Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.
Dr. Anand received MBBS degree from Medical College Amritsar, University of Punjab. He completed his Internal Medicine residency at the Postgraduate Institute of medical Education and Research, Chandigarh, India. He was trained in the field of Gastroenterology and obtained the DPhil degree. Dr. Anand is board-certified in Internal Medicine and Gastroenterology.
The cause of abdominal pain is diagnosed on the basis of its characteristics, the physical examination, and testing. Occasionally, surgery is necessary for diagnosis.
The medical diagnosis of the cause is challenging because the characteristics may be atypical, tests are not always abnormal, diseases causing pain may mimic each other, and the characteristics of the pain may change over time.
Medical treatment depends upon the patient’s history of disease or other health conditions that may be the cause.
What is abdominal pain?
Abdominal pain is felt in the abdomen. The abdomen is an anatomical area that is bounded by the lower margin of the ribs and diaphragm above, the pelvic bone (pubic ramus) below, and the flanks on each side. Although pain can arise from the tissues of the abdominal wall that surround the abdominal cavity (such as the skin and muscles), the term abdominal pain generally is used to describe discomfort originating from organs within the abdominal cavity. Organs of the abdomen include the stomach, small intestine, colon, liver, gallbladder, spleen, and pancreas.
Technically, the lowermost portion of the area described previously, is the pelvis, which contains the urinary bladder and rectum, as well as the prostate gland in men, and the uterus, Fallopian tubes, and ovaries in women. Often, it can be difficult to know if lower abdominal pain is coming from the lower abdomen or pelvis (pelvic pain).
Occasionally, pain may be felt in the belly even though it is arising from organs that are close to, but not within, the abdominal cavity, for example, conditions of the lower lungs, the kidneys, and the uterus or ovaries. On the other hand, it also is possible for pain from organs within the belly to be felt outside of the it. For example, the pain of pancreatic inflammation may be felt in the back. These latter types of pain are described as "referred” because it does not originate in the location that it is felt. Rather, the cause is located away from where it is felt (i.e., it is referred to a different area).
Abdominal pain is caused by inflammation of an organ (for example, appendicitis, diverticulitis, colitis), by stretching or distention of an organ (for example, obstruction of the intestine, blockage of a bile duct by gallstones, swelling of the liver with hepatitis), or by loss of the supply of blood to an organ (for example, ischemic colitis).
To complicate matters, however, abdominal pain also can occur without inflammation, distention or loss of blood supply. An important example of the latter is the irritable bowel syndrome (IBS). It is not clear what causes the belly pain in IBS, but it is believed to be due either to abnormal contractions of the intestinal muscles (for example, spasm) or abnormally sensitive nerves within the intestines that give rise to painful sensations inappropriately (visceral hyper-sensitivity). This often is referred to as functional pain because no recognizable specific abnormality to account for the cause of the pain has been found - at least not yet.
Doctors will ask you a variety of questions about your belly pain in order to help find the possible causes of it, for example:
How did the pain begin?
If it comes on suddenly, this may suggest a problem with an organ within the belly; for example, the interruption of the supply of blood to the colon (ischemia) or obstruction of the bile duct by a gallstone (biliary colic).
Where is the pain located?
Appendicitis typically causes discomfort in the middle of the abdomen, and then moves to the right lower abdomen, the usual location of the appendix.
Diverticulitis typically causes discomfort in the left lower abdomen where most colonic diverticuli are located.
Discomfort from the gallbladder (biliary colic or cholecystitis) typically is felt in the middle, upper abdomen or the right upper abdomen near where the gallbladder is located.
What is the type and pattern of the pain?
Is it severe, crampy, steady; or does it wax and wane? Obstruction of the intestine initially causes waves of crampy pain due to contractions of the intestinal muscles and distention of the intestine. True cramp-like pain suggests vigorous contractions of the intestines.
Obstruction of the bile ducts by gallstones typically causes steady (constant) upper belly pain that lasts between 30 minutes and several hours.
Acute pancreatitis typically causes severe, unrelenting, steady pain in the upper abdomen and upper back.
The pain of acute appendicitis initially may start near the umbilicus, but as the inflammation progresses, it moves to the right lower abdomen.
The character of pain may change over time. For example, obstruction of the bile ducts sometimes progresses to inflammation of the gallbladder with or without infection (acute cholecystitis). When this happens, the characteristics change to those of inflammatory pain.
How long does the pain last?
The discomfort of IBS typically waxes and wanes over months or years and may last for years or decades.
The pain of acid-related diseases - gastroesophageal reflux disease (GERD) or duodenal ulcers - typically occurs over a period of weeks or months that is worse followed by periods of weeks or months during which it is better (periodically).
Functional pain may show this same pattern of periodicity.
What makes the pain worse?
Pain due to inflammation (appendicitis, diverticulitis, cholecystitis, and pancreatitis) typically is aggravated by sneezing, coughing or any jarring motion. Individuals with inflammation prefer to lie still.
What health conditions make abdominal pain worse or better?
What relieves the pain?
The pain of IBS and constipation often is relieved temporarily by bowel movements and may be associated with changes in bowel habit.
Pain due to obstruction of the stomach or upper small intestine may be relieved temporarily by vomiting which reduces the distention that is caused by the obstruction.
Eating or taking antacids may temporarily relieve ulcer pain from the stomach or duodenum because both food and antacids neutralize the acid that is responsible for irritating the ulcers and causing the pain.
Pain that awakens a patient from sleep is more likely to be due to non-functional causes and is more significant.
Other associated symptoms that accompany abdominal pain may suggest:
Finding tenderness and signs of inflammation in the left lower abdomen often means that diverticulitis is present, while finding a tender (inflamed) mass in the same area may mean that the inflammation has progressed and that an abscess has formed.
Finding tenderness and signs of inflammation in the right lower abdomen often means that appendicitis is present, while finding a tender mass in the same area may mean that the inflammation has progressed and that an abscess has formed.
Inflammation in the right lower abdomen, with or without a mass, also may be found in Crohn's disease. (Crohn's disease most commonly affects the last part of the small intestine, usually located in the right lower abdomen.)
A mass without signs of inflammation may mean that a cancer is present.
While the health history and physical examination are vitally important in determining the cause of abdominal pain, other medical tests often are necessary to determine the cause.
Plain X-rays of the abdomen also are referred to as a KUB (because they include the kidney, ureter, and bladder). The KUB may show enlarged loops of intestines filled with copious amounts of fluid and air when there is intestinal obstruction. Patients with a perforated ulcer may have air escape from the stomach into the abdominal cavity. The escaped air often can be seen on a KUB on the underside of the diaphragm. Sometimes a KUB may reveal a calcified kidney stone that has passed into the ureter and resulted in referred abdominal pain or calcifications in the pancreas that suggest chronic pancreatitis.
Ultrasound is useful in diagnosing gallstones, cholecystitis appendicitis, or ruptured ovarian cysts as the cause of the pain.
Computerized tomography (CT) of the abdomen is useful in diagnosing pancreatitis, pancreatic cancer, appendicitis, and diverticulitis, as well as in diagnosing abscesses in the abdomen. Special CT scans of the abdominal blood vessels can detect diseases of the arteries that block the flow of blood to the abdominal organs.
Barium X-rays of the stomach and the intestines (upper gastrointestinal series or UGI with a small bowel follow-through) can be helpful in diagnosing ulcers, inflammation, and blockage in the intestines.
Computerized tomography (CT) of the small intestine can be helpful in diagnosing diseases in the small bowel such as Crohn's disease.
Capsule enteroscopy, uses a small camera the size of a pill swallowed by the patient, which can take pictures of the entire small bowel and transmit the pictures onto a portable receiver. The small bowel images can be downloaded from the receiver onto a computer to be inspected by a doctor later. Capsule enteroscopy can be helpful in diagnosing Crohn's disease, small bowel tumors, and bleeding lesions not seen on x-rays or CT scans.
Balloon enteroscopy, the newest technique allows endoscopes to be passed through the mouth or anus and into the small intestine where small intestinal causes of pain or bleeding can be diagnosed, biopsied, and treated.
Surgery. Sometimes, diagnosis requires examination of the abdominal cavity either by laparoscopy or surgery.
How does IBS (irritable bowel syndrome) cause abdominal pain?
As previously mentioned, the discomfort of irritable bowel syndrome is due either to abnormal intestinal muscle contractions or visceral hypersensitivity. Generally, abnormal muscle contractions and visceral hypersensitivity are much more difficult to diagnose than other diseases or other health conditions, particularly since there are no typical abnormalities on physical examination or the usual diagnostic tests. The diagnosis is based on the history (typical symptoms) and the absence of other cause.
Foods, natural remedies, and OTC treatments for certain causes of abdominal pain
If you aren’t sure if you need to seek medical advice for belly pain, contact your doctor or other health care professional before using any home remedies.
Common home remedies and over-the-counter (OTC) medicines include:
Eat less food
Take small amounts of baking soda
Use lemon and/or lime juice
Start a BRAT diet (banana, rice, applesauce and toast) for a day or so for symptom relief.
Some of these may help reduce symptoms, but if symptoms persist, seek medical care. Beware of "cures" advertised as a single treatment that can cure all causes of this problem because no such remedy or cure exists.
Taking aspirin or NSAIDs should be avoided until the cause of the pain is diagnosed because the medications could make some causes worse (for example, peptic ulcers, intestinal bleeding).
Why can diagnosis of the cause of abdominal pain be difficult?
Modern advances in technology have greatly improved the accuracy, speed, and ease of establishing the cause of belly pain, but significant challenges remain. There are many reasons why diagnosing the cause of it can be difficult.
Symptoms may be atypical
For example, the pain of appendicitis sometimes is located in the right upper abdomen, and of diverticulitis on the right side. Elderly patients and those taking corticosteroids may have little or no pain and tenderness when there is inflammation, for example, with cholecystitis or diverticulitis. This occurs because corticosteroids reduce the inflammation.
Tests are not always abnormal.
Ultrasound examinations can miss gallstones, particularly small ones.
Medications that are used for the treatment of underlying cause(s) of the pain are the medications of choice. For example, medications are not needed for the treatment of simple viral gastroenteritis (stomach flu or stomach bug), while surgery and/or chemotherapy may be the best approach to treat certain cancers in the abdomen. Other causes may require antispasmodics, antimicrobials, H2 blockers, or even nitrates or morphine. The diagnosed cause usually narrows the choice of medications. A few causes can only be treated by surgery (for example incarcerated hernia, abdominal adhesions from previous surgeries, and certain abdominal injuries), although some medications may be used (for example, morphine) while the person is waiting to have surgery.
What lifestyle choices can I make to prevent abdominal pain?
Lifestyle changes really depend on the cause of the pain.
Eat a healthy diet, exercise, and avoid smoking and excess alcohol consumption to reduce the chances that you will experience certain causes.
Good hygiene, especially hand washing and avoiding materials and foods contaminated with viruses and bacteria will reduce your chances of developing illness from many infectious causes.
When should I call my doctor about abdominal pain?
Some doctors suggest that if you have a "less serious" cause of abdominal pain you likely won’t need to see a doctor if the symptoms resolve in about 24 to 48 hours. For example, if you have viral or bacterial food poisoning, have had discomfort, but aren’t dehydrated.
If you have a chronic problem that occasionally causes abdominal discomfort, most doctors suggest you contact the person treating you for the ailment for an appointment or prescription (refill). However, if you have any of the problems or symptoms listed in the "serious abdominal pain "section above, you should seek immediate medical care.