ABDOMINAL PAIN

DEPT. OF MEDICINE
Abdominal pain usually results from
GI disorder,
reproductive, genitourinary (GU),
musculoskeletal,
vascular disorder;
drug use; or ingestion of toxins

Abdominal pain arises from the

abdominopelvic viscera,
the parietal peritoneum, or
the capsules of the liver, kidney, or spleen.
It may be acute or chronic and diffuse or localized.
Visceral pain
develops slowly into a deep, dull, aching pain that's poorly localized in the epigastric,
periumbilical, or lower midabdominal (hypogastric) region.

somatic (parietal, peritoneal) pain

produces a sharp, more intense, and well-localized discomfort that rapidly follows the
insult. Movement or coughing aggravates this pain.

Mechanisms that produce abdominal pain

stretching or tension of the gut wall,
traction on the peritoneum or mesentery,
vigorous intestinal contraction,
Inflammation, ischemia, a
sensory nerve irritation
Visceral abdominal pain

distension of hollow organs,

mesenteric traction or excessive smooth muscle contraction is a deep, poorly
localized sensation in the midline.

It is conducted via sympathetic splanchnic nerves.

Somatic pain

from the parietal peritoneum and abdominal wall is lateralized and localized to the
area of inflammation. It is conducted via intercostal (spinal) nerves.
Pain arising from foregut structures (stomach, pancreas, liver and biliary system) is
localized above the umbilicus

Pain solely from the small intestine, e.g. small intestinal obstruction, is felt around the
umbilicus (periumbilical).

Colonic pain can be felt either below the umbilicus, e.g. in the left iliac fossa from
diverticular disease of the sigmoid colon, or in the upper abdomen, e.g. in the right
hypochondrium from disease in the hepatic flexure.

If the parietal peritoneum is involved, the pain will localize to that area, e.g. right iliac
fossa pain in acute appendicitis and in Crohn's disease of the terminal ileum.
Pain from an unpaired structure, such as the pancreas, is felt in the midline
and radiates through to the back.

Pain from paired structures is felt on and radiates to the affected side, e.g.
renal colic.

Boys with abdominal pain may have torsion of the testis .

In women, consider gynaecological causes, e.g. ruptured ovarian cyst,

pelvic inflammatory disease or an ectopic pregnancy.

In any patient with acute right iliac fossa pain, consider appendicitis.

Radiation of pain to either or both shoulder tips indicates peritoneal

inflammation adjacent to the diaphragm, e.g. cholecystitis
In a previously asymptomatic patient, the sudden onset of severe
abdominal pain, rapidly progressing to become generalized and constant,
suggests perforation of a hollow viscus, a ruptured abdominal aortic
aneurysm or mesenteric infarction.

Preceding constipation suggests colorectal cancer or diverticular disease as

the cause of perforation and prior dyspepsia suggests peptic ulceration.

Co-existing peripheral vascular disease, hypertension, heart failure or atrial

fibrillation may suggest a vascular disorder, e.g. aortic aneurysm or
mesenteric ischaemia.
Development of peripheral circulatory failure (shock) following the onset
of pain suggests intra-abdominal sepsis or bleeding, e.g. ruptured aortic
aneurysm or ectopic pregnancy.

Torsion of the testis or ovary produces severe acute abdominal pain and
nausea.

Torsion of the caecum or sigmoid colon (volvulus) presents with sudden

abdominal pain associated with acute intestinal obstruction.

Abdominal pain persisting for hours or days suggests an inflammatory

disorder, such as acute appendicitis, cholecystitis or diverticulitis.
Symptom progression

During the first hour or two after perforation, a 'silent interval' may occur
when abdominal pain resolves transiently. The initial chemical peritonitis
may subside before bacterial peritonitis becomes established.

In appendicitis, pain is initially localized around the umbilicus (visceral

pain) and spreads as the inflammatory response progresses to involve the
right iliac fossa (parietal or somatic pain).

If the appendix ruptures, generalized peritonitis may develop.

Occasionally, a localized appendix abscess develops, with a palpable

mass and localized pain in the right iliac fossa.
Change in the pattern of symptoms suggests either that the initial
diagnosis was wrong, or that complications have developed.

In acute small bowel obstruction, a change from typical intestinal colic to

persistent pain with abdominal tenderness suggests intestinal ischaemia,
e.g. strangulated hernia, an indication for urgent surgical intervention.

Accompanying features

Abdominal pain due to irritable bowel syndrome, diverticular disease or

colorectal cancer is invariably accompanied by an alteration in bowel habit.
NON ALIMENTARY CAUSES OF ABDOMINAL PAIN
ABDOMINAL PAIN, INFANCY

Acute gastroenteritis.
Appendicitis.
Intussusception.
Volvulus.
Meckel diverticulum.
Other: colic, trauma.
ABDOMINAL PAIN, CHILDHOOD

Acute gastroenteritis.
Appendicitis.
Constipation.
Cholecystitis, acute.
Intestinal obstruction.
Pancreatitis.
Neoplasm.
Inflammatory bowel disease.

Other:

Functional abdominal pain.

Pyelonephritis.
Pneumonia.
Diabetic ketoacidosis.
Heavy metal poisoning.
Sickle cell crisis.
Trauma.
ABDOMINAL PAIN, ADOLESCENCE

Acute gastroenteritis.
Appendicitis.
Inflammatory bowel disease.
Peptic ulcer disease (PUD).
Cholecystitis.
Neoplasm.
Diabetic ketoacidosis.
Functional abdominal pain.
Pelvic inflammatory disease (PID).
Pregnancy.
Pyelonephritis.
Renal stone.
Trauma.
ABDOMINAL PAIN, CHRONIC LOWER ORGANIC DISORDERS

Common

Gynecological disease.
Lactase deficiency.
Diverticulitis.
Crohn’s disease.
Intestinal obstruction.

Uncommon

Chronic intestinal pseudoobstruction.

Mesenteric ischemia.
Malignancy (e.g., ovarian carcinoma).
Abdominal wall pain.
Spinal disease.
Testicular disease.
Metabolic diseases (e.g., diabetes mellitus, fa -milial Mediterranean fever, C1 esterase
deficiency [angioneurotic edema], porphyria, lead
poisoning, tabes dorsalis, renal failure
ABDOMINAL PAIN, DIFFUSE

Early appendicitis.
Aortic aneurysm.
Gastroenteritis.
Intestinal obstruction.
Diverticulitis.
Peritonitis.
Mesenteric insufficiency or infarction.
Pancreatitis.
Inflammatory bowel disease.
Irritable bowel.
Mesenteric adenitis.
Metabolic: toxins, lead poisoning, uremia, drug overdose, diabetic ketoacidosis (DKA),
heavy metal poisoning.
Sickle cell crisis.
Pneumonia (rare).
Trauma.
Urinary tract infection, PID.
Other: acute intermittent porphyria, tabes dorsalis, periarteritis nodosa, Henoch-Schönlein
purpura, adrenal insufficiency.
ABDOMINAL PAIN, EPIGASTRIC

Gastric: PUD, gastric outlet obstruction, gastric ulcer.

Duodenal: PUD, duodenitis.

Biliary: cholecystitis, cholangitis.

Hepatic: hepatitis.

Pancreatic: pancreatitis.

Intestinal: high small bowel obstruction, early appendicitis.

Cardiac: angina, MI, pericarditis.

Pulmonary: pneumonia, pleurisy, pneumothorax Subphrenic abscess

Vascular: dissecting aneurysm, mesenteric ischemia.

ABDOMINAL PAIN, LEFT UPPER QUADRANT

Gastric: PUD, gastritis, pyloric stenosis, hiatal hernia.

Pancreatic: pancreatitis, neoplasm, stone inpancreatic duct or ampulla.

Cardiac: MI, angina pectoris.

Splenic: splenomegaly, ruptured spleen, splenic abscess, splenic infarction.

Renal: calculi, pyelonephritis, neoplasm.

Pulmonary: pneumonia, empyema, pulmonary infarction.

Vascular: ruptured aortic aneurysm.

Cutaneous: herpes zoster.

Trauma.

Intestinal: high fecal impaction, perfora ted colon, diverticulitis.

ABDOMINAL PAIN, LEFT LOWER QUADRANT

Intestinal: diverticulitis, intestinal obstruction, perforated ulcer, inflammatory bowel disease,

perforated descending colon, inguinal hernia, neoplasm, appendicitis.

Reproductive: ectopic pregnancy, ovarian cyst, torsion of ovarian cyst, tuboovarian

abscess, mittelschmerz, endometriosis, seminal vesiculitis.

Renal: renal or ureteral calculi, pyelonephritis, neoplasm.

Vascular: leaking aortic aneurysm.

Psoas abscess.

Trauma
ABDOMINAL PAIN, PERIUMBILICAL

Intestinal: small bowel obstruction or gangrene, early appendicitis.

Vascular: mesenteric thrombosis, dissecting aortic aneurysm

.
Pancreatic: pancreatitis.

Metabolic: uremia, DKA.

Trauma.
ABDOMINAL PAIN, RIGHT UPPER QUADRANT

Biliary: calculi, infection, inflammation, neoplasm.

Hepatic: hepatitis, abscess, hepatic congestion, neoplasm, trauma.

Gastric: PUD, pyloric stenosis, neoplasm, alcoholic gastritis, hiatal hernia.

Pancreatic: pancreatitis, neoplasm, stone in pancreatic duct or ampulla.

Renal: calculi, infection, inflammation, neoplasm, rupture of kidney.

Pulmonary: pneumonia, pulmonary infarction, right-sided pleurisy.

Intestinal: retrocecal appendicitis, intestinal obstruction, high fecal impaction, diverticulitis.

Cardiac: myocardial ischemia (particularly involving the inferior wall), pericarditis.

Cutaneous: herpes zoster.

Trauma.

Fitz-Hugh-Curtis syndrome (perihepatitis).

ABDOMINAL PAIN, RIGHT LOWER QUADRANT

Intestinal: acute appendicitis, regional enteritis, incarcerated hernia, cecal diverticulitis,

intestinal obstruction, perforated ulcer, perforated cecum, Meckel diverticulitis.

Reproductive: ectopic pregnancy, ovarian cyst, torsion of ovarian cyst, salpingitis,

tuboovarian abscess, mittelschmerz, endometriosis, seminal vesiculitis.

Renal: renal and ureteral calculi, neoplasms, pyelonephritis.

Vascular: leaking aortic aneurysm.

Psoas abscess.

Trauma.

Cholecystitis
ABDOMINAL PAIN, SUPRAPUBIC

Intestinal: colon obstruction or gangrene, diverticulitis, appendicitis.

Reproductive system: ectopic pregnancy, mittelschmerz, torsion of ovarian cyst, PID,

salpingitis, endometriosis, rupture of endometrioma.
Cystitis, rupture of urinary bladder
ABDOMINAL PAIN, NONSURGICAL CAUSES

Irritable bowel syndrome.

Urinary tract infection, pyelonephritis, salpingitis, PID.
Gastroenteritis, gastritis, peptic ulcer.Diverticular spasm.
Hepatitis, mononucleosis.
Pancreatitis.
Inferior wall myocardial infarction.
Basilar pneumonia, pulmonary embolism.
Diabetic ketoacidosis.
Strain or hematoma of rectus muscle.
Ruptured Graafian follicle.
Herpes zoster.
Nerve root compression.
Sickle cell crisis.
Acute adrenal insufficiency.
Other: acute porphyria, familial Mediterranean fever, tabes dorsalis
ABDOMINAL PAIN, POORLY LOCALIZED EXTRAABDOMINAL

Metabolic
DKA, acute intermittent porphyria, hyperthyroidism, hypothyroidism, hypercalcemia, hypoka
-lemia, uremia, hyperlipidemia, hyperparathyroidism.

Hematologic
Sickle cell crisis, leukemia or lymphoma, Henoch-Schönlein purpura.

Infectious
Infectious mononucleosis, Rocky Mountain spotted fever, acquired immunodeficiency
syndrome (AIDS), streptococcal pharyngitis (in children), herpes zoster.

Drugs and Toxins

Heavy metal poisoning, black widow spider bites, withdrawal syndromes, mushroom
ingestion.
Referred Pain

Pulmonary: pneumonia, pulmonary embolism, pneumothorax.

Cardiac: angina, MI, pericarditis, myocarditis.

Genitourinary: prostatitis, epididymitis, orchitis, testicular torsion.

Musculoskeletal: rectus sheath hematoma.

Functional

Somatization disorder, malingering, hypochondriasis, Munchausen syndrome.

ABDOMINAL PAIN, PREGNANCY GYNECOLOGIC (GESTATIONAL AGE IN
PARENTHESES)

Miscarriage ( ,20 wk; 80% , 12 wk)

Septic abortion ( ,20 wk)
Ectopic pregnancy ( ,14 wk)
Corpus luteum cyst rupture ( ,12 wk)
Ovarian torsion (especially , 24 wk)
Pelvic inflammatory disease ( ,12 wk)
Chorioamnionitis ( .16 wk)
Abruptio placentae ( .16 wk)

NONGYNECOLOGIC
Appendicitis (Throughout)
Cholecystitis (Throughout)
Hepatitis (Throughout)
Pyelonephritis (Throughout)
Preeclampsia ( .20 wk)
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