Abdominal pain

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Abdominal pain
ICD-10 R10
ICD-9 789.0

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2] M.Umer Tariq [3]

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

[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

Complete Differential Diagnosis of the causes of abdominal pain

(In alphabetical order)


Complete Differential Diagnosis of the Causes of abdominal pain

(By organ system)

Cardiovascular

Abdominal Aortic Aneurysm, Budd-Chiari syndrome,

Chemical / poisoning

Amanita phalloides, Arsenic Poisoning, Barium nitrate, Cresol, Fluoride poisoning, Grape seed extract, Lead poisoning, Oleander, Parathion, Pesticide, Pyridine, Snakebites, Spider bite, Tributyl phosphate,

Dermatologic No underlying causes
Drug Side Effect

Acetylsalicylic acid Aciclovir Aminocaproic acid, Auranofin, Azithromycin, Bezafibrate, Caspofungin, Cefdinir, Cefuroxime, Cladribine (patient information), Clidinium, Clindamycin, Clofibrate, Contraceptive patch, Dactinomycin (patient information), Danazol (patient information), Daptomycin, Diflunisal, Donepezil, Drotrecogin alfa, Dydrogesterone, Enoxaparin, Erythromycin, Ethcathinone, Etoposide Phosphate (patient information), Flucytosine, Fluvastatin, Halofantrine, Hydroxychloroquine, Idarubicin (patient information), Isoniazid, Itraconazole, Loperamide, Lopinavir, Loprazolam, Magnesium citrate, Mercaptopurine, Methimazole (patient information), Methylphenidate, Mifepristone, Misoprostol, Moxifloxacin, Nafcillin, Muscarine, Neuromuscular-blocking drugs, Niclosamide, Nitazoxanide, Octreotide injection (patient information), Omeprazole, Orlistat (patient information), Pegaspargase (patient information), Pentavalent antimonial, Pentostatin (patient information), Perindopril, Phenazocine, Praziquantel, Prazosin and polythiazide (patient information), Procainamide (patient information), Procarbazine (patient information), Propylthiouracil (patient information), Roxithromycin, Simvastatin, Sorafenib (patient information), Sucralfate (patient information), Sulfasalazine (patient information), Thiotepa (patient information), Tianeptine, Topiramate, Topotecan Hydrochloride (patient information), Trastuzumab (patient information), Triclofos, Vardenafil, Vigabatrin, Vinblastine (patient information), Voriconazole,

Ear Nose Throat No underlying causes
Endocrine No underlying causes
Environmental No underlying causes
Gastroenterologic

Abdominal cramps, Abdominal cutaneous nerve entrapment syndrome, Abdominal mass, Accessory pancreas, Acute pancreatitis, Appendicitis, Autoimmune Hepatitis, Autoimmune pancreatitis, Bacterial gastroenteritis, Bowel obstruction, Caecitis, Carcinoid syndrome, Celiac disease, Charcot's triad, Cholangiocarcinoma, Cholangitis, Cholecystitis, Choledochal cysts, Chronic pancreatitis, Cirrhosis, Clostridial necrotizing enteritis, Colitis, Colonic polyps, Colorectal cancer, Constipation, Crohn's disease, Diverticulitis, Duodenitis, Dyspepsia, Enteritis, Epiploic appendagitis, Gastric outlet obstruction, Gastritis, Gastroenteritis, Gastrointestinal perforation, Gastrointestinal stromal tumor, Hemosuccus pancreaticus, Ileitis, Ileus, Intestinal malrotation, Intestinal pseudoobstruction, Intussusception (medical disorder), Irritable bowel syndrome, Ischemic colitis, König's syndrome, Krukenberg tumor, Malabsorption, Meckel's diverticulum, Mesenteric ischemia, Ogilvie syndrome, Pancreatic cancer, Pancreatitis, Peptic ulcer, Peritonitis, Porcelain gallbladder, Proctitis, Pseudomembranous colitis, Pseudomyxoma peritonei, Toxic megacolon, Ulcerative colitis, Volvulus, Whipple's disease,

Genetic

Gilbert's syndrome, Marfan syndrome, Periodic fever syndrome, Pyruvate carboxylase deficiency, Slone's Disease,

Hematologic

Capillary leak syndrome, Cholesterol Emboli Syndrome, Mastocytosis, Porphyria,

Iatrogenic

Adjustable gastric band, Postcholecystectomy syndrome, Short bowel syndrome, Transfusion-associated graft versus host disease,


Infectious Disease

African horse sickness, Anisakis, Ascaris infection, Astroviridae, Bacillus cereus, Blastocystosis, Brachylaima, Campylobacteriosis, Cat scratch fever, Cestoda, Clostridium difficile, Colorado tick fever, Cryptosporidium parvum, Dengue fever, Ebola, Entamoeba histolytica, Familial Mediterranean fever, Fasciolopsiasis, Fasciolosis, Fungemia, Fusarium, Giardia lamblia, Hantavirus pulmonary syndrome, Helicobacter pylori infection, Henipavirus, Hookworm, Hymenolepiasis, Isosporiasis, Leptospirosis, Mycobacterium avium complex, Norovirus, Opisthorchis infection, Paragonimus Infection, Q Fever, Rheumatic fever, Rocky Mountain spotted fever, Salmonellosis, Scarlet fever, Schistosomiasis, Scombrotoxic fish poisoning, Shigellosis, Strongyloidiasis, Toxocariasis, Trichomoniasis, Typhoid fever, Vibrio vulnificus, Viral Hepatitis , Whipworm Infection, Yellow fever, Yersiniosis,

Musculoskeletal / Ortho No underlying causes
Neurologic

Autonomic neuropathy,

Nutritional / Metabolic

Diabetic ketoacidosis, Food allergy, Food intolerance, Lactic acidosis, Metabolic acidosis, Pantothenic acid, Zieve's syndrome,

Obstetric/Gynecologic

Cervical cancer, Ectopic pregnancy, Endometrial cancer, Endometriosis, Menstruation, Ovarian cancer, Ovarian cyst, Ovarian hyperstimulation syndrome, Ovarian torsion, Pelvic inflammatory disease, Placental abruption, Pregnancy, Salpingitis, Uterine fibroids, Uterine rupture, Uterine sarcoma,

Oncologic

Desmoplastic small round cell tumor, Liposarcoma, Liver tumor, Mesothelioma, Sacrococcygeal teratoma,

Opthalmologic No underlying causes
Overdose / Toxicity

4-Nitrophenol, Cicutoxin, Cinchonism, Clitocybe dealbata, Colchicine, Hebeloma crustuliniforme, Sorbitol, Statins (patient information), Tegaserod (patient information), Tetrodotoxin, Vitamin A,

Psychiatric No underlying causes
Pulmonary

Empyema, Pleuritis, Basal pneumonia Pulmonary embolism Pulmonary infarction Tuberculosis

Renal / Electrolyte

Hydronephrosis, Hypercalcemia, Hyperkalemia, Hypocalcemia, Nutcracker syndrome, Polycystic kidney disease, Pyelonephritis, Ureterocele, Urinary tract infection,

Rheum / Immune / Allergy

Polyarteritis nodosa, Systemic lupus erythematosus,

Sexual No underlying causes
Trauma No underlying causes
Urologic

Prostate cancer, Prostatitis,

Miscellaneous

Alcoholic Hepatitis, Chronic Fatigue Syndrome, Chronic functional abdominal pain, Foreign body, Ruptured spleen, Side stitch, Situs inversus, Zollinger-Ellison syndrome,

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

Appearance of the Patient

  • Signs of dehydration and fever
  • Patient's body position tends to relieve the pain

Abdomen

Laboratory Findings

Electrolyte and Biomarker Studies

Investigations that would aid the diagnosis include:

Urinalysis and blood tests with markers for:

Electrocardiogram

An electrocardiograph is needed to rule out a heart attack, which can occasionally present as abdominal pain.

Chest X Ray

Imaging including an erect chest X-ray and plain films of the abdomen can aid in the diagnosis.

Ultrasound

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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