Abdominal Pain
Abdominal pain is one of the more challenging symptoms to diagnose and often causes uninformed primary care physicians to order an unnecessary battery of tests.
The cause of Abdominal pain can occur for a variety of reasons. The symptoms can also manifest in various ways, from pain shortly after eating to reproducible pain when pressing on the lower abdomen.
What makes abdominal pain particularly challenging is that most often it is benign, however it can also herald serious and even life threatening disease. Because of this, your doctor must take the symptom seriously but pursue a diagnosis methodically.
What Are the Symptoms Associated with Abdominal Pain?
Diarrhea
There is a relatively technical definition for diarrhea and is a loose or watery stools that occurs at least 3X in a 24 hour period. Diarrhea can be classified as acute diarrhea (14 days or fewer), persistent diarrhea 14 – 30 days), or chronic diarrhea (30 days or more). Diarrhea can also have additional labels attached to it such as Invasive Diarrhea (aka dysentery – which is diarrhea that has visible blood or mucous in it) and watery diarrhea. It is important for you and your doctor to correctly define the diarrhea you are experiencing with your abdominal pain.
Nausea and/or Vomiting
Nausea is the unpleasant sensation of your gastric contents on the verge of expulsion. Nausea can occur without vomiting, but vomiting rarely occurs without nausea. It’s important to distinguish between vomiting and regurgitation. Vomiting is a forceful expulsion of gastric contents whereas regurgitation is the return of recently swallowed food back into the mouth. Regurgitation doesn’t involve retching.
Constipation
Similar to diarrhea, there is a relatively technical definition of constipation. Based on the Rome IV criteria: Constipation is when someone has any of the following two symptoms with 25% of their bowel movements – straining with bowel movements, lumpy and hard stools, sensation of incomplete evacuation, requiring the use of fingers to to expel stool, sensation of rectal obstruction. PLUS a less than three bowel movements per week.
Indigestion
This symptom is a vague symptom that often encompasses many different symptoms most commonly when someone says they have indigestion they are indicating some abdominal discomfort in the upper abdomen similar to symptoms of heartburn.
GERD (Heartburn)
Typically described as a burning sensation behind the sternum of the chest that is felt 20-45mins after eating a meal. The diagnosis of GERD will need to be discussed and confirmed by your doctor.
Abdominal Distention
Abdominal distention is the sensation or physical enlarging of one’s abdomen/belly. Bloating is the sensation of abdominal distention without the belly actually distending.
Blood in the Stool
The appearance of blood in the stool will depend on the source and the amount of blood in the stool. The three common appearances are
- Bright red blood that fills the toilet bowl: This will often appear as a stool mixed or coated with bright red blood with the toilet bowl water turning mostly red. This is a concerning bleed into the GI track that is brisk and oftentimes high volume, the GI tract can hide a lot of blood and it’s possible to lose a dangerously large amount of blood before seeing any blood in the stool. This particular type of blood in the stool should be taken very seriously and if this is happening to you then you should immediately call 9-1-1 and go to the nearest hospital.
- Bright red blood that only appears on the toilet paper after wiping: typically from a either hemorrhoids or a crack in the skin
- Black tarry stool (Melena): Represents a bleed from the mouth, esophagus, stomach, and intestine because the black tarry substance is digested is what happens when blood is digested. This type of blood in the stool should also be taken very seriously and you should go to your nearest hospital to be evaluated for upper gastrointestinal bleeding.
How to Find the Right Diagnosis for Abdominal Pain
There are several important components of the story behind abdominal pain that always help guide doctors to the right diagnosis. These include:
- Are the symptoms new, old, a new-worsening, or long standing pain?
- The Description of the pain:
- Where is the pain and does it move from one place to the next?
- What makes the pain worse? What improves the pain?
- How long does the pain last, how frequent do you have the pain, and what time or circumstances surround the onset of the pain.
- Do you consume a lot of alcohol, illegal substances, have you been traveling and/or trying new foods/restaurants, or does anyone you’ve been in close contact with have similar symptoms?
- What chronic medical conditions do you have that might explain abdominal pain.
- What medications are you taking that have abdominal pain as a side effect.
Once the doctor gathers all of the information, they begin narrowing the diagnosis down based on the location of the symptoms. While the location of the abdominal pain is not a surefire way to exclude diagnoses, it can help point you into the right direction.
The reason why the location of abdominal pain can be misleading is because while the nerves on the skin are very good at two-point discrimination (the ability to pinpoint exactly where the symptom is), organ pain sensory systems often lack this nerve type. So the source of the pain might be different from where your brain is telling you the pain is.
With that said, use the below guide with a grain of salt because your brain might not be pinpointing the location of the pain correctly. See below for the location of your pain, a diagnosis, and a description of the pain commonly found for the diagnosis. This in no way replaces a true work up and you should not use this guide as a substitute for scheduling an appointment with a doctor.
If you divide the abdomen into four quadrants with your belly button being the very center we will label the quadrants Right upper quadrant, Left upper quadrant, Right lower quadrant, and Left lower quadrant. In addition to the four quadrants there is also the “epigastric” region which refers to the top middle portion of the abdomen 1-2 inches down from the bottom of your sternum.
Right Upper Quadrant
Gallbladder Pain
Intense but dull pain often lasts no less than 30 mins and can often persist for 1-2 hours. There is often a relationship to heavy, hit fat content foods. Associated symptoms are often nausea, vomiting, and developing the sweats.
Gall Bladder Infection
Gallbladder pain can often progress into a more prolonged episode of pain lasting more than 4 to 6 hours at a time and will typically have fevers associated with it. This is a serious infection and should be treated at the hospital because it requires IV antibiotics and surgical removal of the gallbladder.
Infection of Bile Duct
The bile duct connects the gallbladder to the intestine and is the pathway bile takes before it can begin helping with digestion. If a bile stone gets lodged in the bile duct it can cause infection of the bile duct itself. This results in a severe infection with high fevers, significant pain and the characteristic yellowing of the skin. This is a serious infection and will require IV antibiotics and GI procedures.
Acute Hepatitis
Often accompanied with nausea, vomiting, significant malaise, fatigue, and good aversion. Depending on the severity, there might also be yellowing of the skin, dark urine (tea colored), and light colored stools (clay colored).
Left Upper Quadrant
Disease of the Spleen
This could range from an enlarged spleen as seen sometimes in patients with mononucleosis, to infections of the spleen, to loss of blood flow and tissue of the spleen. The pain often leads to symptoms of your stomach feeling full after very little food and L shoulder pain. Infections of the spleen will be accompanied with fevers.
The Right and Left Lower Quadrants
Because the diseases that cause disease in the lower quadrants commonly cause misleading pain symptoms on the opposite side or can stretch all the way across the abdomen, we will group them together.
Appendicitis
The appendix is a small organ that is a normal outpouching of the intestines. This organ can become infected and is a common cause of abdominal pain in young adult patients. Other associated symptoms typically include fevers, nausea, vomiting, and food aversion. It’s typically in the right lower quadrant. Appendicitis needs to be treated promptly and typically requires surgical removal.
Diverticulitis
Diverticula are abnormal outpouchings of the colon. These diverticula, similar to the appendix, can become infected causing sharp, stabbing pain typically in the lower left quadrant. It causes pain in the lower left quadrant mostly because these outpouchings are most likely to develop in the lower left quadrant of the abdomen. These will cause similar symptoms as an appendicitis with fevers, nausea, vomiting, and food aversion. These require prompt antibiotic treatment, but don’t necessarily require surgical intervention.
Kidney Stones
A kidney stone travels from the kidney down a small tube called the ureter that is typically reserved for urine only. As the stone travels from the kidney to the bladder it causes pain. The pain is often episodic, lasting for 20-40mins before disappearing again. The pain often begins in the back but can progressive forward to the abdomen.
Kidney Infection
Untreated urinary tract infections can ascend up from the bladder through the ureter and into the kidneys. These infections make patients feel very sick and have associated fevers and chills. This is a serious infection and requires hospitalization and administration of IV antibiotics.
Urinary Tract Infection
Urinary tract infections often cause lower abdominal discomfort and have associated pain with urination, needing to urinate more frequently, and a strong sense of urinary urgency.
Food Poisoning
This is a common condition that occurs when ingesting food that has been left out or wasn’t properly refrigerated. It is typically associated with nausea, vomiting and diarrhea. The symptoms come on fast and last 1-2 days.
Gastroenteritis
Presents with nearly identical symptoms of food poisoning with the main different between the length of illness. The vast majority of these infections are viral, however there are bacterial causes that can be more severe which may or may not include fevers, chills, and blood in the stool.
Epigastric Region
Inflamed Pancreas (Pancreatitis)
Persistent pain that often feels like a sharp stabbing pain that radiates through to the back. Severe food aversion, with food making the pain significantly worse. Commonly, nausea and vomiting are associated with it.
Stomach Ulcers
Significant pain usually made worse with food.
GERD (Reflux Symptoms)
Heartburn or burning sensation beneath the sternum worse with large meals or meals where the person moves to a reclining position within 30 mins of the meal.
Gastritis
Significant pain usually made worse with food.
Dyspepsia
Often referred to as “Indigestion”. Persons develop one or more of the following: burning sensation in the stomach after meals, feeling full just after eating, and abdominal pain.
This is not an exclusive list but these are by far the most common causes of abdominal pain. It is very important that you not try to diagnose yourself when you have abdominal pain, instead engage with your doctor and the two of you will determine whether your abdominal pain requires urgent evaluation and admission to the emergency room or can be managed from home.
In most situations, there will be a need for labs or imaging tests, but with asking the right questions and narrowing the diagnosis down far enough a good doctor can avoid breaking the bank on unnecessary tests while capturing the right diagnosis.
Special Populations
There are certain patients who must take a different approach to their abdominal pain. Please consult your physician or see a telemedicine doctor if you fall into one of these categories:
- Sickle Cell Patient
- HIV-Infected Patients
- Those over the age of 65
- Women of childbearing age
How Do I Get Rid of My Abdominal Pain?
The approach to treating abdominal pain is two-part.
- Treat the Direct Symptoms: Treating the pain itself will provide immediate relief but you must be careful when masking the symptoms of a serious disease that will get worse if left untreated. If you have a ruptured appendix, then your body is producing pain to tell you something is wrong. If you simply mask the pain with pain medication, then there is risk that a life-threatening infection could take hold. It is always best practice to find the diagnosis of the pain while you are treating the pain.
- For mild to moderate pain we use Tylenol or Tramadol. Please avoid NSAIDS like IBUprofen, Advil, Aleve, Aspirin, etc. because these medications can make it more difficult for your body to stop bleeding. This is especially important if your abdominal pain is caused by a stomach ulcer or something that might require surgery.
- For nausea, Zofran is a first line treatment. This is a prescription you’ll need to get from your doctor.
- For diarrhea, you want to avoid using Immodium or other medications that will slow down your bowels until you’ve discussed things with your doctor. For infectious causes of abdominal pain and diarrhea, it is important that bowels continue to clear out while you treat the infection. Otherwise, abdominal distention and perforation can occur. Once your doctor approves of the immodium, take it on an as-needed basis and be careful not to induce constipation by taking too much of it.
- For constipation, similar to the treatment of diarrhea, do not use laxatives until you discuss the underlying cause of your abdominal pain and constipation with your doctor. Some causes of constipation will be made worse by promotility medications for the gut and can even lead to the perforation of your bowels. Once discussed with your doctor, we typically use Milk of Magnesia or Miralax to help get the bowels moving again.
- GERD or Indigestion, it is nearly always safe to start taking PrilosecProtonix, or another PPI to help treat GERD symptoms. However, if you plan to continue taking it for more than 90 days, we recommend discussing this with your doctor to determine if this is the right treatment plan.
- Treat the Underlying Cause: Once a diagnosis has been determined, it will typically take either medications or surgery to treat the underlying cause of the abdominal pain. There are a few conditions like food poisoning or viral gastroenteritis that will just require symptom management. However, it is important to discuss this with your doctor first before deciding that you know what you have and proceeding without any treatment.