• Abdominal (belly) pain is pain or discomfort felt in the trunk below the ribs and above the pelvis.
• It comes from organs within the abdomen or organs adjacent to the belly.
• It is caused by inflammation, distention of an organ, or loss of the blood supply to an organ.
• In irritable bowel syndrome (IBS), it may be caused by contraction of the intestinal muscles or hypersensitivity to normal intestinal activities.
• Symptoms associated with it may include:
○ Gas (flatus, farting)
○ Discomfort in the upper left or right; middle; or lower left or right abdomen
○ GERD (gastroesophageal reflux disease)
○ Chest discomfort
○ Pelvic discomfort
• The cause of abdominal pain is diagnosed based on its characteristics, the physical examination, and testing. Occasionally, surgery is necessary for diagnosis.
• The medical diagnosis of the cause is challenging because the characteristics may be atypical, tests are not always abnormal, diseases causing pain may mimic each other. The characteristics of the pain may change over time.
• Medical treatment depends upon the patient’s history of the disease or other health conditions that may be the cause.
Abdominal pain is a common symptom, and most people have experienced some abdominal pain (belly or stomach pain). Causes of more serious causes of abdominal pain include:
• Bloody stools
• Black tarry stools
• Painful urination
• Lack of urination
• Abrupt cessation of bowel movements
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).However, to complicate matters, abdominal pain can also occur without inflammation, distention, or loss of blood supply. An actual example of the latter is irritable bowel syndrome (IBS). It is not clear what causes belly pain in IBS. It is still 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). This often is referred to as functional pain because no recognizable specific abnormality to account for the cause of the pain has been found – at least not yet
Abdominal pain is felt in the abdomen. The abdomen is an anatomical area bounded by the lower margin of the ribs and diaphragm above, the pelvic bone (pubic ramus) below, and the flanks on each side. Although pain can arise from the abdominal wall tissues surrounding the abdominal cavity (such as the skin and muscles), abdominal pain is generally used to describe discomfort 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, the prostate gland in men, and the uterus, Fallopian tubes ovaries in women. It can often be challenging to know if lower abdominal pain comes from the lower abdomen or pelvis (pelvic pain).
Occasionally, pain may be felt in the belly even though it arises from organs close to, but not within, the abdominal cavity, for example, conditions of the lower lungs, the kidneys, and the uterus or ovaries. On the other hand, it also is possible for pain from organs within the belly to be felt outside of it. For example, the pain of pancreatic inflammation may be felt in the back. These latter types of pain are described as “referred” because it does not originate in the location that it is felt. Instead, the cause is located away from where it is felt (i.e., it is referred to as a different area).
How did the pain begin?
• If it comes on suddenly, this may suggest a problem with an organ within the belly, such as the interruption of blood supply to the colon (ischemia) or obstruction of the bile duct by a gallstone (biliary colic).
Where is the pain located?
• Appendicitis typically causes discomfort in the middle of the abdomen. It 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 diverticula are located.
• Discomfort 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.
What is the type and pattern of the pain?
• Is it severe, crampy, steady, or does it wax and wane? The intestine obstruction initially causes waves of crampy pain due to contractions of the intestinal muscles and distention of the intestine. Real cramp-like pain suggests vigorous contractions of the intestines.
• Obstruction of the bile ducts by gallstones typically causes steady (constant) upper belly pain that lasts between 30 minutes and several hours.
• Acute pancreatitis typically causes severe, unrelenting, persistent pain in the upper abdomen and upper back.
• The pain of acute appendicitis initially may start near the umbilicus. Still, as the inflammation progresses, it moves to the right lower abdomen.
• The character of pain may change over time. For example, obstruction of the bile ducts sometimes goes to inflammation of the gallbladder with or without infection (acute cholecystitis). When this happens, the characteristics change to those of inflammatory pain.
How long does the pain last?
• The discomfort 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 occurs over weeks or months, followed by periods of weeks or months is better (periodically).
• Functional pain may show this same pattern of periodicity.
What makes the pain worse?
• Pain due to inflammation (appendicitis, diverticulitis, cholecystitis, and pancreatitis) typically is aggravated by sneezing, coughing, or any jarring motion. Individuals with inflammation prefer to lie still.
• What health conditions make abdominal pain worse or better?
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 habits.
• Pain due to obstruction of the stomach or upper small intestine may be relieved temporarily by vomiting, reducing the obstruction’s distention.
• Eating or taking antacids may temporarily relieve ulcer pain from the stomach or duodenum because both food and antacids neutralize the acid responsible for irritating the ulcers and causing the pain.
• Pain that awakens a patient 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:
• Fever suggests inflammation or infection.
• Diarrhea or rectal bleeding suggests an intestinal cause.
• Fever and diarrhea suggest inflammation of the intestines that may be infectious or non-infectious.
• How is the cause of abdominal pain diagnosed?
• Doctors determine the cause of the pain by relying on:
• Its characteristics, physical signs, and other accompanying symptoms
• Findings on physical examination
• Medical laboratory, radiological, and endoscopic testing
Doctors determine the cause of the pain by relying on:
1. Characteristics, physical signs, and other accompanying symptoms
2. Findings on physical examination
3. Laboratory, radiological, and endoscopic testing
Examining the patient will provide the doctor with additional clues to the cause of the 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 may signify an intestinal problem such as an ulcer, colon cancer, colitis, or ischemia.
• Finding tenderness and signs of inflammation in the left lower abdomen often means that diverticulitis is present. Finding a tender (inflamed) mass in the same area may mean that the inflammation has progressed, and an abscess has formed.
• Finding tenderness and signs of inflammation in the right lower abdomen often means that appendicitis is present. Finding a tender mass in the same area may mean that the inflammation has progressed, and 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 cancer is present.
While the health history and physical examination are vitally important in determining abdominal pain, other medical tests are often necessary to determine the cause.
Laboratory tests such as the complete blood count (CBC), liver enzymes, pancreatic enzymes (amylase and lipase), pregnancy test, and urinalysis are frequently ordered.
• 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 promoted 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 intestinal obstruction occurs. Patients with a perforated ulcer may have air escape from the stomach into the abdominal cavity. The escaped air can often 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.
• Ultrasound is useful in diagnosing gallstones, cholecystitis appendicitis, or ruptured ovarian cysts as the cause of the pain.
• Computerized tomography (CT) of the abdomen helps diagnose pancreatitis, pancreatic cancer, appendicitis, and diverticulitis and diagnosing abscesses in the stomach. Special CT scans of the abdominal blood vessels can detect the arteries that block the blood flow 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 help diagnose ulcers, inflammation, and blockage in the intestines.
• Computerized tomography (CT) of the small intestine can help diagnose small bowel diseases such as Crohn’s disease.
• Capsule enteroscopy uses a small camera the size of a pill swallowed by the patient, taking pictures of the entire small bowel, and transmitting the images 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 help diagnose Crohn’s disease, small bowel tumors, and bleeding lesions not seen on x-rays or CT scans.
• 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 pain or bleeding can be diagnosed, biopsied, and treated.
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