- Abdominal pain
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.
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 medicinedoctors, 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
#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.
#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 appendicitisand gastroenteritisand are somewhat relieved by writhing and massage.
#The pain associated with abdominal vascular disturbances (
thrombosisor embolism) can be sudden or gradual in onset, and can be severe or mild. Pain associated with the rupture of an abdominal aortic aneurysmmay radiate to the back, flank, or genitals.
#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 bladderpain—in cholecystitisor cholelithiasis—is often referred to the shoulder).
The following is an incomplete list of possible causes of abdominal pain.Cartwright SL, Knudson MP. [http://www.aafp.org/afp/20080401/971.html Evaluation of Acute Abdominal Pain in Adults] . Am Fam Physician. 2008;77(7):971-978.]
gastroenteritis, appendicitis, gastritis, esophagitis, diverticulitis, Crohn's disease, ulcerative colitis, microscopic colitis
hernia, intussusception, volvulus, post-surgical adhesions, tumours, superior mesenteric artery syndrome, severe constipation
embolism, thrombosis, hemorrhage, sickle cell disease, abdominal angina, blood vessel compression (such as celiac artery compression syndrome)
digestive: peptic ulcer, lactose intolerance, celiac sprue, Jasohnstritis
hepatitis, liver abscess
*Renal and urological
pyelonephritis, bladder infection
**Obstruction: kidney stones,
urolithiasis, Urinary retention, tumours
left renal vein entrapment
*Gynecological or obstetric
pelvic inflammatory disease
**Mechanical: ovarian torsion
endometriosis, fibroids, ovarian cyst, ovarian cancer
ectopic pregnancy, threatened abortion
**muscle strain or trauma
neurogenicpain: herpes zoster, radiculitisin Lyme disease, abdominal cutaneous nerve entrapment syndrome(ACNES), tabes dorsalis
thorax: pneumonia, pulmonary embolism, ischemic heart disease, pericarditis
**from the spine:
genitals: testicular torsion
uremia, diabetic ketoacidosis, porphyria, C1-esterase inhibitor deficiency, adrenal insufficiency, lead poisoning, black widow spiderbite, narcotic withdrawal
aortic dissection, abdominal aortic aneurysm
familial Mediterranean fever
irritable bowel syndrome(affecting up to 20% of the population, IBS is the most common cause of recurrent, intermittent abdominal pain)
Acute abdomencan 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 nauseaand vomiting, abdominal distention, feverand signs of shock.
Selected causes of acute abdomen
*Traumatic : blunt or perforating trauma to the
stomach, bowel, spleen, liver, or kidney
** Infections such as
appendicitis, cholecystitis, pancreatitis, pyelonephritis, pelvic inflammatory disease, hepatitis, mesenteric adenitis, or a subdiaphragmatic abscess
** Perforation of a
peptic ulcer, a diverticulum, or the caecum
** Complications of
inflammatory bowel diseasesuch as Crohn's diseaseor ulcerative colitis
Small bowelobstruction secondary to adhesions caused by previous surgeries, intussusception, hernias, benign or malignant neoplasms
Large bowelobstruction caused by colorectal cancer, inflammatory bowel disease, volvulus, fecal impactionor hernia
*Vascular : occlusive intestinal ischemia, usually caused by
thromboembolismof the superior mesenteric artery
Recurrent Abdominal Pain in Children and Adolescents
Recurrent abdominal pain (RAP) occurs in 5–15% of 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 account for a very large number of office visits and medical resources in proportion to their actual numbers. Most patients with RAP benefit from reassurance and techniques to manage anxiety and stress, which are frequently associated with episodes.
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 attacksand pneumonias which can occasionally present as abdominal pain.
Investigations that would aid diagnosis include
*Blood tests including full blood count,
electrolytes, urea, creatinine, liver function tests, pregnancy testand lipase.
*Imaging including erect chest
X-rayand plain films of the abdomen
electrocardiographto rule out a heart attack which can occasionally present as abdominal pain
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
Computed Tomographyof the abdomen/pelvis
*Abdominal or pelvic
Endoscopyand colonoscopy(not used for diagnosing acute pain)
Chronic functional abdominal pain
Irritable bowel syndrome
* Apley J, Naish N: Recurrent abdominal pains: A field survey of 1,000 school children. "Arch Dis Child" 1958;33:165 - 170.
* [http://www.health.am/gyneco/chronic-pelvic-pain/ 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.
* [http://www.suburbanchicagonews.com/beaconnews/lifestyles/438133,2_5_AU22_DUNCAN_S1.article] 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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