Differential diagnosis of abdominal pain in adults
Mary B Fishman, MD
Mark D Aronson, MD
Robert H Fletcher, MD, MSc
Fenny H Lin, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2013. | This topic last updated: ene 4, 2013.
INTRODUCTION — The evaluation of abdominal pain requires an understanding of the possible
mechanisms responsible for pain, a broad differential of common causes, and recognition of typical
patterns and clinical presentations. All patients do not have classic presentations. Thus, unusual causes
of abdominal pain must also be considered, especially in older adult and immunocompromised
An epidemiologic assessment of acute abdominal pain found that 10 diagnostic groups could be
classified in outpatients complaining of abdominal pain on their first visit to primary care physicians:
whole abdominal, epigastric, right subcostal, left subcostal, right flank, left flank, periumbilical, rightlower, mid-lower, and left-lower (table 1) . The overall sensitivity of history taking and physical
examination was poor. Specificity was highest in patients with epigastric pain caused by
gastroduodenal diseases, right subcostal pain caused by hepatobiliary diseases, and mid-lower pain
caused by gynecologic diseases.
This topic review will provide an overview of the mechanisms and differential diagnosis in patients with
abdominal pain. Detailed discussions of the specific causes of abdominal pain and initial management
are presented separately. A detailed history and physical examination in adults with abdominal pain is
also discussed separately. (See "History and physical examination in adults with abdominal pain".)
Many patients with abdominal pain will have a functional disorder such as irritable bowel syndrome or
functional dyspepsia. A diagnostic approach appropriate for most patients with abdominal pain and
aimed at appropriately distinguishing functional disorders from more serious etiologies of abdominal
pain is also presented separately. (See"Diagnostic approach to abdominal pain in adults".)
NEUROLOGIC BASIS OF ABDOMINAL PAIN — Pain receptors in the abdomen respond to mechanical
and chemical stimuli. Stretch is the principal mechanical stimulus involved in visceral nociception,
although distention, contraction, traction, compression, and torsion are also perceived . Visceral
receptors responsible for these sensations are located on serosal surfaces, within the mesentery, and
within the walls of hollow viscera, in which they exist between the muscularis mucosa and submucosa.
Mucosal receptors respond primarily to chemical stimuli, in contrast to other visceral nociceptors that
respond to chemical or mechanical stimuli. A variety of chemical stimuli are capable of triggering these
receptors including substance P, bradykinin, serotonin, histamine, and prostaglandins, which are
released in response to inflammation or ischemia [3,4].
The events responsible for the perception of pain are not completely understood, but depend upon
the type of stimulus and the interpretation of visceral nociceptive inputs in the central nervous system
(CNS). Multiple types of stimuli may exist concurrently and influence the perception of pain. As an
example, the gastric mucosa is insensitive to pressure or chemical stimuli. However, in the presence of
pre-existing inflammation, these same stimuli can cause pain .
Processing of visceral pain signals by the CNS is also important for their interpretation. The threshold
for perceiving pain from visceral stimuli may vary among individuals and in certain diseases. As an
example, distension of the sigmoid colon by a balloon is perceived as painful at lower distension
thresholds in some patients with irritable bowel syndrome (IBS) compared with controls . In
contrast, the perception of somatic pain in patients with IBS is similar to controls. Psychologic factors
are also likely to be important in the perception of pain. (See "Pathophysiology of irritable bowel
Localization of pain — The type and density of visceral afferent nerves makes the localization of
visceral pain imprecise. However, a few general rules are useful at the bedside:
Most digestive tract pain is perceived in the midline because of bilaterally symmetric
innervation [2,7]. Pain that is clearly lateralized most likely arises from the ipsilateral kidney,
ureter, ovary, or somatically innervated structures, which have predominantly unilateral
innervation. Exceptions to this rule include the gallbladder and ascending and descending
colons which, although bilaterally innervated, have predominant innervation located on their
Visceral pain is perceived in the spinal segment at which the visceral afferent nerves enter the
spinal cord . As an example, afferent nerves mediating pain arising from the small intestine
enter the spinal cord between T8 to L1. Thus, distension of the small intestine is usually
perceived in the periumbilical region.
Referred pain — Pain originating in the viscera may sometimes be perceived as originating from a site
distant from the affected organ (figure 1) [9-11]. One explanation is that visceral afferent nerve fibers
enter the spinal cord close to inputs from somatic receptors, and both types of inputs activate the
same spinothalamic pathways . Because the density of somatic inputs is higher than visceral inputs
and because somatic inputs are more commonly stimulated, the brain tends to associate the
stimulation with a somatic source.
Referred pain is usually located in the cutaneous dermatomes sharing the same spinal cord level as the
visceral inputs. As an example, nociceptive inputs from the gallbladder enter the spinal cord at T5 to
T10. Thus, pain from an inflamed gallbladder may be perceived in the scapula (figure 1). Precise
localization of the pain to the right upper quadrant in patients with acute cholecystitis usually occurs
once the overlying parietal peritoneum (which is somatically innervated) becomes inflamed.
The quality of referred pain is aching and perceived to be near the surface of the body. In addition to
pain, two other correlates of referred pain can be detected: skin hyperalgesia and increased muscle
tone of the abdominal wall (which accounts for the abdominal wall rigidity sometimes observed in
patients with an acute abdomen).
Extra-abdominal causes of abdominal pain — Pain perceived as originating in the abdomen may arise
from extra-abdominal sites or from acute systemic illness (table 2) . In patients with herpes zoster,
for example, neuropathic pain may sometimes precede the development of skin lesions. An attack of
herpes zoster involving the thoracic dermatomes can sometimes cause severe right upper quadrant
pain, which can be confused with visceral causes such as acute cholecystitis (see "Postherpetic
neuralgia"). Another example is lower thoracic or epigastric abdominal pain that may accompany acute
myocardial infarction or ischemia. (See "Pathophysiology and clinical presentation of ischemic chest
UPPER ABDOMINAL PAIN SYNDROMES — The different pain syndromes typically, but not always, have
characteristic locations (table 1).
Biliary disease — Disorders involving the liver, biliary organs, pancreas, kidneys, stomach, intestines,
diaphragms, and lung may cause right upper quadrant pain. The biliary tract syndromes are classified
according to the source of pain and the pathogenesis of the disorder (eg, distention of a duct,
inflammation, or infection).
Cholelithiasis refers to the presence of gallstones within the gallbladder; it is often
Biliary colic is usually caused by the gallbladder contracting in response to a fatty meal and
pressing a stone against the gallbladder outlet or cystic duct opening, leading to increased
intragallbladder pressure and pain. The term biliary colic is a misnomer, since the pain is not
typically colicky. It is entirely visceral in origin, without true gallbladder wall inflammation.
Affected patients typically complain of deep and gnawing pain that is occasionally sharp and
severe. The pain is localized in the right upper quadrant or epigastrium. As the gallbladder
relaxes, the stones often fall back from the cystic duct. As a result, the attack reaches a
crescendo over a number of hours and then resolves completely; it may recur multiple times.
Biliary colic may be mistaken for irritable bowel syndrome, acute myocardial infarction, and
peptic ulcer disease.
Prolonged or recurrent cystic duct blockage can progress to total obstruction, causing acute
cholecystitis. Patients with acute cholecystitis typically complain of abdominal pain, most often
in the right upper quadrant or epigastrium with possible radiation to the right shoulder or back.
The pain is characteristically steady and severe. Associated complaints may include nausea,
vomiting, and anorexia. There is often a history of fatty food ingestion about one hour or more
before the initial onset of pain. An episode of prolonged right upper quadrant pain (more than
four to six hours), especially if associated with fever, should arouse suspicion for acute
cholecystitis as opposed to an attack of simple biliary colic. (See "Pathogenesis, clinicalfeatures,
and diagnosis of acutecholecystitis".)
Acute cholangitis occurs when a stone becomes impacted in the biliary or hepatic ducts,
causing dilation of the obstructed duct and bacterial superinfection. It is characterized by fever,
jaundice, and abdominal pain, although this classic triad occurs in only 50 to 75 percent of cases
. The abdominal pain is typically vague and located in the right upper quadrant.
Gallstone pancreatitis occurs when a gallstone becomes impacted within the ampulla of Vater,
occluding drainage of the pancreatic duct. This is the most common cause of acute pancreatitis
in the United States . The pain of gallstone pancreatitis is typical of acute pancreatitis.
(See "Clinicalmanifestations and diagnosis of acute pancreatitis".)
Biliary dyskinesia, which is usually attributed to sphincter of Oddi dysfunction, can be a cause of
biliary pain in the absence of gallstones or biliary inflammation. It can occur following
cholecystectomy but is also diagnosed in patients whose gallbladder is intact. (See "Clinical
manifestations and diagnosis of sphincter of Oddi dysfunction".)
Acute pancreatitis — Almost all patients with acute pancreatitis have acute upper abdominal pain at
the onset. The pain is steady and may be in the mid-epigastrium, right upper quadrant, diffuse, or,
infrequently, confined to the left side. Biliary colic, which may herald or progress to acute pancreatitis,
may occur postprandially, while acute pancreatitis related to alcohol frequently occurs one to three
days after a binge or cessation of drinking. (See "Clinical manifestations and diagnosis of acute
Unlike biliary colic, which lasts a maximum of six to eight hours, the pain of pancreatitis lasts days. Its
onset is rapid, but not as abrupt as that with a perforated viscus; in many cases, the pain of
pancreatitis reaches maximum intensity within 10 to 20 minutes. One characteristic of the pain that is
present in about one-half of patients and suggests a pancreatic origin is band-like radiation to the back.
Painless disease is uncommon (5 to 10 percent) but may be complicated and fatal.
The abdominal pain is typically accompanied (approximately 90 percent) by nausea and vomiting that
may persist for many hours. Restlessness, agitation, and relief on bending forward are other notable
symptoms. Patients with fulminant attacks may present in shock or coma. (See "Clinical manifestations
and diagnosis of acute pancreatitis".)
Dyspepsia — An international committee of clinical investigators developed the following definition
(Rome criteria) of dyspepsia for research purposes, which can also be applied to clinical practice :
"Dyspepsia is persistent or recurrent abdominal pain or abdominal discomfort centered in the upper
abdomen. Discomfort refers to a subjective, negative feeling that does not reach the level of pain
according to the patient. Centering refers to pain or discomfort mainly localized to the upper
abdomen; it does not exclude patients who have pain or discomfort elsewhere unless they only have
The differential diagnosis of dyspepsia includes gastroesophageal reflux disease, peptic ulcer disease,
biliary disease, irritable bowel syndrome, chronic pancreatitis, gastric cancer, drug-induced dyspepsia,
psychiatric disease, diabetic gastroparesis, metabolic diseases, gastrointestinal and pancreatic
malignancies, ischemic heart disease, and abdominal wall pain. A detailed description of a patient with
these syndromes is discussed elsewhere. (See "Approach to the patient with dyspepsia".)
Hiatus hernia — Both sliding and paraesophageal hernias can occasionally become incarcerated and
cause severe chest and epigastric pain requiring emergency surgery. Hiatal hernias may also develop
following surgery that involves the diaphragm, including partial gastrectomy, fundoplication, and
bariatric surgery . (See "Hiatus hernia".)
Pneumonia — Pneumonia involving the lower lobes of the lung is a common cause of abdominal pain
syndromes, presumably related to diaphragmatic irritation, and may be confused with acute
cholecystitis or, rarely, an acute abdomen. Abdominal pain is occasionally the sole presenting
complaint in a patient with lower-lobe pneumonia.
Myocardial infarction — Upper abdominal pain can be the presenting symptom of an acute myocardial
infarction. Any patient with cardiac risk factors should have an electrocardiogram.
Splenic abscess or infarction — Left upper quadrant pain often arises from diseases of the spleen
(table 1). (See "Approach to the adult patient with splenomegaly and other splenic disorders", section
on 'Splenic abscess' and "Approach to the adult patient with splenomegaly and other splenic
disorders", section on 'Splenic infarction'.)
Splenic abscesses typically are associated with fever and tenderness in the left upper quadrant
and may also be associated with splenic infarction.
Splenic infarction also presents with severe left upper quadrant pain. This syndrome should be
considered in any patient with atrial fibrillation or other conditions associated with peripheral
embolism . Other causes of splenic infarction include trauma, torsion due to a "wandering
spleen" (see 'Wandering spleen syndrome'below), presence of a hypercoagulable state,
hemoglobinopathies (see 'Sickle cell disease' below), and a number of other hematologic
disorders (eg, polycythemia vera, essential thrombocythemia, myeloid metaplasia) [19-21].
LOWER ABDOMINAL PAIN SYNDROMES
Appendicitis — Acute appendicitis is a major consideration in the assessment of any patient with acute
abdominal disease. Acute appendicitis typically presents with periumbilical pain initially that radiates
to the right lower quadrant; however, occasional patients present with epigastric or generalized
abdominal pain. The pain localizes to the right lower quadrant when the appendiceal inflammation
begins to involve the peritoneal surface. (See "Acute appendicitis in adults: Clinical manifestations and
Diverticular disease — Uncomplicated diverticulosis is often asymptomatic and an incidental finding
on colonoscopy or sigmoidoscopy. Some of these patients complain of symptoms such as cramping,
bloating, flatulence, and irregular defecation. Diverticulitis represents microscopic or macroscopic
perforation of a diverticulum.
The clinical presentation of diverticulitis depends upon the severity of the underlying inflammatory
process and whether or not complications are present. Left lower quadrant pain is the most common
complaint in Western countries, occurring in 70 percent of patients. Right-sided diverticulitis occurs in
only 1.5 percent of patients . In contrast, right-sided disease is more common in Asians (accounting
for as many as 75 percent of cases of diverticulitis), and affected patients may present with right lower
quadrant pain, often leading to a misdiagnosis of acute appendicitis [23,24]. (See "Clinical
manifestations and diagnosis of colonic diverticular disease".)
Pain is often present for several days prior to presentation, which aids in the differentiation of
diverticulitis from other causes of acute abdominal symptoms. Only 17 percent in one series had
symptoms for less than 24 hours . Another helpful diagnostic finding is that up to one-half have
had one or more previous episodes of similar pain. (See"Clinical manifestations and diagnosis of
colonic diverticular disease".)
Kidney stones — Kidney stones usually cause symptoms when the stone passes from the renal pelvis
into the ureter. Pain is the most common symptom and varies from a mild and barely noticeable ache,
to discomfort that is so intense it requires hospitalization and parenteral medications. The pain
typically waxes and wanes in severity and develops in waves or paroxysms that are related to
movement of the stone in the ureter and to associated ureteral spasm. Paroxysms of severe pain
usually last 20 to 60 minutes.
The site of obstruction determines the location of pain. Upper ureteral or renal pelvic obstruction lead
to flank pain or tenderness, whereas lower ureteral obstruction causes pain that may radiate to the
ipsilateral testicle, tip of the penis, or labia. The location of the pain may change as the stone migrates;
a variable location of pain can be misleading and occasionally mimics an acute abdomen or dissecting
aneurysm. In addition, some patients present with abdominal pain in the absence of flank pain. CT scan
is the gold standard to confirm the diagnosis (image 1). (See "Diagnosis and acute management of
suspected nephrolithiasis in adults".)
Bladder distension — Patients with bladder outlet obstruction leading to acute bladder distension, as
may occur in some patients with benign prostatic hypertrophy, can present with lower abdominal pain.
(See "Diagnosis of urinary tract obstruction and hydronephrosis".)
Pelvic pain — Lower abdominal pain in women is frequently due to disorders of the reproductive
organs. (See 'Women' below.)
DIFFUSE ABDOMINAL PAIN SYNDROMES — Diffuse abdominal pain syndromes often represent severe
and potentially life-threatening disease. Examples include mesenteric ischemia and infarction,
ruptured abdominal aortic aneurysm, and diffuse peritonitis.
Mesenteric ischemia and infarction — Mesenteric infarction presents with the acute and severe onset
of diffuse and persistent abdominal pain, while chronic mesenteric ischemia may be manifested by a
variety of symptoms including abdominal pain after eating ("intestinal angina"), weight loss, nausea,
vomiting, and diarrhea . Ischemia that involves the celiac territory causes epigastric or right upper
quadrant pain. (See "Acute mesenteric ischemia" and "Chronic mesenteric ischemia".)
Mesenteric ischemia and infarction are important considerations in older adult patients presenting
with acute abdominal pain and in all patients with acute diffuse abdominal pain. These disorders are
thought to occur in up to 1 to 2 percent of all patients presenting with severe acute gastrointestinal
illness . Infarction typically occurs in patients with known cardiovascular, ischemic, or
arteriosclerotic disease. Mesenteric ischemia may be a manifestation of systemic vasculitis involving
the gastrointestinal tract (see "Gastrointestinal manifestations of vasculitis"). Mesenteric venous
thrombosis rarely is a cause of abdominal pain and may occur in previously healthy individuals .
Angiography or MRI angiography of the celiac artery or mesenteric vessels are the diagnostic tests of
choice. Sigmoidoscopy can also suggest the diagnosis in patients with ischemic colitis but is usually not
required (picture 1). (See "Colonic ischemia".)
Ruptured aneurysm — A ruptured abdominal aortic aneurysm can present with diffuse or localized
abdominal symptoms and can mimic other acute conditions such as renal colic, diverticulitis,
pancreatitis, inferior wall coronary ischemia, mesenteric ischemia, or biliary tract disease.
The patient with a ruptured abdominal aortic aneurysm who survives long enough to reach the
emergency department classically presents with abdominal or back pain, hypotension, and a pulsatile
abdominal mass. Aneurysm rupture typically causes exsanguinating hemorrhage and profound,
unstable hypotension. (See "Clinical features and diagnosis of abdominal aortic aneurysm".)
Peritonitis — Patients with peritonitis attempt to minimize abdominal pain by lying still, often in a
supine position with the knees flexed. The pain may be greatest over the region of the abdomen near
the abdominal viscera from which the pain originated (as in acute cholecystitis) but may spread rapidly
to involve the entire abdomen as inflammation progresses.
Physical examination may reveal fever and evidence for hypovolemia (tachycardia and hypotension).
Abdominal examination should be performed gently, since it can worsen pain. It is usually unnecessary
to elicit rebound tenderness (sudden severe pain caused by rapid release of the hand following
abdominal palpation), since peritonitis can usually be suspected from more gentle palpation. A similar
approach (elicitation of pain after bumping against the bed) is also usually unnecessary. Abdominal
wall rigidity (involuntary guarding) may be present due to activation of primary afferent visceral and
cutaneous pain receptors .
Intestinal obstruction — Severe, acute diffuse abdominal pain can be caused by either partial or
complete obstruction of the intestines. The most common causes in adults are an incarcerated hernia,
adhesions, intussusception, and volvulus; these syndromes account for as many as 96 percent of cases
. Occasionally, severe constipation leading to fecal impaction can cause large bowel obstruction as
can an obstructing colonic carcinoma. Celiac disease occasionally manifests itself with an
Intestinal obstruction should be considered when the patient complains of pain, vomiting, and
constipation. Physical findings of abdominal distention and tenderness to palpation are common.
ABDOMINAL PAIN IN SPECIAL POPULATIONS — Special populations of patients, including women,
older adults , patients with AIDS , hemophiliacs, and patients with sickle cell disease, may
present with unusual causes of abdominal pain or may have unusual presentations of common
Women — Lower abdominal pain (pelvic pain) in women is frequently caused by disorders of the
internal female reproductive organs. The major etiologies of acute pain are: pelvic inflammatory
disease; adnexal cysts or masses with bleeding, torsion, or rupture; ectopic pregnancy; and uterine
pain due to infection (endomyometritis) or due to degeneration, infarction, or torsion of leiomyomas.
Chronic pelvic pain in women is discussed separately. (See "Causes of chronic pelvic pain in women".)
Pelvic inflammatory disease — Lower abdominal pain is the cardinal presenting symptom in women
with pelvic inflammatory disease (PID), although the character of the pain may be quite subtle. Recent
onset of pain that occurs during menses or coitus or with jarring movement may be the only
presenting symptom of PID; the new onset of pain during or shortly after menses is particularly
suggestive . The abdominal pain is usually bilateral and rarely of more than two to three weeks
duration . (See"Clinical features and diagnosis of pelvic inflammatory disease".)
Fever is present in 50 percent, and abnormal uterine bleeding occurs in one-third of patients with PID
. New vaginal discharge, urethritis, proctitis, and chills can be associated signs but are neither
sensitive nor specific for the diagnosis. The presence of PID is less likely if symptoms referable to the
bowel or urinary tract predominate.
Adnexal pathology — Cysts and neoplasms of the ovary, fallopian tube, or paraovarian or paratubal
areas can cause pain due to rupture, bleeding, or torsion (see"Ovarian and fallopian tube torsion").
Large size alone, even with compression of adjacent structures, usually does not result in acute pain.
(See "Approach to the patient with an adnexal mass" and "Differential diagnosis of the adnexal mass".)
The new onset of mid-cycle pain in premenopausal women suggests the presence of a
physiologic cyst (follicular or corpus luteum).
Pain immediately following intercourse is suggestive of a ruptured cyst.
The sudden onset of severe pain, often associated with nausea and vomiting, is suggestive of
ovarian torsion or a degenerating leiomyoma. Acute severe pain simulating appendicitis or
peritonitis may also result from perforation, infarction, or hemorrhage into or from an ovarian
Pain accompanied by fever suggests an infection such as PID, appendicitis, or diverticulitis, but
it may be associated with torsion (ovary or leiomyoma) or degeneration (leiomyoma).
Endometriosis — Common symptoms of endometriosis include chronic pelvic pain (which is often
more severe during menses), dysmenorrhea, dyspareunia, abnormal menstrual bleeding, and
infertility. Acute pain, however, may occur due to rupture of an endometrioma. (See "Pathogenesis,
clinical features, and diagnosis of endometriosis" and "Causes of chronic pelvic pain in women".)
Ectopic pregnancy — Abdominal pain, menstrual cycle abnormalities (missed or late menstrual
period), and vaginal bleeding are the classic symptoms of ectopic pregnancy. Clinical manifestations
typically appear six to eight weeks after the last normal menstrual period, but they can occur later.
Vital signs may reveal orthostatic changes and, occasionally, fever. Findings on physical examination
may include adnexal, cervical motion, and/or abdominal tenderness, an adnexal mass, and mild uterine
enlargement. However, the physical examination is often unremarkable in a woman with a small,
unruptured ectopic pregnancy. A sensitive test for human chorionic gonadotropin will always be
positive and serves to distinguish ectopic pregnancy from other causes of lower abdominal pain in
women. (See "Clinical manifestations, diagnosis, and management of ectopic pregnancy".)
Endometritis — Endometritis refers to inflammation of the endometrium, the inner lining of the
uterus. It is characterized by uterine pain, vaginal bleeding, and fever. Sexually transmitted infections
and invasive gynecologic procedures are the most common predecessors of acute endometritis in the
nonobstetric population. Postpartum infection, usually after a labor concluded by cesarean delivery or
after prolonged labor or rupture of membranes with multiple vaginal examinations, is the most
frequent antecedent of acute endometritis in the obstetric population. (See "Postpartum
Leiomyomas — Leiomyomas (fibroids) infrequently cause acute pain from degeneration (eg, carneous
or red degeneration) or torsion of a pedunculated tumor. Pain may be associated with a low grade
fever, uterine tenderness on palpation, elevated white blood cell count, or peritoneal signs. The
discomfort resulting from degenerating leiomyomas is self-limited, lasting from days to a few weeks,
and it usually responds to nonsteroidalantiinflammatory drugs. (See "Epidemiology, clinical
manifestations, diagnosis, and natural history of uterine leiomyomas (fibroids)".)
Older adults — Older adult patients often do not present with the same signs and symptoms of disease
characteristic of younger individuals. This was illustrated in a retrospective review of 231 patients over
the age of 64 who presented to an emergency department with acute (less than one week)
nontraumatic abdominal pain . The presence or absence of abnormal test values (hemoglobin,
alkaline phosphatase, aspartate aminotransferase, bilirubin, lactate, and leukocytosis) did not
distinguish those who were admitted and did not require surgery from patients with surgical disease;
clinical suspicion was a more important distinguishing feature. Normal laboratory tests at presentation
occurred in 13 percent of patients who ultimately required surgery. Biliary tract disease and small
bowel obstruction were common disorders in older patients presenting with acute abdominal pain.
In a second review of 168 older adult patients presenting to an emergency department with acute
cholecystitis (confirmed later by surgery), 84 percent had neither epigastric nor right upper quadrant
pain, and 5 percent had no pain at all . Common presenting symptoms were nausea (57 percent)
and vomiting (38 percent). Many patients were afebrile (56 percent), and 13 percent had no fever and
normal laboratory studies.
Common causes of abdominal pain in older persons include appendicitis, aneurysmal disease,
mesenteric ischemia, diverticulitis, and small bowel obstruction. The frequency of misdiagnosis of the
acute abdomen in older patients is high and associated with higher mortality rates than in younger
HIV infection — Gastrointestinal and hepatobiliary symptoms are among the most frequent complaints
in patients with human immunodeficiency virus (HIV) infection and acquired immunodeficiency
syndrome (AIDS). The frequency of abdominal pain as a symptom in patients with AIDS is unknown;
however, acute abdominal pain is often a serious finding. In the majority of patients with AIDS,
abdominal pain is directly related to HIV and its consequences , but the more common causes of
abdominal pain in the general population also need to be considered. Many studies of abdominal pain
in patients with AIDS stress the broad spectrum of potential causes for this symptom (table 3) [39,40].
Hemophilia — Hemophiliacs may spontaneously develop hematomas of the bowel wall, which can
cause symptoms that mimic acute appendicitis . The diagnosis of "pseudo-appendicitis" can usually
be made with CT imaging; at times, surgery is required to confirm the diagnosis.
Sickle cell disease — Patients with sickle cell disease may have abdominal pain as part of a
vasoocclusive crisis. Such pain may be difficult to distinguish from an acute surgical abdomen (eg,
appendicitis, cholecystitis) and may be due to such conditions as cholelithiasis, splenic infarction,
pancreatitis, ischemic colitis, and nonsurgical genitourinary disorders [42-45].
Right upper quadrant symptoms are common in the setting of hepatic involvement. (See "Hepatic
manifestations of sickle cell disease", section on 'Acute sickle hepatic crisis'.)
Chronic narcotic users — With increasing use of narcotics for chronic pain syndromes, the narcotic
bowel syndrome has been recognized [46,47]. This syndrome is characterized by chronic or
intermittent abdominal pain, bloating, abdominal distention, and occasional vomiting in patients on
chronic or escalating doses of opiates. Relief occurs when the narcotics are gradually withdrawn,
though there is a high rate of recurrence.
High-dose glucocorticoids — Patients receiving high-dose glucocorticoids are at an increased risk of
bowel perforation and peritonitis. Clinical presentation is often nonspecific, and thus a high level of
clinical suspicion and aggressive diagnostic evaluation should be performed when a patient taking
glucocorticoids presents with new abdominal pain [48,49].
RARE CAUSES OF ABDOMINAL PAIN — Rare causes of abdominal pain should be considered in the
following circumstances :
Patients with repeated visits to physicians or emergency departments for the same complaint
without a definite diagnosis
An ill appearing patient with minimal or nonspecific findings
Pain out of proportion to clinical findings
Immunocompromised, HIV-infected, or older patients (see above)
Celiac artery compression syndrome — The celiac artery compression syndrome is a rare condition
that typically occurs in otherwise healthy young and middle-aged individuals. It presents as chronic,
epigastric abdominal pain that typically occurs after eating and may be associated with an
epigastricbruit and weight loss. The diagnosis is suggested by narrowing or occlusion of the celiac axis
on angiography. (See "Celiac artery compression syndrome".)
Painful rib syndrome — The painful rib syndrome is an increasingly common condition characterized
by discomfort in the lower chest or upper abdomen, tenderness over the costal margins, and
reproduction of the pain by pressure on the ribs . This syndrome accounts for as many as 3 percent
of new referrals to surgeons for the evaluation of upper abdominal pain. It is most common in women.
The syndrome has a benign outcome and is important to recognize and diagnose to avoid unnecessary
testing and treatment and to provide reassurance to the patient. In one review, 8 of 76 patients
underwent noncurative cholecystectomy .
Wandering spleen syndrome — The wandering spleen syndrome is a rare cause of acute abdominal
pain that is most typically seen in younger adolescents and children, although it can occur in adults.
Patients typically present with acute left upper quadrant pain associated with an abdominal mass. CT
imaging confirms the diagnosis. Ultrasound has also been helpful . The treatment of choice is
splenopexy; splenectomy may be required if the spleen is infarcted and there is torsion and absence of
splenic blood flow .
Abdominal wall pain — Pain emanating from the abdominal wall may be difficult to distinguish from
deep visceral pain. The pain can originate from a hernia, hematoma, or the abdominal wall
musculature. Abdominal wall hernias can be difficult to diagnosis clinically, and CT scan of the
abdomen and the abdominal wall are often required. Hematomas of the abdominal wall occur
spontaneously or after unrecognized trauma. Abdominal pain originating from the abdominal
musculature can be diagnosed by finding a focal area of abdominal tenderness that remains
unchanged or increases with abdominal muscle contraction (Carnett's sign). (See "Chronic abdominal
Abdominal migraine — Recurrent abdominal pain may occur in patients with abdominal migraine .
These patients usually also suffer from typical migraine headaches, although occasional patients
present with gastrointestinal symptoms only . Abdominal migraine is much more common during
childhood and adolescence. This is discussed elsewhere. (See "Classification of migraine in children",
section on 'Abdominal migraine' and "Evaluation of the child and adolescent with chronic abdominal
pain", section on 'Abdominal migraine' and "Pathophysiology, clinical manifestations, and diagnosis of
migraine in adults" and "Cyclic vomiting syndrome".)
Mesenteric lymphadenitis — Mesenteric lymphadenitis is a cause of lower abdominal pain that can be
confused with appendicitis. It is defined radiologically when a cluster of three or more lymph nodes
measuring 5 mm or greater are seen [56,57]. The etiology is usually infectious (eg, Y. enterocolitica, M.
tuberculosis, Salmonella species), malignant, or autoimmune. Mesenteric lymphadenitis may also be
seen incidentally on abdominal CT scan. (See "Clinical manifestations and diagnosis of Yersinia
Eosinophilic gastroenteritis — Eosinophilic gastroenteritis is a rare condition that may present with
variable symptoms including abdominal pain, nausea, vomiting, and diarrhea. The signs and symptoms
are related to the layer(s) and extent of bowel involved with eosinophilic infiltration: mucosa,
muscle, and/or subserosa . The diagnosis is suspected in patients with abdominal pain, diarrhea,
and peripheral eosinophilia; it may be confused with the irritable bowel syndrome. (See "Eosinophilic
Epiploicappendagitis — Epiploicappendagitis is a benign and self-limited condition of the epiploic
appendages that occurs secondary to torsion or spontaneous venous thrombosis of a draining vein
. Patients most commonly present with acute abdominal pain. Symptoms can mimic an acute
abdomen, frequently leading patients to be misdiagnosed as having acute appendicitis or diverticulitis.
Abdominal compartment syndrome — Abdominal compartment syndrome should be considered
when severe abdominal pain with abdominal distension occurs in someone who has suffered trauma
or is experiencing unusual abdominal pain post operatively. The syndrome is lethal if not diagnosed
early. Findings noted on CT imaging are bowel wall thickening, elevated diaphragm, and collapse of the
inferior vena cava along with mucosal hyperenhancement and hemoperitoneum .
Fitz-Hugh-Curtis syndrome — The Fitz-Hugh-Curtis syndrome, or perihepatitis, is a cause of right upper
quadrant pain in young women. It occurs in approximately 10 percent of patients with pelvic
inflammatory disease caused by Chlamydia trachomatis or Neisseria gonorrhoeae. Physical
examination typically reveals marked right upper quadrant tenderness. (See "Clinical features and
diagnosis of pelvic inflammatory disease".)
Familial Mediterranean fever — The typical manifestations of familial Mediterranean fever are
recurrent attacks of severe pain (due to serositis at one or more sites) and fever, lasting one to three
days and then resolving spontaneously. In between attacks, patients feel entirely well. Pain and fever
are usually abrupt and reach their peak soon after onset, although some patients tend to have a
stereotypic, mild prodrome component of their attacks. (See "Clinical manifestations and diagnosis of
familial Mediterranean fever".)
Hereditary angioedema — Hereditary angioedema (HAE) is a disease that arises from abnormal
activation of the complement-mediated inflammatory pathways and can present with recurrent
episodes of abdominal pain, accompanied by nausea, vomiting, colicky pain, and diarrhea. It most
often presents in adolescence, but occurs as well in children and adults. HAE results from defects in the
C1 inhibitor of the classical complement pathway.
Patients may have a history of intermittent swelling of other tissues (face and hands are common) and
can experience life-threatening laryngeal swelling. There may be a family history of similar symptoms.
Episodes of abdominal pain resolve spontaneously in two to four days. The diagnosis is made by the
demonstration of a low C4 level and low C1 inhibitor antigenic levels or functional levels.
(See "Hereditary angioedema: Epidemiology, clinical manifestations, exacerbating factors, and
In one series of over 33,000 cases of recurrent abdominal pain, 153 patients were identified with HAE
. These patient had a high likelihood of also having diarrhea and vomiting. Rarely, these patients
presented with circulatory collapse and loss of consciousness.
Other — Abdominal pain can be caused by myriad illnesses. Thesemayinclude:
Metabolic disorders ranging from diabetic ketoacidosis to acute intermittent porphyria
(see "Clinical manifestations and diagnosis of acute intermittent porphyria")
Abdominal malignancies (see "Overview of cancer pain syndromes")
Lactoseintolerance (see "Lactoseintolerance")
Helminthic and other tropical infectious diseases
Functional disorders (see "Clinical manifestations and diagnosis of irritable bowel
syndrome" and "Functional dyspepsia")
Psychogenic etiologies (see "Somatization: Epidemiology, pathogenesis, clinical features,
medical evaluation, and diagnosis")
Aortic dissection involving the descending aorta (see "Clinical manifestations and diagnosis of
Systemic vasculitis, which can lead to mesenteric ischemia (see 'Mesenteric ischemia and
ACE inhibitor therapy can cause a visceral form of angioedema and present with recurrent
episodes of abdominal pain [62,63]
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The
Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at
the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview and who
prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10 th to 12th grade reading level and
are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on “patient info” and the keyword(s) of interest.)
Basics topic (see "Patient information: Acute abdomen (belly pain) (The Basics)")
Beyond the Basics topics (see "Patient information: Upset stomach (functional dyspepsia) in
adults (Beyond the Basics)" and "Patient information: Chronic pelvic pain in women (Beyond
SUMMARY AND RECOMMENDATIONS
Abdominal pain typically, but not always, has characteristic locations: right upper, right lower,
epigastric, periumbilical, left upper, left lower, and diffuse (table 1). (See 'Upper abdominal pain
syndromes' above and 'Lower abdominal pain syndromes' above and 'Diffuse abdominal pain
Pain originating in the viscera may also be perceived as originating from a site distant from the
affected organ (figure 1). (See 'Referredpain' above.)
Special populations of patients, including women, older adults, patients with AIDS,
hemophiliacs, and patients with sickle cell disease, may present with unusual causes of
abdominal pain or may have unusual presentations of common disorders. (See 'Abdominal pain
in specialpopulations' above.)
Rare causes of abdominal pain should be considered in patients with repeated visits for the
same complaint without a definite diagnosis, an ill appearing patient with minimal or
nonspecific findings, patients with pain out of proportion to clinical findings, and in
immunocompromised patients. (See 'Rare causes of abdominal pain'above.)
Use of UpToDate is subject to the Subscription and License Agreement.
Yamamoto W, Kono H, Maekawa M, Fukui T. The relationship between abdominal pain regions and specific diseases: an epidemiologic approach to clinical
practice. J Epidemiol 1997; 7:27.
Ray BS, Neill CL. Abdominal Visceral Sensation in Man. Ann Surg 1947; 126:709.
Cervero F. Neurophysiology of gastrointestinal pain. BaillieresClinGastroenterol 1988; 2:183.
Haupt P, Jänig W, Kohler W. Response pattern of visceral afferent fibres, supplying the colon, upon chemical and mechanical stimuli. PflugersArch 1983;
Bentley FH. Observations on Visceral Pain : (1) Visceral Tenderness. Ann Surg 1948; 128:881.
Whitehead WE, Holtkotter B, Enck P, et al. Toleranceforrectosigmoiddistention in irritable bowelsyndrome. Gastroenterology 1990; 98:1187.
CHAPMAN WP, HERRERA R, JONES CM. A comparison of pain produced experimentally in lower esophagus, common bile duct, and upper small intestine
with pain experienced by patients with diseases of biliary tract and pancreas. SurgGynecolObstet 1949; 89:573.
Brown FR. The Problem of Abdominal Pain. Br Med J 1942; 1:543.
Bloomfield AL, Polland WS. EXPERIMENTAL REFERRED PAIN FROM THE GASTRO-INTESTINAL TRACT. PART II. STOMACH, DUODENUM AND COLON. J
ClinInvest 1931; 10:453.
DWORKEN HJ, BIEL FJ, MACHELLA TE. Supradiaphragmatic reference of pain from the colon. Gastroenterology 1952; 22:222.
Ryle JA. Visceral pain and referred pain. Lancet 1926; 1:895.
Selzer M, Spencer WA. Convergence of visceral and cutaneous afferent pathways in the lumbar spinal cord. Brain Res 1969; 14:331.
Purcell TB. Nonsurgical and extraperitoneal causes of abdominal pain. EmergMedClin North Am 1989; 7:721.
Saik RP, Greenburg AG, Farris JM, Peskin GW. Spectrum of cholangitis. Am J Surg 1975; 130:143.
Go VL, Everhart JE. Pancreatitis. In: Digestive diseases in the United States: Epidemiology and impact, Everhart JE (Ed), National Institutes of Health,
National Institute of Diabetes and Digestive and Kidney Diseases. US GovernmentPrinting Office, Washington, DC 1994. p.693.
Talley NJ, Colin-Jones D, Koch KL, et al. Functional dyspepsia: A classification with guidelines for diagnosis and management. GastroenterolInt 1992; 4:145.
Flanagin BA, Mitchell MT, Thistlethwaite WA, Alverdy JC. Diagnosis and treatment of atypical presentations of hiatal hernia following bariatric surgery.
ObesSurg 2010; 20:386.
Beeson MS. Splenic infarct presenting as acute abdominal pain in an older patient. J EmergMed 1996; 14:319.
Nores M, Phillips EH, Morgenstern L, Hiatt JR. Theclinicalspectrum of splenicinfarction. Am Surg 1998; 64:182.
Franklin QJ, Compeggie M. Splenic syndrome in sickle cell trait: four case presentations and a review of the literature. Mil Med 1999; 164:230.
Görg C, Seifart U, Görg K. Acute, complete splenic infarction in cancer patient is associated with a fatal outcome. AbdomImaging 2004; 29:224.
Fischer MG, Farkas AM. Diverticulitis of the cecum and ascending colon. Dis Colon Rectum 1984; 27:454.
Sugihara K, Muto T, Morioka Y, et al. Diverticular disease of the colon in Japan. A review of 615 cases. Dis Colon Rectum 1984; 27:531.
Ngoi SS, Chia J, Goh MY, et al. Surgicalmanagement of right colon diverticulitis. Dis Colon Rectum 1992; 35:799.
Rodkey GV, Welch CE. Changing patterns in the surgical treatment of diverticular disease. Ann Surg 1984; 200:466.
Schneider TA, Longo WE, Ure T, Vernava AM 3rd. Mesentericischemia. Acute arterial syndromes. Dis Colon Rectum 1994; 37:1163.
Mock JN, Orsay EM. Primary mesenteric venous thrombosis: an unusual cause of abdominal pain in a young, healthy woman. Ann EmergMed 1994;
Selzer M, Spencer WA. Interactions between visceral and cutaneous afferents in the spinal cord: reciprocal primary afferent fiber depolarization. Brain Res
Silen W. Cope's Early Diagnosis of the Acute Abdomen. In: Cope's Early Diagnosis of the Acute Abdomen, Oxford University Press, Oxford 1990.
Gonda TA, Khan SU, Cheng J, et al. Association of intussusception and celiac disease in adults. Dig Dis Sci 2010; 55:2899.
deDombal FT. Acute abdominal pain in the elderly. J ClinGastroenterol 1994; 19:331.
Thuluvath PJ, Connolly GM, Forbes A, Gazzard BG. Abdominal pain in HIV infection. Q J Med 1991; 78:275.
Korn AP, Hessol NA, Padian NS, et al. Risk factors for plasma cell endometritis among women with cervical Neisseria gonorrhoeae, cervical Chlamydia
trachomatis, or bacterial vaginosis. Am J ObstetGynecol 1998; 178:987.
Westrom L, Mardh PA. Epidemiology, etiology, and prognosis of acute salpingitis: A study of 1,457 laparoscopically verified cases. In: Nongonococcal
Urethritis and Related Diseases, Hobson D, Holmes KK (Eds), Am SocMicrobiol, Washington, DC 1977. p.84.
Jacobson L, Weström L. Objectivized diagnosis of acute pelvic inflammatory disease. Diagnostic and prognostic value of routine laparoscopy. Am J
ObstetGynecol 1969; 105:1088.
Bugliosi TF, Meloy TD, Vukov LF. Acute abdominal pain in theelderly. Ann EmergMed 1990; 19:1383.
Parker LJ, Vukov LF, Wollan PC. Emergency department evaluation of geriatric patients with acute cholecystitis. AcadEmerg Med 1997; 4:51.
Lyon C, Clark DC. Diagnosis of acute abdominal pain in older patients. Am FamPhysician 2006; 74:1537.
Parente F, Cernuschi M, Antinori S, et al. Severe abdominal pain in patients with AIDS: frequency, clinical aspects, causes, and outcome. Scand J
Gastroenterol 1994; 29:511.
Ferguson CM. Surgical complications of human immunodeficiency virus infection. Am Surg 1988; 54:4.
McCoy HE 3rd, Kitchens CS. Small bowel hematoma in a hemophiliac as a cause of pseudoappendicitis: diagnosis by CT imaging. Am J Hematol 1991;
Baumgartner F, Klein S. The presentation and management of the acute abdomen in the patient with sickle-cell anemia. Am Surg 1989; 55:660.
Jama AH, Salem AH, Dabbous IA. Massive splenic infarction in Saudi patients with sickle cell anemia: a unique manifestation. Am J Hematol 2002; 69:205.
Karim A, Ahmed S, Rossoff LJ, et al. Fulminant ischaemic colitis with atypical clinical features complicating sickle cell disease. PostgradMed J 2002; 78:370.
Ahmed S, Siddiqui AK, Siddiqui RK, et al. Acute pancreatitis during sickle cell vaso-occlusive painful crisis. Am J Hematol 2003; 73:190.
Grunkemeier DM, Cassara JE, Dalton CB, Drossman DA. The narcotic bowel syndrome: clinical features, pathophysiology, and management.
ClinGastroenterolHepatol 2007; 5:1126.
Drossman DA, Morris CB, Edwards H, et al. Diagnosis, characterization, and 3-month outcome after detoxification of 39 patients with narcotic bowel
syndrome. Am J Gastroenterol 2012; 107:1426.
ReMine SG, McIlrath DC. Bowel perforation in steroid-treated patients. Ann Surg 1980; 192:581.
Menegaux F, Chenard X, Wechsler B, et al. Diffuse peritonitis in steroid-treatedpatients. DigSurg 1998; 15:247.
Pearigen PD. Unusual causes of abdominal pain. EmergMedClin North Am 1996; 14:593.
Scott EM, Scott BB. Painful rib syndrome--a review of 76 cases. Gut 1993; 34:1006.
Karmazyn B, Steinberg R, Gayer G, et al. Wandering spleen--the challenge of ultrasound diagnosis: report of 7 cases. J ClinUltrasound 2005; 33:433.
Hussain M, Deshpande R, Bailey ST. Splenic torsion: a case report. Ann R CollSurgEngl 2010; 92:W51.
Roberts JE, deShazo RD. Abdominal migraine, another cause of abdominal pain in adults. Am J Med 2012; 125:1135.
d'Onofrio F, Cologno D, Buzzi MG, et al. Adult abdominal migraine: a new syndrome or sporadic feature of migraine headache? A case report. Eur J Neurol
Rao PM, Rhea JT, Novelline RA. CT diagnosis of mesenteric adenitis. Radiology 1997; 202:145.
Macari M, Hines J, Balthazar E, Megibow A. Mesenteric adenitis: CT diagnosis of primary versus secondary causes, incidence, and clinical significance in
pediatric and adult patients. AJR Am J Roentgenol 2002; 178:853.
Klein NC, Hargrove RL, Sleisenger MH, Jeffries GH. Eosinophilic gastroenteritis. Medicine (Baltimore) 1970; 49:299.
Ozdemir S, Gulpinar K, Leventoglu S, et al. Torsion of the primary epiploicappendagitis: a case series and review of the literature. Am J Surg 2010; 199:453.
Patel A, Lall CG, Jennings SG, Sandrasegaran K. Abdominal compartment syndrome. AJR Am J Roentgenol 2007; 189:1037.
61. Bork K, Meng G, Staubach P, Hardt J. Hereditary angioedema: new findings concerning symptoms, affected organs, and course. Am J Med 2006; 119:267.
62. Spahn TW, Grosse-Thie W, Mueller MK. Endoscopic visualization of angiotensin-converting enzyme inhibitor-induced small bowel angioedema as a cause
of relapsing abdominal pain using double-balloon enteroscopy. DigDisSci 2008; 53:1257.
63. Byrne TJ, Douglas DD, Landis ME, Heppell JP. Isolated visceral angioedema: an underdiagnosed complication of ACE inhibitors? Mayo ClinProc 2000;
64. Nicholson JA, Smith D, Diab M, Scott MH. Mesenteric panniculitis in Merseyside: a case series and a review of the literature. Ann R CollSurgEngl 2010;