| disease | Abdominal Pain |
| alias | Abdominal Pain, Stomachache, Stomachache |
Abdominal pain refers to pain in the abdomen caused by various conditions affecting the internal or external organs within the abdominal cavity. It can be classified into acute and chronic categories. The causes of abdominal pain are extremely complex, including inflammation, tumors, hemorrhage, obstruction, perforation, trauma, and functional disorders.
bubble_chart Etiology
(1) Pathological changes of abdominal organs, ranked by incidence rate as follows:
1. Inflammation: Acute gastritis, acute enteritis, cholecystitis, pancreatitis, peritonitis, etc.
2. Perforation: Gastric perforation, intestinal perforation, gallbladder perforation, etc.
3. Obstruction and torsion: Intestinal obstruction, biliary stone obstruction, biliary ascariasis, ureteral stone obstruction, acute gastric volvulus, greater omentum torsion, and ovarian cyst torsion, etc.
4. Rupture: Ectopic pregnancy rupture, ovarian cyst rupture, splenic rupture, liver cancer nodule rupture, etc.
5. Vascular diseases: Mesenteric artery thrombosis, abdominal aortic aneurysm, splenic infarction, renal infarction, etc.
6. Others: Intestinal spasm, acute gastric dilatation, premenstrual tension syndrome, etc.
(2) Diseases of extra-abdominal organs and systemic diseases, more common ones include:
1. Thoracic diseases: Acute myocardial infarction, acute pericarditis, lobar pneumonia, pleuritis, herpes zoster, etc.
2. Allergic diseases: Abdominal purpura, abdominal wind-dampness fever, etc.
3. Toxic and metabolic diseases: Lead poisoning, porphyria, etc.
4. Neuropsychiatric system diseases: Abdominal epilepsy, neurosis, etc. Guanneng syndrome, etc.
Abdominal pain includes visceral abdominal pain, somatic abdominal pain, and referred abdominal pain.
Visceral abdominal pain is caused by the excessive tension and contraction of the smooth muscles of hollow organs in the abdominal cavity or by the stretching and expansion due to increased intracavitary pressure. It can also be caused by the internal expansion force or external traction on the membrane of solid organs. The pain sensation is transmitted to the central nervous system through the visceral sensory nerve endings associated with the spinal nerves.Somatic abdominal pain is caused by the stimulation of spinal nerve endings distributed in the abdominal skin, abdominal wall muscle layer, parietal peritoneum, and the root of the mesentery due to intra-abdominal or extra-abdominal lesions or trauma. It is transmitted to the central nervous system through various spinal nerves from thoracic 6 to lumbar 1.
Referred abdominal pain is the pain felt on the body surface or deep within the corresponding nerve segment when there is a lesion in the abdominal organs. It can also manifest as radiating pain in distant areas.
bubble_chart Auxiliary Examination
(1) Routine blood, urine, and stool tests: An increase in total white blood cells and neutrophils in the blood suggests inflammatory lesions, and these are almost mandatory tests for every patient with abdominal pain. The presence of a large number of red blood cells in the urine indicates urinary system stones, tumors, or trauma. Proteinuria and white blood cells in the urine suggest a urinary tract infection. Pus and blood in the stool indicate intestinal infection, while bloody stool suggests strangulated intestinal obstruction, mesenteric thrombosis, hemorrhagic enteritis, etc.
(2) Blood generation and transformation tests: An increase in serum amylase suggests pancreatitis, which is the most commonly used blood generation and transformation test in the differential diagnosis of abdominal pain. Blood glucose and ketone measurements can be used to rule out abdominal pain caused by diabetic ketoacidosis. An increase in serum bilirubin suggests biliary diseases. Liver and kidney function tests and electrolyte tests are also helpful in assessing the condition.
(4) X-ray examination: Abdominal X-ray plain films are the most widely used in the diagnosis of abdominal pain. The detection of free gas under the diaphragm almost confirms gastrointestinal perforation. Gas accumulation and expansion in the intestinal cavity and multiple fluid levels in the intestine can diagnose intestinal obstruction. Calcification shadows in the ureter area may indicate ureteral stones. Blurring or disappearance of the psoas muscle shadow suggests retroperitoneal inflammation or bleeding. X-ray barium meal or barium enema can detect gastric and duodenal ulcers, tumors, etc. However, barium meal is contraindicated when intestinal obstruction is suspected. Gallbladder and bile duct imaging, endoscopic retrograde cholangiopancreatography, and percutaneous transhepatic cholangiography are very helpful in the differential diagnosis of biliary and pancreatic diseases.
(5) Real-time ultrasound and CT scans: These are crucial for the differential diagnosis of liver, gallbladder, and pancreatic diseases. If necessary, ultrasound-guided liver puncture can confirm diagnoses such as liver abscess and liver cancer.
(6) Endoscopy: This can be used for the differential diagnosis of gastrointestinal diseases and is often necessary in patients with chronic abdominal pain.
1. Medical History
(1) Gender and Age: Common disease causes of abdominal pain in children include ascariasis, mesenteric lymphadenitis, and intussusception. In young adults, ulcer disease, gastroenteritis, and pancreatitis are more common. In middle-aged and elderly individuals, cholecystitis and gallstones are more prevalent, and attention should also be paid to the possibility of gastrointestinal cancer, liver cancer, and myocardial infarction. Renal colic is more common in males, while ovarian cyst torsion and corpus luteum cyst rupture are common causes of acute abdominal pain in women. In women of childbearing age, ectopic pregnancy should be considered.
(2) Onset: Insidious onset is more common in ulcer disease, chronic cholecystitis, and mesenteric lymphadenitis. Sudden onset is more common in gastrointestinal perforation, biliary stones, and ureteral stones. Mesenteric artery embolism, ovarian cyst torsion, liver cancer nodule rupture, and ectopic pregnancy rupture are also common. A history of overeating or excessive fatty meals before the onset should raise suspicion of cholecystitis and pancreatitis.
(3) Past Medical History: A history of similar episodes is common in patients with biliary colic and renal colic. A history of abdominal surgery may suggest intestinal adhesions. A history of atrial fibrillation should raise suspicion of mesenteric vascular embolism.
2. Clinical Manifestations
(1) Characteristics of Abdominal Pain: The location of abdominal pain often indicates the site of the lesion and is an important factor in differential diagnosis. However, visceral pain is often poorly localized. Therefore, the site of tenderness is more important than the patient's subjective perception of pain. The radiation of pain can also provide diagnostic clues, such as right shoulder and back pain in biliary diseases, left lumbar pain in pancreatitis, and perineal radiation in renal colic.
The severity of abdominal pain reflects the severity of the condition to some extent. Generally, pain from gastrointestinal perforation, liver and spleen rupture, acute pancreatitis, biliary colic, and renal colic is severe, while pain from ulcer disease and mesenteric lymphadenitis is relatively mild. However, pain perception varies among individuals, especially in the elderly, who may have dulled sensations. For example, acute appendicitis may not cause abdominal pain until perforation occurs. The nature of pain is generally related to its severity. Severe pain is often described as knife-like or colicky, while milder pain may be described as aching or distending. The pain of biliary ascariasis is often described as drilling and is quite characteristic.
The rhythm of abdominal pain is strongly indicative of diagnosis. Pain from solid organ lesions is often continuous, while pain from hollow organ lesions is often paroxysmal. Continuous pain with paroxysmal exacerbations is often seen in conditions where inflammation and obstruction coexist, such as cholecystitis with biliary obstruction or late-stage intestinal obstruction with peritonitis.
(2) Associated Symptoms: Associated symptoms of abdominal pain are very important in differential diagnosis. Fever suggests inflammatory or sexually transmitted diseases. Vomiting and diarrhea are often seen in food poisoning or gastroenteritis, while diarrhea alone suggests intestinal infection. Vomiting may indicate gastrointestinal obstruction or pancreatitis. Jaundice suggests biliary disease. Hematochezia may indicate intussusception or mesenteric thrombosis. Hematuria may indicate ureteral stones. Abdominal distension and fullness may indicate intestinal obstruction. Shock is often seen in visceral rupture and hemorrhage or gastrointestinal perforation complicated by peritonitis. Upper abdominal pain with fever and cough may suggest pneumonia, while upper abdominal pain with arrhythmia and hypotension may suggest myocardial infarction.
(3) Abdominal pressure: The sign in the abdomen is the focus of the examination. First, it should be determined whether the tenderness is generalized or localized. Generalized abdominal tenderness indicates a diffuse lesion, such as tenderness at McBurney's point, which is a sign of appendicitis. When checking for tenderness, attention should also be paid to the presence of muscle tension and rebound pain. Muscle tension often suggests inflammation, while rebound pain indicates that the lesion (usually inflammation—including chemical inflammation) involves the abdominal membrane. Irregularly, it is necessary to check for the presence of abdominal masses. If a tender and indistinctly bordered abdominal mass is palpated, it often suggests inflammation. A mass without obvious tenderness and with relatively clear borders suggests the possibility of a tumor. Tumor masses are generally hard in texture. Intussusception, volvulus, and closed-loop intestinal obstruction can also palpate the affected intestinal loops. In children, a mass of roundworms in the small intestine, and in the elderly, feces in the colon may also be palpated as "abdominal masses."
Seeing gastric or intestinal patterns on the abdominal wall is a typical sign of pyloric obstruction or intestinal obstruction. Hearing hyperactive borborygmi suggests intestinal obstruction, while the absence of borborygmi indicates intestinal paralysis.
For lesions in the lower abdomen and pelvic region, a rectal examination is often necessary. Tenderness in the right iliac fossa or the presence of a palpable mass may suggest appendicitis or pelvic inflammation. A full rectal uterine fossa and cervical motion tenderness may indicate a ruptured ectopic pregnancy, among other conditions.
Since diseases of extra-abdominal organs can also cause abdominal pain, examination of the heart and lungs is essential. Temperature, pulse, respiration, and blood pressure reflect the patient's vital status and must be checked. The inguinal region is a common site for hernias and should not be overlooked during examination. Enlargement of the supraclavicular lymph nodes may indicate intra-abdominal neoplastic diseases and should be given special attention during physical examination.
bubble_chart Treatment Measures
Patients with abdominal pain should identify the disease cause and treat according to the disease cause. Some conditions such as strangulated intestinal obstruction, gastrointestinal perforation, necrotizing pancreatitis, and acute appendicitis should be treated with timely surgery.
General treatment for abdominal pain includes:
1. Fasting, fluid infusion, correction of typical edema, and disturbances in electrolyte and acid-base balance.
2. Active resuscitation for shock.
3. Gastrointestinal decompression for those with gastrointestinal obstruction.
4. Use of broad-spectrum antibiotics to prevent and control infection.
5. Antispasmodic and analgesic agents may be used as appropriate, but narcotic analgesics should be avoided unless the diagnosis is clear.
6. Other symptomatic treatments.
There are many diseases that can cause abdominal pain. Below are some of the most common and representative ones:
1. Acute gastroenteritis: The abdominal pain is mainly in the upper abdomen and around the navel, often presenting as continuous sharp pain with paroxysmal intensification. It is often accompanied by nausea, vomiting, and diarrhea, and may also include fever. Physical examination may reveal tenderness in the upper abdomen or around the navel, usually without muscle tension or rebound pain, and slightly hyperactive bowel sounds. A history of unclean eating before the onset makes the diagnosis straightforward.
2. Gastric and duodenal ulcers: Common in young and middle-aged adults, the abdominal pain is mainly in the mid-upper abdomen, often presenting as continuous dull pain that typically occurs on an empty stomach and can be relieved by eating or taking antacids. Physical examination may show tenderness in the mid-upper abdomen but without muscle tension or rebound pain. Frequent episodes may be accompanied by a positive fecal occult blood test. Diagnosis can be confirmed by barium meal or endoscopy.
If there is a history of gastric or duodenal ulcers or similar symptoms, and sudden severe pain in the mid-upper abdomen, like a knife cut, rapidly spreading to the entire abdomen, with tenderness, muscle tension ("board-like rigidity"), rebound pain, and disappearance of bowel sounds, along with signs of pneumoperitoneum and shifting dullness, and a reduction or disappearance of liver dullness, it suggests gastric or duodenal perforation. Diagnosis can be confirmed by abdominal X-ray showing free gas under the diaphragm and inflammatory exudate obtained by abdominal puncture.
3. Acute appendicitis: Most patients initially feel continuous dull pain in the mid-abdomen, which shifts to the right lower abdomen after a few hours, presenting as continuous dull pain with paroxysmal intensification. A few patients may feel right lower abdominal pain from the onset. The shift of dull pain from the mid-abdomen to the right lower abdomen over a few hours is characteristic of acute appendicitis. It may be accompanied by fever and nausea. Physical examination may reveal tenderness at McBurney's point and muscle tension, typical signs of appendicitis. Diagnosis is confirmed by elevated total white blood cell count and neutrophils. If acute appendicitis is not diagnosed and treated promptly, within 1-2 days, the right lower abdomen may show continuous pain, with obvious tenderness, muscle tension, and rebound pain around McBurney's point, and significantly elevated white blood cell count and neutrophils, suggesting gangrenous appendicitis. If a mass with indistinct edges is palpated in the right lower abdomen, an appendiceal mass has formed.
4. Cholecystitis and gallstones: This disease is common in middle-aged and elderly women. Chronic cholecystitis often presents as dull pain in the right upper abdomen, exacerbated after eating fatty meals, and radiating to the right shoulder. Acute cholecystitis often occurs after eating fatty meals, presenting as continuous severe pain in the right upper abdomen radiating to the right shoulder, often accompanied by fever and nausea. Gallstone patients often have chronic cholecystitis. Gallstones entering the cystic duct or moving in the bile duct can cause paroxysmal colicky pain in the right upper abdomen, also radiating to the right shoulder and back, often accompanied by nausea. Physical examination may show obvious tenderness and muscle tension in the right upper abdomen, with a positive Murphy's sign characteristic of cholecystitis. Jaundice indicates biliary obstruction, and a palpable gallbladder suggests more complete obstruction. Acute cholecystitis shows significantly elevated total white blood cell count and neutrophils. Diagnosis can be confirmed by ultrasound and X-ray.
5. Acute pancreatitis: Often occurs suddenly after a heavy meal, presenting as continuous severe pain in the mid-upper abdomen, often accompanied by nausea, vomiting, and fever. Deep tenderness, muscle tension, and rebound pain in the upper abdomen are not very obvious. Diagnosis is confirmed by significantly elevated serum amylase. However, serum amylase often rises 6-8 hours after onset, so a normal serum amylase in the initial stage does not rule out the disease. If abdominal pain spreads to the entire abdomen and shock symptoms appear rapidly, with diffuse tenderness, muscle tension, and rebound pain, and even ascites and periumbilical or lateral abdominal skin discoloration, it suggests hemorrhagic necrotizing pancreatitis. Serum amylase may be significantly elevated or not. Abdominal X-ray may show distended stomach and small intestine with collapsed colon. CT may show pancreatic enlargement and disappearance of surrounding fat layers.
6. Intestinal Obstruction Intestinal obstruction can be seen in patients of various ages. In children, it is often caused by conditions such as ascariasis and intussusception. In adults, it is more commonly caused by hernias or intestinal adhesions, while in the elderly, it can be caused by conditions such as intestinal cancer. The pain of intestinal obstruction is usually around the navel, presenting as paroxysmal colicky pain, accompanied by vomiting and cessation of defecation and gas. During the physical examination, intestinal patterns, significant abdominal tenderness, and hyperactive borborygmi can be observed, and even the sound of "gas passing through water" can be heard. If the abdominal pain is persistent with paroxysmal exacerbations, accompanied by significant abdominal tenderness, muscle tension, and rebound tenderness, or if ascites is detected and shock rapidly develops, it suggests strangulated intestinal obstruction. The diagnosis of intestinal obstruction can be confirmed by X-ray plain film if intestinal gas and multiple fluid levels are observed.
7. Rupture of abdominal organs Common examples include splenic rupture due to external force, rupture of liver cancer nodules due to external force or spontaneous rupture, and spontaneous rupture of ectopic pregnancy. The onset is sudden, with persistent severe pain involving the entire abdomen, often accompanied by shock. Examination often reveals tenderness throughout the abdomen, possible muscle tension, and rebound tenderness. Signs of intra-abdominal hemorrhage are often detectable. Intra-abdominal puncture revealing blood confirms the rupture of abdominal organs. In cases of ectopic pregnancy rupture with bleeding, if no blood is obtained from the abdominal puncture, puncture of the posterior fornix often yields positive results. Real-time ultrasound, alpha-fetoprotein testing, CT scans, and gynecological examinations can aid in the differential diagnosis of common organ ruptures.
8. Ureteral stones Abdominal pain often occurs suddenly, mostly on the left or right side of the abdomen, presenting as paroxysmal colicky pain radiating to the perineum. Abdominal tenderness is not obvious. The characteristic feature of this condition is hematuria during pain episodes. Abdominal X-rays and intravenous pyelography can confirm the diagnosis.
9. Acute myocardial infarction Seen in middle-aged and elderly people, if the infarction is located on the diaphragmatic surface, especially if the area is large, it often causes upper abdominal pain. The pain usually occurs suddenly after exertion, stress, or a heavy meal, presenting as persistent colicky pain radiating to the left shoulder or the inner side of both arms. It is often accompanied by nausea and may lead to shock. Examination may reveal grade I tenderness in the upper abdomen, without muscle tension or rebound tenderness, but cardiac auscultation often reveals arrhythmias. Electrocardiogram (ECG) can confirm the diagnosis.
10. Lead poisoning Seen in individuals who have long-term exposure to lead powder dust or fumes, or occasionally from accidental ingestion of large amounts of lead compounds. Lead poisoning can be acute or chronic. However, whether acute or chronic, paroxysmal abdominal colicky pain is a characteristic feature. The onset is sudden, mostly around the umbilical region. It is often accompanied by abdominal distension and fullness, constipation, and loss of appetite. Examination may reveal unclear abdominal signs, no fixed tender points, and often reduced borborygmi. Additionally, a lead line may be visible at the gingival margin, a characteristic sign of lead poisoning. Basophilic stippling of red blood cells may be seen in peripheral blood, and elevated blood and urine lead levels can confirm the diagnosis.
