Most acute abdominal diagnoses are made before anyone touches the patient. The history tells you which organ, the examination confirms how angry it is, and the scan usually agrees with what a careful clerking already said. The skill worth learning is not a list of causes — it is knowing which five questions separate them.
Where the pain started, and where it went
A hollow organ in trouble sends pain to the midline, because the viscera have no precise representation in the cortex. The patient feels it vaguely, centrally, and cannot point to it. Only when the inflammation reaches the parietal peritoneum does the pain become sharp, localised and worse on movement — and the parietal peritoneum is somatically innervated, so now the patient can point to it with one finger.
That single transition explains the classic histories:
| Embryological gut | First felt | Then localises to | Typical cause |
|---|---|---|---|
| Foregut | Epigastrium | Right upper quadrant, epigastrium | Gallbladder, stomach, duodenum |
| Midgut | Periumbilical | Right iliac fossa | Appendix, small bowel |
| Hindgut | Suprapubic, lower abdomen | Left iliac fossa | Sigmoid colon, diverticular disease |
The five questions that do the work
- Where did it start, and where is it now? Migration is diagnostic in itself.
- Sudden or gradual? Instantaneous pain suggests perforation, rupture or torsion. Pain building over hours suggests inflammation.
- Does anything make it worse? Pain on coughing, on the drive in, or on moving in bed is peritonism described by a patient who has never heard the word.
- Vomiting before or after the pain? Pain first then vomiting fits a surgical cause; vomiting first fits gastroenteritis.
- When did you last open your bowels or pass wind? The question students forget, and the one that identifies obstruction.
Before you leave the bedside
In a woman of reproductive age, the last menstrual period and the possibility of pregnancy are part of the history, not an afterthought — an ectopic pregnancy presents as an acute abdomen. In an older patient, ask about weight loss and a change in bowel habit, because an obstruction can be the first presentation of a cancer. In anyone, ask what they take: anticoagulants, steroids and NSAIDs all change the differential, and steroids can mask peritonism almost completely.
Surgical pearl
A silent abdomen in a patient who is lying perfectly still is more worrying than a noisy abdomen in a patient who is rolling around. Colic makes people move; peritonitis makes them stop.
Clerk a patient with an acute abdomen
Three of the nine simulated patients present this way. Each opens with a referral stem, then you choose your own questions — the patient answers only what you actually ask.
Migratory pain and the visceral-to-parietal transition, in the patient it was described for.Case 5 · clerk this patientLeft iliac fossa painRonald Pryce, 63, retired
Diverticulitis, and why an interval endoscopy is not optional afterwards.Case 6 · clerk this patientScrotal painKyle Docherty, 15, school pupil
A time-critical diagnosis, and why an adolescent is offered time alone.
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