Acute Abdominal PainChapter 1
Abdominal pain is the most common symptom of the pathologies of the gastrointestinal tract. The pain can occur in any part of the abdomen, but for convenience, it can be divided into upper abdominal and lower abdominal.
The main visceral pain receptors in the abdomen respond to mechanical and chemical stimuli.
Mechanical stimuli: Stretch, distension, contraction, compression and torsion.
Chemical stimuli: Bradykinin, substance P, serotonin and prostaglandins. These receptors are located on the serosal surfaces, within the mesentery and within the walls of hollow viscera.
Gut related visceral pain is usually perceived in the midline because it is a midline structure in an embryo and has bilateral symmetric innervations, except for pains originating from the gallbladder and the ascending and descending colon. Pain from other intra-abdominal organs tends to be unilateral.
Pain at epigastrium—Diseases of the foregut (abdominal esophagus, stomach and proximal half of second part of duodenum and their offshoots like liver, gallbladder, pancreas and spleen) (e.g. gastric and duodenal ulcers).
Pain at the umbilical region—Diseases of midgut (distal half of second part of duodenum, small bowel, colon up to the proximal 2/3 of transverse colon) (e.g. intestinal tuberculosis).2
Pain at the hypogastrium—Diseases of hindgut (distal 1/3 of transverse colon to the anorectal junction) (e.g. colorectal pathologies).
The perception of visceral pain corresponds to the spinal segments where the visceral afferent nerve fibers enter the spinal cord. Table 1.1 shows some common spinal segments where visceral pain is perceived.
The abdominal pain has particular pattern and has regional localization. The abdomen is divided into ten arbitrary regions for convenience of understanding and localization (Fig. 1.1).
Fig. 1.1: Regions of abdomen: 1. Right hypochondrium, 2. Epigastrium, 3. Left hypochondrium, 4. Right lumbar, 5. Umbilical, 6. Left lumbar, 7. Right iliac fossa, 8. Hypogastrium, 9. Left iliac fossa, 10. External genitalia
Table 1.1 Visceral pain and dermatomal perceptions
Organ of pathology
Large bowel proximal to splenic flexure
Large bowel distal to splenic flexure
Epigastrium, right scapular region
While evaluating the upper abdominal pain, it is necessary to keep some pathologies in mind (Table 1.2).
Continuous (e.g. acute pancreatitis)
Episodic (e.g. acute hyperacidity)
Colicky (e.g. biliary colic).
Epigastric pain (e.g. acute hyperacidity, acute pancreatitis)
Left hypochondrial pain (e.g. acute hyperacidity, left renal colic)
Right hypochondrial pain (e.g. acute cholecystitis, acute hepatitis).
Table 1.2 Acute upper abdominal pain and related pathologies
Acute hyperacidity
Acute hepatitis (left lobe)
Association of vomiting
Presence of vomiting is not a very reliable symptom to narrow down the diagnosis, as it can be present with any severe painful pathology in the upper abdomen.
Association of fever
Fever indicates infective pathology (e.g. acute cholecystitis, acute pancreatitis, acute colitis, perforated duodenal ulcer).
Association of jaundice
Jaundice may be present with acute cholangitis, acute hepatitis or acute cholecystitis.
Association of loose stools
Association of loose stools may indicate colitis or rarely acute pancreatitis.
Radiation to right scapula or shoulder is common with acute cholecystitis, perforated duodenal ulcer due to irritation of diaphragm.
Food—in acute hyperacidity
Lying supine—in acute pancreatitis
Deep breathing—in acute cholecystitis.
Leaning forward while sitting—acute pancreatitis.
In some pathologies, the pathology and the area of the pain are different, since both of them share the same nerve supply. (Fig. 1.2) (Table 1.1).
History of pain (e.g. acute on chronic cholecystitis)5
Fig. 1.2: Referred pain
Previous surgery (e.g. cholecystectomy will rule out cholecystitis from consideration).6
Breath for fetor (e.g. alcoholic hepatitis, acute pancreatitis)
Conjunctiva for anemia, jaundice
Tongue for anemia
Neck for lymphadenopathy
Hands for signs of liver failure (e.g. clubbing, palmar erythema, liver flap, etc.).
Generalized (e.g. perforated duodenal ulcer or gallbladder with peritonitis)
Right upper abdominal (e.g. hepatomegaly)
Epigastric (e.g. left lobar hepatomegaly, carcinoma stomach)
Left upper abdominal (e.g. splenomegaly).
All quadrants—generalized peritonitis
Right upper quadrant (e.g. acute hepatitis, acute cholecystitis, acute hyperacidity)
Epigastric (e.g. acute gastritis, acute hepatitis)
Left upper quadrant (e.g. acute gastritis, acute pancreatitis).7
Right upper quadrant (e.g. hepatomegaly, distended gallbladder)
Epigastric (e.g. carcinoma stomach, left lobar hepatomegaly)
Left upper quadrant (e.g. carcinoma stomach, splenomegaly).
Percuss the liver for:
Its enlargement (e.g. acute hepatitis)
Obliteration of liver dullness (e.g. perforated duodenal ulcer).
Absence of bowel sounds indicates paralytic ileus (e.g. perforated peritonitis).
Normal bowel sounds indicate that there is no gross infection of the peritoneum.
Right hypochondrial pain
Without fever and but local tenderness (e.g. acute cholecystitis, acute hepatitis, acute hyperacidity).
With fever and local tenderness
± distension (e.g. acute cholecystitis)
Obliteration of liver dullness (e.g. perforated duodenal ulcer)
± hepatomegaly (e.g. acute liver abscess).
With vomiting and
Local tenderness (e.g. acute cholecystitis, acute hyperacidity)
Local tenderness with obliteration of liver dullness (e.g. perforated duodenal ulcer).8
With diarrhea and local tenderness (e.g. acute colitis).
With jaundice and
Local tenderness ± hepatomegaly (e.g. acute hepatitis, acute cholecystitis, choledocholithiasis, cholangitis, acute liver abscess)
Local tenderness, fever, +/- abdominal lump (e.g. mucocele gallbladder, choledochal cyst)
Colicky in nature +/- local tenderness (e.g. biliary colic).
Without fever but with local tenderness (e.g. acute hyperacidity, acute pancreatitis, acute hepatitis—left lobe)
With fever and local tenderness ± distension (e.g. acute pancreatitis, perforated duodenal or gastric ulcer).
Local tenderness (e.g. acute hyperacidity, acute pancreatitis)
Local tenderness and obliteration of liver dullness (e.g. perforated ulcer).
+ tender hepatomegaly (e.g. left lobar hepatitis, left lobar liver abscess)
Non-tender hepatomegaly (e.g. metastatic liver).
Left hypochondrial pain
Without fever but with local tenderness (e.g. acute gastritis, acute pancreatitis)
With fever and local tenderness +/- splenomegaly (e.g. acute pancreatitis, splenic infarct)
Leukocytosis in infective pathologies (e.g. acute cholecystitis, perforated duodenal ulcer, perforated cholecystitis, acute pancreatitis)
Raised ESR in all infective pathologies.
Plain X-ray abdomen—gas under the diaphragm (e.g. perforated hollow viscus). Radiopaque shadows in the right upper abdomen (e.g. renal stones, gallstones)
Ultrasonography—renal stones, gallstones.
Non-perforated pathologies—medical management.
Perforated pathologies—early surgical management.
Diagnosis not clear and not responding to medical management—exploratory laparotomy.
Acute nephritis and renal colic can cause upper abdominal pain in their respective sides.
Severe pain in the lower part of the abdomen.10
While evaluating lower abdominal pain, it is necessary to keep some pathologies in mind (Table 1.3).
Continuous (e.g. acute appendicitis)
Colicky (e.g. appendicular colic).
Right lower abdomen (e.g. acute appendicitis, right ureteric colic)
Hypogastrium (e.g. acute colorectal pathologies)
Left lower abdomen (e.g. acute diverticulitis, left ureteric colic)
Association of nausea and vomiting
Presence of vomiting is not a very reliable symptom to narrow down the diagnosis, as it can be present with any severe painful pathology in the lower abdomen. Nausea is a predominant symptom of acute appendicitis.
Table 1.3 Acute lower abdominal pain and GI pathologies
Acute Meckel's diverticulitis
Acute congestive dysmenorrhea
Acute cecal diverticulitis
Note: Diabetic ketoacidosis is one of the important metabolic causes of acute lower abdominal pain.
Fever indicates infective pathology (e.g. acute appendicitis, acute colitis).
Association of loose stools may indicate colitis, acute diverticulitis.
History of pain (e.g. acute on chronic appendicitis)
Previous surgery (e.g. appendicectomy will rule out appendicitis from consideration).
Conjunctiva for anemia (e.g. GI malignancy)
Tongue for anemia (e.g. GI malignancy).
Generalized (e.g. perforated appendicitis with generalized peritonitis)
Right lower abdominal (e.g. ruptured appendicitis).12
Right lower quadrant (e.g. acute appendicitis, acute mesenteric adenitis)
Left lower quadrant (e.g. acute colitis, acute diverticulitis).
Right lower quadrant (e.g. acute appendicitis mesenteric adenitis, right ovarian cyst)
Left lower quadrant (e.g. carcinoma colon).
Its enlargement (e.g. associated metastases liver)
Obliteration of liver dullness (e.g. perforated appendicitis and diverticulitis).
Absence of bowel sounds indicates paralytic ileus (e.g. perforation and peritonitis)
Exaggerated bowel sounds may indicate obstruction of small bowel (e.g. intestinal colic)
Pain in the right iliac fossa with
Nausea/vomiting and fever and local tenderness (e.g. acute catarrhal/perforated appendicitis, acute typhlitis, acute Meckel's diverticulitis, acute mesenteric adenitis).13
± local tenderness (colicky pain, e.g. appendicular colic)
Abdominal lump (e.g. ileocecal tuberculosis, Crohn's disease, cecal malignancy).
Diarrhea or dysentery and local tenderness (e.g. acute amebic typhlitis, cecal diverticulitis).
Pain in the left iliac fossa with vomiting
± local tenderness (e.g. left ureteric colic)
Abdominal lump (e.g. colonic malignancy)
Diarrhea or dysentery with or without local tenderness (e.g. acute colitis, acute diverticulitis).
Hypogastric pain with
Constipation (e.g. rectal pathology).
Acute lower abdominal pain (any or all quadrants of lower abdomen) with
Vague symptoms and signs (e.g. Metabolic causes- diabetes mellitus).
Reduced hematocrit (e.g. colonic malignancy)
Leukocytosis in infective pathologies (e.g. acute appendicitis, perforated appendicitis, and diverticulitis)
Gas under the diaphragm (e.g. perforated appendicitis and diverticulitis)14
Opaque abdomen (e.g. peritonitis)
Radiopaque shadows (e.g. ureteric stone).
Cystic swelling (e.g. appendicular abscess, paracolic abscess).
Non-perforated pathologies—medical management (except acute appendicitis)
Perforated pathologies—early surgical management
Diagnosis not clear and not responding to medical management—exploratory laparotomy or diagnostic laparoscopy.
Obstetric conditions like ruptured ectopic gestation should be thought of in a woman of reproductive age
Gynecologic conditions like torsion of ovarian cyst should be considered in acute lower abdominal pain
Urologic conditions like acute cystitis should be considered in patients with acute lower abdominal pain with urinary symptoms
Ureteric colic should be considered in patients with acute pain in the iliac fossae
Complicated hernia should be considered in patients with acute lower abdominal pain.
Colic is defined as a sudden squeezing or griping pain lasting for about 3–5 minutes with pain free intervals.15
Nausea, vomiting and retching are common accompaniments
The cause of a colic is partial obstruction of a tubular structure due to varied causes.
While evaluating abdominal colic, the following GI pathologies should be kept in mind (Table 1.4).
The clinical features of various colics of GI pathologies are given in Table 1.5.
Table 1.4 Colic related to GI pathologies
Table 1.5 Clinical features of various colics
Fat, fertile, flatulent, female of fifty
Parasitic infestations (younger age), strictures (middle age), malignancy (old age)
Fecaliths, Worms
Right hypochondrial pain, referred to right scapula or shoulder
Colicky pain in the umbilical region
Colicky pain in the right iliac fossa
Repeated attacks of dull pain in right iliac fossa
Severe griping pain with pain free intervals.
Location almost gives the clue.
Presence of vomiting is not a very reliable symptom to narrow down the diagnosis, as it can be present with any colic.
Fever indicates associated infections (e.g. cholangitis in biliary colic).
Jaundice may be present with biliary colic (e.g. acute cholangitis, acute hepatitis or acute cholecystitis).
Association of loose stools may indicate colitis.
Radiation to right scapula or shoulder is common with biliary colic (e.g. acute cholecystitis).
History of pain (e.g. colics can be recurrent)
Previous surgery (e.g. intestinal colic can occur in adhesive obstruction of small bowel).
Gallstones.17
Associated jaundice (e.g. cholangitis).
May not be contributory.
Generalized (e.g. intestinal colic of intestinal obstruction)
Localized (e.g. intussusception).
Elicitable in infective pathologies.
Right upper quadrant (e.g. distended gallbladder)
Umbilical (e.g. post operative adhesions)
Not a very useful method.
Normal bowel sounds does not rule out any pathology.
Leukocytosis in infective pathologies (e.g. acute cholecystitis)
Plain X-ray abdomen—gas filled loops of bowel (e.g. acute intussusceptions, acute intestinal obstruction)
Ultrasonography—intussusception.
Medical management will suffice in most instances
Obstructive pathologies may require surgery to relieve the cause of obstruction
Repeated attacks of colic will require evaluation and management.