Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues. Since the abdomen contains most of the body's vital organs, it can be an indicator of a wide variety of diseases. Given that, approaching the examination of a person and planning of a differential diagnosis is extremely important.
Common causes of pain in the abdomen include gastroenteritis and irritable bowel syndrome.[ About 15% of people have a more serious underlying condition such as appendicitis, leaking or ruptured abdominal aortic aneurysm, diverticulitis, or ectopic pregnancy.][ In a third of cases, the exact cause is unclear.][
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Signs and symptoms
The onset of abdominal pain can be abrupt, quick, or gradual. Sudden onset pain happens in a split second. Rapidly onset pain starts mild and gets worse over the next few minutes. Pain that gradually intensifies only after several hours or even days has passed is referred to as gradual onset pain.
One can describe abdominal pain as either continuous or sporadic and as , dull, or aching. The characteristic of cramping abdominal pain is that it comes in brief waves, builds to a peak, and then abruptly stops for a period during which there is no more pain. The pain flares up and off periodically. The most common cause of persistent dull or aching abdominal pain is edema or distention of the wall of a hollow viscus. A dull or aching pain may also be felt due to a stretch in the liver and spleen capsules.
Causes
The most frequent reasons for abdominal pain are gastroenteritis (13%), irritable bowel syndrome (8%), urinary tract problems (5%), gastritis (5%) and constipation (5%). In about 30% of cases, the cause is not determined. About 10% of cases have a more serious cause including gallbladder ( or biliary dyskinesia) or pancreas problems (4%), diverticulitis (3%), appendicitis (2%) and cancer (1%).
Acute abdomen
Acute abdomen is a condition where there is a sudden onset of severe abdominal pain requiring immediate recognition and management of the underlying cause.[
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The pain may elicit nausea and vomiting, abdominal distention, fever and signs of shock.[ A common condition associated with acute abdominal pain is appendicitis.]
By system
A more extensive list includes the following:
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Gastrointestinal
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GI tract
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Inflammatory: gastroenteritis, appendicitis, gastritis, esophagitis, diverticulitis, Crohn's disease, ulcerative colitis, microscopic colitis
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Obstruction: hernia, intussusception, volvulus, post-surgical adhesions, , severe constipation, hemorrhoids
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Vascular: embolism, thrombosis, hemorrhage, sickle cell disease, abdominal angina, blood vessel compression (such as celiac artery compression syndrome), superior mesenteric artery syndrome, postural orthostatic tachycardia syndrome
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digestion: peptic ulcer, lactose intolerance, coeliac disease, food allergies, indigestion
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Glands
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Bile system
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Liver
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Pancreatic
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Renal and urological
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Gynaecological or obstetric
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Abdominal wall
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Referred pain
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Metabolic disturbance
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Blood vessels
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aortic dissection, abdominal aortic aneurysm
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Immune system
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Idiopathic
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irritable bowel syndrome (IBS) (affecting up to 20% of the population, IBS is the most common cause of recurrent and intermittent abdominal pain)
By location
The location of abdominal pain can provide information about what may be causing the pain. The abdomen can be divided into four regions called quadrants. Locations and associated conditions include:
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Diffuse
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Epigastric
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Right upper quadrant
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Liver: hepatomegaly, fatty liver, hepatitis, liver cancer, abscess
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Gallbladder and biliary tract: Cholecystitis, , Helminthiasis, cholangitis
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Colon: bowel obstruction, functional disorders, Bloating, spasm, inflammation, colon cancer
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Other: pneumonia, Fitz-Hugh-Curtis syndrome
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Left upper quadrant
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Splenomegaly
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Colon: bowel obstruction, functional disorders, gas accumulation, spasm, inflammation, colon cancer
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Peri-umbilical (the area around the umbilicus, i.e., the belly button)
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Appendicitis
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Pancreatitis
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Inferior myocardial infarction
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Peptic ulcer
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Diabetic ketoacidosis
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Vascular: aortic dissection, aortic rupture
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Bowel: mesenteric ischemia, Coeliac disease, inflammation, intestinal spasm, functional disorders, small bowel obstruction
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Lower abdominal pain
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Right lower quadrant
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Colon: intussusception, bowel obstruction, appendicitis (McBurney's point)
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Renal: kidney stone (nephrolithiasis), pyelonephritis
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Pelvic: cystitis, bladder stone, bladder cancer, pelvic inflammatory disease, pelvic pain syndrome
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Gynecologic: endometriosis, intrauterine pregnancy, ectopic pregnancy, ovarian cyst, ovarian torsion, fibroid (leiomyoma), abscess, ovarian cancer, endometrial cancer
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Left lower quadrant
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Right low back pain
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Liver: hepatomegaly
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Kidney: kidney stone (nephrolithiasis), complicated urinary tract infection
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Left low back pain
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Spleen
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Kidney: kidney stone (nephrolithiasis), complicated urinary tract infection
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Low back pain
Mechanism
Abdominal pain can be referred to as visceral pain or Peritoneum pain. The contents of the abdomen can be divided into the foregut, midgut, and hindgut.
Each subsection of the gut has an associated visceral afferent nerve that transmits sensory information from the viscera to the spinal cord.
Diagnosis
A thorough patient history and physical examination is used to better understand the underlying cause of abdominal pain.
The process of gathering a history may include:
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Identifying more information about the chief complaint by eliciting a history of present illness; i.e. a narrative of the current symptoms such as the onset, location, duration, character, aggravating or relieving factors, and temporal nature of the pain. Identifying other possible factors may aid in the diagnosis of the underlying cause of abdominal pain, such as recent travel, recent contact with other ill individuals, and for females, a thorough Gynaecology history.
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Learning about the patient's past medical history, focusing on any prior issues or surgical procedures.
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Clarifying the patient's current medication regimen, including prescriptions, over-the-counter medications, and supplements.
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Confirming the patient's drug and food allergies.
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Discussing with the patient any family history of disease processes, focusing on conditions that might resemble the patient's current presentation.
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Discussing with the patient any health-related behaviors (e.g. tobacco use, alcohol consumption, drug use, and sexual activity) that might make certain diagnoses more likely.
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Reviewing the presence of non-abdominal symptoms (e.g., fever, chills, chest pain, shortness of breath, vaginal bleeding) that can further clarify the diagnostic picture.
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Using Carnett's sign to differentiate between visceral pain and pain originating in the muscles of the abdominal wall.
After gathering a thorough history, one should perform a physical exam in order to identify important physical signs that might clarify the diagnosis, including a cardiovascular exam, lung exam, thorough abdominal exam, and for females, a genitourinary exam.
Additional investigations that can aid diagnosis include:
If diagnosis remains unclear after history, examination, and basic investigations as above, then more advanced investigations may reveal a diagnosis. Such tests include:
Management
The management of abdominal pain depends on many factors, including the etiology of the pain. Some behavioural changes implemented to prevent pain include: resting after a meal, chewing food completely and slowly, and avoiding stressful and high excitement situations after a meal. Such at home strategies may reduce the need to seek professional assistance via prevention of future abdominal pain.
Emergencies
Below is a brief overview of abdominal pain emergencies.
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!Condition
!Presentation
!Diagnosis
!Management |
Appendicitis | Abdominal pain, nausea, vomiting, fever
Periumbilical pain, migrates to RLQ | Clinical (history and physical exam)
Abdominal CT | Patient made NPO (nothing by mouth)
IV fluids as needed
General surgery consultation, possible appendectomy
Antibiotics
Pain control |
Cholecystitis | Abdominal pain (RUQ, radiates epigastric), nausea, vomiting, fever, Murphy's sign | Clinical (history and physical exam)
Imaging (RUQ ultrasound)
Labs (leukocytosis, transamintis, hyperbilirubinemia) | Patient made NPO (nothing by mouth)
IV fluids as needed
General surgery consultation, possible cholecystectomy
Antibiotics
Pain, nausea control |
Acute pancreatitis | Abdominal pain (sharp epigastric, shooting to back), nausea, vomiting | Clinical (history and physical exam)
Labs (elevated lipase)
Imaging (abdominal CT, ultrasound) | Patient made NPO (nothing by mouth)
IV fluids as needed
Pain, nausea control
Possibly consultation of Surgery or interventional radiology |
Bowel obstruction | Abdominal pain (diffuse, crampy), Bile Vomiting, constipation | Clinical (history and physical exam)
Imaging (abdominal X-ray, abdominal CT) | Patient made NPO (nothing by mouth)
IV fluids as needed
Nasogastric tube placement
General surgery consultation
Pain control |
Upper GI bleed | Abdominal pain (epigastric), hematochezia, melena, hematemesis, hypovolemia | Clinical (history & physical exam, including digital rectal exam)
Labs (complete blood count, coagulation profile, , stool guaiac) | Aggressive IV fluid resuscitation
Blood transfusion as needed
Medications: proton pump inhibitor, octreotide
Stable patient: observation
Unstable patient: consultation (general surgery, gastroenterology, interventional radiology) |
Lower GI bleed | Abdominal pain, hematochezia, melena, hypovolemia | Clinical (history and physical exam, including digital rectal exam)
Labs (complete blood count, coagulation profile, , stool guaiac) | Aggressive IV fluid resuscitation
Blood transfusion as needed
Medications: proton pump inhibitor
Stable patient: observation
Unstable patient: consultation (general surgery, gastroenterology, interventional radiology) |
Perforated Viscous | Abdominal pain (sudden onset of localized pain), abdominal distension, rigid abdomen | Clinical (history and physical exam)
Imaging (abdominal X-ray or CT showing free air)
Labs (complete blood count) | Aggressive IV fluid resuscitation
General surgery consultation
Antibiotics |
Volvulus | Sigmoid colon volvulus: Abdominal pain (>2 days, distention, constipation)
Cecal volvulus: Abdominal pain (acute onset), nausea, vomiting | Clinical (history and physical exam)
Imaging (abdominal X-ray or CT) | Sigmoid: Gastroenterology consultation (Sigmoidoscopy)
Cecal: General surgery consultation (Colectomy) |
Ectopic pregnancy | Abdominal and pelvic pain, bleeding
If ruptured ectopic pregnancy, the patient may present with peritoneal irritation and hypovolemic shock | Clinical (history and physical exam)
Labs: complete blood count, urine pregnancy test followed with quantitative blood beta-hCG
Imaging: transvaginal ultrasound | If patient is unstable: IV fluid resuscitation, urgent obstetrics and gynecology consultation
If patient is stable: continue diagnostic workup, establish OBGYN follow-up |
Abdominal aortic aneurysm | Abdominal pain, flank pain, back pain, hypotension, pulsatile abdominal mass | Clinical (history and physical exam)
Imaging: Ultrasound, CT angiography, MRA/magnetic resonance angiography | If patient is unstable: IV fluid resuscitation, urgent surgical consultation
If patient is stable: admit for observation |
Aortic dissection | Abdominal pain (sudden onset of epigastric or back pain), hypertension, new aortic Heart murmur | Clinical (history and physical exam)
Imaging: Chest X-ray (showing widened mediastinum), CT angiography, MRA, transthoracic echocardiogram/TTE, transesophageal echocardiogram/TEE | IV fluid resuscitation
Blood transfusion as needed (obtain type and cross)
Medications: reduce blood pressure (sodium nitroprusside plus beta blocker or calcium channel blocker)
Surgery consultation |
Liver injury | After trauma (Blunt trauma or penetrating), abdominal pain (RUQ), right rib pain, right flank pain, right shoulder pain | Clinical (history and physical exam)
Imaging: FAST examination, CT of abdomen and pelvis
Diagnostic peritoneal aspiration and lavage | Resuscitation (advanced trauma life support) with IV fluids (crystalloid) and blood transfusion
If patient is unstable: General surgery or trauma surgery consultation with subsequent exploratory laparotomy |
Splenic injury | After trauma (Blunt trauma or penetrating), abdominal pain (LUQ), left rib pain, left flank pain | Clinical (history and physical exam)
Imaging: FAST examination, CT of abdomen and pelvis
Diagnostic peritoneal aspiration and lavage | Resuscitation (advanced trauma life support) with IV fluids (crystalloid) and blood transfusion
If patient is unstable: General surgery or trauma surgery consultation with subsequent exploratory laparotomy and possible splenectomy
If patient is stable: medical management, consultation of interventional radiology for possible Embolization |
Outlook
One well-known aspect of primary health care is its low prevalence of potentially dangerous abdominal pain causes. Patients with abdominal pain have a higher percentage of unexplained complaints (category "no diagnosis") than patients with other symptoms (such as dyspnea or chest pain).
Epidemiology
Abdominal pain is the reason about 3% of adults see their family physician.[ Rates of emergency department (ED) visits in the United States for abdominal pain increased 18% from 2006 through to 2011. This was the largest increase out of 20 common conditions seen in the ED. The rate of ED use for nausea and vomiting also increased 18%.]
Special populations
Geriatrics
More time and resources are used on older patients with abdominal pain than on any other patient presentation in the emergency department (ED).
Age does not reduce the total number of , but it does reduce their functionality. The elderly person's ability to fight infection is weakened as a result.
The challenge of obtaining a sufficient history from an elderly patient can be attributed to multiple factors. Reduced memory or hearing could make the issue worse. It is common to encounter stoicism combined with a fear of losing one's independence if a serious condition is discovered. Changes in mental status, whether acute or chronic, are common.
Pregnancy
Unique clinical challenges arise when pregnant women experience abdominal pain. First off, there are many possible causes of abdominal pain during pregnancy. These include intraabdominal diseases that arise incidentally during pregnancy as well as obstetric or gynecologic disorders associated with pregnancy. Secondly, pregnancy modifies the natural history and clinical manifestation of numerous abdominal disorders.
See also
Further reading
External links
