Characteristic Features of Abdominal Pain

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Duration and pattern: These provide clues to nature and severity, although acute abdominal crisis may occasionally present insidiously or on a background of chronic pain.

Type and location provide a rough guide to nature of disease. Visceral pain (due to distention of a hollow viscus) localizes poorly and is often perceived in the midline. Intestinal pain tends to be crampy; when originating proximal to the ileocecal valve, it usually localizes above and around the umbilicus. Pain of colonic origin is perceived in the hypogastrium and lower quadrants. Pain from biliary or ureteral obstruction often causes pts to writhe in discomfort. Somatic pain (due to peritoneal inflammation) is usually sharper and more precisely localized to the diseased region (e.g., acute appendicitis; capsular distention of liver, kidney, or spleen), exacerbated by movement, causing pts to remain still. Pattern of radiation may be helpful: right shoulder (hepatobiliary origin), left shoulder (splenic), midback (pancreatic), flank (proximal urinary tract), and groin (genital or distal urinary tract).

Factors that precipitate or relieve pain: Ask about its relationship to eating (e.g., upper GI, biliary, pancreatic, ischemic bowel disease), defecation (colorectal), urination (genitourinary or colorectal), respiratory (pleuropulmonary, hepatobiliary), position (pancreatic, gastroesophageal reflux, musculoskeletal), menstrual cycle/menarche (tuboovarian, endometrial, including endometriosis), exertion (coronary/intestinal ischemia, musculoskeletal), medication or specific foods (motility disorders, food intolerance, gastroesophageal reflux, porphyria, adrenal insufficiency, ketoacidosis, toxins), and stress (motility disorders, nonulcer dyspepsia, irritable bowel syndrome).

Associated symptoms: Look for fevers/chills (infection, inflammatory disease, infarction), weight loss (tumor, inflammatory disease, malabsorption, ischemia), nausea/vomiting (obstruction, infection, inflammatory disease, metabolic disease), dysphagia/odynophagia (esophageal), early satiety (gastric), hematemesis (esophageal, gastric, duodenal), constipation (colorectal, perianal, genitourinary), jaundice (hepatobiliary, hemolytic), diarrhea (inflammatory disease, infection, malabsorption, secretory tumors, ischemia, genitourinary), dysuria/hematuria/vaginal or penile discharge (genitourinary), hematochezia (colorectal or, rarely, urinary), and skin/joint/eye disorders (inflammatory disease, bacterial or viral infection).

Predisposing factors: Inquire about family history (inflammatory disease, tumors, pancreatitis), hypertension and atherosclerotic disease (ischemia), diabetes mellitus (motility disorders, ketoacidosis), connective tissue disease (motility disorders, serositis), depression (motility disorders, tumors), smoking (ischemia), recent smoking cessation (inflammatory disease), and ethanol use (motility disorders, hepatobiliary, pancreatic, gastritis, peptic ulcer disease).

Physical examination: Evaluate abdomen for prior trauma or surgery, current trauma; abdominal distention, fluid, or air; direct, rebound, and referred tenderness; liver and spleen size; masses, bruits, altered bowel sounds, hernias, arterial masses. Rectal examination assesses presence and location of tenderness, masses, blood (gross or occult). Pelvic examination in women is essential.

General examination: Evaluate for evidence of hemodynamic instability, acid-base disturbances, nutritional deficiency, coagulopathy, arterial occlusive disease, stigmata of liver disease, cardiac dysfunction, lymphadenopathy, and skin lesions.

Routine laboratory and radiologic studies: Choices depend on clinical setting (esp. severity of pain, rapidity of onset) and may include complete blood count, serum electrolytes, coagulation parameters, serum glucose, and biochemical tests of liver, kidney, and pancreatic function; chest x-ray to determine the presence of diseases involving heart, lung, mediastinum, and pleura; electrocardiogram is helpful to exclude referred pain from cardiac disease; plain abdominal radiographs to evaluate bowel displacement, intestinal distention, fluid and gas pattern, free peritoneal air, liver size, and abdominal calcifications (e.g., gallstones, renal stones, chronic pancreatitis).

Special studies: These include abdominal ultrasonography (to visualize biliary ducts, gallbladder, liver, pancreas, and kidneys); CT to identify masses, abscesses, evidence of inflammation (bowel wall thickening, mesenteric “stranding,” lymphadenopathy, appendicitis), aortic aneurysm; barium contrast radiographs (barium swallow, upper GI series, small-bowel follow-through, barium enema); upper GI endoscopy, sigmoidoscopy, or colonoscopy; cholangiography (endoscopic, percutaneous, or via MRI), angiography (direct or via CT or MRI), and radionuclide scanning. In selected cases, percutaneous biopsy, laparoscopy, and exploratory laparotomy may be required.