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Updated 09 September 2013

Abdominal pain

Abdominal pain is a frequent manifestation of disorders of the abdominal organs, but it may also result from disorders in which the primary problem lies outside the abdomen.

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Summary

  • Abdominal pain is a frequent manifestation of disorders of the abdominal organs, but it may also result from disorders in which the primary problem lies outside the abdomen.
  • The cause of abdominal problems can be hard to pinpoint. Sometimes serious and minor abdominal problems start with the same symptoms.
  • Any sudden, severe, unfamiliar stomach or abdominal pain lasting longer than 30 minutes requires immediate attention.

Description

When the problem is in your abdomen

  • The abdomen contains various organs and other structures and disease processes in many of these give rise to pain.
  • The site, character, relieving and aggravating factors of the pain are taken into consideration in the diagnostic process.
  • Accompanying symptoms such as vomiting, constipation, rectal bleeding and jaundice are evaluated in conjunction with the pain.
  • Various special investigations may be indicated to make a final diagnosis.
  • The treatment of abdominal pain will be determined by the underlying disease process.
Facts about the intra-abdominal organs
  • The liver is one of the largest organs in the body, representing 2% of the total body weight with 1,5L of blood entering this organ every minute
  • The gallbladder holds about 50ml of bile but as much as 1,5L of bile is produced every day by the liver cells
  • Although the pancreas is only 12-15cm long and weighs about 100g, it produces 1-2L of secretions per day containing digestive enzymes
  • An amazing 250-350L of blood flow through the spleen every day with each red blood cell averaging 1 000 passes through this 12 by 7 cm organ each day
  • The volume of the empty stomach is only 50 ml, but by a process of active relaxation, the stomach can accommodate about 1 000 ml before pressure in the lumen starts to rise
  • It is estimated that stool contains up to 400 different species of bacteria which participates in numerous physiological processes
  • The small intestine in an adult is 5-6m long and the principal function is absorbing nutrients from the food that we eat
  • Each kidney contains over 1 million functioning units called nephrons responsible for maintaining homeostasis of body fluids.

When the problem is outside of your abdomen

This is classified as abdominal pain due to diseases of extra abdominal organs. There are two types of pain due to diseases of extra abdominal organs:

  • Disease processes in organs outside of the abdomen (with referred pain to the abdomen)
  • Systemic diseases with abdominal pain as a manifestation
Disease processes in organs outside of the abdomen -
Diseases of the vertebral column such as vertebral collapse, prolapsed intervertebral disc or spinal tumour affecting the nerves running onto the anterior (front) abdominal wall, can give rise to abdominal pain. Myocardial infarction (heart attack) can occasionally present with abdominal pain.

Systemic diseases with abdominal pain as a manifestation -
Systemic diseases such as diabetic ketoacidosis, acute intermittent porphyria, lead poisoning and sickle cell anaemia can all present with abdominal pain. This may misdirect the investigative pathway and lead to a delay in diagnosing the underlying condition.

It should be borne in mind that abdominal pain, sometimes of a severe nature, may result from disorders in which the alimentary system (the organs of digestion) is not primarily at fault.

Cause

Site of the pain

The abdomen can be divided into four quadrants: upper right, upper left, lower left and lower right quadrants. Various regions are also present such as the epigastric region (in the centre just below the rib cage), periumbilical region (around the umbilicus) and pelvic region (in the centre just above the pelvic bone).

Pain that occurs in half or more of the abdomen is called generalised pain. Generalised pain can occur with many different illnesses, most of which will go away without medical treatment. Indigestion and the stomach flu (gastroenteritis) are common problems that can cause generalised abdominal pain.

Examples of more localised pain and the possible causative problems are as follows:

  • Epigastric Pain: peptic ulcers, pancreatitis, gastro-oesophageal reflux disease
  • Right Upper Quadrant Pain: gallbladder inflammation (cholecystitis), hepatitis, liver abscess
  • Left Upper Quadrant Pain: diseases of the spleen (infarction, infiltration, abscess)
  • Periumbilical Pain: bowel obstruction, early appendicitis
  • Right Lower Quadrant Pain: late appendicitis, female genital tract diseases (ectopic pregnancy, ovarian cyst, infection, Mittelschmirtz (pain of ovulation))
  • Left Lower Quadrant Pain: female genital tract diseases (as above), diverticular disease
  • Pelvic Region Pain: urinary tract infection, bladder obstruction.

The exact site of the pain is important and can point to the diagnosis of the underlying problem

Abdominal pain may also radiate. For example the pain of pancreatitis, felt in the epigastrium, often radiates to the back. So does the pain related to a dissecting abdominal aneurysm. Disease entities irritating the diaphragm, such as cholecystitis (gallbladder inflammation) often radiates to the shoulder. The pain of oesophageal reflux can radiate to the neck and that of kidney stones to the groin.

Abdominal pain in children

This is a common childhood complaint ranging from mild discomfort to a life-threatening emergency requiring immediate attention. If a child has severe or persistent abdominal pain, get medical care without delay.

In most cases, surgery will not be required, but children with such symptoms should have a thorough check-up to make sure there is not a serious underlying problem.

What causes abdominal pain in children?

In infancy, the most common cause of abdominal pain is colic, which usually clears by age three months. As the child grows older, abdominal pain may be associated with minor disruptions of normal body functions (such as constipation) or with a variety of organic disorders or emotional problems. The abdominal pain associated with emotional problems usually occurs in the age group 5-10 years.

Organic pain (pain due to a physical disease process) is often due to diseases of the abdominal organs, such as the intestines, liver, pancreas and stomach, but it may be relayed from other, more distant parts of the body. Pneumonia and streptococcal throat infection, for example, sometimes cause abdominal symptoms. Hernias, testicular torsion (in boys) and Hirschsprung's disease are other possible causes. Urinary tract infections also causes abdominal pain and can be indicative of a structural abnormality of the urinary tract. Milk intolerance, due to lactose intolerance, results in abdominal pain associated with diarrhoea.

One of the most common emergency causes of abdominal pain in infancy is intussusception, a telescope-like folding of the intestines. In childhood, appendicitis is the most common cause of abdominal pain requiring surgery.

Symptoms

Character of the pain

  • Dull, burning pain relieved by antacids or food, is classical of peptic ulcer disease.
  • Colicky pain, pain which comes and goes in waves, is related to obstruction of a hollow part of a organ seen in renal stone obstruction of an ureter and bowel obstruction. The accompanying irritable bowel syndrome is often described as cramping.
  • The lower abdominal pain of an urinary tract infection is burning in nature.

Accompanying symptoms and signs

Often the importance of abdominal pain can only be determined when other symptoms are evaluated. Abdominal pain without other symptoms is usually not a serious problem.

  • The patient with acute cholecystitis is often jaundiced (yellow discolouration of sclera and mucous membranes) and vomits intermittently.
  • The ureteric colic of a passing renal stone is usually accompanied by blood in the urine.
  • Diarrhoea and/or vomiting are frequent complaints in a patient with abdominal pain related to gastroenteritis.
  • Alternating constipation and diarrhoea is commonly found in irritable bowel syndrome.
  • Constipation and eventually the absence of any bowel actions can be a feature of colonic obstruction caused by a growing tumour.
  • Abnormal bleeding that accompanies abdominal pain is almost always an ominous sign. Vomiting of blood can indicate the presence of a peptic ulcer whereas blood passed per rectum can be related to diverticulitis or a tumour of the colon.

Diagnosis

Site of the pain

(see causes)

The relieving and aggravating factors

These factors also point the clinician in the right diagnostic direction.

  • The pain of irritable bowel syndrome is often relieved by passing stool or flatus and that of peptic ulcer disease is often relieved by eating food.
  • Ingestion of alcohol aggravates the pain of pancreatitis, but sitting up straight and leaning forward will relieve this type of pain.
  • The pain of an inflamed abdominal organ (appendicitis or gallbladder disease) may increase with movement or coughing. Generalised abdominal pain usually does not. Pain that increases with movement or coughing and does not appear to be caused by strained muscles is more likely to mean there is a serious problem.

Duration of the pain

The duration of pain can be divided into two broad categories: acute and chronic pain. This aspect of your abdominal pain also provides clues as to the cause of the pain.

  • Acute onset pain (pain of quick onset) in the epigastric area can be due to perforation of a peptic ulcer, cholecystitis or acute pancreatitis. In the periumbilical area, acute pain can be due to small bowel obstruction, appendicitis or infarction of the intestines (insufficient blood supply to the intestines with resultant gangrene). Acute pain in the lower quadrants can denote dissecting aortic aneurysm, diverticulitis and obstruction of the colon.
  • Pain of a slower and often recurrent nature is termed chronic pain. Chronic pain in the epigastric area can be due to reflux oesophagitis or a chronic peptic ulcer. In the periumbilical region, chronic pain can point to the presence of inflammatory bowel disease and in the lower quadrants to inflammatory bowel disease.

Specialised investigations

After the clinician has taken all the above into account, further special investigations may be indicated in order to make a diagnosis. Diagnostic tests that may be performed include:

  • Blood, urine and stool tests
  • X-rays of the abdomen
  • Upper gastrointestinal endoscopy
  • Colonoscopy
  • Upper gastrointestinal tract and small bowel series
  • Barium enema
  • Ultrasound of the abdomen
Blood, urine and stool tests

Various tests are performed on the above samples in a patient with abdominal pain. The white blood cell count in blood is elevated in appendicitis, a positive culture result is obtained in urinary tract infections and blood can be detected in the stools of a patient with bowel cancer.

X-rays of the abdomen

X-rays are a form of electromagnetic radiation (like light). They are of higher energy, however, and can penetrate the body to form an image on film. Structures that are dense (such as bone) will appear white, air will be black and other structures will be shades of gray.

The test is performed in a hospital radiology department or in the health care provider's office by an X-ray technician. You lie on your back on the X-ray table. The X-ray machine is positioned over your abdominal area. You hold your breath as the picture is taken so that the picture will not be blurry. You may be asked to change position to the side or to stand up for additional pictures.

Possible abnormal findings include:

  • abdominal masses
  • an accumulation of fluid in the abdominal area
  • kidney stones
  • some types of gallstones
  • intestinal blockage
  • foreign bodies in the intestines
  • trauma to the abdominal tissue with rupture or haemorrhage of certain organs
  • perforation of the stomach or intestines
Upper gastrointestinal endoscopy

This test involves examining the lining of the oesophagus, stomach and upper duodenum with a flexible fiberoptic endoscope. An endoscope is a device consisting of a tube and an optical system. In upper GIT endoscopy, this device is introduced through the mouth to view the interior of the body. The operator can visualise the area being examined by looking into the proximal part of the scope.You may be given a sedative and/or an analgesic in order to relax you. A local anaesthetic will be sprayed into your mouth to suppress the need to cough or gag when the endoscope is inserted. (The gag and cough reflexes are natural protective reflexes initiated by the presence of a foreign body in the upper airway).

A mouth guard will be inserted to protect the endoscope from an involuntary biting action by the patient. Dentures will be removed as they may dislodge and get in the way of the scope. An IV may be inserted to administer medications during the procedure.

The procedure is performed with the patient lying on his or her left hand side. After the gag reflex has been suppressed by the anaesthetic spray, the endoscope will be advanced through the mouth into the oesophagus and to the stomach and duodenum. Air will be introduced through the endoscope to enhance viewing by gently pushing away any excess tissue.

The inner mucosal surface of the said structures are examined and biopsies can be obtained through the endoscope. The biopsies are sent to the laboratory for various tests. When the area has been viewed and any biopsies taken, the endoscope will be removed and you will be asked to cough to expel the extra air.

The intake of food and liquids are restricted until your cough reflex returns. The test lasts about 30 to 60 minutes.

Possible abnormal findings can indicate the presence of one or more of the following:

  • ulcers (acute or chronic)
  • inflammation of the stomach and duodenum
  • tumours and masses
  • diverticulae
  • Mallory-Weiss syndrome (tear of the oesophagus)
  • oesophageal rings
  • strictures
  • obstruction
  • gastric erosion
  • dilated oesophageal veins
  • the presence of foreign bodies
Colonoscopy

A colonoscopy is a procedure of viewing the interior lining of the large intestine (colon) using a colonoscope, a flexible fiber-optic tube.

You will have to prepare your colon in order to clear out as much of the faeces as possible to improve the visibility of the operator. This is done with various laxatives and enemas.

You lie on your left side with your knees drawn up toward the abdomen and your lower body exposed. After administration of an intravenous sedative and analgesic, the lubricated scope is inserted through the anus and gently advanced under direct vision to the terminal small bowel. Air will be inserted through the scope to provide a better view by gently pushing away any excess tissue. Suction may be used to remove secretions.

Since better views are obtained during withdrawal than during insertion, a more careful examination is done during withdrawal of the scope. Tissue samples may be taken with tiny biopsy forceps inserted through the scope, polyps can be removed with electrocautery snares and photographs can be taken. All tissue removed will be sent to the laboratory for analysis. Specialised procedures, such as laser therapy, can also be done via the scope.

Possible abnormal findings include:

  • lower gastrointestinal (GI) bleeding
  • polyps (which can be removed through the colonoscope during the exam)
  • tumours can be visualized and biopsied
  • inflammatory bowel disease
  • diverticulitis
Upper gastrointestinal tract and small bowel series
X-rays to examine the oesophagus, stomach and small intestine. X-ray pictures are taken after one has swallowed a barium suspension (contrast medium). The contrast medium better defines the structures that are being examined by X-rays.

This test may be done in an office or a hospital radiology department. You will be given a milky substance to drink that has barium in it. The passage of the barium through the oesophagus, stomach, and small intestine is monitored by X-ray images. Pictures are taken with you in a variety of positions. The test takes 30 minutes to 1 hour to complete.

In the oesophagus, abnormal results may mean:

  • oesophageal cancer
  • oesophageal stricture
  • hiatus hernia (a portion of the stomach protrudes through the oesophageal opening)
  • diverticula (a pouch-like sac that protrudes from the walls of an organ)
  • ulcers (open sores)
  • achalasia (oesophagus fails to relax)

In the stomach, abnormal results may mean:

  • stomach ulcers
  • cancer of the stomach
  • polyps (a tumour that is usually noncancerous that grows on the inner lining of the stomach)
  • pyloric stenosis (a narrowing of the opening from the stomach)

In the small intestines the test may reveal:

  • tumours
  • inflammation of the small intestines
  • obstruction
Barium enema
An X-ray examination of the large intestines. Pictures are taken after rectal instillation of barium sulphate (a radio opaque - contrast medium).

This test may be done in an office or a hospital radiology department. You lie on the X-ray table and an initial X-ray is taken before the administration of the contrast medium. You are asked to lie on the side while a well lubricated enema tube is inserted gently into your rectum via your anus. The barium, a radio opaque (shows up on X-ray) contrast medium, is then allowed to flow into the colon through the enema tube. A small balloon at the tip of the enema tube may be inflated to help keep the barium inside your bowel. The flow of the barium is monitored by the health care provider on an X-ray fluoroscope screen (like a TV monitor). X-ray pictures are taken at various levels as the contrast medium flows through your colon.

Possible abnormal findings include:

  • Cancer
  • Diverticulitis (small pouches formed on the colon wall that can become inflamed)
  • Polyps (a tumour, usually noncancerous, that grows on the inner lining of the colon)
  • Inflammation of the inner lining of the intestine (ulcerative colitis)
  • Irritable colon
  • Acute appendicitis
  • Twisted loop of the bowel
Ultrasound of the abdomen
Ultrasound examination uses high-frequency sound waves to echo off the internal structures of the body and create a picture of these structures.

The test is done in the ultrasound or radiology department. You will be lying down. A conducting and lubricating gel is applied to the skin of your abdomen. The transducer (a hand-held instrument) is then moved over your abdomen. You may be asked to move to other positions or hold your breath at times during the procedure.

Various conditions can be diagnosed with an ultrasound investigation. These include:

  • A liver abscess
  • Gallstones
  • Malignant secondaries in the liver
  • Obstruction of one or both kidneys can be seen
  • An aneurysm of the aorta (abnormal dilation of the large artery running trough the abdomen)
  • Pathology in the pelvic organs such as an ectopic pregnancy and uterine fibroids
  • The exact location of palpable abdominal masses can be determined.
Diagnosing abdominal pain in children
Look for the following common signs of abdominal pain in babies and toddlers:
  • Crying
  • Irritability
  • Restlessness
  • A sudden refusal to eat.
  • The symptoms of intussusception include a cycle of screaming fits, with or without vomiting, alternating with quiet periods.

Crying may exacerbate the pain of appendicitis so greatly that a suffering infant will not cry. Instead, look for irritability and flexing of the hips (pulling the legs up to the stomach), as well as a general appearance of illness and signs that moving is painful.

Older children who can talk will usually complain of "a sore tummy".

Treatment

The treatment of abdominal pain will depend on the underlying cause. Refer to individual diseases.

(Reviewed by Prof Don du Toit)

 
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