Abdominal pain

Abdominal pain usually results from a GI disorder, but it can also be caused by a reproductive, genitourinary (GU), musculoskeletal, or vascular disorder; drug use; or ingestion of toxins. At times, such pain signals life-threatening complications.

Abdominal pain arises from the abdominopelvic viscera, the parietal peritoneum, or the capsules of the liver, kidney, or spleen. It may be acute or chronic and diffuse or localized. Visceral pain develops slowly into a deep, dull, aching pain that's poorly localized in the epigastric, periumbilical, or lower midabdominal (hypogastric) region. In contrast, somatic (parietal, peritoneal) pain produces asharp, more intense, and well-localized discomfort that rapidly follows the insult. Movement or coughing aggravates this pain.

Pain may also be referred to the abdomen from another site with the same or similar nerve supply. This sharp, well-localized, referred pain is felt in skin or deeper tissues and may coexist with skin
hyperesthesia and muscle hyperalgesia. Mechanisms that produce abdominal pain include stretching or tension of the gut wall, traction on the peritoneum or mesentery, vigorous intestinal contraction, inflammation, ischemia, and sensory nerve irritation.

HISTORY AND PHYSICAL EXAMINATION

If the patient has no life-threatening signs or symptoms, take his history. Ask him if he has had this type of pain before. Have him describe the pain—for example, is it dull, sharp, stabbing, or burning? Ask if anything relieves the pain or makes it worse. Ask the patient if the pain is constant or intermittent and when the pain began. Constant, steady abdominal pain suggests organ perforation, ischemia, or inflammation or blood in the peritoneal cavity. Intermittent, cramping abdominal pain suggests the patient may have an obstruction of a hollow organ.
If pain is intermittent, find out the duration of a typical episode. In addition, ask the patient where the pain is located and if it radiates to other areas.
Find out if movement, coughing, exertion, vomiting, eating, elimination, or walking worsens or relieves the pain. The patient may report abdominal pain as indigestion or gas pain, so have him
describe it in detail. Ask the patient about substance abuse and any history of vascular, GI, GU, or reproductive disorders. Ask the female patient the date of her last menses and if she has had changes in her menstrual pattern or dyspareunia.

Abdominal pain: Types and locations

Stomach
Middle epigastrium
Middle epigastrium and left upper quadrant
Shoulders
Small intestine
Periumbilical area
Over affected site
Midback (rare)
Appendix
Periumbilical area
Right lower quadrant
Right lower quadrant
Proximal colon
Periumbilical area and right flank for ascending colon
Over affected site
Right lower quadrant and back (rare)
Distal colon
Hypogastrium and left flank for descending colon
Over affected site
Left lower quadrant and back (rare)
Gallbladder
Middle epigastrium
Right upper quadrant
Right subscapular area
Ureters
Costovertebral angle
Over affected site
Groin; scrotum in men, labia in women (rare)
Pancreas
Middle epigastrium and left upper quadrant
Middle epigastrium and left upper quadrant
Back and left shoulder
Ovaries, fallopian tubes, and uterus
Hypogastrium and groin
Over affected site
Inner thighs

MEDICAL CAUSES OF ABDOMINAL PAIN

Abdominal aortic aneurysm (dissecting)
Abdominal cancer
Abdominal trauma
Adrenal crisis
Anthrax, GI
Appendicitis
Cholecystitis
Cholelithiasis
Cirrhosis
Crohn's disease
Cystitis
Diabetic ketoacidosis
Diverticulitis
Duodenal ulcer
Ectopic pregnancy
Endometriosis
Gastric ulcer
Gastritis
Gastroenteritis
Heart failure
Hepatic abscess
Hepatic amebiasis
Intestinal obstruction
Pelvic inflammatory disease
Peritonitis

SPECIAL CONSIDERATIONS

Help the patient find a comfortable position to ease his distress. The patient should lie in a supine position, with his head flat on the table, arms at his sides, and knees slightly flexed to relax the abdominal muscles. Monitor him closely because abdominal pain can signal a life-threatening disorder. Especially important indications include tachycardia, hypotension, clammy skin, abdominal rigidity, rebound tenderness, a change in the pain's location or intensity, or sudden relief from the pain.
Withhold analgesics from the patient because they may mask symptoms. Also withhold food and fluids because surgery may be needed. Prepare for I.V. infusion and insertion of a nasogastric or other intestinal tube. Peritoneal lavage or abdominal paracentesis may be required.
You may have to prepare the patient for a diagnostic procedure, such as a pelvic and rectal examination; blood, urine, and stool tests; X-rays; barium studies; ultrasonography; endoscopy; and
biopsy.

...