Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues. Since the abdomen contains most of the body's vital organs, it can be an indicator of a wide variety of diseases. Given that, approaching the examination of a person and planning of a differential diagnosis is extremely important.[3]
The onset of abdominal pain can be abrupt, quick, or gradual. Sudden onset pain happens in a split second. Rapidly onset pain starts mild and gets worse over the next few minutes. Pain that gradually intensifies only after several hours or even days has passed is referred to as gradual onset pain.[4]
One can describe abdominal pain as either continuous or sporadic and as cramping, dull, or aching. The characteristic of cramping abdominal pain is that it comes in brief waves, builds to a peak, and then abruptly stops for a period during which there is no more pain. The pain flares up and off periodically. The most common cause of persistent dull or aching abdominal pain is edema or distention of the wall of a hollow viscus. A dull or aching pain may also be felt due to a stretch in the liver and spleen capsules.[4]
Acute abdomen is a condition where there is a sudden onset of severe abdominal pain requiring immediate recognition and management of the underlying cause.[7] The underlying cause may involve infection, inflammation, vascular occlusion or bowel obstruction.[7]
Viscero-visceral referral: happens when one organ with afferent nerves close to another organ is sensitized or inflamed (in this case any of the abdominal viscera)[10]
Viscero-somatic referral: any pain in the viscera that causes pain in the muscle, bone, and skin (of the abdomen in case of abdominal pain)
Somatic-visceral referral: pain in the skin, muscles, and bone that causes referred pain in the viscera (of the abdomen such as the stomach, kidneys, bladder, etc.)
irritable bowel syndrome (IBS) (affecting up to 20% of the population, IBS is the most common cause of recurrent and intermittent abdominal pain)
By location
The location of abdominal pain can provide information about what may be causing the pain. The abdomen can be divided into four regions called quadrants. Locations and associated conditions include:[12][13]
Each subsection of the gut has an associated visceral afferent nerve that transmits sensory information from the viscera to the spinal cord.[16] The visceral sensory information from the gut traveling to the spinal cord, termed the visceral afferent, is non-specific and overlaps with the somatic afferent nerves, which are very specific.[17] Therefore, visceral afferent information traveling to the spinal cord can present in the distribution of the somatic afferent nerve; this is why appendicitis initially presents with T10 periumbilical pain when it first begins and becomes T12 pain as the abdominal wall peritoneum (which is rich with somatic afferent nerves) is involved.[17]
Diagnosis
A thorough patient history and physical examination is used to better understand the underlying cause of abdominal pain.
The process of gathering a history may include:[18]
Identifying more information about the chief complaint by eliciting a history of present illness; i.e. a narrative of the current symptoms such as the onset, location, duration, character, aggravating or relieving factors, and temporal nature of the pain. Identifying other possible factors may aid in the diagnosis of the underlying cause of abdominal pain, such as recent travel, recent contact with other ill individuals, and for females, a thorough gynecologic history.
Learning about the patient's past medical history, focusing on any prior issues or surgical procedures.
Clarifying the patient's current medication regimen, including prescriptions, over-the-counter medications, and supplements.
Confirming the patient's drug and food allergies.
Discussing with the patient any family history of disease processes, focusing on conditions that might resemble the patient's current presentation.
Discussing with the patient any health-related behaviors (e.g. tobacco use, alcohol consumption, drug use, and sexual activity) that might make certain diagnoses more likely.
After gathering a thorough history, one should perform a physical exam in order to identify important physical signs that might clarify the diagnosis, including a cardiovascular exam, lung exam, thorough abdominal exam, and for females, a genitourinary exam.[18]
Additional investigations that can aid diagnosis include:[20]
If diagnosis remains unclear after history, examination, and basic investigations as above, then more advanced investigations may reveal a diagnosis. Such tests include:[20]
The management of abdominal pain depends on many factors, including the etiology of the pain. Some behavioural changes implemented to prevent pain include: resting after a meal, chewing food completely and slowly, and avoiding stressful and high excitement situations after a meal. Such at home strategies may reduce the need to seek professional assistance via prevention of future abdominal pain.[21] In the emergency department, a person presenting with abdominal pain may initially require IV fluids due to decreased intake secondary to abdominal pain and possible emesis or vomiting.[22] Treatment for abdominal pain includes analgesia, such as non-opioid (ketorolac) and opioid medications (morphine, fentanyl).[22] Choice of analgesia is dependent on the cause of the pain, as ketorolac can worsen some intra-abdominal processes.[22] Patients presenting to the emergency department with abdominal pain may receive a "GI cocktail" that includes an antacid (examples include omeprazole, ranitidine, magnesium hydroxide, and calcium chloride) and lidocaine.[22] After addressing pain, there may be a role for antimicrobial treatment in some cases of abdominal pain.[22]Butylscopolamine (Buscopan) is used to treat cramping abdominal pain with some success.[23] Surgical management for causes of abdominal pain includes but is not limited to cholecystectomy, appendectomy, and exploratory laparotomy.[citation needed]
Emergencies
Below is a brief overview of abdominal pain emergencies.
One well-known aspect of primary health care is its low prevalence of potentially dangerous abdominal pain causes. Patients with abdominal pain have a higher percentage of unexplained complaints (category "no diagnosis") than patients with other symptoms (such as dyspnea or chest pain).[25] Most people who suffer from stomach pain have a benign issue, like dyspepsia.[26] In general, it is discovered that 20% to 25% of patients with abdominal pain have a serious condition that necessitates admission to an acute care hospital.[27]
Epidemiology
Abdominal pain is the reason about 3% of adults see their family physician.[2] Rates of emergency department (ED) visits in the United States for abdominal pain increased 18% from 2006 through to 2011. This was the largest increase out of 20 common conditions seen in the ED. The rate of ED use for nausea and vomiting also increased 18%.[28]
Special populations
Geriatrics
More time and resources are used on older patients with abdominal pain than on any other patient presentation in the emergency department (ED).[29] Compared to younger patients with the same complaint, their length of stay is 20% longer, they need to be admitted almost half the time, and they need surgery 1/3 of the time.[30]
Age does not reduce the total number of T cells, but it does reduce their functionality. The elderly person's ability to fight infection is weakened as a result.[31] Additionally, they have changed the strength and integrity of their skin and mucous membranes, which are physical barriers to infection. It is well known that older patients experience altered pain perception.[32]
The challenge of obtaining a sufficient history from an elderly patient can be attributed to multiple factors. Reduced memory or hearing could make the issue worse. It is common to encounter stoicism combined with a fear of losing one's independence if a serious condition is discovered. Changes in mental status, whether acute or chronic, are common.[33]
Pregnancy
Unique clinical challenges arise when pregnant women experience abdominal pain. First off, there are many possible causes of abdominal pain during pregnancy. These include intraabdominal diseases that arise incidentally during pregnancy as well as obstetric or gynecologic disorders associated with pregnancy. Secondly, pregnancy modifies the natural history and clinical manifestation of numerous abdominal disorders.[34] Third, pregnancy modifies and limits the diagnostic assessment. For instance, concerns about fetal safety during pregnancy are raised by invasive exams and radiologic testing. Fourth, while receiving therapy during pregnancy, the mother's and the fetus' interests need to be taken into account.[35]
^ abcdefMoore KL (2016). "11". The Developing Human Tenth Edition. Philadelphia, PA: Elsevier, Inc. pp. 209–240. ISBN978-0-323-31338-4.
^Hansen JT (2019). "4: Abdomen". Netter's Clinical Anatomy, 4e. Philadelphia, PA: Elsevier. pp. 157–231. ISBN978-0-323-53188-7.
^Drake RL, Vogl AW, Mitchell AW (2015). "4: Abdomen". Gray's Anatomy For Students (Third ed.). Churchill Livingstone Elsevier. pp. 253–420. ISBN978-0-7020-5131-9.
^ abNeumayer L, Dangleben DA, Fraser S, Gefen J, Maa J, Mann BD (2013). "11: Abdominal Wall, Including Hernia". Essentials of General Surgery, 5e. Baltimore, MD: Wolters Kluwer Health.
^ abBickley L (2016). Bates' Guide to Physical Examination & History Taking. Philadelphia, Pennsylvania: Lippincott Williams & Wilkins. ISBN978-1-4698-9341-9.
^ abcdefghijklmSherman SC, Cico SJ, Nordquist E, Ross C, Wang E (2016). Atlas of Clinical Emergency Medicine. Wolters Kluwer. ISBN978-1-4511-8882-0.
^Viniol A, Keunecke C, Biroga T, Stadje R, Dornieden K, Bösner S, et al. (2014). "Studies of the symptom abdominal pain—a systematic review and meta-analysis". Family Practice. 31 (5): 517–529. doi:10.1093/fampra/cmu036. ISSN1460-2229. PMID24987023.
^Gulacti U, Arslan E, Ooi MW, Tuck J, Mattu A, Dubosh NM, et al. (1 February 2001). "Abdominal Pain and Emergency Department Evaluation". Emergency Medicine Clinics of North America. 19 (1). Elsevier: 123–136. doi:10.1016/S0733-8627(05)70171-1. ISSN0733-8627. PMID11214394.
^Chandramohan R, Pari L, Schrock JW, Lum M, Örnek N, Usta G, et al. (1 May 1991). "Probability of appendicitis before and after observation". Annals of Emergency Medicine. 20 (5). Mosby: 503–507. doi:10.1016/S0196-0644(05)81603-8. ISSN0196-0644. PMID2024789.
^Rodríguez-Lomba E, Pulido-Pérez A, Ricciardi R, Marcello PW, Kuki I, Nakane S, et al. (1 February 1976). "Abdominal pain: An analysis of 1,000 consecutive cases in a university hospital emergency room". The American Journal of Surgery. 131 (2). Elsevier: 219–223. doi:10.1016/0002-9610(76)90101-X. ISSN0002-9610. PMID1251963.
^Isani MA, Kim ES, Mateu PB, Tormo FB, Thilakarathna K, Xie G, et al. (1 May 2006). "Abdominal Pain in the Elderly". Emergency Medicine Clinics of North America. 24 (2). Elsevier: 371–388. doi:10.1016/j.emc.2006.01.010. ISSN0733-8627. PMID16584962.
^Souza Fd, Ferreira CH, Young RC, Cerit L, Lejong M, Louryan S, et al. (1 March 2003). "Abdominal pain during pregnancy". Gastroenterology Clinics of North America. 32 (1). Elsevier: 1–58. doi:10.1016/S0889-8553(02)00064-X. ISSN0889-8553. PMID12635413.
Further reading
Shinar Z, Dembitsky W, Smith ME, Moak JH, Traub SJ, Saghafian S, et al. (1 September 2011). "Abdominal pain in the ED: a 35 year retrospective". The American Journal of Emergency Medicine. 29 (7). W.B. Saunders: 711–716. doi:10.1016/j.ajem.2010.01.045. ISSN0735-6757. PMID20825873.
