Abdominal pain classification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Abdominal pain can be classified into three categories: acute abdomen, recurrent, and chronic functional. Acute abdomen refers to a sudden, severe pain in the abdomen that is less than 24 hours in duration. It is in many cases an emergency condition requiring urgent and specific diagnosis, and the treatment usually involves surgery.

Classification

Abdominal pain is traditionally described by its:

• Chronicity (acute or chronic)
• Progression over time
• Nature (sharp, dull, colicky)
• Characterization of the factors that make the pain worse or alleviate it
• Distribution determined by various methods:
  • Such as abdominal quadrant (left upper quadrant, left lower quadrant, right upper quadrant, right lower quadrant)
  • Other methods that divide the abdomen into nine sections

Acute abdomen

Peritonitis

Acute abdomen is occasionally used synonymously with peritonitis. This is not incorrect; however, peritonitis is the more specific term, referring to inflammation of the peritoneum. It is diagnosed on physical examination as rebound tenderness, or pain upon removal of pressure rather than application of pressure to the abdomen. Peritonitis may result from several diseases, notably appendicitis and pancreatitis.

Ischemic Acute abdomen

Vascular disorders are more likely to affect the small bowel than the large bowel. Arterial supply to the intestines is provided by the superior and inferior mesenteric arteries, (SMA and IMA respectively) both of which are direct branches of the aorta.

The superior mesenteric artery supplies:

1. Small bowel
2. Ascending and proximal 2/3 of the transverse colon

The inferior mesenteric artery supplies:

1. Distal 1/3 of the transverse colon
2. Descending colon
3. Sigmoid colon

Of note, the splenic flexure, or the junction between the transverse and descending colon, is supplied by the most distal portions of both the inferior mesenteric artery and superior mesenteric artery. It is referred to medically as a watershed area, or an area especially vulnerable to ischemia during periods of systemic hypoperfusion, such as in shock (medical).

Acute abdomen of the ischemic variety is usually due to:

1. A thromboembolism from the left side of the heart, such as may be generated during atrial fibrillation, occluding the SMA.
2. Nonocclusive ischemia, such as that seen in hypotension secondary to heart failure may also contribute, but usually results in a mucosal or mural infarct, as contrasted with the typically transmural infarct seen in thromboembolus of the SMA.
3. Primary mesenteric vein thromboses may also cause ischemic acute abdomen, usually precipitated by hypercoagulable states such as polycythemia vera