Acute lower central (hypogastric) abdominal pain

Taken from Oxford Handbook of Clinical Diagnosis

Acute lower central (hypogastric) abdominal pain

Examination of the abdomen may provide better leads.

Initial investigations:

FBC, U&E, CXR, AXR

other tests in bold below

Main differential diagnosis and typical outline evidence, etc.

1. Cystitis due to bacterial infection

Suggested by: frequency, urgency, dysuria, ± haematuria.

Confirmed by: MSU (midstream urine) for microscopy and culture.

Initial management: fluids IV if dehydrated, antibiotics.

2. Pelvic inflammatory disease

Suggested by: vaginal discharge, dysuria, dyspareunia, pelvic tenderness on moving cervix, ↑ ESR and CRP. WCC: leukocytosis

Confirmed by: high vaginal swab for culture and sensitivity, pelvic US scan ± laparoscopy.

Initial management: analgesia, fluids IV if dehydrated, provisional antibiotic, e.g. cefoxitin pending sensitivities.

3. Pelvic endometriosis

Suggested by: dysmenorrhea, ovulation pain, dyspareunia, infertility, pelvic mass.

Confirmed by: laparoscopy.

Initial management: analgesics, fluids IV for hypovolemia, blood transfusion for severe bleeding, gynae referral for large or ruptured endometriosis.

4. Ectopic pregnancy

Suggested by: constant unilateral pain ± referred shoulder pain, amenorrhea, vaginal bleeding (usually less than normal period), faintness with an acute rupture.

Confirmed by: pregnancy test +ive, bimanual examination finding enlarged uterus, pelvic US scan showing empty uterus with thickened decidua.

Initial management: analgesics, fluids ++ if hypotension or shock, urgent gynae/surgical referral.

5. Large bowel obstruction

Suggested by: severe distension, late vomiting, visible peristalsis, resonant percussion, increased bolwe sounds. Supine AXR showing peripheral abdominal large bowel shadow (with haustra partly crossing the lumen). Fluid levels on erect film.

Confirmed by: US scan an laparotomy findings.

Initial management: NG tube, ‘drip and suck’, fluids IV, monitor intake/output, antibiotics, surgical referral.

6. Infective or ulcerative colitis

Suggested by: abdominal pain, diarrhea with blood and mucus.

Confirmed by: stool microscopy and culture, colonoscopy.

Initial management: nil by mouth, fluids IV with K supplement, corticosteroids IV, antibiotic prophylaxis, may need parenteral nutrition, consult surgeon if toxic megacolon.