Abdominal pain
Abdominal pain is a frequent complaint in both outpatient and emergency settings, encompassing a diverse range of conditions from benign to life-threatening. It can be acute or chronic, localised or diffuse. A thorough understanding of the underlying pathophysiological mechanisms and potential causes is crucial for accurate diagnosis and effective management.
Background
The abdominal cavity contains various organs including the stomach, liver, gallbladder, spleen, pancreas, kidneys, intestines and reproductive organs. Pain can originate from any of these structures or from the abdominal wall itself. The innervation of these organs is complex and involves somatic and visceral nerves which contribute to the nature and perception of pain.
Differential Diagnosis
The table below gives characteristic exam question features for conditions causing abdominal pain. Unusual and 'medical' causes of abdominal pain should also be remembered:
ConditionCharacteristic exam featurePeptic ulcer diseaseDuodenal ulcers: more common than gastric ulcers, epigastric pain relieved by eating
Gastric ulcers: epigastric pain worsened by eating
Features of upper gastrointestinal haemorrhage may be seen (haematemesis, melena etc)
AppendicitisPain initial in the central abdomen before localising to the right iliac fossa
Anorexia is common
Tachycardia, low-grade pyrexia, tenderness in RIF
Rovsing's sign: more pain in RIF than LIF when palpating LIF
Acute pancreatitisUsually due to alcohol or gallstones
Severe epigastric pain
Vomiting is common
Examination may reveal tenderness, ileus and low-grade fever
Periumbilical discolouration (Cullen's sign) and flank discolouration (Grey-Turner's sign) is described but rare
Biliary colicPain in the RUQ radiating to the back and interscapular region, may be following a fatty meal. Slight misnomer as the pain may persist for hours
Obstructive jaundice may cause pale stools and dark urine
It is sometimes taught that patients are female, forties, fat and fair although this is obviously a generalisation
Acute cholecystitisHistory of gallstones symptoms (see above)
Continuous RUQ pain
Fever, raised inflammatory markers and white cells
Murphy's sign positive (arrest of inspiration on palpation of the RUQ)
DiverticulitisColicky pain typically in the LLQ
Fever, raised inflammatory markers and white cells
Abdominal aortic aneurysmSevere central abdominal pain radiating to the back
Presentation may be catastrophic (e.g. Sudden collapse) or sub-acute (persistent severe central abdominal pain with developing shock)
Patients may have a history of cardiovascular disease
Intestinal obstructionHistory of malignancy/previous operations
Vomiting
Not opened bowels recently
'Tinkling' bowel sounds
Diagram showing stereotypical areas where particular conditions present. The diagram is not exhaustive and only lists the more common conditions seen in clinical practice. Note how pain from renal causes such as renal/ureteric colic and pyelonephritis may radiate and move from the loins towards the suprapubic area.
Abdominal pain is a frequent complaint in both outpatient and emergency settings, encompassing a diverse range of conditions from benign to life-threatening. It can be acute or chronic, localised or diffuse. A thorough understanding of the underlying pathophysiological mechanisms and potential causes is crucial for accurate diagnosis and effective management.
Background
The abdominal cavity contains various organs including the stomach, liver, gallbladder, spleen, pancreas, kidneys, intestines and reproductive organs. Pain can originate from any of these structures or from the abdominal wall itself. The innervation of these organs is complex and involves somatic and visceral nerves which contribute to the nature and perception of pain.
Differential Diagnosis
The table below gives characteristic exam question features for conditions causing abdominal pain. Unusual and 'medical' causes of abdominal pain should also be remembered:
- acute coronary syndrome
- diabetic ketoacidosis
- pneumonia
- acute intermittent porphyria
- lead poisoning
ConditionCharacteristic exam featurePeptic ulcer diseaseDuodenal ulcers: more common than gastric ulcers, epigastric pain relieved by eating
Gastric ulcers: epigastric pain worsened by eating
Features of upper gastrointestinal haemorrhage may be seen (haematemesis, melena etc)
AppendicitisPain initial in the central abdomen before localising to the right iliac fossa
Anorexia is common
Tachycardia, low-grade pyrexia, tenderness in RIF
Rovsing's sign: more pain in RIF than LIF when palpating LIF
Acute pancreatitisUsually due to alcohol or gallstones
Severe epigastric pain
Vomiting is common
Examination may reveal tenderness, ileus and low-grade fever
Periumbilical discolouration (Cullen's sign) and flank discolouration (Grey-Turner's sign) is described but rare
Biliary colicPain in the RUQ radiating to the back and interscapular region, may be following a fatty meal. Slight misnomer as the pain may persist for hours
Obstructive jaundice may cause pale stools and dark urine
It is sometimes taught that patients are female, forties, fat and fair although this is obviously a generalisation
Acute cholecystitisHistory of gallstones symptoms (see above)
Continuous RUQ pain
Fever, raised inflammatory markers and white cells
Murphy's sign positive (arrest of inspiration on palpation of the RUQ)
DiverticulitisColicky pain typically in the LLQ
Fever, raised inflammatory markers and white cells
Abdominal aortic aneurysmSevere central abdominal pain radiating to the back
Presentation may be catastrophic (e.g. Sudden collapse) or sub-acute (persistent severe central abdominal pain with developing shock)
Patients may have a history of cardiovascular disease
Intestinal obstructionHistory of malignancy/previous operations
Vomiting
Not opened bowels recently
'Tinkling' bowel sounds
Diagram showing stereotypical areas where particular conditions present. The diagram is not exhaustive and only lists the more common conditions seen in clinical practice. Note how pain from renal causes such as renal/ureteric colic and pyelonephritis may radiate and move from the loins towards the suprapubic area.