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Abdominal pain

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Template:Short description Template:Redirect Template:Cs1 config Template:Use dmy dates Template:Use American English Template:Infobox medical condition (new)

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.<ref name=Hopcroft2020>Template:Cite book</ref>

Common causes of pain in the abdomen include gastroenteritis and irritable bowel syndrome.<ref name=Hopcroft2020/> About 15% of people have a more serious underlying condition such as appendicitis, leaking or ruptured abdominal aortic aneurysm, diverticulitis, or ectopic pregnancy.<ref name=Vin2014/> In a third of cases, the exact cause is unclear.<ref name=Vin2014/>Template:TOC limit

Signs and symptomsEdit

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.<ref name="Sherman 1990 r770">Template:Cite book</ref>

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.<ref name="Sherman 1990 r770" />

CausesEdit

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%).<ref name="Vin2014">Template:Cite journal</ref> More common in those who are older, ischemic colitis,<ref>Template:Cite journal</ref> mesenteric ischemia, and abdominal aortic aneurysms are other serious causes.<ref name="Spangler 2014">Template:Cite journal</ref>

Acute abdomenEdit

Acute abdomen is a condition where there is a sudden onset of severe abdominal pain requiring immediate recognition and management of the underlying cause.<ref name="aa">Template:Citation</ref> The underlying cause may involve infection, inflammation, vascular occlusion or bowel obstruction.<ref name=aa/>

The pain may elicit nausea and vomiting, abdominal distention, fever and signs of shock.<ref name=aa/> A common condition associated with acute abdominal pain is appendicitis.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Here is a list of acute abdomen causes:

Surgical causesEdit

Source:<ref name="aa" />

InflammatoryEdit

MechanicalEdit

VascularEdit

Referred painEdit

Source:<ref>Template:Cite journal</ref>

  • Viscero-visceral referral: happens when one organ with afferent nerves close to another organ is sensitized or inflamed (in this case any of the abdominal viscera)<ref>Template:Cite book</ref>
  • Viscero-somatic referral: any pain in the viscera that causes pain in the muscle, bone, and skin (of the abdomen in case of abdominal pain)
  • Somatic-visceral referral: pain in the skin, muscles, and bone that causes referred pain in the viscera (of the abdomen such as the stomach, kidneys, bladder, etc.)

Medical causesEdit

Source:<ref name="aa" />

Acute pancreatitis.

Sickle cell anemia.

Diabetic ketoacidosis (DKA).

Adrenal crisis.

Pyelonephritis.

Lead poisoning.

Familial Mediterranean fever (FMF).

Gynecological causesEdit

Source:<ref>Template:Cite journal</ref>

Pelvic inflammatory disease (PID) and abscess.

Ectopic pregnancy.

Hemorrhagic ovarian cyst.

Adnexal or ovarian torsion.

By systemEdit

A more extensive list includes the following:Template:Citation needed

By locationEdit

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:<ref>Template:Cite book</ref><ref>Template:Cite book</ref>

MechanismEdit

Region Blood supply<ref name="Moore 2016" /> Innervation<ref>Template:Cite book</ref> Structures<ref name="Moore 2016" />
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.<ref name="Moore 2016">Template:Cite book</ref> 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.<ref name="Moore 2016" /> The midgut contains portions of the duodenum (distal), cecum, appendix, ascending colon, and first half of the transverse colon.<ref name="Moore 2016" /> The hindgut contains the distal half of the transverse colon, descending colon, sigmoid colon, rectum, and superior anal canal.<ref name="Moore 2016" />

Each subsection of the gut has an associated visceral afferent nerve that transmits sensory information from the viscera to the spinal cord.<ref>Template:Cite book</ref> 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.<ref name="Neumayer 2013">Template:Cite book</ref> 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.<ref name="Neumayer 2013" />

DiagnosisEdit

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:<ref name="Bickley 2016">Template:Cite book</ref>

  • 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.
  • Using Carnett's sign to differentiate between visceral pain and pain originating in the muscles of the abdominal wall.<ref>Template:Cite book</ref>

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.<ref name="Bickley 2016" />

Additional investigations that can aid diagnosis include:<ref name="Cartwright 2008">Template:Cite journal</ref>

If diagnosis remains unclear after history, examination, and basic investigations as above, then more advanced investigations may reveal a diagnosis. Such tests include:<ref name="Cartwright 2008" />

ManagementEdit

The management of abdominal pain depends on many factors, including the etiology of the pain. Some behavioural changes implemented to prevent pain include: resting after a meal, chewing food completely and slowly, and avoiding stressful and high excitement situations after a meal. Such at home strategies may reduce the need to seek professional assistance via prevention of future abdominal pain.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> 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.<ref name="Mahadevan">Template:Cite book</ref> Treatment for abdominal pain includes analgesia, such as non-opioid (ketorolac) and opioid medications (morphine, fentanyl).<ref name="Mahadevan" /> Choice of analgesia is dependent on the cause of the pain, as ketorolac can worsen some intra-abdominal processes.<ref name="Mahadevan" /> 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.<ref name="Mahadevan" /> After addressing pain, there may be a role for antimicrobial treatment in some cases of abdominal pain.<ref name="Mahadevan" /> Butylscopolamine (Buscopan) is used to treat cramping abdominal pain with some success.<ref>Template:Cite journal</ref> Surgical management for causes of abdominal pain includes but is not limited to cholecystectomy, appendectomy, and exploratory laparotomy.Template:Citation needed

EmergenciesEdit

Below is a brief overview of abdominal pain emergencies.

Condition Presentation Diagnosis Management
Appendicitis<ref name="Sherman 2016">Template:Cite book</ref> Abdominal pain, nausea, vomiting, fever

Periumbilical 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<ref name="Sherman 2016" /> 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<ref name="Sherman 2016" /> 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<ref name="Sherman 2016" /> 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<ref name="Sherman 2016" /> 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<ref name="Sherman 2016" /> 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 resuscitation

Blood transfusion as needed

Medications: proton pump inhibitor

Stable patient: observation

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

Perforated Viscous<ref name="Sherman 2016" /> 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 resuscitation

General surgery consultation

Antibiotics

Volvulus<ref name="Sherman 2016" /> 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<ref name="Sherman 2016" /> Abdominal and pelvic pain, bleeding

If 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 consultation

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

Abdominal aortic aneurysm<ref name="Sherman 2016" /> 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 consultation

If patient is stable: admit for observation

Aortic dissection<ref name="Sherman 2016" /> 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 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<ref name="Sherman 2016" /> 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

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<ref name="Sherman 2016" /> 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

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

OutlookEdit

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).<ref name="A C T R p. ">Template:Cite journal</ref> Most people who suffer from stomach pain have a benign issue, like dyspepsia.<ref name="Gulacti Arslan Ooi Tuck 2001 pp. 123–136">Template:Cite journal</ref> 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.<ref name="Chandramohan Pari Schrock Lum 1991 pp. 503–507">Template:Cite journal</ref>

EpidemiologyEdit

Abdominal pain is the reason about 3% of adults see their family physician.<ref name=Vin2014/> 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%.<ref>Template:Cite journal</ref>

Special populationsEdit

GeriatricsEdit

More time and resources are used on older patients with abdominal pain than on any other patient presentation in the emergency department (ED).<ref name="SA LZ p. ">Template:Cite journal</ref> 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.<ref name="Rodríguez-Lomba Pulido-Pérez Ricciardi Marcello 1976 pp. 219–223">Template:Cite journal</ref>

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.<ref name="Weyand Goronzy p. ">Template:Cite journal</ref> 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.<ref name="Sherman p.">Template:Cite journal</ref>

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.<ref name="Isani Kim Mateu Tormo 2006 pp. 371–388">Template:Cite journal</ref>

PregnancyEdit

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.<ref>Template:Cite journal</ref> 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.<ref name="Souza Ferreira Young Cerit 2003 pp. 1–58">Template:Cite journal</ref>

See alsoEdit

ReferencesEdit

Template:Reflist

Further readingEdit

External linksEdit

Template:Medical resources

Template:Digestive system and abdomen symptoms and signs

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