Abdominal pain
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]; Iqra Qamar M.D.[4] Amandeep Singh M.D.[5]
Synonyms and keywords: Abdominal cramping; abdominal cramps; belly ache; abdominal discomfort; abdominal fullness
Overview
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Abdominal pain can be one of the symptoms associated with many transient disorders or serious diseases. Making a definitive diagnosis of the cause of abdominal pain can be difficult because many diseases present with this symptom, abdominal pain is a common problem. Most frequently the cause of the pain is benign and/or self-limited, but in cases of serious causes urgent intervention may be required.
Classification
Abdominal pain can be classified into three categories: acute abdomen, recurrent, and chronic functional. Abdominal pain is traditionally described by its chronicity (acute or chronic), progression over time, nature (sharp, dull, colicky), characterization of the factors that worsen or alleviate pain, and distribution of the pain.
Causes
The causes of abdominal pain vary with the distribution of the pain. The distribution can be determined by various methods, such as abdominal quadrants. Other methods exist that divide the abdomen into nine sections.
Differentiating Abdominal pain from other Diseases
Chronic functional abdominal pain 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.
Diagnosis
Physical Examination
When a physician assesses a patient to determine the etiology and subsequent treatment for abdominal pain, the patient’s history of the presenting complaint and their 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.
Electrocardiogram
An electrocardiograph is needed to rule out a heart attack, which can occasionally present as abdominal pain.
X Ray
Imaging including an erect chest X-ray and plain films of the abdomen can aid in the diagnosis of the disorder causing the abdominal pain.
References
Classification
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. Abdominal pain is traditionally described by its chronicity (acute or chronic), progression over time, nature (sharp, dull, colicky), characterization of the factors that worsen or alleviate pain, and distribution of the pain.
Classification
Acute Abdomen
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.
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.
Recurrent Abdominal Pain
As with other difficult to diagnose chronic medical problems, patients with recurrent abdominal pain (RAP) account for a very large number of office visits and medical resources in proportion to their actual numbers. RAP can be classified under the Rome II criteria as one of the following:[1]
- Abdominal migraine
- Aerophagia
- Functional abdominal pain
- Functional dyspepsia
- Irritable bowel syndrome
Chronic Fuctional Abdominal Pain
Chronic functional abdominal pain (CFAP) is the ongoing presence of abdominal pain for which there is no known medical explanation.
References
- ↑ Bufler P, Gross M, Uhlig HH (2011). “Recurrent abdominal pain in childhood”. Dtsch Arztebl Int. 108 (17): 295–304. doi:10.3238/arztebl.2011.0295. PMC 3103980. PMID 21629513.
Pathophysiology
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Pathophysiology
The pain associated with the abdomen in cases of inflammation of the parietal peritoneum (the part of the peritoneum lining the abdominal wall) is steady and aching and is worsened by changes in the tension of the peritoneum caused by pressure or positional change. This pain is often accompanied by tension of the abdominal muscles contracting in an effort to relieve such tension. The pain associated with the 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 in early acute appendicitis and gastroenteritis and are somewhat relieved by writhing and massages. 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). 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.
Acute Abdomen
Ischemic Acute Abdomen
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:
- Small bowel
- Ascending and proximal 2/3 of the transverse colon
The inferior mesenteric artery supplies:
- Distal 1/3 of the transverse colon
- Descending colon
- 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:
- A thromboembolism from the left side of the heart, such as may be generated during atrial fibrillation, occluding the SMA.
- 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.
- Primary mesenteric vein thromboses may also cause ischemic acute abdomen, usually precipitated by hypercoagulable states such as polycythemia vera.
Chronic Functional Abdominal Pain
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.
References
Causes
Diffuse | Left Upper Quadrant | Left Flank | Left Lower Quadrant | Epigastric Region | Umbilical Region | Pelvic Region | Right Upper Quadrant | Right Flank | Right Lower Quadrant
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]
Overview
Life threatening causes of abdominal pain include acute peritonitis, bowel obstruction, diabetic ketoacidosis and testicular torsion. Other common causes of abdominal pain include appendicitis, constipation, dysmenorrhea and lactose intolerance.
Causes
Causes Based upon Location
Diffuse | Left Upper Quadrant | Left Flank | Left Lower Quadrant | Epigastric Region | Umbilical Region | Pelvic Region | Right Upper Quadrant | Right Flank | Right Lower Quadrant
Life Threatening Causes
Common Causes
- Appendicitis
- Celiac disease
- Constipation
- Crohn’s disease
- Dysmenorrhea
- Endometriosis
- Food allergies
- Food poisoning
- Gastroesophageal reflux
- Irritable bowel syndrome
- Lactose intolerance
- Urinary tract infection
Causes by Organ System
Causes in Alphabetical Order
Acute Abdomen
Common causes of acute abdomen include:
- Acute appendicitis
- Acute cholecystitis
- Acute diverticulitis
- Acute intestinal ischemia
- Acute pancreatitis
- Acute peptic ulcer and its complications
- Acute peritonitis
- Acute ureteral colic
- Bowel perforation with free air or bowel contents in the abdominal cavity
- Bowel volvulus
- Diabetic ketoacidosis
- Ectopic pregnancy with tubal rupture
Chronic Functional Abdominal Pain
Common causes of CFAP stem from:
- Abdominal etiologies
- Gynecologic etiologies
- Dysmenorrhea
- Endometriosis
- Müllerian abnormalities
- Ovarian abnormalities
- Pelvic inflammatory disease
References
Differentiating Abdominal pain from other Diseases
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]Seyedmahdi Pahlavani, M.D. [3]Iqra Qamar M.D.[4]
Overview
Diagnosing the cause of abdominal pain can be difficult, because many diseases can cause this symptom. Most frequently the cause is benign and/or self-limiting, but more serious causes may require urgent intervention. Acute abdominal pain is a severe, persistent abdominal pain of sudden onset that is likely to require surgical intervention to treat its cause. The following table summarizes differential diagnosis for abdominal pain.
Differential Diagnosis of Abdominal Pain
To review the differential diagnosis of Abdominal pain, click here.
To review the differential diagnosis of Abdominal pain and fever, click here.
To review the differential diagnosis of Abdominal pain, nausea and vomiting, click here.
To review the differential diagnosis of Abdominal pain and jaundice, click here.
To review the differential diagnosis of Abdominal pain and weight loss, click here.
To review the differential diagnosis of Abdominal pain and constipation, click here.
To review the differential diagnosis of Abdominal pain and diarrhea, click here.
To review the differential diagnosis of Abdominal pain and GI bleeding, click here.
To review the differential diagnosis of Abdominal pain, fever and jaundice, click here.
To review the differential diagnosis of Abdominal pain, fever, nausea and vomiting, click here.
To review the differential diagnosis of Abdominal pain, fever, and diarrhea, click here.
To review the differential diagnosis of Abdominal pain, fever and constipation, click here.
To review the differential diagnosis of Abdominal pain, fever and weight loss, click here.
To review the differential diagnosis of Abdominal pain, fever and GI bleeding, click here.
To review the differential diagnosis of Abdominal pain, nausea,vomiting and jaundice, click here.
To review the differential diagnosis of Abdominal pain, nausea,vomiting and weight loss, click here.
To review the differential diagnosis of Abdominal pain, nausea,vomiting and constipation, click here.
To review the differential diagnosis of Abdominal pain, nausea,vomiting and diarrhea, click here.
To review the differential diagnosis of Abdominal pain, nausea, vomiting and GI bleeding, click here.
To review the differential diagnosis of Abdominal pain, jaundice and weight loss, click here.
To review the differential diagnosis of Abdominal pain, jaundice and diarrhea, click here.
To review the differential diagnosis of Abdominal pain, jaundice and GI bleeding, click here.
To review the differential diagnosis of Abdominal pain,weight loss and constipation, click here.
To review the differential diagnosis of Abdominal pain,weight loss and diarrhea, click here.
To review the differential diagnosis of Abdominal pain, weight loss and GI bleeding, click here.
To review the differential diagnosis of Abdominal pain, constipation and diarrhea, click here.
To review the differential diagnosis of Abdominal pain, constipation and GI bleeding, click here.
To review the differential diagnosis of Abdominal pain, diarrhea and GI bleeding, click here.
Abdominal Pain
The following table outlines the major differential diagnoses of abdominal pain.
Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram, US = Ultrasound
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The following is a list of diseases that present with acute onset severe lower abdominal pain:
| Disease | Findings |
|---|---|
| Ectopic pregnancy | History of missed menses, positive pregnancy test, ultrasound reveals an empty uterus and may show a mass in the fallopian tubes.[1] |
| Appendicitis | Pain localized to the right iliac fossa, vomiting, abdominal ultrasound sensitivity for diagnosis of acute appendicitis is 75% to 90%.[2] |
| Rupturedovarian cyst | Usually spontaneous, can follow history of trauma, mild chronic lower abdominal discomfort may suddenly intensify, ultrasound is diagnostic.[3] |
| Ovarian cyst torsion | Presents with acute severe unilateral lower quadrant abdominal pain, nausea and vomiting, tender adnexal mass palpated in 90%, ultrasound is diagnostic.[4] |
| Hemorrhagic ovarian cyst | Presents with localized abdominal pain, nausea and vomiting. Hypovolemic shock may be present, abdominal tenderness and guarding are physical exam findings, ultrasound is diagnostic.[4] |
| Endometriosis | Presents with cyclic pain that is exacerbated by onset of menses, dyspareunia. laparoscopic exploration is diagnostic.[4] |
| Acute cystitis | Presents with features of increased urinary frequency, urgency, dysuria, and suprapubic pain.[5][6] |
References
- ↑ Morin L, Cargill YM, Glanc P (2016). “Ultrasound Evaluation of First Trimester Complications of Pregnancy”. J Obstet Gynaecol Can. 38 (10): 982–988. doi:10.1016/j.jogc.2016.06.001. PMID 27720100.
- ↑ Balthazar EJ, Birnbaum BA, Yee J, Megibow AJ, Roshkow J, Gray C (1994). “Acute appendicitis: CT and US correlation in 100 patients”. Radiology. 190 (1): 31–5. doi:10.1148/radiology.190.1.8259423. PMID 8259423.
- ↑ Bottomley C, Bourne T (2009). “Diagnosis and management of ovarian cyst accidents”. Best Pract Res Clin Obstet Gynaecol. 23 (5): 711–24. doi:10.1016/j.bpobgyn.2009.02.001. PMID 19299205.
- ↑ 4.0 4.1 4.2 Bhavsar AK, Gelner EJ, Shorma T (2016). “Common Questions About the Evaluation of Acute Pelvic Pain”. Am Fam Physician. 93 (1): 41–8. PMID 26760839.
- ↑ {{Cite journal | author = W. E. Stamm | title = Etiology and management of the acute urethral syndrome | journal = Sexually transmitted diseases | volume = 8 | issue = 3 | pages = 235–238 | year = 1981 | month = July-September | pmid = 7292216
- ↑ {{Cite journal | author = W. E. Stamm, K. F. Wagner, R. Amsel, E. R. Alexander, M. Turck, G. W. Counts & K. K. Holmes | title = Causes of the acute urethral syndrome in women | journal = The New England journal of medicine | volume = 303 | issue = 8 | pages = 409–415 | year = 1980 | month = August | doi = 10.1056/NEJM198008213030801 | pmid = 6993946
Epidemiology and Demographics
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Epidemiology and Demographics
Age
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 account for a very large number of office visits and medical resources in proportion to their actual numbers.
References
Risk Factors
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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References
Screening
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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References
Natural History, Complications and Prognosis
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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References
Diagnosis
Diagnosis
History and Symptoms | Physical Examination | Laboratory Findings | Electrocardiogram | X Ray | Other Imaging Findings | Other Diagnostic Studies
Treatment
Treatment
Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies
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