How can I differentiate between surgical and non-surgical causes of abdominal pain in primary care?

To differentiate between surgical and non-surgical causes of abdominal pain in primary care, clinicians should focus on key clinical features, examination findings, and appropriate investigations.

• Red flag symptoms and signs suggestive of surgical causes include severe, acute onset pain, signs of peritonitis (e.g., guarding, rebound tenderness), abdominal masses consistent with organ enlargement or obstruction, and systemic signs such as fever or unexplained weight loss. These features may indicate conditions like bowel obstruction, perforation, or malignancy requiring urgent surgical assessment ¹.
• Non-surgical causes often present with less acute symptoms, absence of peritonitis, and may be associated with chronic or recurrent pain without alarming features. These cases may be managed initially with conservative treatment and further investigations in primary care ¹.
• Physical examination findings such as an abdominal or pelvic mass (not obviously uterine fibroids) in women, unexplained splenomegaly, or hepatosplenomegaly warrant urgent referral or investigation to exclude malignancy or other serious pathology ¹.
• Investigations in primary care such as quantitative faecal immunochemical testing for colorectal cancer, serum CA125 for ovarian cancer, and urgent direct access ultrasound scans for suspected gall bladder or liver enlargement can help differentiate causes and guide referral urgency ¹.
• Urgent referral pathways should be used when there is suspicion of cancer or serious surgical pathology based on symptoms, signs, or investigation results ¹.

In summary, differentiation relies on careful history taking to identify red flags, thorough abdominal examination to detect masses or signs of peritonitis, and targeted investigations to identify or exclude malignancy or surgical emergencies. When in doubt, urgent referral or specialist advice should be sought ¹.