| Abdominal pain | |
| Synonyms: | Stomach ache, tummy ache, belly ache, belly pain, gastralgia |
| Field: | Gastroenterology, general surgery |
| Causes: | Serious: Appendicitis, perforated stomach ulcer, pancreatitis, ruptured diverticulitis, ovarian torsion, volvulus, ruptured aortic aneurysm, lacerated spleen or liver, ischemic colitis, ischaemic myocardial conditions[1] Common: Gastroenteritis, irritable bowel syndrome |
Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues. Since the abdomen contains most of the body's vital organs, it can be an indicator of a wide variety of diseases. Given that, approaching the examination of a person and planning of a differential diagnosis is extremely important.[2]
Common causes of pain in the abdomen include gastroenteritis and irritable bowel syndrome. About 15% of people have a more serious underlying condition such as appendicitis, leaking or ruptured abdominal aortic aneurysm, diverticulitis, or ectopic pregnancy. In a third of cases, the exact cause is unclear.
The onset of abdominal pain can be abrupt, quick, or gradual. Sudden onset pain happens in a split second. Rapidly onset pain starts mild and gets worse over the next few minutes. Pain that gradually intensifies only after several hours or even days has passed is referred to as gradual onset pain.[3]
One can describe abdominal pain as either continuous or sporadic and as cramping, dull, or aching. The characteristic of cramping abdominal pain is that it comes in brief waves, builds to a peak, and then abruptly stops for a period during which there is no more pain. The pain flares up and off periodically. The most common cause of persistent dull or aching abdominal pain is edema or distention of the wall of a hollow viscus. A dull or aching pain may also be felt due to a stretch in the liver and spleen capsules.[3]
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%).[4] More common in those who are older, ischemic colitis,[5] mesenteric ischemia, and abdominal aortic aneurysms are other serious causes.[6]
Acute abdomen is a condition where there is a sudden onset of severe abdominal pain requiring immediate recognition and management of the underlying cause. The underlying cause may involve infection, inflammation, vascular occlusion or bowel obstruction.
The pain may elicit nausea and vomiting, abdominal distention, fever and signs of shock. A common condition associated with acute abdominal pain is appendicitis.[7] Here is a list of acute abdomen causes:
Surgical causes | Source:Inflammatory
Mechanical
Vascular
Referred painSource:[8]
| |
|---|---|---|
Medical causes | Source:
Diabetic ketoacidosis (DKA). Lead poisoning. Familial Mediterranean fever (FMF). | |
Gynecological causes | Source:[10] Pelvic inflammatory disease (PID) and abscess. Hemorrhagic ovarian cyst. Adnexal or ovarian torsion. |
A more extensive list includes the following:
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:[11] [12]
| Region | Blood supply | Innervation[13] | Structures | |
|---|---|---|---|---|
| Foregut | Celiac artery | T5 - T9 | PharynxEsophagus
Proximal duodenum | |
| Midgut | Superior mesenteric artery | T10 – T12 | Distal duodenumCecum
Proximal transverse colon | |
| Hindgut | Inferior mesenteric artery | L1 – L3 | Distal transverse colonDescending colon
Fever Superior anal canal |
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.[15] 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.[16] 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.
A thorough patient history and physical examination is used to better understand the underlying cause of abdominal pain.
The process of gathering a history may include:[17]
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.
Additional investigations that can aid diagnosis include:[19]
If diagnosis remains unclear after history, examination, and basic investigations as above, then more advanced investigations may reveal a diagnosis. Such tests include:
The management of abdominal pain depends on many factors, including the etiology of the pain. Some dietary changes that some may participate in are: resting after a meal, chewing food completely and slowly, and avoiding stressful and high excitement situations after a meal. Some at home strategies like these can avoid future abdominal issues, resulting in the need of professional assistance.[20] 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.[21] Treatment for abdominal pain includes analgesia, such as non-opioid (ketorolac) and opioid medications (morphine, fentanyl). Choice of analgesia is dependent on the cause of the pain, as ketorolac can worsen some intra-abdominal processes. 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. After addressing pain, there may be a role for antimicrobial treatment in some cases of abdominal pain. Butylscopolamine (Buscopan) is used to treat cramping abdominal pain with some success.[22] Surgical management for causes of abdominal pain includes but is not limited to cholecystectomy, appendectomy, and exploratory laparotomy.
Below is a brief overview of abdominal pain emergencies.
| Appendicitis[23] | Abdominal pain, nausea, vomiting, feverPeriumbilical pain, migrates to RLQ | Clinical (history and physical exam)Abdominal CT | Patient made NPO (nothing by mouth)IV fluids as needed General surgery consultation, possible appendectomy Antibiotics Pain control | |
| Cholecystitis | Abdominal pain (RUQ, radiates epigastric), nausea, vomiting, fever, Murphy's sign | Clinical (history and 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 | Abdominal pain (sharp epigastric, shooting to back), nausea, vomiting | Clinical (history and 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 | Abdominal pain (diffuse, crampy), bilious emesis, constipation | Clinical (history and 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 | 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 resuscitationBlood transfusion as needed Medications: proton pump inhibitor, octreotide Stable patient: observation Unstable patient: consultation (general surgery, gastroenterology, interventional radiology) | |
| Lower GI bleed | Abdominal pain, hematochezia, melena, hypovolemia | Clinical (history and physical exam, including digital rectal exam)Labs (complete blood count, coagulation profile, transaminases, stool guaiac) | Aggressive IV fluid resuscitationBlood transfusion as needed Medications: proton pump inhibitor Stable patient: observation Unstable patient: consultation (general surgery, gastroenterology, interventional radiology) | |
| Perforated Viscous | Abdominal pain (sudden onset of localized pain), abdominal distension, rigid abdomen | Clinical (history and physical exam)Imaging (abdominal X-ray or CT showing free air) Labs (complete blood count) | Aggressive IV fluid resuscitationGeneral surgery consultation Antibiotics | |
| Volvulus | Sigmoid colon volvulus Abdominal pain (>2 days, distention, constipation)Cecal volvulus: Abdominal pain (acute onset), nausea, vomiting | Clinical (history and physical exam)Imaging (abdominal X-ray or CT) | Sigmoid: Gastroenterology consultation (flexibile sigmoidoscopy)Cecal: General surgery consultation (right hemicolectomy) | |
| Ectopic pregnancy | Abdominal and pelvic pain, bleedingIf ruptured ectopic pregnancy, the patient may present with peritoneal irritation and hypovolemic shock | Clinical (history and 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 consultationIf patient is stable: continue diagnostic workup, establish OBGYN follow-up | |
| Abdominal aortic aneurysm | Abdominal pain, flank pain, back pain, hypotension, pulsatile abdominal mass | Clinical (history and physical exam)Imaging: Ultrasound, CT angiography, MRA/magnetic resonance angiography | If patient is unstable: IV fluid resuscitation, urgent surgical consultationIf patient is stable: admit for observation | |
| Aortic dissection | Abdominal pain (sudden onset of epigastric or back pain), hypertension, new aortic murmur | Clinical (history and physical exam)Imaging: Chest X-ray (showing widened mediastinum), CT angiography, MRA, transthoracic echocardiogram/TTE, transesophageal echocardiogram/TEE | IV fluid resuscitationBlood transfusion as needed (obtain type and cross) Medications: reduce blood pressure (sodium nitroprusside plus beta blocker or calcium channel blocker) Surgery consultation | |
| Liver injury | After trauma (blunt or penetrating), abdominal pain (RUQ), right rib pain, right flank pain, right shoulder pain | Clinical (history and physical exam)Imaging: FAST examination, CT of abdomen and pelvis | Resuscitation (advanced trauma life support) with IV fluids (crystalloid) and blood transfusionIf patient is unstable: general or trauma surgery consultation with subsequent exploratory laparotomy | |
| Splenic injury | After trauma (blunt or penetrating), abdominal pain (LUQ), left rib pain, left flank pain | Clinical (history and physical exam)Imaging: FAST examination, CT of abdomen and pelvis | Resuscitation (advanced trauma life support) with IV fluids (crystalloid) and blood transfusionIf 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 |
One well-known aspect of primary health care is its low prevalence of potentially dangerous abdominal pain causes. Patients with abdominal pain have a higher percentage of unexplained complaints (category "no diagnosis") than patients with other symptoms (such as dyspnea or chest pain).[24] Most people who suffer from stomach pain have a benign issue, like dyspepsia.[25] In general, it is discovered that 20% to 25% of patients with abdominal pain have a serious condition that necessitates admission to an acute care hospital.[26]
Abdominal pain is the reason about 3% of adults see their family physician.[4] Rates of emergency department (ED) visits in the United States for abdominal pain increased 18% from 2006 through to 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%.[27]
More time and resources are used on older patients with abdominal pain than on any other patient presentation in the emergency department (ED).[28] Compared to younger patients with the same complaint, their length of stay is 20% longer, they need to be admitted almost half the time, and they need surgery 1/3 of the time.[29]
Age does not reduce the total number of T cells, but it does reduce their functionality. The elderly person's ability to fight infection is weakened as a result.[30] Additionally, they have changed the strength and integrity of their skin and mucous membranes, which are physical barriers to infection. It is well known that older patients experience altered pain perception.[31]
The challenge of obtaining a sufficient history from an elderly patient can be attributed to multiple factors. Reduced memory or hearing could make the issue worse. It is common to encounter stoicism combined with a fear of losing one's independence if a serious condition is discovered. Changes in mental status, whether acute or chronic, are common.[32]
Unique clinical challenges arise when pregnant women experience abdominal pain. First off, there are many possible causes of abdominal pain during pregnancy. These include intraabdominal diseases that arise incidentally during pregnancy as well as obstetric or gynecologic disorders associated with pregnancy. Secondly, pregnancy modifies the natural history and clinical manifestation of numerous abdominal disorders. Third, pregnancy modifies and limits the diagnostic assessment. For instance, concerns about fetal safety during pregnancy are raised by invasive exams and radiologic testing. Fourth, while receiving therapy during pregnancy, the mother's and the fetus' interests need to be taken into account.[33]