Official reprint from UpToDate www.uptodate.

com
2012 UpToDate

Differential diagnosis of abdominal pain in adults

Authors
Mary B Fishman, MD
Mark D Aronson, MD

Section Editor
Robert H Fletcher, MD, MSc

Deputy Editor
H Nancy Sokol, MD

Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2012. | This topic last updated: Oct 21, 2011.
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 patients.
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, right-lower, mid-lower, and left-lower (table 1) [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 [2]. 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 [5].
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 [6]. 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
syndrome".)
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
ipsilateral sides.
Visceral pain is perceived in the spinal segment at which the visceral afferent nerves enter the spinal cord [8]. 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 [12]. 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 extraabdominal sites or from acute systemic illness (table 2) [13]. 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 pain".)
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 asymptomatic.
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, clinical features, and diagnosis of acute cholecystitis".)
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 [14]. The abdominal pain is typically vague and located
in the right upper quadrant. (See "Acute cholangitis".)
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 [15]. The pain of
gallstone pancreatitis is typical of acute pancreatitis. (See "Clinical manifestations 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 pancreatitis".)
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 [16]:
"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 pain elsewhere."
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 [17]. (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 [18]. 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 diagnosis".)
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 [22]. 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 [25]. 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 (picture 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 [26]. 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 [26]. 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 [27].
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 2).
(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 evaluation 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 [28].
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 [29]. 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 intussusception [30].
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 [31],
patients with AIDS [32], hemophiliacs, and patients with sickle cell disease, may present with unusual causes of
abdominal pain or may have unusual presentations of common disorders.
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 [33]. The abdominal pain is usually bilateral and rarely of more
than two to three weeks duration [34]. (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 [35]. 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 "Overview of the evaluation and
management of adnexal masses" 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 neoplasm.
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 endometritis".)
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 nonsteroidal antiinflammatory 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 [36]. 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 [37]. 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 patients [38].
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 [39], 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 [41]. 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'.)
RARE CAUSES OF ABDOMINAL PAIN Rare causes of abdominal pain should be considered in the following
circumstances [46]:
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 epigastric bruit 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 [47]. 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 [47].
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 [48]. 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 [49].
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 wall pain".)
Abdominal migraine Recurrent abdominal pain may occur in patients with abdominal migraine [50]. These patients
usually also suffer from typical migraine headaches, although occasional patients present with gastrointestinal symptoms
only [51]. 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 [52,53]. 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 infections".)
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 [54]. The diagnosis is suspected in

patients with abdominal pain, diarrhea, and peripheral eosinophilia; it may be confused with the irritable bowel
syndrome. (See "Eosinophilic gastroenteritis".)
Epiploic appendagitis Epiploic appendagitis is a benign and self-limited condition of the epiploic appendages that
occurs secondary to torsion or spontaneous venous thrombosis of a draining vein [55]. 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. (See "Epiploic appendagitis".)
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 [56].
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 "Clinical manifestations and pathogenesis of hereditary angioedema".)
In one series of over 33,000 cases of recurrent abdominal pain, 153 patients were identified with HAE [57]. 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. These may include:
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")
Lactose intolerance (see "Lactose intolerance")
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 aortic dissection")
Systemic vasculitis, which can lead to mesenteric ischemia (see 'Mesenteric ischemia and infarction' above)
ACE inhibitor therapy can cause a visceral form of angioedema and present with recurrent episodes of abdominal
pain [58,59]
Mesenteric panniculitis [60]
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 10th 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 e-mail 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 the Basics)")
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 syndromes' above.)
Pain originating in the viscera may also be perceived as originating from a site distant from the affected organ
(figure 1). (See 'Referred pain' 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 special populations' 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.)

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Topic 6860 Version 9.0

GRAPHICS
Causes of abdominal pain by location
Right upper quadrant

Left upper quadrant

Hepatitis

Splenic abscess

Cholecystitis

Splenic infarct

Cholangitis

Gastritis

Biliary colic

Gastric ulcer

Pancreatitis

Pancreatitis

Budd-Chiari syndrome

Left lower quadrant

Pneumonia/empyema pleurisy

Diverticulitis

Subdiaphragmatic abscess

Salpingitis

Right lower quadrant

Ectopic pregnancy

Appendicitis

Inguinal hernia

Salpingitis

Nephrolithiasis

Ectopic pregnancy

Irritable bowel syndrome

Inguinal hernia

Inflammatory bowel disease

Nephrolithiasis

Diffuse

Inflammatory bowel disease

Gastroenteritis

Mesenteric adenitis (yersina)

Mesenteric ischemia

Epigastric

Metabolic (eg, DKA, porphyria)

Peptic ulcer disease

Malaria

Gastroesophageal reflux disease

Familial Mediterranean fever

Gastritis

Bowel obstruction

Pancreatitis

Peritonitis

Myocardial infarction

Irritable bowel syndrome

Pericarditis
Ruptured aortic aneurysm

Periumbilical
Early appendicitis
Gastroenteritis
Bowel obstruction
Ruptured aortic aneurysm

Referred pain patterns

Selected extraabdominal causes of acute abdominal pain

Cardiac

Hematologic

Myocardial ischemia and infarction

Sickle cell anemia

Myocarditis

Hemolytic anemia

Endocarditis

Henoch-Schnlein purpura

Heart failure

Acute leukemia

Thoracic

Toxins

Pneumonitis

Hypersensitivity reactions: insect

bites, reptile venoms

Pleurodynia, Bornholm's disease

Pulmonary embolism and infarction

Heavy metals and corrosives (eg, lead

or iron)

Pneumothorax

Infections

Empyema

Herpes zoster

Esophagitis

Osteomyelitis

Esophageal spasm

Typhoid fever

Esophageal rupture (Boerhaave's syndrome)

Miscellaneous

Neurologic

Muscular contusion, hematoma, or

tumor

Radiculitis: spinal cord or peripheral nerve tumors,

degenerative arthritis of spine

Narcotic withdrawal

Abdominal epilepsy

Familial Mediterranean fever

Tabes dorsalis (tertiary syphilis)

Psychiatric disorders

Metabolic

Heat stroke

Uremia
Diabetes mellitus (ketoacidosis)
Porphyria
Acute adrenal insufficiency
Hyperlipidemia
Hyperparathyroidism
Reproduced with permission from: Glasgow RE, Mulvihill SJ. Abdominal pain, including the acute
abdomen. In: Gastrointestinal and Liver Disease, Feldman M, Scharschmidt BF, Sleisenger MH (Eds). WB
Saunders, Philadelphia 1998, p.80. Copyright 1998 W.B. Saunders.

Calculus obstructing left ureter

CT scan shows a calculus in the proximal left ureter causing

delayed excretion of contrast material from the left kidney
(long arrow). All the contrast has been excreted from the
normal functioning right kidney and is in the nondilated right
ureter (small arrow). Courtesy of Jonathan Kruskal, MD.

Ischemic colitis

Endoscopy of ischemic colitis may reveal continuous necrosis

and mucosal friability that resembles ulcerative colitis (left
panel); discrete ulcers with surrounding edema may also be
seen (right panel). Courtesy of James B McGee, MD.

Normal sigmoid colon

Endoscopic appearance of the normal sigmoid colonic mucosa.

The fine vasculature is easily visible, and the surface is shiny
and smooth. The folds are of normal thickness. Courtesy of
James B McGee, MD.

Differential diagnosis of abdominal pain in AIDS

Organ

Causes

Stomach
Gastritis

CMV*, cryptosporidium, H. pylori

Focal ulcer

CMV*, acid-peptic disease

Outlet
obstruction

Cryptosporidium*, CMV, lymphoma, MAC

Mass

Lymphoma, KS, CMV

Small bowel
Enteritis

Cryptosporidium*, CMV, MAC

Obstruction

Lymphoma*, KS

Perforation

CMV*, lymphoma

Colon
Colitis

CMV*, HSV, salmonella, Histoplama

Obstruction

Lymphoma*, KS, intussusception,

Perforation

CMV*, lymphoma, HSV

Appendicitis

KS*, cryptosporidium, CMV

Anorectum
Proctitis

Herpes*, bacteria, CMV

Tumor

KS, lymphoma, condyloma

Liver, spleen
Infiltration

Lymphoma*, CMV, MAC

Biliary tract
Cholecystitis

CMV*, cryptosporidium*, KS

Papillary
stenosis

CMV*, cryptosporidium*, KS, cholangitis, CMV*

Pancreas
Inflammation

CMV*, KS, pentamidine, DDI

Tumor

Lymphoma, KS

Mesentery, peritoneum
Infiltration

* More frequent.

MAC*, cryptococcus, KS, lymphoma, histoplasmosis, tuberculosis,

coccidiomycosis, toxoplasmosis

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