Abdominal pain

Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues.

Abdominal pain
Other namesStomach ache, tummy ache, belly ache, belly pain
Abdominal pain can be characterized by the region it affects
SpecialtyGeneral surgery
CausesSerious: Appendicitis, perforated stomach ulcer, pancreatitis, ruptured diverticulitis, ovarian torsion, volvulus, ruptured aortic aneurysm, lacerated spleen or liver, ischemic colitis[1]
Common: Gastroenteritis, irritable bowel syndrome[2]

Common causes of pain in the abdomen include gastroenteritis and irritable bowel syndrome.[2] About 15% of people have a more serious underlying condition such as appendicitis, leaking or ruptured abdominal aortic aneurysm, diverticulitis, or ectopic pregnancy.[2] In a third of cases the exact cause is unclear.[2]

Given that a variety of diseases can cause some form of abdominal pain, a systematic approach to examination of a person and the formulation of a differential diagnosis remains important.

Differential diagnosis

The most frequent reasons for abdominal pain are gastroenteritis (13%), irritable bowel syndrome (8%), urinary tract problems (5%), inflammation of the stomach (5%) and constipation (5%). In about 30% of cases, the cause is not determined. About 10% of cases have a more serious cause including gallbladder (gallstones or biliary dyskinesia) or pancreas problems (4%), diverticulitis (3%), appendicitis (2%) and cancer (1%).[2] More common in those who are older, mesenteric ischemia and abdominal aortic aneurysms are other serious causes.[3]

Acute abdominal pain

Acute abdomen can 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 nausea and vomiting, abdominal distention, fever and signs of shock. One of the most common conditions associated with acute abdominal pain is acute appendicitis.

Selected causes

By system

A more extensive list includes the following:

By location

The location of abdominal pain can provide information about what may be causing the pain. The abdomen can be divided into four regions called quadrants. Locations and associated conditions include:[4][5]

Pathophysiology
Region Blood supply[6] Innervation[7] Structures[6]
Foregut Celiac artery T5 - T9 Pharynx

Esophagus

Lower respiratory tract

Stomach

Proximal duodenum

Liver

Biliary tract

Gallbladder

Pancreas

Midgut Superior mesenteric artery T10 - T12 Distal duodenum

Cecum

Appendix

Ascending colon

Proximal transverse colon

Hindgut Inferior mesenteric artery L1 - L3 Distal transverse colon

Descending colon

Sigmoid colon

Rectum

Fever

Superior anal canal

Abdominal pain can be referred to as visceral pain or peritoneal pain. The contents of the abdomen can be divided into the foregut, midgut, and hindgut.[6] The foregut contains the pharynx, lower respiratory tract, portions of the esophagus, stomach, portions of the duodenum (proximal), liver, biliary tract (including the gallbladder and bile ducts), and the pancreas.[6] The midgut contains portions of the duodenum (distal), cecum, appendix, ascending colon, and first half of the transverse colon.[6] The hindgut contains the distal half of the transverse colon, descending colon, sigmoid colon, rectum, and superior anal canal.[6]

Each subsection of the gut has an associated visceral afferent nerve that transmits sensory information from the viscera to the spinal cord, traveling with the autonomic sympathetic nerves.[8] The visceral sensory information from the gut traveling to the spinal cord, termed the visceral afferent, is non-specific and overlaps with the somatic afferent nerves, which are very specific.[9] Therefore, visceral afferent information traveling to the spinal cord can present in the distribution of the somatic afferent nerve; this is why appendicitis initially presents with T10 periumbilical pain when it first begins and becomes T12 pain as the abdominal wall peritoneum (which is rich with somatic afferent nerves) is involved.[9]

Diagnostic approach

In order to better understand the underlying cause of abdominal pain, one can perform a thorough history and physical examination.

The process of gathering a history may include:[10]

  • Identifying more information about the chief complaint by eliciting a history of present illness; i.e. a narrative of the current symptoms such as the onset, location, duration, character, aggravating or relieving factors, and temporal nature of the pain. Identifying other possible factors may aid in the diagnosis of the underlying cause of abdominal pain, such as recent travel, recent contact with other ill individuals, and for females, a thorough gynecologic history.
  • Learning about the patient's past medical history, focusing on any prior issues or surgical procedures.
  • Clarifying the patient's current medication regimen, including prescriptions, over-the-counter medications, and supplements.
  • Confirming the patient's drug and food allergies.
  • Discussing with the patient any family history of disease processes, focusing on conditions that might resemble the patient's current presentation.
  • Discussing with the patient any health-related behaviors (e.g. tobacco use, alcohol consumption, drug use, and sexual activity) that might make certain diagnoses more likely.
  • Reviewing the presence of non-abdominal symptoms (e.g., fever, chills, chest pain, shortness of breath, vaginal bleeding) that can further clarify the diagnostic picture.

After gathering a thorough history, one should perform a physical exam in order to identify important physical signs that might clarify the diagnosis, including a cardiovascular exam, lung exam, thorough abdominal exam, and for females, a genitourinary exam.[10]

Additional investigations that can aid diagnosis include:[11]

If diagnosis remains unclear after history, examination, and basic investigations as above, then more advanced investigations may reveal a diagnosis. Such tests include:[11]

Management

The management of abdominal pain depends on many factors, including the etiology of the pain. In the emergency department, a person presenting with abdominal pain may initially require IV fluids due to decreased intake secondary to abdominal pain and possible emesis or vomiting.[12] Treatment for abdominal pain includes analgesia, such as non-opioid (ketorolac) and opioid medications (morphine, fentanyl).[12] Choice of analgesia is dependent on the cause of the pain, as ketorolac can worsen some intra-abdominal processes.[12] Patients presenting to the emergency department with abdominal pain may receive a "GI cocktail" that includes an antacid (examples include omeprazole, ranitidine, magnesium hydroxide, and calcium chloride) and lidocaine.[12] After addressing pain, there may be a role for antimicrobial treatment in some cases of abdominal pain.[12] Butylscopolamine (Buscopan) is used to treat cramping abdominal pain with some success.[13] Surgical management for causes of abdominal pain includes but is not limited to cholecystectomy, appendectomy, and exploratory laparotomy.

Emergencies

Below is a brief overview of abdominal pain emergencies.

Condition Presentation Diagnosis Management
Appendicitis[14] Abdominal pain, nausea, vomiting, fever

Periumbilical pain, migrates to RLQ

 Clinical (history & physical exam)

Abdominal CT

 Patient made NPO (nothing by mouth)

IV fluids as needed

General surgery consultation, possible appendectomy

Antibiotics

Pain control

Cholecystitis[14] Abdominal pain (RUQ, radiates epigastric), nausea, vomiting, fever, Murphy's sign Clinical (history & physical exam)

Imaging (RUQ ultrasound)

Labs (leukocytosis, transamintis, hyperbilirubinemia)

 Patient made NPO (nothing by mouth)

IV fluids as needed

General surgery consultation, possible cholecystectomy

Antibiotics

Pain, nausea control

Acute pancreatitis[14] Abdominal pain (sharp epigastric, shooting to back), nausea, vomiting Clinical (history & physical exam)

Labs (elevated lipase)

Imaging (abdominal CT, ultrasound)

 Patient made NPO (nothing by mouth)

IV fluids as needed

Pain, nausea control

Possibly consultation of general surgery or interventional radiology

Bowel obstruction[14] Abdominal pain (diffuse, crampy), bilious emesis, constipation Clinical (history & physical exam)

Imaging (abdominal X-ray, abdominal CT)

 Patient made NPO (nothing by mouth)

IV fluids as needed

Nasogastric tube placement

General surgery consultation

Pain control

Upper GI bleed[14] Abdominal pain (epigastric), hematochezia, melena, hematemesis, hypovolemia Clinical (history & physical exam, including digital rectal exam)

Labs (complete blood count, coagulation profile, transaminases, stool guaiac)

 Aggressive IV fluid resuscitation

Blood transfusion as needed

Medications: proton pump inhibitor, octreotide

Stable patient: observation

Unstable patient: consultation (general surgery, gastroenterology, interventional radiology)

Lower GI Bleed[14] Abdominal pain, hematochezia, melena, hypovolemia Clinical (history & physical exam, including digital rectal exam)

Labs (complete blood count, coagulation profile, transaminases, stool guaiac)

 Aggressive IV fluid resuscitation

Blood transfusion as needed

Medications: proton pump inhibitor

Stable patient: observation

Unstable patient: consultation (general surgery, gastroenterology, interventional radiology)

Perforated Viscous[14] Abdominal pain (sudden onset of localized pain), abdominal distension, rigid abdomen Clinical (history & physical exam)

Imaging (abdominal X-ray or CT showing free air)

Labs (complete blood count)

 Aggressive IV fluid resuscitation

General surgery consultation

Antibiotics

Volvulus[14] Sigmoid colon volvulus: Abdominal pain (>2 days, distention, constipation)

Cecal volvulus: Abdominal pain (acute onset), nausea, vomiting

 Clinical (history & physical exam)

Imaging (abdominal X-ray or CT)

 Sigmoid: Gastroenterology consultation (flexibile sigmoidoscopy)

Cecal: General surgery consultation (right hemicolectomy)

Ectopic pregnancy[14] Abdominal and pelvic pain, bleeding

If ruptured ectopic pregnancy, patient may present with peritoneal irritation and hypovolemic shock

 Clinical (history & physical exam)

Labs: complete blood count, urine pregnancy test followed with quantitative blood beta-hCG

Imaging: transvaginal ultrasound

 If patient is unstable: IV fluid resuscitation, urgent obstetrics and gynecology consultation

If patient is stable: continue diagnostic workup, establish OBGYN follow-up

Abdominal aortic aneurysm[14] Abdominal pain, flank pain, back pain, hypotension, pulsatile abdominal mass Clinical (history & physical exam)

Imaging: Ultrasound, CT angiography, MRA/magnetic resonance angiography

 If patient is unstable: IV fluid resuscitation, urgent surgical consultation

If patient is stable: admit for observation

Aortic dissection[14] Abdominal pain (sudden onset of epigastric or back pain), hypertension, new aortic murmur Clinical (history & physical exam)

Imaging: Chest X-Ray (showing widened mediastinum), CT angiography, MRA, transthoracic echocardiogram/TTE, transesophageal echocardiogram/TEE

 IV fluid resuscitation

Blood transfusion as needed (obtain type and cross)

Medications: reduce blood pressure (sodium nitroprusside plus beta blocker or calcium channel blocker)

Surgery consultation

Liver injury[14] After trauma (blunt or penetrating), abdominal pain (RUQ), right rib pain, right flank pain, right shoulder pain Clinical (history & physical exam)

Imaging: FAST examination, CT of abdomen and pelvis

Diagnostic peritoneal aspiration and lavage

 Resuscitation (Advanced Trauma Life Support) with IV fluids (crystalloid) and blood transfusion

If patient is unstable: general or trauma surgery consultation with subsequent exploratory laparotomy

Splenic injury[14] After trauma (blunt or penetrating), abdominal pain (LUQ), left rib pain, left flank pain Clinical (history & physical exam)

Imaging: FAST examination, CT of abdomen and pelvis

Diagnostic peritoneal aspiration and lavage

 Resuscitation (Advanced Trauma Life Support) with IV fluids (crystalloid) and blood transfusion

If patient is unstable: general or trauma surgery consultation with subsequent exploratory laparotomy and possible splenectomy

If patient is stable: medical management, consultation of interventional radiology for possible arterial embolization

Epidemiology

Abdominal pain is the reason about 3% of adults see their family physician.[2] Rates of emergency department visits in the United States for abdominal pain increased 18% from 2006 through 2011. This was the largest increase out of 20 common conditions seen in the ED. The rate of ED use for nausea and vomiting also increased 18%.[15]

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References
  1. Patterson JW, Dominique E (14 November 2018). "Acute Abdomen". StatPearls. PMID 29083722.
  2. Viniol A, Keunecke C, Biroga T, Stadje R, Dornieden K, Bösner S, et al. (October 2014). "Studies of the symptom abdominal pain--a systematic review and meta-analysis". Family Practice. 31 (5): 517–29. doi:10.1093/fampra/cmu036. PMID 24987023.
  3. Spangler R, Van Pham T, Khoujah D, Martinez JP (2014). "Abdominal emergencies in the geriatric patient". International Journal of Emergency Medicine. 7: 43. doi:10.1186/s12245-014-0043-2. PMC 4306086. PMID 25635203.
  4. Masters P (2015). IM Essentials. American College of Physicians. ISBN 9781938921094.
  5. LeBlond RF (2004). Diagnostics. US: McGraw-Hill Companies, Inc. ISBN 978-0-07-140923-0.
  6. Moore KL (2016). "11". The Developing Human Tenth Edition. Philadelphia, PA: Elsevier, Inc. pp. 209–240. ISBN 978-0-323-31338-4.
  7. Hansen JT (2019). "4: Abdomen". Netter's Clinical Anatomy, 4e. Philadelphia, PA: Elsevier. pp. 157–231. ISBN 978-0-323-53188-7.
  8. Drake RL, Vogl AW, Mitchell AW (2015). "4: Abdomen". Gray's Anatomy For Students (Third ed.). Churchill Livingstone Elsevier. pp. 253–420. ISBN 978-0-7020-5131-9.
  9. Neumayer L, Dangleben DA, Fraser S, Gefen J, Maa J, Mann BD (2013). "11: Abdominal Wall, Including Hernia". Essentials of General Surgery, 5e. Baltimore, MD: Wolters Kluwer Health.
  10. Bickley L (2016). Bates' Guide to Physical Examination & History Taking. Philadelphia, Pennsylvania: Lippincott Williams & Wilkins. ISBN 9781469893419.
  11. Cartwright SL, Knudson MP (April 2008). "Evaluation of acute abdominal pain in adults". American Family Physician. 77 (7): 971–8. PMID 18441863.
  12. Mahadevan SV. Essentials of Family Medicine 6e. p. 149.
  13. Tytgat GN (2007). "Hyoscine butylbromide: a review of its use in the treatment of abdominal cramping and pain". Drugs. 67 (9): 1343–57. doi:10.2165/00003495-200767090-00007. PMID 17547475.
  14. Sherman SC, Cico SJ, Nordquist E, Ross C, Wang E (2016). Atlas of Clinical Emergency Medicine. Wolters Kluwer. ISBN 978-1-4511-8882-0.
  15. Skiner HG, Blanchard J, Elixhauser A (September 2014). "Trends in Emergency Department Visits, 2006-2011". HCUP Statistical Brief #179. Rockville, MD: Agency for Healthcare Research and Quality.
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