-bilious vomiting. He denies any PR bleeding, haematemesis, or change in bowel habit. He is still passing flatus. There is no urinary or gynaecological complaint.
His past medical history includes a 10-year history of peptic ulcer disease and hypertension. He has no history of previous abdominal surgery.
His regular medications include aspirin 80 mg daily, amlodipine 5 mg daily, and he reports recently self-medicating with ibuprofen for back pain over the past 2 weeks. He has no known drug allergies.
Family history is unremarkable. He is a current smoker of 20 pack-years and drinks approximately 2 units of alcohol daily. He is independent in activities of daily living.
In summary, this is a 65-year-old gentleman with a background of PUD and recent NSAID use, presenting with sudden-onset severe epigastric pain now generalised, lying completely still — my leading differential is a perforated peptic ulcer and I would appreciate your urgent review. I have kept him nil by mouth, started IV access, taken bloods including a group and save, and requested an erect CXR."
High Yield Summary
The core framework for abdominal pain history-taking:
- SOCRATES — Site, Onset (seconds/minutes/hours), Character (constant/colicky/stretching), Radiation, Associations (UGI/LGI/HBP/Uro/O&G/constitutional), Timing, Exacerbating/Relieving, Severity.
- Screen all four systems — UGI, LGI, Urological, O&G (always ask LMP in females).
- Background — PMHx (vascular RF, DM, PUD, cancer, hernia), surgical Hx (adhesions!), drugs (NSAIDs, steroids, opioids, anticoagulants), FHx (GI malignancy), social Hx (smoking, alcohol, travel).
- Life-threatening DDx — PPU, ruptured AAA, mesenteric ischaemia, IO, severe pancreatitis, ruptured ectopic, DKA, MI, Addisonian crisis, ruptured HCC.
- Red flags — haemodynamic instability, peritonism, pain out of proportion to signs, GI bleeding, positive pregnancy + pain, age >55 + constitutional symptoms.
- Key discriminators — onset timing (seconds vs hours), pain character (colic vs constant), relationship to food/movement, vomiting timing relative to pain, passage of flatus, LMP.
Active Recall - History Taking
[1] Senior notes: Ryan Ho GI.pdf (Section 3.1.1 Abdominal Pain, pp. 92–103; Section on RUQ approach, pp. 210); also Ryan Ho Fundamentals.pdf (Section 3.3.5 Abdominal Pain, pp. 266–277) [2] Senior notes: maxim.md (Abdominal Pain section, p. 44) [3] Senior notes: felixlai.md (Cholecystitis section, pp. 556; also Ryan Ho GI.pdf p. 210) [4] Lecture slides: GC 195. Lower and diffuse abdominal pain RLQ problems; pelvic inflammatory disease; peritonitis and abdominal emergencies.pdf (pp. 2, 10, 44) [5] Senior notes: felixlai.md (Intestinal obstruction section, pp. 607) [6] Lecture slides: GC 194. Intestinal obstruction colorectal cancer.pdf [7] Lecture slides: GC 226. Lumbar Spine Pathology_Part B (2).pdf
Abdominal Aortic Aneurysm
Abnormal focal dilation of the abdominal aorta exceeding 3 cm in diameter, most commonly occurring infrarenally, with risk of rupture and life-threatening hemorrhage.
Acute Retention Of Urine
Acute retention of urine is the sudden inability to pass urine voluntarily, resulting in painful distension of the bladder that requires urgent catheterization.