Abdominal pain is a frequent complaint in both outpatient and emergency settings, encompassing a diverse range of conditions from benign to life-threatening. It can be acute or chronic, localised or diffuse. A thorough understanding of the underlying pathophysiological mechanisms and potential causes is crucial for accurate diagnosis and effective management.
The abdominal cavity contains various organs including the stomach, liver, gallbladder, spleen, pancreas, kidneys, intestines and reproductive organs. Pain can originate from any of these structures or from the abdominal wall itself. The innervation of these organs is complex and involves somatic and visceral nerves which contribute to the nature and perception of pain.
The table below gives characteristic exam question features for conditions causing abdominal pain. Unusual and 'medical' causes of abdominal pain should also be remembered:
| Condition | Characteristic exam feature |
|---|---|
| Peptic ulcer disease | Duodenal ulcers: more common than gastric ulcers, epigastric pain relieved by eating |
| Gastric ulcers: epigastric pain worsened by eating | |
| Features of upper gastrointestinal haemorrhage may be seen (haematemesis, melena etc) | |
| Appendicitis | Pain initial in the central abdomen before localising to the right iliac fossa |
| Anorexia is common | |
| Tachycardia, low-grade pyrexia, tenderness in RIF | |
| Rovsing's sign: more pain in RIF than LIF when palpating LIF | |
| Acute pancreatitis | Usually due to alcohol or gallstones |
| Severe epigastric pain | |
| Vomiting is common | |
| Examination may reveal tenderness, ileus and low-grade fever | |
| Periumbilical discolouration (Cullen's sign) and flank discolouration (Grey-Turner's sign) is described but rare | |
| Biliary colic | Pain in the RUQ radiating to the back and interscapular region, may be following a fatty meal. Slight misnomer as the pain may persist for hours |
| Obstructive jaundice may cause pale stools and dark urine | |
| It is sometimes taught that patients are female, forties, fat and fair although this is obviously a generalisation | |
| Acute cholecystitis | History of gallstones symptoms (see above) |
| Continuous RUQ pain | |
| Fever, raised inflammatory markers and white cells | |
| Murphy's sign positive (arrest of inspiration on palpation of the RUQ) | |
| Diverticulitis | Colicky pain typically in the LLQ |
| Fever, raised inflammatory markers and white cells | |
| Abdominal aortic aneurysm | Severe central abdominal pain radiating to the back |
| Presentation may be catastrophic (e.g. Sudden collapse) or sub-acute (persistent severe central abdominal pain with developing shock) | |
| Patients may have a history of cardiovascular disease | |
| Intestinal obstruction | History of malignancy/previous operations |
| Vomiting | |
| Not opened bowels recently | |
| 'Tinkling' bowel sounds |
Diagram showing stereotypical areas where particular conditions present. The diagram is not exhaustive and only lists the more common conditions seen in clinical practice. Note how pain from renal causes such as renal/ureteric colic and pyelonephritis may radiate and move from the loins towards the suprapubic area.