Preliminary management of acute onset right sided abdominal pain in women

• Published in: BMJ (Online) Vol. 376; p. e068020
• Main Authors: Borthwick, Molly, Bannaga, Ayman, Ashmore, Ayisha A, Johnson, Charles H N, Arasaradnam, Ramesh P
• Format: Journal Article
• Language: English
• Published: England British Medical Journal Publishing Group 08.02.2022; BMJ Publishing Group LTD
• Subjects: Abdomen; Abdominal Pain - etiology; Abscesses; Appendicitis; Appendicitis - complications; Appendicitis - diagnosis; Contamination; Diagnosis, Differential; Diarrhea; Ectopic pregnancy; Emergency medical care; Enteritis; Female; Gynecology; High temperature; Humans; Inflammatory diseases; Intrauterine devices; Irritation; IUD; Laparoscopy; Menstruation; Ovaries; Pain; Pathology; Patients; Pelvic inflammatory disease; Peritonitis; Peritonitis - complications; Peritonitis - diagnosis; Physiology; Practice; Pregnancy; Pregnancy complications; Pregnancy, Ectopic - diagnosis; Primary care; Pyelonephritis; Risk factors; Sepsis; Surgery; Vagina; Womens health; Young Adult
• ISSN: 1756-1833; 1756-1833
• DOI: 10.1136/bmj-2021-068020

Consider the symptomatic triad: chronic mucoid watery diarrhoea without blood, weight loss, and intermittent colicky abdominal pain, often related to eating A 23 year old woman presents to the emergency department with a 24 hour history of abdominal pain that is worse in her right lower quadrant. Evidence of peritonism on clinical examination can be thought of as a spectrum, from absence of peritonism to generalised peritonitis (table 1).Table 1 Examining for evidence of peritonism: a spectrum of clinical findings and their possible causes Clinical finding Possible cause Soft non-tender abdomen Normal Soft but tender abdomen Gastro-enteritis, pyelonephritis, very early appendicitis Rebound tenderness/Rovsing’s sign positive Peritoneal irritation (eg, acute appendicitis, diverticulitis) Percussion tenderness Non-distractable localised guarding Perforated appendicitis, ruptured ectopic pregnancy, diverticular perforation Rigid, board-like abdomen (general peritonitis) Perforated appendicitis/duodenal ulcer with contamination throughout abdomen. Ask about risk factors such as previous ectopic pregnancy, pelvic inflammatory disease, presence of an intrauterine device, or previous pelvic surgery. [...]one third of women do not have any risk factors.10 If a patient is haemodynamically unstable with a suspected ectopic pregnancy, refer for urgent gynaecological review for consideration of diagnostic laparoscopy or laparotomy, with or without salpingectomy.11 History of the last menstrual period, or recent unprotected intercourse, can help inform clinical suspicion of pregnancy.