Abdominal pain

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Abdominal pain
ICD-10 R10
ICD-9 789.0

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Overview

Abdominal pain can be one of the symptoms associated with transient disorders or serious disease. Making a definitive diagnosis of the cause of abdominal pain can be difficult, because many diseases can result in this symptom. Abdominal pain is a common problem. Most frequently the cause is benign and/or self-limited, but more serious causes may require urgent intervention.

Introduction

Abdominal pain is traditionally described by its chronicity (acute or chronic), its progression over time, its nature (sharp, dull, colicky), its distribution (by various methods, such as abdominal quadrant (left upper quadrant, left lower quadrant, right upper quadrant, right lower quadrant) or other methods that divide the abdomen into nine sections, and by characterization of the factors that make it worse, or alleviate it.

Due to the many organ systems in the abdomen, abdominal pain is a concern of general practitioners/family physicians, surgeons, internists, emergency medicine doctors, pediatricians, gastroenterologists, urologists and gynecologists. Occasionally, patients with rare causes can see a number of specialists before being diagnosed adequately (e.g., chronic functional abdominal pain)

Types and mechanisms

  1. The pain associated with the abdomen of inflammation of the parietal peritoneum (the part of the peritoneum lining the abdominal wall) is steady and aching, and worsened by changes in the tension of peritoneum caused by pressure or positional change. It is often accompanied by tension of the abdominal muscles contracting to relieve such tension.
  2. The pain associated with obstruction of a hollow viscus (as opposed to peritoneal and solid organ pain) is often intermittent or "colicky", coinciding with the peristaltic waves of the organ. Such cramps are exactly what is experienced with early acute appendicitis and gastroenteritis and are somewhat relieved by writhing and massage.
  3. The pain associated with abdominal vascular disturbances (thrombosis or embolism) can be sudden or gradual in onset, and can be severe or mild. Pain associated with the rupture of an abdominal aortic aneurysm may radiate to the back, flank, or genitals.
  4. Pain that is felt in the abdomen may be "referred" from elsewhere (e.g., a disease process in the chest may cause pain in the abdomen), and abdominal processes can cause radiated pain elsewhere (e.g., gall bladder pain—in cholecystitis or cholelithiasis—is often referred to the shoulder).

Differential Diagnosis According to Localization

Diffuse Abdominal Pain

Updated 10th September 2008 [1] [2] [3]

Epigastric and upper quadrant

Right upper quadrant

Left upper quadrant

Left Lower Quadrant

Pelvic/Hypogastric Region

Right Lower Quadrant

Intraperitoneal Causes of Acute Abdominal Pain

Inflammatory

Peritoneal

  • Chemical and nonbacterial peritonitis
    • Perforated peptic ulcer/biliary tree, pancreatitis, ruptured ovarian cyst, mittelschmerz
  • Bacterial peritonitis
    • Primary peritonitis (Pneumococcal, streptococcal, tuberculous; spontaneous bacterial peritonitis)
    • Perforated hollow viscus

Hollow visceral

Solid visceral

Mesenteric

Pelvic

Mechanical (obstruction, acute distention)

Hollow visceral

Solid visceral

Mesenteric

Pelvic

Hemoperitoneum

Ischemic

Traumatic

Extraperitoneal Causes of Acute Abdominal Pain

Genitourinary

Pulmonary

Cardiac

Metabolic

Endocrine

Musculoskeletal

Neurogenic

Inflammatory

Infectious

Hematologic

Vascular

Toxins

Retroperitoneal

Psychogenic

Factitious

Differential Diagnosis of Underlying Etiology

Cardiovascular • Abdominal aortic aneurysm • Aortic aneurysms • Budd-Chiari syndrome (hepatic vein obstruction) • Myocardial ischemia • Pericarditis •
Chemical / poisoning • No underlying causes
Dermatologic • No underlying causes
Drug Side Effect • No underlying causes
Ear Nose Throat • No underlying causes
Endocrine No underlying causes
Environmental No underlying causes
Gastroenterologic • Cholecystitis • Cholecystolithiasis • Colon cancer • Congested liver • Dyspepsia • Gastric tumors • Gastritis • Gastroesophageal reflux disease (GERD) • Lamblia • Hepatic tumors • Irritable stomach • Pancreatic tumors • Pancreatitis • Parasitosis of the liver • Peptic ulcer disease • Postcholecystectomy syndrome • Basal pneumonia • Splenic cancer • Splenic infarction • Splenic rupture • Stomach emptying disorder • Ulcerative colitis •
Genetic No underlying causes
Hematologic No underlying causes
Iatrogenic No underlying causes
Infectious Disease No underlying causes
Musculoskeletal / Ortho No underlying causes
Neurologic No underlying causes
Nutritional / Metabolic No underlying causes
Obstetric/Gynecologic No underlying causes
Oncologic No underlying causes
Opthalmologic No underlying causes
Overdose / Toxicity No underlying causes
Psychiatric No underlying causes
Pulmonary • Empyema • Pleuritis • Basal pneumonia • Pulmonary embolism • Pulmonary infarction • Tuberculosis •
Renal / Electrolyte Kidney cancer
Rheum / Immune / Allergy No underlying causes
Sexual No underlying causes
Trauma No underlying causes
Urologic No underlying causes
Miscellaneous No underlying causes

Selected causes

Acute Abdomen

Acute abdomen can be defined as severe, persistent abdominal pain of sudden onset that is likely to require surgical intervention to treat its cause. The pain may frequently be associated with nausea and vomiting, abdominal distention, fever and signs of shock.

Selected causes of acute abdomen

Recurrent Abdominal Pain in Female Adolescents

Recurrent abdominal pain (RAP) occurs in 5–15% of female children 6–19 years old. In a community-based study of middle and high school students, 13–17% had weekly abdominal pain. Using criteria for irritable bowel syndrome (IBS), 14% of high school students and 6% of middle school students fit the criteria for adult IBS. As with other difficult to diagnose chronic medical problems, patients with RAP [Recurrent Abdominal Pain] account for a very large number of office visits and medical resources in proportion to their actual numbers.

Chronic Functional Abdominal Pain

Chronic functional abdominal pain (CFAP) is the ongoing presence of abdominal pain for which there is no known medical explanation. It is quite similar to, but less common than, Irritable Bowel Syndrome (IBS), and many of the same treatments for IBS can also be of benefit to those with CFAP. The fundamental difference between IBS and CFAP is that in CFAP, unlike in IBS, there is no change in bowel habits such as constipation or diarrhea. Bowel dysfunction is a necessary diagnostic criteria of IBS.

CFAP is characterized by chronic pain, with no physical explanation or findings (no structural, infectious, or mechanical causes can be found). It is theorized that CFAP is a disorder of the nervous system where normal nerve impulses are amplified "like a stereo system turned up too loud" resulting in pain. This visceral hypersensitivity may be a stand-alone cause of CFAP, or CFAP may result from the same type of brain-gut nervous system disorder that underlies IBS. As with IBS, low doses of antidepressants have been found useful in controlling the pain of CFAP.

Non-pharmaceutical approaches to CFAP also overlap with treatments for Irritable Bowel Syndrome. This includes enteric coated peppermint oil capsules, which act as anti-spasmodics to relax the gut and also have pain-killing properties due to the methyl salicylate that naturally occurs in peppermint. Gut-directed hypnotherapy or self-hypnosis can also mitigate the hyperreactive nervous system of CFAP, and help alleviate abdominal pain.

Etiology

Medical Assessment

When a physician assesses a patient to determine the etiology and subsequent treatment for abdominal pain the patients history of the presenting complaint and physical examination should derive a diagnosis in over 90% of cases.

It is important also for a physician to remember that abdominal pain can be caused by problems outside the abdomen, especially heart attacks and pneumonias which can occasionally present as abdominal pain.

Anamnesis

  • Note the following during a complete history and physical examination:
  • Symptom progression
  • Associated complaints
  • Urinary complaints
  • Exposure to medications and illness
  • Past medical history (including previous episodes of discomfort)

Physical Examination and Diagnostic Tests

Other Tests

If diagnosis remains unclear after history, examination and basic investigations as above then more advanced investigations may reveal a diagnosis. These as such would include

See also

References

  1. ↑ Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:5 ISBN 140510368X
  2. ↑ Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:6 ISBN 1591032016
  3. ↑ Raftery, Andrew, Lim, Eric. Churchill's Pocketbook of Differential Diagnosis. London, UK: Elsevier Limited, 2005:17-21 ISBN 0443100616

Additional Reading

  • Apley J, Naish N: Recurrent abdominal pains: A field survey of 1,000 school children. Arch Dis Child 1958;33:165 - 170.
  • Chronic Pelvic Pain and Recurrent Abdominal Pain in Female Adolescents
  • Boyle JT, Hamel-Lambert J: Biopsychosocial issues in functional abdominal pain. Pediatr Ann 2001;30:1.
  • [4] Stomach ache or abdominal pain can be misdiagnosed.Consult a Gastroenterologist rather than ER doctor if Pain persists more than a day.

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