Physiologic Causes of Chronic Abdominal Pain
Cause | Suggestive Findings* | Diagnostic Approach† |
|---|---|---|
Genitourinary disorders | ||
Recurrent UTIs | IVU Ultrasonography | |
Discomfort before or during menses | Laparoscopy | |
Vague lower abdominal discomfort, bloating Sometimes a palpable pelvic mass | Pelvic ultrasonography Gynecologic consultation | |
Fever, flank pain, dark or bloody urine | Urine culture IVU CT | |
Sequelae of acute PID | Pelvic discomfort History of acute PID | Pelvic examination Sometimes laparoscopy |
Gastrointestinal disorders | ||
In children, failure to thrive Abdominal bloating, diarrhea, and often steatorrhea Symptoms that worsen when gluten-containing products are ingested | Serologic markers/HLA-DQ2/HLA-DQ8 haplotype testing Small-bowel biopsy | |
Several previous discrete episodes of RLQ pain | Abdominal CT Ultrasonography | |
Recurrent colicky RUQ pain | Ultrasonography | |
Upper abdominal discomfort, malaise, anorexia Jaundice uncommon In about one third of patients, a history of acute hepatitis | Titers for viral, autoimmune, or metabolic causes of hepatitis | |
Episodes of severe epigastric pain Sometimes malabsorption (eg, diarrhea, fatty stool) Usually a history of acute pancreatitis | Serum lipase levels (frequently not elevated) CT or MRI often with MRCP Stool tests (fecal elastase or fecal fat) | |
Discomfort uncommon but possibly colicky discomfort if left colon is partially obstructed Often occult or visible blood in stool | Colonoscopy | |
Episodic severe pain with fever, anorexia, weight loss, diarrhea Extraintestinal symptoms (joints, eyes, mouth, skin) | CT enterography or upper GI series with SBFT Colonoscopy and esophagogastroduodenoscopy with biopsies | |
Dyspepsia or mild pain Often occult blood in stool | Upper endoscopy | |
Granulomatous enterocolitis | Family history Recurrent infections in other sites (eg, lungs, lymph nodes) | ESR Colonoscopy CT enterography |
Hiatus hernia with gastroesophageal reflux | Heartburn Sometimes cough and/or hoarseness Symptoms relieved by taking antacids Sometimes regurgitation of gastric contents into mouth | Barium swallow Endoscopy |
Chronic nonspecific pain Sometimes palpable RLQ mass Fever, diarrhea, weight loss | Tuberculin test Endoscopy for biopsy CT with oral contrast Chest x-ray | |
Bloating and cramps after ingesting milk products | Hydrogen breath test Trial of elimination of lactose-containing foods | |
Severe upper abdominal pain that
May cause obstructive jaundice | CT MRI/MRCP or ERCP Endoscopic ultrasonography | |
Parasitic infestation (particularly giardiasis) | History of travel or exposure Cramps, flatulence, diarrhea | Stool examination for ova or parasites Stool enzyme immunoassay (for Giardia) |
Upper abdominal pain relieved by food and antacids May awaken patient at night | Endoscopy and biopsy for Helicobacter pylori H. pylori breath test or stool antigen assays Evaluation of nonsteroidal anti-inflammatory drug, alcohol, and tobacco use Stool examination for occult blood | |
Postoperative adhesive bands | Previous abdominal surgery Colicky discomfort accompanied by nausea and sometimes vomiting | Upper GI series, SBFT, or CT enterography Abdominal CT |
Crampy pain with bloody diarrhea | Sigmoidoscopy Rectal biopsy Colonoscopy Sometimes fecal calprotectin | |
Systemic disorders | ||
Abdominal epilepsy | Very rare Episodic pain No other GI symptoms | EEG |
Recurrent severe abdominal pain, vomiting Benign abdominal examination Sometimes neurologic symptoms (eg, muscle weakness, seizures, mental disturbance) In some types, skin lesions | RBC deaminase assay | |
Cannabis use (cannabis hyperemesis syndrome) | Persistent nausea, vomiting, and dyspepsia, often relieved with a hot shower or marijuana cessation Usually requires chronic use of cannabis | Clinical evaluation Urine drug screen |
Family history Quotidian fever and peritonitis often accompanying the bouts of pain Starting in childhood or adolescence | Genetic testing | |
Symptoms developing only after consuming certain foods (eg, seafood) | Elimination diet | |
Immunoglobulin A–associated vasculitis (formerly Henoch-Schönlein purpura) | Palpable purpuric rash Joint pains Occult blood in stool | Biopsy of skin lesions |
Family history Pain often with peripheral angioedema and fever | Serum complement level (C4) during attacks | |
Cognitive/behavioral abnormalities | Blood lead level | |
Rare variant with epigastric pain and vomiting Mainly in children Usually family history of migraine | Clinical evaluation | |
Family history Severe episodes of abdominal pain lasting over a day Recurrent pain in nonabdominal sites | Sickle preparation Hemoglobin electrophoresis | |
* Findings are not always present and may be present in other disorders. | ||
† Clinical evaluation is always done but is mentioned in this column only when that can be the sole means of diagnosis. | ||
EEG = electroencephalography; ERCP = endoscopic retrograde cholangiopancreatography; ESR = erythrocyte sedimentation rate; GI = gastrointestinal; IVU = intravenous urography; MRCP = magnetic resonance cholangiopancreatography; PID = pelvic inflammatory disease; RBC = red blood cell; RLQ = right lower quadrant; RUQ = right upper quadrant; SBFT = small-bowel follow-through; UTI = urinary tract infection. | ||
Modified from Barbero GJ: Recurrent abdominal pain in childhood. Pediatr Rev 4(1):29–34, 1982, doi: 10.1542/pir.4-1-29, and from Greenberger NJ: Sorting through nonsurgical causes of acute abdominal pain. J Crit Illn 7:1602–1609, 1992. | ||