abdominal pain abdominal pain abdominal pain, also known as a stomach ache, is a symptom associated with both cancer and serious medical issues. abdominal painother namesstomach ache, tummy ache, belly ache, belly pain, gastralgiaabdominal pain can be characterized by the region it affects.specialtygastroenterology, general surgerycausesserious: appendicitis, perforated stomach ulcer, pancreatitis, ruptured diverticulitis, ovarian torsion, volvulus, ruptured aortic aneurysm, lacerated spleen or liver, ischemic colitis, ischaemic myocardial conditionscommon: gastroenteritis, irritable bowel syndrome common causes of pain in the abdomen include gastroenteritis and irritable bowel syndrome. about 15% of people have a more serious underlying condition such as appendicitis, leaking or ruptured abdominal aortic aneurysm, diverticulitis, or ectopic pregnancy. in a third of cases the exact cause is unclear. given that a variety of diseases can cause some form of abdominal pain, a systematic approach to the examination of a person and the formulation of a differential diagnosis remains important. differential diagnosis 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%). more common in those who are older, ischemic colitis, mesenteric ischemia, and abdominal aortic aneurysms are other serious causes. acute abdominal pain acute abdomen can be defined as severe, persistent abdominal pain of sudden onset that is likely to require surgical intervention to treat its cause. the pain may frequently be associated with nausea and vomiting, abdominal distention, fever and signs of shock. one of the most common conditions associated with acute abdominal pain is acute appendicitis. selected causes traumatic: blunt or perforating trauma to the stomach, bowel, spleen, liver, or kidney inflammatory: infections such as appendicitis, cholecystitis, pancreatitis, pyelonephritis, peritonitis, pelvic inflammatory disease, hepatitis, mesenteric adenitis, or a subdiaphragmatic abscess perforation of a peptic ulcer, a diverticulum, or the caecum complications of inflammatory bowel disease such as crohn's disease or ulcerative colitis mechanical: small bowel obstruction secondary to adhesions caused by previous surgeries, intussusception, hernias, benign or malignant neoplasms large bowel obstruction caused by colorectal cancer, inflammatory bowel disease, volvulus, fecal impaction or hernia vascular: occlusive intestinal ischemia, usually caused by thromboembolism of the superior mesenteric artery genetic factors dysmenorrhea is not affected directly by weight, height, or the pattern of menstrual cycles. by system a more extensive list includes the following: gastrointestinal gi tract inflammatory: gastroenteritis, appendicitis, gastritis, esophagitis, diverticulitis, crohn's disease, ulcerative colitis, microscopic colitis obstruction: hernia, intussusception, volvulus, post-surgical adhesions, tumors, severe constipation, hemorrhoids vascular: embolism, thrombosis, hemorrhage, sickle cell disease, abdominal angina, blood vessel compression (such as celiac artery compression syndrome), superior mesenteric artery syndrome, postural orthostatic tachycardia syndrome digestive: peptic ulcer, lactose intolerance, celiac disease, food allergies, indigestion glands bile system inflammatory: cholecystitis, cholangitis obstruction: cholelithiasis, tumours liver inflammatory: hepatitis, liver abscess pancreatic inflammatory: pancreatitis renal and urological inflammation: pyelonephritis, bladder infection obstruction: kidney stones, urolithiasis, urinary retention, tumours vascular: left renal vein entrapment gynaecological or obstetric inflammatory: pelvic inflammatory disease mechanical: ovarian torsion endocrinological: menstruation, mittelschmerz tumors: endometriosis, fibroids, ovarian cyst, ovarian cancer pregnancy: ruptured ectopic pregnancy, threatened abortion abdominal wall muscle strain or trauma muscular infection neurogenic pain: herpes zoster, radiculitis in lyme disease, abdominal cutaneous nerve entrapment syndrome (acnes), tabes dorsalis referred pain from the thorax: pneumonia, pulmonary embolism, ischemic heart disease, pericarditis from the spine: radiculitis from the genitals: testicular torsion metabolic disturbance uremia, diabetic ketoacidosis, porphyria, c1-esterase inhibitor deficiency, adrenal insufficiency, lead poisoning, black widow spider bite, narcotic withdrawal blood vessels aortic dissection, abdominal aortic aneurysm immune system sarcoidosis vasculitis familial mediterranean fever idiopathic irritable bowel syndrome (ibs)(affecting up to 20% of the population, ibs is the most common cause of recurrent and intermittent abdominal pain) by location 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: diffuse peritonitis vascular: mesenteric ischemia, ischemic colitis, henoch-schonlein purpura, sickle cell disease, systemic lupus erythematosus, polyarteritis nodosa small bowel obstruction irritable bowel syndrome metabolic disorders: ketoacidosis, porphyria, familial mediterranean fever, adrenal crisis epigastric heart: myocardial infarction, pericarditis stomach: gastritis, stomach ulcer, stomach cancer pancreas: pancreatitis, pancreatic cancer intestinal: duodenal ulcer, diverticulitis, appendicitis right upper quadrant liver: hepatomegaly, fatty liver, hepatitis, liver cancer, abscess gallbladder and biliary tract: inflammation, gallstones, worm infection, cholangitis colon: bowel obstruction, functional disorders, gas accumulation, spasm, inflammation, colon cancer other: pneumonia, fitz-hugh-curtis syndrome left upper quadrant splenomegaly colon: bowel obstruction, functional disorders, gas accumulation, spasm, inflammation, colon cancer peri-umbilical (the area around the umbilicus, aka the belly button) appendicitis pancreatitis inferior myocardial infarction peptic ulcer diabetic ketoacidosis vascular: aortic dissection, aortic rupture bowel: mesenteric ischemia, celiac disease, inflammation, intestinal spasm, functional disorders, small bowel obstruction lower abdominal pain diarrhea colitis crohn's dysentery hernia right lower quadrant colon: intussusception, bowel obstruction, appendicitis (mcburney's point) renal: kidney stone (nephrolithiasis), pyelonephritis pelvic: cystitis, bladder stone, bladder cancer, pelvic inflammatory disease, pelvic pain syndrome gynecologic: endometriosis, intrauterine pregnancy, ectopic pregnancy, ovarian cyst, ovarian torsion, fibroid (leiomyoma), abscess, ovarian cancer, endometrial cancer left lower quadrant bowel: diverticulitis, sigmoid colon volvulus, bowel obstruction, gas accumulation, toxic megacolon right low back pain liver: hepatomegaly kidney: kidney stone (nephrolithiasis), complicated urinary tract infection left low back pain spleen kidney: kidney stone (nephrolithiasis), complicated urinary tract infection low back pain kidney pain (kidney stone, kidney cancer, hydronephrosis) ureteral stone pain pathophysiology region blood supply innervation structures 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. 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. the midgut contains portions of the duodenum (distal), cecum, appendix, ascending colon, and first half of the transverse colon. the hindgut contains the distal half of the transverse colon, descending colon, sigmoid colon, rectum, and superior anal canal. each subsection of the gut has an associated visceral afferent nerve that transmits sensory information from the viscera to the spinal cord, traveling with the autonomic sympathetic nerves. 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. 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. diagnosis 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: 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. 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. additional investigations that can aid diagnosis include: blood tests including complete blood count, basic metabolic panel, electrolytes, liver function tests, amylase, lipase, troponin i, and for females, a serum pregnancy test. urinalysis imaging including chest and abdominal x-rays electrocardiogram if diagnosis remains unclear after history, examination, and basic investigations as above, then more advanced investigations may reveal a diagnosis. such tests include: computed tomography of the abdomen/pelvis abdominal or pelvic ultrasound endoscopy and/or colonoscopy management the management of abdominal pain depends on many factors, including the etiology of the pain. some dietary changes that some may participate in are: resting after a meal, chewing food completely and slowly, and avoiding stressful and high excitement situations after a meal. some at home strategies like these can avoid future abdominal issues, resulting in the need of professional assistance. 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. treatment for abdominal pain includes analgesia, such as non-opioid (ketorolac) and opioid medications (morphine, fentanyl). choice of analgesia is dependent on the cause of the pain, as ketorolac can worsen some intra-abdominal processes. 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. after addressing pain, there may be a role for antimicrobial treatment in some cases of abdominal pain. butylscopolamine (buscopan) is used to treat cramping abdominal pain with some success. surgical management for causes of abdominal pain includes but is not limited to cholecystectomy, appendectomy, and exploratory laparotomy. emergencies below is a brief overview of abdominal pain emergencies. condition presentation diagnosis management appendicitis abdominal pain, nausea, vomiting, fever periumbilical pain, migrates to rlq clinical (history & physical exam) abdominal ct patient made npo (nothing by mouth) iv fluids as needed general surgery consultation, possible appendectomy antibiotics pain control cholecystitis abdominal pain (ruq, radiates epigastric), nausea, vomiting, fever, murphy's sign clinical (history & 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 abdominal pain (sharp epigastric, shooting to back), nausea, vomiting clinical (history & 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 abdominal pain (diffuse, crampy), bilious emesis, constipation clinical (history & 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 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 abdominal pain, hematochezia, melena, 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 stable patient: observation unstable patient: consultation (general surgery, gastroenterology, interventional radiology) perforated viscous abdominal pain (sudden onset of localized pain), abdominal distension, rigid abdomen clinical (history & physical exam) imaging (abdominal x-ray or ct showing free air) labs (complete blood count) aggressive iv fluid resuscitation general surgery consultation antibiotics volvulus sigmoid colon volvulus: abdominal pain (>2 days, distention, constipation) cecal volvulus: abdominal pain (acute onset), nausea, vomiting clinical (history & physical exam) imaging (abdominal x-ray or ct) sigmoid: gastroenterology