Pain

Published on 23/05/2015 by admin

Last modified 22/04/2025

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Abdominal Pain

Abdominal pain is an extremely common presenting symptom. The pain may be acute (sudden onset) or chronic (lasting for more than a few days or presenting intermittently). It is important to be able to distinguish causes of abdominal pain which need urgent surgery, e.g. ruptured aortic aneurysm, perforated diverticular disease, from those that do not, e.g. biliary colic, ureteric colic, acute pancreatitis. The causes of abdominal pain are legion and the list below contains some of the more common causes but is not intended to be comprehensive.

Causes

Gastrointestinal

GUT

Gastroduodenal

• Peptic ulcer

• Gastritis

• Malignancy

• Gastric volvulus

Intestinal

• Appendicitis

• Obstruction

• Diverticulitis (Fig. 1)

• Gastroenteritis

• Mesenteric adenitis

• Strangulated hernia

• Inflammatory bowel disease

• Intussusception

• Volvulus

• TB • (common in parts of the world where TB is endemic)

Figure 1 Diverticular disease.
A barium enema showing numerous diverticulae in the sigmoid colon.

Hepatobiliary

• Acute cholecystitis

• Chronic cholecystitis

• Cholangitis

• Hepatitis

Pancreatic

• Acute pancreatitis

• Chronic pancreatitis

• Malignancy

Splenic

• Infarction

• Spontaneous rupture

Urinary Tract

• Cystitis

• Acute retention of urine

• Acute pyelonephritis

• Ureteric colic

• Hydronephrosis

• Tumour

• Pyonephrosis

• Polycystic kidney

Gynaecological

• Ruptured ectopic pregnancy

• Torsion of ovarian cyst

• Ruptured ovarian cyst

• Salpingitis

• Severe dysmenorrhoea

• Mittelschmerz

• Endometriosis

• Red degeneration of a fibroid

Vascular

• Aortic aneurysm

• Mesenteric embolus

• Mesenteric angina (claudication)

• Mesenteric venous thrombosis

• Ischaemic colitis

• Acute aortic dissection

Peritoneum

• Secondary peritonitis

• Primary peritonitis

Abdominal Wall

• Strangulated hernia

• Rectus sheath haematoma

• Cellulitis

Retroperitoneum

• Retroperitoneal haemorrhage, e.g. anticoagulants

Referred Pain

• Myocardial infarction

• Pericarditis

• Testicular torsion

• Pleurisy

• Herpes zoster

• Lobar pneumonia

• Thoracic spine disease, e.g. disc, tumour

‘Medical’ Causes

• Hypercalcaemia

• Uraemia

• Diabetic ketoacidosis

• Sickle cell disease

• Addison’s disease

• Acute intermittent porphyria

• Henoch–Schönlein purpura

• Tabes dorsalis

History

Age

Certain conditions are more likely to occur in certain age groups, e.g. mesenteric adenitis in children, diverticular disease in the elderly.

Examination

General

Is the patient lying comfortably? Is the patient lying still but in pain, e.g. peritonitis? Is the patient writhing in agony, e.g. ureteric or biliary colic? Is the patient flushed, suggesting pyrexia?

Pulse, temperature, respiration

Pulse and temperature are raised in inflammatory conditions. They may also be raised with impending infarction of bowel. An increased respiratory rate might suggest chest infection referring pain to the abdomen.

Cervical lymphadenopathy

Associated with mesenteric adenitis.

Chest

Referred pain from lobar pneumonia.

Abdomen

■ Inspection. Does the abdomen move on respiration? Look for scars, distension, visible peristalsis (usually due to chronic obstruction in patient with very thin abdominal wall). Check the hernial orifices. Are there any obvious masses, e.g. visible, pulsatile mass to suggest aortic aneurysm?

■ Palpation. The patient should be relaxed, lying flat, with arms by side. Be gentle and start as far from the painful site as possible. Check for guarding and rigidity. Check for masses, e.g. appendix mass, pulsatile expansile mass to suggest aortic aneurysm. Carefully examine the hernial orifices. Examine the testes to exclude torsion.

■ Percussion, e.g. tympanitic note with distension with intestinal obstruction; dullness over bladder due to acute retention.

■ Auscultation. Take your time (30–60 s); e.g. silent abdomen of peritonitis; high-pitched tinkling bowel sounds of intestinal obstruction.

Rectal examination

Always carry out a rectal examination.

Vaginal examination

There may be discharge or tenderness associated with pelvic inflammatory disease. Examine the uterus and adnexa, e.g. pregnancy, fibroids, ectopic pregnancy.