Acute Lower Abd Pain

Colonic: colitis, diverticulitis, IBD, IBS
Gynecologic: ectopic pregnancy, fibroids, ovarian mass, torsion, PID

Renal: nephrolithiasis, pyelonephritis
29 year old Malay lady (wt 65kg, ht 167cm, bmi 22.8)
NKMI/NKDA/NKFA
Housewife
Married, para 2, LCB 4 years ago
LNMP 18/10/23, regular menses
History of LSCS x2 in 2017 and 2019, uncomplicated
Previous hospitalisation in H. Selayang on 25/10/23- 27/10/23- planned for colonoscopy in December 2023
- Done X-ray and US Abdomen- claims normal

- Given analgesia and lactulose
- Did not bring discharge note
HOPI (accompanied by sister in law)
1. Abdominal pain x 3/52

- Left iliac fossa and suprapubic
- Started within the past year on and off however worsened since 25/10/23
- Cramping in nature
- Radiates to the left lumbar and umbilical region
- Associated with sweating, reduced appetite and weight loss of 4kg in 3 weeks
- Continuous
- No aggravating factor- not associated with food, menses or midcycle, movement, position
- Relieved temporarily with T. Paracetamol 1g TDS taken since 25th Oct (7 >5/10)
- Severity: 7/10
2. Increased frequency of urination

- Noticed when worsening pain of every 1-2 hours
- Otherwise, (Storage/irritative) no urgency, incontinence, dysuria, (voiding/obstructive) no hesitancy,
straining, weak flow, terminal dribbling)
- No sandy urine, no haematuria, no dysuria, not foul smelling
Otherwise,
No fever
No prolonged cough
No known TB contact
No abnormal PV discharge
No history of STI
No diarrhea or constipation
No PR bleeding
No family history of inflammatory bowel disease or malignancy
No visits to clinics in the past
No history of taking any other medications/ analgesia OTC/ supplements
No travelling history
No trauma or heavy lifting
No low mood or anhedonia
No abdominal distension or vomiting
No loss of consciousness or lightheadedness
Able to pass flatus
Able to tolerate fluids but due to pain did not feel like eating
Was able to ambulate slowly
Menstrual History
Menarche 14 years old
Regular menses for 3 days of 30 day cycle
Soaks 3 pads on 1st two days
No dysmenorrhea
No blood clots
No heavy menstrual bleeding
Using condom
Last papsmear in 2021- normal
O/E
Alert, pink
No conjunctival pallor
Speaking in full sentences
CRT <2s
Warm peripheries
Good hydration status
Sweating
BP 115/75
PR 110 (manual 108)
T 36C
Lungs: clear
CVS: DRNM
PA: Tender over umbilical and suprapubic region. No rebound tenderness, no guarding. Mc Burney sign,
Rovsing sign negative. No palpable mass. Bowel sounds present. Renal punch negative
(Guarding- peritonitis, rebound – peritoneal irritation
Ix
UFEME negative
UPT negative
Unable to perform FBC, X-ray abdomen d/t pain
IMP: Adhesion colic
Differential Diagnosis:
Appendicitis, torsion ovarian cyst, ureteric colic, endometriosis, diverticulitis, salpingitis, ruptured ectopic
Plan
Refer YE for adhesion colic
UPT
UFEME
Unable to perform FBC, X-ray abdomen d/t pain
IM Voltaren 75mg stat (not keen for opioid- vomited badly previously)
Red flags
Older pt
Nocturnal pain or diarrhea
Rectal bleeding
Fever
Anemia
Weight loss
Abd mass
Faecal incontinence or urgency
Radiographic features
The main feature of torsion is ovarian enlargement due to venous/lymphatic engorgement,
oedema, and haemorrhage. Secondary signs include free pelvic fluid, an underlying ovarian
lesion, reduced or absent vascularity and a twisted dilated tubular structure corresponding to
the vascular pedicle. Adnexal torsion is commonly unilateral, with a slight (3:2) right-sided
predilection (presumably due to the protective effects of the sigmoid colon on the left) 6,8.
Ultrasound
Ultrasound is the initial imaging modality of choice. Sonographic features include:
 enlarged (>4 cm) ovary, if the ovaries are normal in size and symmetric, torsion is
unlikely.
 ovarian oedema 17
 variable echogenicity (hypo- or hyperechoic)
o a long-standing infarcted ovary may have a more complex appearance with
cystic or haemorrhagic degeneration
 peripherally displaced follicles with hyperechoic central stroma
o follicular ring sign 16
 midline ovary position
 Doppler findings in torsion are widely variable 3
o little or no ovarian venous flow (common; sensitivity of 100% and specificity of
97%) 14
o absent arterial flow (a less common, sign of poor prognosis)
o absent or reversed diastolic flow
o normal vascularity does not rule out intermittent torsion
 normal Doppler flow can also occasionally be found due to dual
supply from both the ovarian and uterine arteries
 whirlpool sign of twisted vascular pedicle 3
 an underlying ovarian lesion may be seen (possible lead point for torsion)
 ovary tenderness to transducer pressure 13
 free pelvic fluid may be seen in >80% of cases
Plain X ray abdomen
Kidney/ ureteric stone ( 70% opaque- calcium oxalate (most common), calcium phosphate) lucent-
struvite, uric
Biliary stone- 10-305 opaque
Marked distension in bowel
Distended bowel with air fluid level- bowel obstruction
Blurred right psoas shadow- appendicitis

Diverticulitis- usually over 40 years old, LIF, pain increase w walking and change in position and
usually assoc w constipation, fever

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Colonic: colitis, diverticulitis, IBD, IBS

Gynecologic: ectopic pregnancy, fibroids, ovarian mass, torsion, PID

29 year old Malay lady (wt 65kg, ht 167cm, bmi 22.8)

Married, para 2, LCB 4 years ago

LNMP 18/10/23, regular menses

History of LSCS x2 in 2017 and 2019, uncomplicated

- Done X-ray and US Abdomen- claims normal

HOPI (accompanied by sister in law)

1. Abdominal pain x 3/52

2. Increased frequency of urination

No family history of inflammatory bowel disease or malignancy

No visits to clinics in the past

No history of taking any other medications/ analgesia OTC/ supplements

No trauma or heavy lifting

No low mood or anhedonia

No abdominal distension or vomiting

No loss of consciousness or lightheadedness

Able to pass flatus

Was able to ambulate slowly

Menarche 14 years old

Regular menses for 3 days of 30 day cycle

Soaks 3 pads on 1st two days

No heavy menstrual bleeding

Last papsmear in 2021- normal

Speaking in full sentences

Good hydration status

PR 110 (manual 108)

(Guarding- peritonitis, rebound – peritoneal irritation

Unable to perform FBC, X-ray abdomen d/t pain

IMP: Adhesion colic

Refer YE for adhesion colic

Unable to perform FBC, X-ray abdomen d/t pain

Nocturnal pain or diarrhea

Faecal incontinence or urgency

Biliary stone- 10-305 opaque

Marked distension in bowel

Distended bowel with air fluid level- bowel obstruction

Blurred right psoas shadow- appendicitis

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