MICA · FIRST-LINE LEARNING NOTES
Understand, prioritise and organise follow-up
Acute abdominal pain first requires assessment of stability and urgent causes; location alone does not establish the diagnosis.
Recognise a high-risk presentation
Abrupt or very severe pain, syncope, shock, marked guarding, gastrointestinal bleeding or persistent vomiting require urgent assessment. Ask about absent stool or flatus with distension and inability to drink. Possible pregnancy changes the differential: pain with bleeding, collapse or shoulder-tip pain can indicate ectopic pregnancy. In older or immunocompromised people, a less dramatic presentation does not reliably exclude serious disease.
[1][2]Build a differential diagnosis
Clarify onset, migration, radiation, bowel function, vomiting, urinary symptoms, last menstrual period and previous surgery. Record vital signs, hydration and abdominal findings, extending examination according to associated symptoms. Consider gastrointestinal, urinary and gynaecological causes, including an extra-abdominal source when relevant. Offer a pregnancy test when pregnancy is possible. Select laboratory testing and imaging for the clinical question; an isolated abnormality does not replace clinical correlation.
[2][3][1]Distinguish stable localised pain from diffuse pain with systemic illness. Severe pain disproportionate to examination findings or deterioration after initially reassuring tests requires renewed reasoning. Age, possible pregnancy and anticoagulants modify concern. Urinary or gastrointestinal symptoms do not exclude an urgent gynaecological cause.
[1][2]Link testing to disposition
Persistent localised pain or associated systemic illness warrants prompt reassessment and surgical or gynaecological advice as appropriate. Epigastric pain with vomiting may suggest pancreatitis: interpret lipase alongside the history and competing diagnoses. Do not automatically attribute pancreatitis to alcohol. Appendicitis treatment options are selected within specialist care after classifying the disease and discussing risks.
[3][4][2]Avoid missing evolving disease
Discharge should follow reassessment, explanation of uncertainty and an arranged follow-up plan. Specify where and how to seek reassessment for increasing pain, fever, collapse, bleeding, vomiting or inability to maintain hydration. Assign responsibility for pending results. Persistent pain or a change in location requires a new examination; an inconclusive initial ultrasound or temporary improvement must not become definitive evidence that disease is absent.
[1][2]A learning situation
FICTIONAL CASE · SELF-REFLECTION WITHOUT A SCORE
A young woman has lower abdominal pain and light bleeding she believes is menstrual. She nearly collapsed on standing and is uncertain of her last menstrual period.
Which diagnostic pitfall should be avoided?
Read the reasoning
Do not treat bleeding as proof that pregnancy is absent. Immediately assess stability, test for pregnancy and arrange urgent referral when ectopic pregnancy is possible, particularly after near-collapse. Specialist assessment combines clinical findings, ultrasound and laboratory testing as appropriate; a single result does not establish pregnancy location.
References and scope
- Stomach ache — emergency signs and assessment ↗
- Ectopic pregnancy and miscarriage — NG126: Symptoms and signs of ectopic pregnancy and initial assessment (updated June 2026) ↗
- Pancreatitis — NG104: Recommendations (updated December 2020) ↗
- Podda et al. Diagnosis and Treatment of Acute Appendicitis: 2025 Edition of the WSES Jerusalem Guidelines. JAMA Surg. 2026;161:283–295 — public abstract ↗
Original educational synthesis for adult first-line practice. International references must be interpreted with the clinical setting and local care pathways. Independent human scientific review remains to be confirmed.