Diseases information. Disorders. Treatment.

History should include the quality, timing, and type of abdominal pain.
Pain of sudden onset often denotes colic, perforation or acute ischemia caused by torsion or volvulus.
Slower onset of pain suggests inflammatory conditions, such as appendicitis, pancreatitis, or cholecystitis.
Chronic pain can occur with non-surgical conditions or with early problems that are potentially surgical.

Colic results from spasms of a hollow viscus organ secondary to an obstruction. It is characterized by severe, intermittent cramping, followed by intervals when the pain is present but less intense. When spasms are present, the patient will appear agitated and restless, pale and diaphoretic. Colic pain usually originates from the biliary tree, pancreatic duct, gastrointestinal tract, urinary system, or uterus and tubes.

Inflammatory pain is caused by peritoneal irritation, and the patient presents quietly without much motion and appears ill. The pain is initially less severe and is exacerbated by movement.

Vomiting
The timing of the onset of vomiting is important. Usually abdominal pain will precede vomiting.
The interval between abdominal pain and vomiting is shorter when associated with colic.
Delayed vomiting for many hours is often associated with distal bowel obstruction or ileus secondary to peritonitis.

Diarrhea

Mild diarrhea with the onset of abdominal pain suggests acute gastroenteritis or early appendicitis.
Delayed onset of diarrhea may indicate a perforated appendicitis, with the inflamed mass causing irritation of the sigmoid colon.
Pain medications
Physical Examination

The abdomen should be observed, auscultated, and palpated for distention, localized tenderness, masses, and peritonitis. The groin must be examined to exclude an incarcerated hernia or ovary, or torsion of an ovary or testicle.

Rectal Examination

Gross blood in the stool suggests ectopic gastric mucosa, Meckel’s diverticula, or polyps.

Blood and mucus (currant jelly stool) suggests inflammatory bowel disease or intussusception.

Melena suggests upper gastrointestinal bleeding, necessitating gastric aspiration for blood.

Tests for occult blood in the stool should be performed.

Pelvic examinations are mandatory for postmenarchal and/or sexually active female patients. The rectal examination may also be used to evaluate the cervix, uterus, adnexa, and other pelvic masses.

Fever

Thoracic disease (eg, pneumonia) may be the cause of abdominal pain associated with fever.

Costovertebral angle tenderness with fever suggests pyelonephritis or a high retrocecal appendicitis.

The evaluation of abdominal pain is problematic because the pain is often difficult to localize, and the history in children is often nonspecific. In children the differential diagnosis of abdominal pain is extensive.

Localization of Abdominal Pain

Generalized pain in the epigastrium usually comes from the stomach, duodenum, or the pancreas.
Pain in the midgut (small bowel and colon or spleen) usually localizes to the periumbilical region.
Inflammation (parietal pain) is usually well localized.
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Referred abdominal pain occurs when poorly localized visceral pain is felt at a distant location.

Pancreatitis, cholecystitis, liver abscess, or a bleeding spleen cause diaphragmatic irritation, which is referred to the ipsilateral neck and shoulders.
Intraabdominal fluid may produce shoulder pain on reclining.
Gallbladder pain may be felt in the lower back or infrascapular area.
Pancreatic pain often is referred to the posterior flank.
A migrating ureteral stone often is felt as pain radiating toward the ipsilateral groin.
Rectal or gynecological pain often is perceived as sacral pain.
Right lower lobe pneumonia may be perceived as right upper quadrant abdominal pain.

History

Abdominal distention is a common complaint, particularly among women, who often note that the problem becomes more pronounced during the latter part of the day. Patients and physicians usually ascribe the problem to excess gaseousness. The ingestion of food causes relaxation of the stomach and rectus muscles. Any weakening of the rectus muscles, therefore, leads to more-pronounced distention. Because the largest meal usually is taken in the evening, distention following this meal is more pronounced than observed after breakfast. Although gaseousness is not the dominant cause, excess gas ingestion or generation will add to the problem. The absence of significant associated complaints such as vomiting, diarrhea, fever, and severe pain is often helpful in determining whether the complaint is caused by muscle relaxation or gastrointestinal structural pathology. A long history of symptoms also supports a functional cause. Women who have had one or more pregnancies or individuals who have undergone abdominal surgeries or have debilitating diseases may lose rectus muscle tone and thus distend easily.
Physical Examination
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The most important clinical observation is whether the distention is present in the erect and recumbent positions. If the evaluation is in the late afternoon and the patient is able to show abdominal distention while standing erect, the patient should be asked to lie recumbent on the examining table. If the distention is no longer apparent to the physician and patient, the diagnosis has been established. Many patients unfortunately have been subjected to numerous endoscopic and radiographic procedures and treated with a variety of drugs for a problem that is primarily mechanical. If the distention persists while the patient is recumbent, an obstruction series should be obtained and appropriate studies directed to determine whether the disorder is related to abnormal motility (pseudo-obstruction) or to a partial bowel obstruction.
Management

Efforts can be directed toward reducing the swallowing of air, the use of carbonated beverages, and the ingestion of foods that generate colonic gas such as cabbage, broccoli, cauliflower, and baked beans. A larger lunch and smaller dinner may prove beneficial. Dietary manipulation unfortunately is less helpful for patients with distention than for individuals with belching or flatulence. If weakened rectus muscles are thought to be the cause, younger patients may benefit from exercises aimed at strengthening the muscles (rectus-tensing exercises that are variations of the standard sit-up), but this strategy is not likely to be effective in older individuals. An abdominal support garment can reduce the cosmetic problems associated with distention.
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