Abdominal pain

Abdominal pain

Pain the Abdomen can be due to many different causes including inflammatory, bowel obstruction, cancer or other tumor related, or trauma.

Abdominal quadrants

Abdominal pain is a common clinical symptom that can arise from a wide variety of conditions affecting the gastrointestinal tract, urinary system, reproductive organs, and even structures outside the abdomen. This article provides a detailed overview of abdominal pain, including its classification, causes, diagnostic approach, and management strategies. The guide is structured into four chapters to facilitate a comprehensive understanding of this important medical topic.

Chapter 1: Classification and Types of Abdominal Pain

Abdominal pain can be classified based on various factors, including location, nature, and pathophysiology. Understanding these classifications is crucial for accurately diagnosing and managing abdominal conditions.

Classification Based on Location

The abdomen is divided into four quadrants and nine regions, which help localize the source of pain.

Four Quadrants

1. Right Upper Quadrant (RUQ): Pain in this region may be caused by conditions affecting the liver, gallbladder, right kidney, pancreas, and intestines. 2. Left Upper Quadrant (LUQ): Causes of pain include disorders of the stomach, spleen, pancreas, left kidney, and intestines. 3. Right Lower Quadrant (RLQ): Common causes include appendicitis, right ovarian or fallopian tube pathology, and cecal or ileal disorders. 4. Left Lower Quadrant (LLQ): Often associated with diverticulitis, left ovarian pathology, and sigmoid colon disease.

Nine Regions

A more detailed classification divides the abdomen into nine regions:

• Epigastric: Pain here is often related to gastritis, peptic ulcer disease, or pancreatitis.
• Right Hypochondriac: Associated with gallbladder disease or liver conditions.
• Left Hypochondriac: May indicate spleen disorders or gastric problems.
• Umbilical: Pain here may be linked to small bowel obstruction or early appendicitis.
• Right Lumbar: Often related to renal colic or ureteric stones.
• Left Lumbar: Commonly associated with kidney infections or ureteric stones.
• Hypogastric (Suprapubic): Pain in this region may suggest bladder infections, pelvic inflammatory disease, or diverticulitis.
• Right Iliac: Common causes include appendicitis and right ovarian conditions.
• Left Iliac: Often associated with sigmoid diverticulitis or left ovarian pathology.

Classification Based on Nature of Pain

Abdominal pain is also categorized based on its quality, which provides clues about the underlying cause:

1. Visceral Pain:

• Originates from the internal organs.
• Described as dull, crampy, or aching.
• Often associated with nausea and autonomic symptoms (sweating, pallor).
• Examples: Irritable bowel syndrome (IBS), gastroenteritis, early appendicitis.

2. Parietal (Somatic) Pain:

• Originates from the peritoneum and is sharp and localized.
• Exacerbated by movement.
• Examples: Peritonitis, perforated ulcer, advanced appendicitis.

3. Referred Pain:

• Felt at a distant site from the affected organ due to shared nerve pathways.
• Examples:
• Gallbladder pain referred to the right shoulder.
• Diaphragmatic irritation referred to the shoulder (Kehr’s sign).

Classification Based on Duration

1. Acute Abdominal Pain:

• Develops suddenly and may indicate a surgical emergency.
• Examples: Appendicitis, perforated peptic ulcer, ruptured ectopic pregnancy.

2. Chronic Abdominal Pain:

• Persists for weeks to months.
• Often associated with chronic conditions like IBS, inflammatory bowel disease (IBD), or chronic pancreatitis.

3. Recurrent Abdominal Pain:

• Pain that occurs in episodes, separated by pain-free intervals.
• Common in functional disorders like IBS and cyclic vomiting syndrome.

Classification Based on Pathophysiology

1. Inflammatory Pain:

• Due to infection, ischemia, or autoimmunity.
• Examples: Appendicitis, pancreatitis, cholecystitis.

2. Obstructive Pain:

• Due to blockage of a hollow organ.
• Crampy and colicky in nature.
• Examples: Bowel obstruction, ureteric colic, biliary colic.

3. Vascular Pain:

• Caused by reduced blood supply to an organ.
• Severe and poorly localized.
• Examples: Mesenteric ischemia, abdominal aortic aneurysm (AAA) rupture.

4. Neuropathic Pain:

• Due to nerve involvement.
• Burning, shooting, or tingling in nature.
• Example: Diabetic neuropathy affecting the abdomen.

Chapter 2: Common Causes of Abdominal Pain

Abdominal pain can arise from various conditions affecting the gastrointestinal, hepatobiliary, urinary, gynecological, vascular, and systemic systems. Identifying the cause of abdominal pain requires a thorough understanding of common diseases affecting these organs. This chapter categorizes and describes the most common causes of abdominal pain.

1. Gastrointestinal Causes

Disorders of the stomach, intestines, and associated structures are the most frequent causes of abdominal pain.

Peptic Ulcer Disease (PUD)

• Location: Epigastric pain
• Nature: Burning pain, worse at night, relieved by food (duodenal ulcer) or worsened by food (gastric ulcer)
• Causes: *Helicobacter pylori* infection, NSAID use, stress
• Diagnosis: Upper endoscopy, *H. pylori* breath test
• Management: Proton pump inhibitors (PPIs), eradication of *H. pylori*

Gastroesophageal Reflux Disease (GERD)

• Location: Epigastric pain, often radiating to the chest
• Nature: Burning pain, worsened by lying down or eating spicy foods
• Causes: Lower esophageal sphincter dysfunction, obesity, pregnancy
• Diagnosis: Esophageal pH monitoring, endoscopy
• Management: Lifestyle modifications, antacids, PPIs

Irritable Bowel Syndrome (IBS)

• Location: Variable, often lower abdomen
• Nature: Cramping, associated with bloating and alternating diarrhea/constipation
• Triggers: Stress, certain foods (FODMAPs)
• Diagnosis: Clinical diagnosis (Rome IV criteria), exclusion of organic disease
• Management: Dietary changes, fiber supplements, antispasmodics

Inflammatory Bowel Disease (IBD)

• Types:
• Crohn's Disease: Affects any part of the GI tract, often with skip lesions.
• Ulcerative Colitis: Limited to the colon, characterized by continuous inflammation.
• Symptoms: Chronic abdominal pain, bloody diarrhea, weight loss
• Diagnosis: Colonoscopy with biopsy
• Management: Corticosteroids, immunosuppressants, biologics

Appendicitis

• Location: Right lower quadrant (McBurney's point)
• Nature: Initially dull periumbilical pain that later localizes and becomes sharp
• Associated Symptoms: Fever, nausea, vomiting, rebound tenderness
• Diagnosis: Ultrasound or CT scan
• Management: Surgical appendectomy, IV antibiotics

Diverticulitis

• Location: Left lower quadrant (sigmoid colon)
• Nature: Constant pain, associated with fever, constipation
• Risk Factors: Low-fiber diet, aging
• Diagnosis: CT scan with contrast
• Management: Antibiotics (mild cases), surgery for complications

2. Hepatobiliary Causes

The liver, gallbladder, and pancreas contribute to abdominal pain in various disease states.

Gallstones (Cholelithiasis) & Cholecystitis

• Location: Right upper quadrant, radiating to the right shoulder
• Nature: Colicky pain (biliary colic), worse after fatty meals
• Diagnosis: Ultrasound
• Management: Cholecystectomy (if symptomatic), pain management

Pancreatitis

• Location: Epigastric pain, radiating to the back
• Nature: Severe, persistent, worse after meals
• Causes: Alcohol, gallstones, hypertriglyceridemia
• Diagnosis: Elevated amylase/lipase, CT scan
• Management: NPO (nothing by mouth), IV fluids, pain control

Liver Disease (Hepatitis, Cirrhosis)

• Location: Right upper quadrant
• Symptoms: Jaundice, ascites, hepatomegaly
• Diagnosis: Liver function tests (LFTs), ultrasound
• Management: Depends on the underlying cause (e.g., antiviral therapy for hepatitis)

3. Urological Causes

The kidneys, ureters, and bladder can contribute to abdominal pain.

Kidney Stones (Nephrolithiasis)

• Location: Flank pain, radiating to the groin
• Nature: Colicky pain
• Associated Symptoms: Hematuria, nausea, vomiting
• Diagnosis: CT scan without contrast
• Management: Pain control, hydration, lithotripsy for large stones

Urinary Tract Infections (UTIs)

• Location: Suprapubic pain
• Symptoms: Dysuria, frequency, urgency
• Diagnosis: Urinalysis, urine culture
• Management: Antibiotics (trimethoprim-sulfamethoxazole, nitrofurantoin)

4. Gynecological Causes

Women presenting with abdominal pain require evaluation for gynecological conditions.

Ectopic Pregnancy

• Location: Lower abdominal pain (unilateral)
• Nature: Sudden and severe, associated with vaginal bleeding
• Risk Factors: Prior ectopic pregnancy, tubal surgery
• Diagnosis: Serum hCG, transvaginal ultrasound
• Management: Methotrexate (medical) or surgical intervention

Ovarian Torsion

• Location: Lower abdomen (unilateral)
• Nature: Sudden, severe pain, nausea, vomiting
• Diagnosis: Doppler ultrasound
• Management: Emergency surgery

Pelvic Inflammatory Disease (PID)

• Location: Lower abdominal pain
• Symptoms: Fever, cervical motion tenderness, vaginal discharge
• Diagnosis: Clinical, pelvic ultrasound
• Management: Antibiotic therapy

5. Vascular Causes

Vascular conditions may cause ischemic pain, which is often severe and associated with hypotension.

Abdominal Aortic Aneurysm (AAA)

• Location: Lower abdominal/flank pain, may radiate to the back
• Nature: Tearing or pulsating pain
• Risk Factors: Hypertension, smoking, atherosclerosis
• Diagnosis: Ultrasound, CT angiography
• Management: Urgent surgical repair if ruptured

Mesenteric Ischemia

• Location: Periumbilical pain
• Nature: Severe pain out of proportion to physical findings
• Causes: Arterial embolism, thrombosis
• Diagnosis: CT angiography
• Management: Anticoagulation, surgery

6. Systemic Causes

Abdominal pain can also result from systemic conditions, such as:

• Diabetic Ketoacidosis (DKA): Diffuse abdominal pain, nausea, fruity breath, high glucose levels.
• Lead Poisoning: Chronic abdominal pain with neurologic symptoms.
• Porphyria: Severe episodic abdominal pain with neurological involvement.

Chapter 3: Diagnostic Approach to Abdominal Pain

Accurately diagnosing abdominal pain requires a systematic approach that includes a detailed history, physical examination, laboratory investigations, and imaging studies. This chapter provides an in-depth review of the diagnostic process, helping clinicians determine the underlying cause of abdominal pain efficiently.

1. Clinical History

A thorough history-taking is the first and most important step in evaluating abdominal pain. Key aspects of history include:

• Onset:
• Sudden onset: Suggests perforated peptic ulcer, ruptured aortic aneurysm, or ovarian torsion.
• Gradual onset: More typical of appendicitis, cholecystitis, or diverticulitis.

• Location and Radiation:
• Right upper quadrant (RUQ) → Cholecystitis, hepatitis, liver abscess.
• Left upper quadrant (LUQ) → Gastritis, splenic infarction.
• Right lower quadrant (RLQ) → Appendicitis, Crohn’s disease, ectopic pregnancy.
• Left lower quadrant (LLQ) → Diverticulitis, irritable bowel syndrome (IBS).
• Epigastric region → Peptic ulcer disease, pancreatitis, myocardial infarction (referred pain).
• Diffuse abdominal pain → Peritonitis, gastroenteritis, mesenteric ischemia.

• Pain Characteristics:
• Colicky pain: Associated with obstruction (e.g., ureteric colic, gallstones, bowel obstruction).
• Sharp, localized pain: Suggests parietal pain (e.g., peritonitis, appendicitis).
• Burning pain: Seen in acid-related disorders like gastroesophageal reflux disease (GERD) or peptic ulcer disease.

• Aggravating and Relieving Factors:
• Worse with food: Gastric ulcer, cholelithiasis.
• Better with food: Duodenal ulcer.
• Worse after fatty meals: Cholecystitis, pancreatitis.
• Worse with movement: Peritonitis, appendicitis.

• Associated Symptoms:
• Nausea and vomiting → Gastroenteritis, bowel obstruction, pancreatitis.
• Diarrhea → Irritable bowel syndrome, infectious colitis, Crohn's disease.
• Constipation → Bowel obstruction, hypothyroidism, opioid-induced constipation.
• Fever → Appendicitis, pyelonephritis, peritonitis.
• Jaundice → Hepatitis, choledocholithiasis, liver cirrhosis.
• Hematuria (blood in urine) → Kidney stones, bladder cancer, glomerulonephritis.
• Vaginal bleeding → Ectopic pregnancy, pelvic inflammatory disease (PID).

2. Physical Examination

A focused abdominal examination helps confirm clinical suspicions. Important components include:

Inspection

• Scars from previous surgeries → Adhesions causing small bowel obstruction.
• Distension → Suggests ascites, bowel obstruction, or hepatosplenomegaly.
• Pulsatile abdominal mass → Suspicious for an abdominal aortic aneurysm.

Palpation

• McBurney’s point tenderness → Suggests appendicitis.
• Murphy’s sign → Pain on deep palpation in the RUQ, seen in acute cholecystitis.
• Rovsing’s sign → RLQ pain when palpating the LLQ, seen in appendicitis.
• Rebound tenderness → Suggests peritonitis.
• Cullen’s sign → Periumbilical bruising, seen in hemorrhagic pancreatitis.
• Grey Turner’s sign → Flank bruising, indicating retroperitoneal bleeding.

Percussion

• Shifting dullness → Indicates ascites, common in liver cirrhosis.
• Hyperresonance → Suggests bowel obstruction.

Auscultation

• Hyperactive bowel sounds → Suggests gastroenteritis or early bowel obstruction.
• Absent bowel sounds → Suggests paralytic ileus or peritonitis.
• Bruits over the aorta → Suggests abdominal aortic aneurysm or renal artery stenosis.

3. Laboratory Investigations

Basic blood and urine tests aid in identifying systemic and organ-specific conditions.

• Complete Blood Count (CBC):
• Leukocytosis (high WBC count) → Seen in infections (e.g., appendicitis, cholecystitis, diverticulitis).
• Anemia (low hemoglobin) → Suggests gastrointestinal bleeding (e.g., gastric ulcer, colon cancer).

• Liver Function Tests (LFTs):
• Elevated AST/ALT → Suggests hepatitis.
• Elevated ALP and bilirubin → Suggests biliary obstruction (e.g., choledocholithiasis).

• Amylase/Lipase:
• Elevated levels → Indicative of pancreatitis.

• Electrolytes and Renal Function Tests:
• Abnormal sodium, potassium → Seen in vomiting, diarrhea, kidney disease.
• Elevated creatinine → Suggests acute kidney injury.

• Urinalysis:
• Hematuria → Suggests kidney stones or urinary tract infection.
• Proteinuria → Can indicate glomerulonephritis.

4. Imaging Studies

Imaging is crucial for confirming the diagnosis of many abdominal conditions.

• Ultrasound (USG):
• First-line for gallstones, cholecystitis, appendicitis (in children and pregnant women).
• Detects liver disease, ascites, ovarian cysts.

• X-ray (Abdominal Radiography):
• Air-fluid levels → Suggests bowel obstruction.
• Free air under diaphragm → Suggests perforated peptic ulcer.

• Computed Tomography (CT) Scan:
• Gold standard for evaluating acute abdominal pain.
• Used for appendicitis, pancreatitis, bowel obstruction, trauma.

• Endoscopy (Upper GI & Colonoscopy):
• Upper Endoscopy (EGD) → Used for GERD, peptic ulcer disease, gastric cancer.
• Colonoscopy → Evaluates ulcerative colitis, colorectal cancer, diverticulitis.

Chapter 4: Management of Abdominal Pain

The management of abdominal pain depends on the underlying cause, severity, and patient condition. Treatment strategies range from conservative management (dietary modifications, pain control) to medical therapy (antibiotics, acid-suppressing drugs) and surgical interventions when necessary. This chapter discusses treatment approaches for different causes of abdominal pain.

1. General Principles of Abdominal Pain Management

Regardless of the cause, the initial approach to abdominal pain involves:

• Assessing severity:
• Mild, self-limiting pain → Managed conservatively with observation and symptomatic treatment.
• Severe pain with instability (e.g., hypotension, tachycardia) → Requires urgent resuscitation and surgical evaluation.

• Symptomatic relief:
• Analgesics:
• Acetaminophen (paracetamol) for mild pain.
• NSAIDs (e.g., ibuprofen, naproxen) for inflammatory conditions (e.g., pancreatitis, peritonitis), but should be avoided in cases of suspected peptic ulcer disease due to risk of worsening mucosal injury.
• Opioids (e.g., morphine, fentanyl) for severe pain but used cautiously as they may mask surgical signs.

• Antiemetics for nausea and vomiting:
• Ondansetron (5-HT3 antagonist) – Preferred for gastroenteritis and postoperative nausea.
• Metoclopramide – Used in gastroparesis, reflux-related nausea.

• IV Fluids:
• Ringer’s lactate or normal saline → Used for dehydration, electrolyte imbalances, and shock.

2. Medical Management for Specific Conditions

Treatment varies depending on the cause of abdominal pain.

Gastrointestinal Disorders

• Gastroesophageal reflux disease (GERD)
• Proton pump inhibitors (PPIs): Omeprazole, pantoprazole
• H2-receptor blockers: Ranitidine (less commonly used now)
• Lifestyle changes: Avoid trigger foods, elevate head while sleeping

• Peptic ulcer disease (PUD)
• PPIs: To reduce stomach acid
• H. pylori eradication therapy: Triple therapy (PPI + clarithromycin + amoxicillin or metronidazole)
• Avoid NSAIDs and alcohol

• Irritable bowel syndrome (IBS)
• Dietary modifications: Low FODMAP diet, increased fiber intake
• Antispasmodics: Hyoscine, dicyclomine
• Probiotics: To regulate gut microbiota

• Inflammatory bowel disease (IBD)
• Mild cases: 5-ASA drugs (mesalamine, sulfasalazine)
• Moderate-severe cases: Corticosteroids, immunomodulators (azathioprine, methotrexate)
• Biologics: Infliximab, adalimumab for severe disease

• Appendicitis
• Surgical management: Appendectomy (laparoscopic or open)
• Antibiotics (preoperative and postoperative): Ceftriaxone + metronidazole

• Diverticulitis
• Uncomplicated: Oral antibiotics (ciprofloxacin + metronidazole), bowel rest
• Complicated (perforation, abscess): IV antibiotics, surgical drainage or resection

Hepatobiliary and Pancreatic Conditions

• Cholecystitis (inflammation of the gallbladder)
• Supportive care: NPO (nil per os), IV fluids, pain control
• Antibiotics: Ceftriaxone + metronidazole
• Definitive treatment: Laparoscopic cholecystectomy

• Pancreatitis
• Supportive care: NPO, IV hydration, pain control (opioids)
• Severe cases: ICU admission, enteral feeding
• Antibiotics: Only if infected necrosis is suspected

• Hepatitis
• Viral hepatitis (A, B, C, etc.): Supportive care; antiviral therapy for chronic hepatitis B/C
• Alcoholic hepatitis: Corticosteroids or pentoxifylline for severe cases

Urological Conditions

• Kidney stones
• Pain management: NSAIDs, opioids
• Hydration therapy: Increased fluid intake to facilitate stone passage
• Alpha-blockers: Tamsulosin (for ureteric stones)
• Lithotripsy or surgery: If large or obstructive stones are present

• Urinary tract infections (UTIs)
• Uncomplicated UTI: Nitrofurantoin, trimethoprim-sulfamethoxazole
• Complicated UTI (pyelonephritis): IV antibiotics (ceftriaxone, piperacillin-tazobactam)

Gynecological Conditions

• Ectopic pregnancy
• Stable patients: Methotrexate (medical management)
• Unstable or ruptured cases: Emergency laparoscopic surgery

• Ovarian torsion
• Emergency surgery to untwist or remove the ovary

• Pelvic inflammatory disease (PID)
• Antibiotics: Ceftriaxone + doxycycline + metronidazole

Vascular and Systemic Conditions

• Abdominal aortic aneurysm (AAA)
• Unruptured: Elective surgical repair
• Ruptured: Emergency open or endovascular aneurysm repair (EVAR)

• Mesenteric ischemia
• Initial treatment: IV fluids, broad-spectrum antibiotics, anticoagulation
• Surgical revascularization for thrombotic cases

• Diabetic ketoacidosis (DKA)
• IV insulin therapy
• Correction of fluids and electrolytes (K+, Na+, HCO3-)

3. When to Consider Surgery

Surgical intervention is required for conditions such as:

• Acute appendicitis → Appendectomy
• Perforated peptic ulcer → Emergency laparotomy
• Intestinal obstruction → Bowel resection if strangulated
• Severe diverticulitis with perforation → Surgical colectomy
• Gallstone-related complications → Cholecystectomy

4. Lifestyle Modifications for Prevention

Certain lifestyle changes can help prevent recurrent abdominal pain:

• Dietary Adjustments:
• Increase fiber intake (prevents constipation, diverticulosis)
• Reduce spicy and acidic foods (prevents GERD, PUD)
• Avoid excess alcohol consumption (prevents pancreatitis, liver disease)

• Regular Exercise:
• Reduces risk of obesity-related conditions (e.g., gallstones, diabetes)
• Improves bowel motility, reducing constipation and bloating

• Adequate Hydration:
• Prevents kidney stones, constipation, dehydration

• Routine Medical Checkups:
• Colorectal cancer screening (colonoscopy for >50 years)
• Liver function tests for those at risk of chronic liver disease

Prevention

For prevention of many types of abdominal pain:

1. Eat small meals more frequently.
2. Make sure that your meals are well-balanced and high in fiber. Eat plenty of fruits and vegetables.
3. Limit foods that produce gas.
4. Drink plenty of water each day.
5. Exercise regularly.

For prevention of symptoms from heartburn or gastroesophageal reflux disease:

1. Quit smoking.
2. Lose weight if you need to.
3. Finish eating at least 2 hours before you go to bed.
4. After eating, stay upright for at least 30 minutes.
5. Elevate the head of your bed.

ICD codes

• R10.0 - external R10

• 789.0 - external 789.0

Summary

The management of abdominal pain involves:

• 1. General supportive measures (pain control, fluids, antiemetics).
• 2. Medical therapy tailored to the underlying cause.
• 3. Surgical intervention when necessary.
• 4. Lifestyle modifications to prevent recurrence.

Final Thoughts

Understanding the classification, causes, diagnosis, and management of abdominal pain is essential for medical students, physicians, and healthcare providers.

For further reading, refer to related topics such as:

• Gastrointestinal diseases
• Emergency medicine
• Surgical interventions for abdominal pain

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