UBC Objectives: Surgical + Procedural Skills & Priority Topic: Abdominal Pain

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Assess and manage surgical disease including referral to surgical specialties as needed

Key Feature 6a: Given a patient with a life-threatening cause of acute abdominal pain (ex: a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy): Recognize the life-threatening situation. 
Skill: Selectivity
Phase: Diagnosis

Key Feature 6b: Given a patient with a life-threatening cause of acute abdominal pain (ex: a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy): Make the diagnosis
Skill: Clinical Reasoning
Phase: Diagnosis

Key Feature 6c: Given a patient with a life-threatening cause of acute abdominal pain (ex: a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy): Stabilize the patient
Skill: Selectivity, Clinical Reasoning
Phase: Treatment

Key Feature 6d: Given a patient with a life-threatening cause of acute abdominal pain (ex: a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy): Promptly refer the patient for definitive treatment. 
Skill: Selectivity
Phase: Diagnosis, Referral

I have not had the unfortunate experience of ever encountering a patient with an acutely life-threatening cause of abdominal pain. In fact, over the duration of my residency and my only occasional training in critical care/emergency, I may never encounter this. So I don't want to cop out on this, but I also don't want to delve into detail that will probably never be too clinically relevant for me. What I do want to know is what I would need to do to help try to save a patient's life if I am the physician who encounters a patient with an acutely life-threatening cause of abdominal pain. Here is what I feel I need to know to manage such a situation:

1. Recognize the life-threatening situation: With an acutely life-threatening cause of abdominal pain, the patient will likely either present with a complaint of acute abdominal pain, or else they may present in a decompensated state as a consequence of the underlying etiology (ex: the patient may be unconscious secondary to hypotension resulting from a massive bleed into the abdomen from a ruptured AAA or ectopic pregnancy). For patients who may be less able to localise or communicate their symptoms, the physical examination would be expected to reveal a peritonitic abdomen.
2. Make the diagnosis: In a patient with a life-threatening cause of abdominal pain, I need to make the call. Now I think it is certainly important to have an understanding of the different signs and symptoms associated with different etiologies for what could be going on, but rather than focus on this, I think it is more important to recognise that in this situation, a working DDx is more important than an accurate Dx. If a patient develops peritonitis from a perforated organ, of course knowing which organ was perforated, say, will only improve successful resuscitation. But regardless, in order to react urgently, we need to move on to stabilising the patient and saving their life, which is not amenable to a detailed workup if the etiology for the life-threatening abdominal pain is not overtly clear. So to me, this key feature is really about having a working DDx that takes into account patient risk factors (ex: in the elderly man with cardiac risk factors this must include the possibility of a ruptured AAA, and in the female of reproductive age this must include the possibility of a ruptured ectopic pregnancy). 
3. Stabilize the patient: ABCs. Although I won't outline the steps of the ABC emergency response algorithm here, this is the time to call them into action. In the setting of life-threatening causes of abdominal pain, there may very well be a bleed in the abdomen, and so circulation may be compromised and resuscitation efforts may centre around this. In the setting of acute abdominal pain and signs of hypovolemia (see two posts back for signs to look for), the patient should be suspected of having a bleed in their abdomen. As resuscitation efforts are underway, as part of this process, ordering investigations to determine the cause, severity, and consequences of the presentation should help refine the working DDx.
4. Promptly refer the patient for definitive treatment: In the setting of an acutely life-threatening cause of abdominal pain, making an urgent referral to the most appropriate surgeon is critical. The working DDx comes into play here. If suspicion of a ruptured AAA is at the top of the differential, an urgent consult to vascular surgery would be in order. If one is most suspicious of a ruptured ectopic pregnancy or another urgent gynecological cause, an urgent consult to an obstetrician-gynaecologist would be indicated. And if the cause of the life-threatening abdominal insult is undifferentiated, or if there aren't any more specialised surgeons available at the centre you are working, then an urgent consult to general surgery would be warranted.