A. Types of Pain
- Focal: organ distension (parietal pain)
- Diffuse: organ involvement (visceral pain)
B. Character of Pain
- Burning: Peptic Ulcer, Reflux
- Cramping: Biliary Colic, Irritable Bowel, Inflammatory Bowel, Mesenteric Ischemia
- Colicky: appendicitis, impacted feces, cholecystitis, renal stone
- Aching: appendiceal irritation
- Knife-like: Pancreatitis, Aortic Dissection / Rupture
- Gradual Onset: Infection, primary or secondary, retroperitoneal fibrosis
- Sudden Onset
- Peptic ulcer
- Pancreatitis
- Obstruction
- Perforation
- Ruptured ectopic pregnancy
- Opiate treatment may alter physical exam findings but no significant change in management in patients with abdominal pain [1]
C. Epigastric Pain
- Esophagus
- Achalasia
- Esophageal Spasm
- Tumor
- Scleroderma
- Esophagitis
- Esophageal perforation (usually thoracic pain)
- Lungs
- Lower Lobe Pneumonia
- Collapse
- Pulmonary Infarction (lower lobes)
- Heart
- Angina / Myocardial Infarction - especially in women, Diabetes
- Pericarditis
- Aneurysm
- Gastrointestinal / Dyspepsia
- Gastritis and Gastric Ulcer - usually worse with eating
- Duodenal Ulcer - usually better with eating
- Gastroesphageal Reflux Disease (GERD)
- Gastroparesis
- Gastric Neoplasm
- Gall bladder disease
- Malabsorption syndrome
- Pancreatitis
- Intestinal parasites
- Mesenteric Ischemia - usually worse 1/2 to 2 hours after eating
D. Kidney Pain
- Costovertebral angle (CVA) tenderness
- Radiation anteriorly, including RUQ pain
- Infection: urinalysis, culture
- Renal Stone: often very painful on passing stone
- Obstruction: rule out with ultrasound
- Retroperitoneal fibrosis may mimic kidney pain
E. Clinical Evaluation Of Abdominal Pain
- Women
- If premenopausal or <55 years old, consider a pregnancy test (HCG)
- If last menstrual period was >30 days ago, perform a pregnancy test
- If lower abdominal pain present, perform a urinalysis
- If urinalysis is negative for infection, perform a pelvic exam
- Pregnant patients with abdominal pain should have ultrasound and gynecologic evaluation
- Men with lower abdominal pain should have a genital examination
- All patients with abdominal pain should have a rectal exam and stool guaiac exam
- Orthostatic vital signs should ALWAYS be performed
- Blood on Rectal or Stool Guaiac Positive - complete blood count ± reticulocyte count
- Upper Abdominal Pain
- If tenderness is present on palpation, imaging is essential
- If no tenderness, then consider an ECG (particularly if cardiac risks present)
- Lower abdominal pain and/or flank pain should always include a urinalysis
- Surgical Consultation
- Abnormal vital signs or temerature >38°C
- Rebound or guarding on examination
- White blood cell count >10K/mL
DIAGNOSIS OF ABDOMINAL PAIN BY ORGAN |
A. Cholecystitis - Acute
- Pain in epigastrium and RUQ
- Colicky then steady
- Nausea and vomting
- Low grade fever
- Leukocytosis
- Possible mild bilirubinemia
- Bilirubinuria after 24 hours
- Constipation
- Mild Paralytic ileus with air filled jejunal loop
- 90% of patients have gallstones
- Chronic
- Chronic crampy RUQ pain
- Colicky at times
- Low grade Fever
- Constipation
- Usually chronic gallstones
- Cholelithiasis with obstruction
- Obstruction is the major cause of cholecystitis
- Cholesterol stones
- Bilirubin stones
B. Ileus
- Intestinal obstruction
- Mechanical: adhesions, tumor
- Paralytic: no bowel sounds
- Symptoms
- Abdominal Pain
- Distension
- Vomiting
- Obstipation
- Etiology
- Small bowel adhesions [4]
- Incarcerated hernias
- Intra-abdominal abscess
- Neoplasms
- Fecal impaction
C. Appendicitis
- Classically RLQ pain, but may be mid or RUQ
- Pain usually begins epigastrium then migrates
- Fever, leukocytosis
- Nausea and vomiting
D. Diverticulitis
- Usually causes acute LLQ pain
- Sigmoid colon most commonly involved
- Nausea and vomiting later in course
- Constipation or Bloody Diarrhea
E. Ulcer Perforation
- Usually gastric ulcer with perforation
- Duodenal ulcer much less common
- Recall gastric ulcers usually better with food
- Epigastric burning pain
- Consider Crohn's Disease in perforated ulcers
F. Pancreatitis
- Knife-like epigastric pain
- Radiating usu through to back
- Consider aneurysm, GI ulceration
G. Crampy Abdominal Pain
- Usually due to organ distension
- Infection: bacterial, viral, parasitic
- Inflammatory Bowel Disease
- Malabsorption Syndrome
- Small Bowel Bacterial Overgrowth
- Constipation
- Porphyria
- Angioneurotic Edema
- Familial Mediterranean Fever
- Adhesions
H. Knife-Like Abdominal Pain
- Aortic Aneurysm Dissection (Perforation)
- Pancreatitis
- Esophageal perforation
- Severe gastric ulceration
- Celiac disease (uncommon) [2]
CHRONIC AND SUBACUTE ABDOMINAL PAIN |
A. Epigastric Pain=- Peptic Ulcer
- Pyloric Obstruction
- Post-gastrostomy
- Diaphragmatic Hernia
- Pancreatitis
- Gastric CA
- Non-Ulcer Dyspepsia / Functional Gastritis
B. Hypogastric Pain
- Cystitis
- Chronic Prostatitis
- Pelvic Inflammatory Disease
- Ovarian Cyst or torsion [6]
- Uterine fibroids
- Small Bowel Adhesions
- Henoch-Schonlein purpura or other vasculitis [5]
C. Right Upper Quadrant (RUQ) Pain [3]
- Gallstones
- Chronic Cholecystitis
- Cholangiocarcinoma (causing obstruction)
- Hepatitis
- Hepatic Abscess (amoebic, bacterial)
- Other Cancers
- Hepatic Neoplasm
- Gastric Cancer
- Metastatic Disease
- Pancreatitis
- Pancreatic Duct Obstruction
- Peptic Ulcer (duodenitis)
- Right lower lobe Pneumonia
- Kidney stones (nephrolithiasis)
- Pyelonephritis
- Intestinal obstruction
- Trauma
- Biliary Tract Obstruction - Tropical Areas [7]
- In addition to RUQ pain above
- Salmonella associated cholelithiasis
- Hepatobiliary parasitosis: ascariasis, liver flukes
- Granulomatous disease: tuberculosis, paragonimiasis
- External compression: tuberculous periporpal lymphadenitis
- Hydatid disease with biliary fistulization or ductal compression
D. Left Upper Quadrant (LUQ) Pain
- Splenic Ischemia / Infarction
- Mesenteric Ischemia
- Left lower lobe Pneumonia
- Pyelonephritis
E. Right Lower Quadrant (RLQ) Pain
- Chronic Appendicitis
- Crohn's Ileitis
- Meckel's Diverticulitis
- Ovarian Process [6]
- Pelvic Inflammatory Disease
- Pericecal abscess
F. Left Lower Quadrant (LLQ) Pain
- Diverticulitis
- Ulcerative Colitis
- Ovarian Process [6]
- Pelvic Inflammatory Disease
G. Abdominal Wall Pain
- Nerve
- Radiculitis
- Rectus Entrapment
- Ischemic Injury
- Myositis
- Contusion
- Hematoma
H. Intestinal Bloating
- Hypomotility Syndromes
- Irritable Bowel
- Neural Disease
- Scleroderma
- Enzyme Deficiency
- Lactase Deficiency
- Celiac Disease
- Small Intestinal Bacterial Overgrowth
- Infection
- Intestinal Obstruction
- Ileus
- Hernia
- Volvulus
- Stricture
- Compression
- Intussusception
- Small Bowel Adhesions
I. Organ Distension
- Stomach
- Spleen
- Liver
- Gall Bladder
- Kidney
- Urinary Bladder
- Intestine
- Uterus
- Ovary [6]
J. Renal Pain
- Pyelonephritis
- Bacterial
- Emphysematous
- Ischemia
- Hydronephrosis
- Obstructive
- Reflux
K. Miscellaneous
- Trauma
- Spleen
- Liver
- Kidney
- Duodenum
- AIDS Enteropathy
- Diverticulitis
- Lymphadenitis
- Hyperthyroidism
- Amyloidosis
- Radiation Enteritis
- Familial Mediterranean Fever (FMF)
- Angioneurotic Edema (Angioedema)
- Porphyria
- Endometriosis
- Retroperitoneal Fibrosis
L. Infection
- Bacterial
- E. coli
- C. difficile
- Salmonella
- Shigella
- Uncommon: yersinia, campylobacter, others
- Viral
- Adenovirus
- Norwalk Agent
- Echovirus
- Poliovirus
- Parasitic
- Malaria
- Amoebiasis
- Giardiasis
- Cryptosporidiosis
- AIDS Enteropathy
- Cryptospiridiosis
- Giardiasis
- Amoebiasis
- Isospora
- Atypical mycobacteria
- Tropical Sprue (?)
- Whipple's Disease (Tropherema whippelii)
M. Inflammatory Diseases
- Crohn's Disease
- Ulcerative Colitis
- Eosinophilic Gastroenteritis
- Retroperitoneal Fibrosis
N. Constipation Syndromes
- Irritable Bowel Syndrome
- Intestinal Hypomotility
- Megacolon / Hirschprung's Syndrome
- Colon Carcinoma (usually Left sided)
- Fecal Impaction
- Medications
- Opiates
- Calcium Channel Blocking Agents
- Iron Salts
- Calcium Salts
- Aluminum Salts
- Anticholinergic Agents
- Less Common:
- Cystic Fibrosis
- Hypothyroidism
- Hyperparathyroidism (from hypercalcemia)
- Rectal Strictures
- Parkinson's Disease
- Cerebral Infarction (Stroke)
- Small Bowel Adhesions with Ileus
O. Malabsorption
- Celiac Disease (Sprue)
- Tropical Sprue
- Lactose Intolerance (Lactase Deficiency)
- Pancreatic Insufficiency
- Zollinger-Ellison Syndrome
References
- Ranji SR, Goldman LE, Simel DL, Shojania KG. 2006. JAMA. 296(14):1762
- Naveb F and Yantiss RK. 2001. NEJM. 344(7):510 (Case Record)
- Ross AM IV, Anupindi SA, Balis UJ. 2003. NEJM. 348(15):1464 (Case Record)

- Swank DJ, Swank-Bordewijk SCG, Hop WCJ, et al. 2003. Lancet. 361(9365):1247

- Kassutto S and Wolf MA. 2003. NEJM. 349(6):597 (Case Discussion)

- McGee DM, Connolly SA, Young RH. 2003. NEJM. 349(5):486 (Case Record)

- Hurtado RM, Sahani DV, Kradin RL. 2006. NEJM. 354(12):1295 (Case Record)
