This document discusses the evaluation and differential diagnosis of abdominal pain. It notes that history and physical examination are important for diagnosis as subtle symptoms can indicate serious conditions. The document outlines key components of a patient's history and details the examination. It describes various causes of abdominal pain classified by location, mechanism, and onset. Radiological investigations that may assist diagnosis are also summarized. The document stresses that the severity of pain does not always correlate with the severity of the underlying condition.

1. DR. PALLAAVI GOEL
JR1

2. • Abdominal pain is the pain that occurs between chest and pelvic
regions.
• It is one of the most common reasons for OPD and emergency visits.

4. • History and Examination comprise an imperative part of
diagnosing a patient with abdominal pain, as the most
catastrophic events may be forecast by the subtlest of
symptoms.
• We should also remember that pain severity does not
necessarily correlate with the severity of the underlying
condition.

5. Key Components of Patient’s History
(Table 12-1 20th Harrison’s Principle of Internal Medicine Pg 81)
 Age
 Time of onset of pain
 Mode of onset of pain
 Characteristics of pain
 Duration of symptoms
 Location of pain
 Sites of radiation
 Associated symptoms
 Nausea, Emesis, Anorexia
 Changes in Urinary habits
 Changes in Bowel habits: Diarrhoea, Constipation
 Menstrual History in females

6. → Inflammation of parietal peritoneum
→ Mechanical Obstruction by hollow viscera
→ Vascular disturbances
→ Abdominal wall
→ Distention of visceral surfaces
→ Inflammation

7. • Pain is steady and aching in character, located directly over the
inflamed area.
• The intensity of the pain is dependent on type and amount of
material to which the peritoneal surfaces are exposed in a given time
period.
• The pain of peritoneal inflammation is invariably accentuated by
pressure or changes in tension of peritoneum, whether produced by
palpation or by movements like coughing, sneezing.

8.  Bacterial contamination
oPerforated appendix or other perforated
viscus
oPelvic inflammatory disease
 Chemical irritation
oPerforated ulcer
oPancreatitis
oMittelschmerz

9. • It elicits intermittent or colicky abdominal pain, which is not well
localized.
• Obstruction of the urinary bladder : usually causes dull, low intensity
pain in the suprapubic region
• Obstruction of the small or large intestine:
causes poorly localized intermittent pain

10. • Obstruction of the biliary tree :
 Sudden distention produces steady pain.
 Acute gall bladder distention pain radiates to tip of right scapula and right
posterior region of thorax.
 Distention of the common bile duct often causes epigastric pain that may
radiate to the upper lumbar region.
 Carcinoma of the head of the pancreas, may cause no pain or
only a mild aching sensation in the epigastrium or
right upper quadrant.

11. • Embolism or thrombosis of the superior mesenteric artery or impending
rupture of an abdominal aortic aneurysm, can be associated with diffuse,
severe pain.
• Pain is mild continuous or of cramping diffuse type for 2 or 3 days before
bleed, in cases of mesenteric artery occlusion.
• Abdominal pain with radiation to the sacral region, flank, or genitalia
should always signal the possible presence of a rupturing abdominal aortic
aneurysm, it persists over a period of several days before rupture and
collapse occur.

12. • Pain arising from the abdominal wall is usually constant and aching.
• Movement, prolonged standing, and pressure accentuate the
discomfort and associated muscle spasm.
• Some important causes:
 Traction of mesentery
 Trauma or infection of muscles

13. It occurs by hemorrhage , can be of hepatic or renal capsules.
 Appendicitis
 Typhoid fever
 Neutropenic enterocolitis or “typhlitis”

14. Pain referred from extra abdominal surfaces
• Pain can referred to the abdomen from the thorax, spine, or genitalia.
• Abdominal disease may cause referred pain elsewhere, For example:
acute cholecystitis or perforated ulcer.
• A most important, yet often forgotten, dictum is that the possibility of
intrathoracic disease must be considered in every patient with
abdominal pain, especially if the pain is in the upper abdomen.

15. • Cardiothoracic
∆ Acute myocardial infarction
∆ Myocarditis, endocarditis, pericarditis
∆ Congestive heart failure
∆ Pneumonia (especially lower lobes)
∆ Pulmonary embolus
∆ Pneumothorax
∆ Empyema
∆ Esophageal disease, including spasm, rupture, or inflammation
• Genitalia : Torsion of the testis

16. ∞ Whenever the cause of abdominal pain is obscure, a metabolic origin always must be
considered.
∞ Hyperlipidemia may be accompanied by pancreatitis.
∞ C’1 esterase deficiency associated with angioneurotic edema can cause severe abdominal pain
∞ Abdominal pain is also the hallmark of familial Mediterranean fever.
∞ Pain of porphyria is similar to intestinal obstruction, because severe hyperperistalsis is
common in them.
∞ The pain of uremia or diabetes is nonspecific, frequently shifts in location and intensity.
∞ Hyperparathyroidism
∞ Acute adrenal insufficiency
∞ If prompt correction of the metabolic abnormality does not lead to resolution of abdominal
pain then an underlying organic problem should be suspected.

17. Immunocompromised
• It includes those who have undergone organ transplantation; receiving
immunosuppressive treatments for autoimmune diseases, chemotherapy, or
glucocorticoids; who have AIDS; and who are very old.
• In these circumstances, normal physiologic responses may be absent or masked.
• Certain unusual infections may cause abdominal pain where the etiologic agents
include cytomegalovirus, mycobacteria, protozoa, and fungi.

18. • Diseases that injure sensory nerves may cause causalgic pain.
• It has a burning character and is usually limited to the distribution of a given
peripheral nerve.
• Pain arising from spinal nerves or roots comes and goes suddenly and is of a
lancinating type.
• It is not associated with food intake, abdominal distention, or changes in respiration.
• Causes:
 Herpes zoster
 Tabes dorsalis
 Radiculitis from infection or arthritis
 Spinal cord or nerve root compression
 Functional disorders
 Psychiatric disorders

19.  Irritable bowel syndrome (IBS) is a
functional gastrointestinal disorder
characterized by abdominal pain and
altered bowel habits.
 The episodes of abdominal pain may be
brought on by stress, and the pain varies
considerably in type and location.
 Localized tenderness and muscle spasm
are absent.

20. Toxic causes
• In chronic lead poisoning , pain is similar to intestinal obstruction,
because severe hyperperistalsis is common in both.
• Insect or animal envenomation.
• Black widow spider bites produce intense pain and rigidity of the
abdominal muscles and back.
• Snake bites

21. Uncertain mechanisms
Narcotic withdrawal
Heat stroke

22. Differential Diagnosis of Abdominal Pain by Location

23. In some cases, abdominal pain can be diffuse nonlocalized

24. TIME
SEVERITY
A- Pain subsides
spontaneously
B- Colicky in nature,
pain progresses and
remits over time
C- Pain is
progressive in
nature
D-Catastrophic
onset

25. Stereotypes of Pain Onset and Associated Pathology
Sudden onset
(full pain in seconds)
 Perforated ulcer
 Mesenteric
infarction
 Ruptured abdominal
aortic aneurysm
 Ruptured
ectopic pregnancy
 Ovarian
torsion or ruptured
cyst
 Pulmonary
embolism
 Acute myocardial
infarction
Rapid onset
(initial sensation to full pain
over minutes or hours)
 Strangulated hernia
 Volvulus
 Intussusception
 Acute pancreatitis
 Biliary colic
 Diverticulitis
 Ureteral and renal
colic
Gradual onset
(hours)
 Appendicitis
 Strangulated hernia
 Chronic
pancreatitis
 Peptic ulcer disease
 Inflammatory
bowel disease
 Mesenteric
lymphadenitis
 Cystitis and
urinary retention
 Salpingitis and
prostatitis

28.  Age
 Course of pain- Time and Mode of onset.
 Characteristics of pain
 Radiation of pain
 Factors that exacerbate or improve symptoms, like
food intake, position change.
 Associated symptoms including fever, chills weight
loss, nausea, vomiting, anorexia
 Change in sleep, appetite, bowel, bladder
 Past medical and surgical history
 Family history
 Alcohol intake
 Intake of medications
 Menstrual and contraceptive history in women

29. • Inspection for facies, position in bed, respiratory
activity, can provide valuable clues.
• Palpation of abdomen for Tenderness, masses,
peritoneal signs and organomegaly.
• Never elicit rebound tenderness by sudden release of
a deeply palpating hand.
• Asking patient to cough will elicit true rebound
tenderness without placing hand on abdomen

30. • Percussion for quantity of gas, hard or soft masses, and sizes of certain
organs, such as the liver and the spleen.
• Auscultation of the abdomen for bowel sounds.
• Rectal examination.
• Pelvic Examination in women with lower abdominal pain.
• Measurement of blood pressure, pulse, and temperature.
• Examination of the eyes and skin for jaundice.
• Auscultation and percussion of the chest

31. • Abdominal signs can be absent in cases of pelvic peritonitis.
• Careful pelvic and rectal examinations are mandatory in patients
with abdominal pain.
• Tenderness in such examination is a sign of operative indication:
» Perforated appendicitis
» Diverticulitis
» Twisted ovarian cyst

32. • Peristaltic sound
 Catastrophes like strangulating small intestinal obstruction or perforated
appendicitis occur in presence of normal peristaltic sounds
 Conversely, when proximal area above obstruction becomes edematous
and distended, peristaltic sounds lose characteristics of borborygmi and
become weak and absent
 Sudden Chemical peritonitis = silent abdomen

33. • Investigations are valuable but they rarely establish diagnosis.
• A white blood cell count >20,000/μL may be observed with perforation of a
viscus.
• But, pancreatitis, acute cholecystitis, pelvic inflammatory disease, and intestinal
infarction may also be associated with marked leukocytosis.
• A diagnosis of anemia may be more helpful than the white blood cell count, with
relevant history.

34. • Urinary analysis is done to rule out:
 Renal disease
 Diabetes
 Urinary infection
• Serum amylase levels can increase in:
 Pancreatitis
 Perforated ulcer
 Strangulating intestinal obstruction
 Acute cholecystitis
• Other important tests:
 Liver function tests
 Blood urea nitrogen
 Glucose

35. • Radiographs of abdomen can show perforated ulcers, and other conditions.
• Water-soluble contrast or barium studies can demonstrate partial upper GI
obstruction.
• If there is any question of obstruction of the colon, oral administration of barium sulfate
should be avoided.
• In suspected colonic obstruction (with no perforation) – contrast enema may be
diagnostic.
• In the absence of trauma, peritoneal lavage has been replaced as a diagnostic tool by CT
scanning and laparoscopy.

37. • Ultrasound:
 Presence of gallstones, kidney stones
 Gall bladder Edema
 Abscesses
 Ascites
 Enlarged ovary
 Tubal pregnancy
 Enlarged pancreas
• Laparoscopy:
o Ovarian cysts
o Tubal pregnancies
o Salpingitis
o Acute appendicitis

38. • Radio-isotopic hepatobiliary iminodiacetic acid scans (HIDAs)
may help to differentiate acute cholecystitis or biliary colic from
acute pancreatitis.
• A CT scan may demonstrate an
 enlarged pancreas
 ruptured spleen
 thickened colonic or appendiceal wall
 streaking of the mesocolon or mesoappendix
characteristic of diverticulitis or appendicitis.

39. • Abdomen is divided into 9 regions and 4 quadrants, and differential diagnosis of
pain is studied by its location.
• Abdominal pain generating in the abdomen can be due to various mechanisms like parietal peritoneum
inflammation, or obstruction.
• It may be referred from extra abdominal regions like thorax, spine and genitalia.
• Metabolic causes are also to be considered.
• Acute abdominal pain may subside spontaneously, can be progressive in nature, it can be colicky, or
sometimes have a catastrophic onset.
• Conditions like ruptured aneurysm , ruptured ectopic should be diagnosed and handled efficiently to save
lives.
• History and physical examination is imperative for diagnosis of abdominal pain.
• Certain lab investigations and USG are sometimes helpful in arriving at final diagnosis.
• It is important to remember that pain severity does not necessarily correlate with the severity of the
underlying condition.

40. Thank you! 