Abdominal Pain

Medical Author : Jay W. Marks, MD,Charles Patrick Davis, MD, PhD

Medical Editor : Bhupinder S. Anand, MBBS, MD, DPHIL (OXON)

Abdominal pain facts

  • Abdominal pain is pain that is felt in the part of the trunk below the ribs and above the pelvis.
  • Abdominal pain comes from organs within the abdomen or organs adjacent to the abdomen.
  • Abdominal pain is caused by inflammation, distention of an organ, or by loss of the blood supply to an organ. Abdominal pain in irritable bowel syndrome (IBS) may be caused by contraction of the intestinal muscles or hyper-sensitivity to normal intestinal activities.
  • Symptoms associated with abdominal pain may include:
  • The cause of abdominal pain is diagnosed on the basis of the characteristics of the pain, physical examination, and testing. Occasionally, surgery is necessary for diagnosis.
  • The diagnosis of the cause of abdominal pain is challenging because the characteristics of the pain may be atypical, tests are not always abnormal, diseases causing pain may mimic each other, and the characteristics of the pain may change over time

What is abdominal pain?

Abdominal pain is pain that is felt in the abdomen. The abdomen is an anatomical area that is bounded by the lower margin of the ribs and diaphragm above, the pelvic bone (pubic ramus) below, and the flanks on each side. Although abdominal pain can arise from the tissues of the abdominal wall that surround the abdominal cavity (such as the skin and abdominal wall muscles), the term abdominal pain generally is used to describe pain originating from organs within the abdominal cavity. Organs of the abdomen include the stomach, small intestine, colon, liver, gallbladder, spleen, and pancreas.

Technically, the lowermost portion of the area described previously, is the pelvis, which contains the urinary bladder and rectum, as well as the prostate gland in men, and the uterus, Fallopian tubes, and ovaries in women. Often, it can be difficult to know if lower abdominal pain is coming from the lower abdomen or pelvis.

Occasionally, pain may be felt in the abdomen even though it is arising from organs that are close to, but not within, the abdominal cavity. For example, conditions of the lower lungs, the kidneys, and the uterus or ovaries can cause abdominal pain. On the other hand, it also is possible for pain from organs within the abdomen to be felt outside of the abdomen. For example, the pain of pancreatic inflammation may be felt in the back. These latter types of pain are called "referred" pain because the pain does not originate in the location that it is felt. Rather, the cause of the pain is located away from where it is felt (i.e., it is referred to a different area). Continue Reading

Picture of the organs and glands in the abdomen

What causes abdominal pain?

Abdominal pain is caused by inflammation of an organ (for example, appendicitis, diverticulitis, colitis), by stretching or distention of an organ (for example, obstruction of the intestine, blockage of a bile duct by gallstones, swelling of the liver with hepatitis), or by loss of the supply of blood to an organ (for example, ischemic colitis).

To complicate matters, however, abdominal pain also can occur without inflammation, distention or loss of blood supply. An important example of this latter type of pain is the irritable bowel syndrome (IBS). It is not clear what causes the abdominal pain in IBS, but it is believed to be due either to abnormal contractions of the intestinal muscles (for example, spasm) or abnormally sensitive nerves within the intestines that give rise to painful sensations inappropriately (visceral hyper-sensitivity). These latter types of pain are often referred to as functional pain because no recognizable specific abnormality to account for the causes of the pain have been found - at least not yet.

When should I call my doctor about abdominal pain?

Some doctors suggest that if you have a "less serious" cause of abdominal pain (see above section on topic), especially if it is likely food poisoning (viral or bacterial) and you have had discomfort but are not dehydrated, you will likely not need medical care as the symptoms should resolve in about 24 to 48 hours. If you have a chronic problem that occasionally causes abdominal pain, most doctors suggest you contact the person treating you for the ailment for an appointment or prescription (refill). However, if you have any of the problems or symptoms listed in the "serious abdominal pain "section above, you should seek immediate medical care.

How is the cause of abdominal pain diagnosed?

Doctors determine the cause of abdominal pain by relying on:

  1. Characteristics, signs, and symptoms of the pain
  2. Findings on physical examination
  3. Laboratory, radiological, and endoscopic testing
  4. Surgery

Signs and symptoms associated with abdominal pain

The following information, obtained by taking a patient's history, is important in helping doctors determine the cause of pain:

  • The way the pain begins. Abdominal pain that comes on suddenly suggests an acute event, for example, the interruption of the supply of blood to the colon (ischemia) or obstruction of the bile duct by a gallstone (biliary colic).
  • The location of the pain.
    • Appendicitis typically causes pain in the middle of the abdomen, and then moves to the right lower abdomen, the usual location of the appendix.
    • Diverticulitis typically causes pain in the left lower abdomen where most colonic diverticuli are located.
    • Pain from the gallbladder (biliary colic or cholecystitis) typically is felt in the middle, upper abdomen or the right upper abdomen near where the gallbladder is located.
  • The pattern of the pain.
    • Obstruction of the intestine initially causes waves of crampy abdominal pain due to contractions of the intestinal muscles and distention of the intestine.
    • True cramp-like pain suggests vigorous contractions of the intestines.
    • Obstruction of the bile ducts by gallstones typically causes steady (constant) upper abdominal pain that lasts between 30 minutes and several hours.
    • Acute pancreatitis typically causes severe, unrelenting, steady pain in the upper abdomen and upper back.
    • The pain of acute appendicitis initially may start near the umbilicus, but as the inflammation progresses, the pain moves to the right lower abdomen.
    • The character of pain may change over time. For example, obstruction of the bile ducts sometimes progresses to inflammation of the gallbladder with or without infection (acute cholecystitis). When this happens, the characteristics of the pain change to those of inflammatory pain. (See below.)
  • The duration of the pain.
    • The pain of IBS typically waxes and wanes over months or years and may last for years or decades.
    • Biliary colic lasts no more than several hours.
    • The pain of pancreatitis lasts one or more days.
    • The pain of acid-related diseases - gastroesophageal reflux disease (GERD) or duodenal ulcers - typically show periodicity, that is, a period of weeks or months during which the pain is worse followed by periods of weeks or months during which the pain is better.
    • Functional pain may show this same pattern of periodicity.
  • What makes the pain worse. Pain due to inflammation (appendicitis, diverticulitis, cholecystitis, pancreatitis) typically is aggravated by sneezing, coughing or any jarring motion. Patients with inflammation as the cause of their pain prefer to lie still.
  • What relieves the pain.
    • The pain of IBS and constipation often is relieved temporarily by bowel movements and may be associated with changes in bowel habit.
    • Pain due to obstruction of the stomach or upper small intestine may be relieved temporarily by vomiting which reduces the distention that is caused by the obstruction.
    • Eating or taking antacids may temporarily relieve the pain of ulcers of the stomach or duodenum because both food and antacids neutralize the acid that is responsible for irritating the ulcers and causing the pain.
    • Pain that awakens patients from sleep is more likely to be due to non-functional causes and is more significant.

Other associated symptoms that accompany abdominal pain may suggest the following:

  • The presence of fever suggests inflammation or infection.
  • Diarrhea or rectal bleeding suggests an intestinal cause of the pain.
  • The presence of fever and diarrhea suggest inflammation of the intestines that may be infectious or non-infectious. 
  • Physical examination to diagnose abdominal pain

    Physical examination

    Examining the patient will provide the doctor with additional clues to the cause of abdominal pain. The doctor will determine:

    1. The presence of sounds coming from the intestines that occur when there is obstruction of the intestines,
    2. The presence of signs of inflammation (by special maneuvers during the examination),
    3. The location of any tenderness
    4. The presence of a mass within the abdomen that suggests a tumor, enlarged organ, or abscess (a collection of infected pus)
    5. The presence of blood in the stool that may signify an intestinal problem such as an ulcer, colon cancer, colitis, or ischemia.

    For example:

    • Finding tenderness and signs of inflammation in the left lower abdomen often means that diverticulitis is present, while finding a tender (inflamed) mass in the same area may mean that the inflammation has progressed and that an abscess has formed.
    • Finding tenderness and signs of inflammation in the right lower abdomen often means that appendicitis is present, while finding a tender mass in the same area may mean that the inflammation has progressed and that an abscess has formed.
    • Inflammation in the right lower abdomen, with or without a mass, also may be found in Crohn's disease. (Crohn's disease most commonly affects the last part of the small intestine, usually located in the right lower abdomen.)
    • A mass without signs of inflammation may mean that a cancer is present.
    • Exams and tests to diagnose abdominal pain

      While the history and physical examination are vitally important in determining the cause of abdominal pain, testing often is necessary to determine the cause.

      Laboratory tests. Laboratory tests such as the complete blood count (CBC), liver enzymes, pancreatic enzymes (amylase and lipase), pregnancy test and urinalysis are frequently performed in the evaluation of abdominal pain.

      • An elevated white count suggests inflammation or infection (as with appendicitis, pancreatitis, diverticulitis, or colitis).
      • A low red blood cell count may indicate a bleed in the intestines.
      • Amylase and lipase (enzymes produced by the pancreas) commonly are elevated in pancreatitis.
      • Liver enzymes may be elevated with gallstone attacks or acute hepatitis.
      • Blood in the urine suggests kidney stones.
      • When there is diarrhea, white blood cells in the stool suggest intestinal inflammation or infection.
      • A positive pregnancy test may indicate an ectopic pregnancy (a pregnancy in the fallopian tube instead of the uterus).

      Plain X-rays of the abdomen. Plain X-rays of the abdomen also are referred to as a KUB (because they include the kidney, ureter, and bladder). The KUB may show enlarged loops of intestines filled with copious amounts of fluid and air when there is intestinal obstruction. Patients with a perforated ulcer may have air escape from the stomach into the abdominal cavity. The escaped air often can be seen on a KUB on the underside of the diaphragm. Sometimes a KUB may reveal a calcified kidney stone that has passed into the ureter and resulted in referred abdominal pain or calcifications in the pancreas that suggests chronic pancreatitis.

      Radiographic studies.

      • Abdominal ultrasoundis useful in diagnosing gallstones, cholecystitis appendicitis, or ruptured ovarian cysts as the cause of the pain.
      • Computerized tomography (CT) of the abdomen is useful in diagnosing pancreatitis, pancreatic cancer, appendicitis, and diverticulitis, as well as in diagnosing abscesses in the abdomen. Special CT scans of the abdominal blood vessels can detect diseases of the arteries that block the flow of blood to the abdominal organs.
      • Magnetic resonance imaging (MRI) is useful in diagnosing many of the same conditions as CT tomography.
      • Barium X-rays of the stomach and the intestines (upper gastrointestinal series or UGI with a small bowel follow-through) can be helpful in diagnosing ulcers, inflammation, and blockage in the intestines.
      • Computerized tomography (CT) of the small intestine can be helpful in diagnosing diseases in the small bowel such as Crohn's disease.
      • Capsule enteroscopy, uses a small camera the size of a pill swallowed by the patient, which can take pictures of the entire small bowel and transmit the pictures onto a portable receiver. The small bowel images can be downloaded from the receiver onto a computer to be inspected by a doctor later. Capsule enteroscopy can be helpful in diagnosing Crohn's disease, small bowel tumors, and bleeding lesions not seen on x-rays or CT scans.

      Endoscopic procedures.

      • Esophagogastroduodenoscopy or EGD is useful for detecting ulcers, gastritis (inflammation of the stomach), or stomach cancer.
      • Colonoscopy or flexible sigmoidoscopy is useful for diagnosing infectious colitis, ulcerative colitis, or colon cancer.
      • Endoscopic ultrasound (EUS) is useful for diagnosing pancreatic cancer or gallstones if the standard ultrasound or CT or MRI scans fail to detect them.
      • Balloon enteroscopy, the newest technique allows endoscopes to be passed through the mouth or anus and into the small intestine where small intestinal causes of abdominal pain or bleeding can be diagnosed, biopsied, and treated.
      Surgery. Sometimes, diagnosis requires examination of the abdominal cavity either by laparoscopy or surgery. 
    • IBS (irritable bowel syndrome) and diagnosing abdominal pain

      As previously discussed, the pain of irritable bowel syndrome is due either to abnormal intestinal muscle contractions or visceral hypersensitivity. Generally, abnormal muscle contractions and visceral hypersensitivity are much more difficult to diagnose than other diseases causing abdominal pain, particularly since there are no typical abnormalities on physical examination or the usual diagnostic tests. The diagnosis is based on the history (typical symptoms) and the absence of other causes of abdominal pain.

      Why can diagnosis of the cause of abdominal pain be difficult?

      Modern advances in technology have greatly improved the accuracy, speed, and ease of establishing the cause of abdominal pain, but significant challenges remain. There are many reasons why diagnosing the cause of abdominal pain can be difficult. They are:

      • Symptoms may be atypical. For example, the pain of appendicitis sometimes is located in the right upper abdomen, and the pain of diverticulitis is on the right side. Elderly patients and patients taking corticosteroids may have little or no pain and tenderness when there is inflammation, for example, with cholecystitis or diverticulitis. This occurs because corticosteroids reduce the inflammation.
      • Tests are not always abnormal.
        • Ultrasound examinations can miss gallstones, particularly small ones.
        • CT scans may fail to show pancreatic cancer, particularly small ones.
        • The KUB can miss the signs of intestinal obstruction or stomach perforation.
        • Ultrasounds and CT scans may fail to demonstrate appendicitis or even abscesses, particularly if the abscesses are small.
        • The CBC and other blood tests may be normal despite severe infection or inflammation, particularly in patients receiving corticosteroids or other drugs that suppress the immune system.
      • Diseases can mimic one another.
        • IBS symptoms can mimic bowel obstruction, cancer, ulcer, gallbladder attacks, or even appendicitis.
        • Crohn's disease can mimic appendicitis.
        • Infection of the right kidney can mimic acute cholecystitis.
        • A ruptured right ovarian cyst can mimic appendicitis; while a ruptured left ovarian cyst can mimic diverticulitis.
        • Kidney stones can mimic appendicitis or diverticulitis.
      • The characteristics of the pain may change. Examples discussed previously include the extension of the inflammation of pancreatitis to involve the entire abdomen and the progression of biliary colic to cholecystitis.
      • What are home remedies for certain causes of abdominal pain?

        If you are unsure that your abdominal pain requires medical evaluation, contact your doctor before using any home remedies.

        • Common home remedies for abdominal pain are:
          • eating less food,
          • taking small amounts of baking soda,
          • using lemon and/or lime juice, and
          • starting a BRAT diet (banana, rice, applesauce and toast) for a day or so.
        • Stop smoking and drinking alcohol.

        Some health care professionals recommend:

        • Taking ginger
        • Peppermint
        • Licorice
        • Chamomile tea
        • Medications such as bismuth subsalicylate (Pepto-Bismol), loperamide (Imodium), ranitidine (Zantac) and other over-the-counter substances

        Some of these listed above may help reduce symptoms, but if symptoms persist, seek medical help. Beware of "cures" advertised for abdominal pains as a single treatment that can cure all types of this problem does not exist.

        Taking aspirin or NSAIDs should be avoided until the cause of the pain is diagnosed because the medications could make some causes worse (for example, peptic ulcers, intestinal bleeding). 
      • What medications can be used to treat certain causes of abdominal pain?

        Medications that are used to treat the underlying cause(s) of abdominal pain are the medications of choice. For example, medications are not needed to treat simple viral gastroenteritis, while surgery and/or chemotherapy may be the best approach to treat certain cancers in the abdomen. Other causes may require antispasmodics, antimicrobials, H2 blockers, or even nitrates or morphine. The diagnosed cause usually narrows the choice of medications. A few causes can only be treated by surgery (for example appendicitis, hernia [incarcerated], and certain abdominal injuries), although some medications may be used (for example, morphine) while the person is awaiting surgery.

        What lifestyle choices can I make to prevent abdominal pain?

        Lifestyle changes really depend on the cause of the abdominal pain.

        • Eat a good diet, exercise, and avoid smoking and excess alcohol consumption to reduce the chances that you will experience certain causes of abdominal pain.
        • Good hygiene, especially hand washing and avoiding materials and foods contaminated with viruses and bacteria will reduce your chances of developing illness and abdominal pain from many infectious causes.
        • For other specific suggestions, the reader should determine what is suggested to prevent or reduce the chance of getting one of the many specific causes of abdominal pain presented in this article.

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