2) MusculoSkeletal abdominal pain – anywhere in the abdomen except periumbilical and generalized, usually flanks and adjacent areas of abdomen, either very localized or spreading wider so that pain felt even beyond the confines of anatomical abdomen for instance to upper lateral chest, thigh below, commonly associated with ipsilateral backache, mild-moderate, usually an ache or non-specific (that is not colicky, not burning, not crampy, not stabbing), spinal movements or posture aggravate or elicit pain, usually short lasting attacks of pain for several minutes, but can also continue for months or years, although widely felt non-radiating, spinal movements painful and/or limited, abdominal pain reproduced by spinal movements, muscular tenderness which is confined to muscle rather than a deep tenderness felt at the abdominal organs at specific locations, Mx – NSAIDS, exercises to strengthen the abdominal muscles – vertical leg crunch, long arm crunch, reverse crunch, strengthening of pelvic muscles,
3) Non-specific abdominal pain – anywhere in the abdomen, very localized, the patient can fingerpoint to the site, mild pain, stabbing type of pain, short-lasting attacks of pain from few seconds to minutes, usually recent onset, no specific triggers nor precipitating events,
4) Abdominal wall pain – very localized, mild-moderate, trigger points, trigger point events, satellite points
5) Dyspepsia – epigastric pain (commonly induced or relieved by a meal but may occur while fasting), epigastric burning (without retrosternal extension), bothersome postprandial fullness, early satiation, upper abdominal bloating, postprandial nausea, excessive belching, symptoms have been present for at least 6 months but the criteria fulfilled for last 3 months, exclude causes like peptic ulcer disease, GERD, esophagitis, malignancy, pancreaticobiliary disease, medication use, clinically in the absence of ALARMS dyspepsia may well be functional dyspepsia, functional dyspepsia thus defined is relapsing and remitting, pain severity and illness fears and worries may be the factors provoking consultation behavior
6) Heartburn – commonly coexists with dyspepsia.
7) GERD – commonly coexists with dyspepsia
8) Irritable Bowel Syndrome – Manning criteria : onset of abdominal pain associated with more frequent bowel movements, onset of abdominal pain associated with loser bowel movements, pain relieved by defecation, visible distension, subjective sensation of incomplete rectal evacuation most of the time, mucus passage most of the time. Rome III criteria : recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months AND 2 or more of the following – abdominal pain improvement with defecation, abdominal pain onset associated with a change in frequency of stools, abdominal pain onset associated with a change in the appearance of stools. Other common symptoms seen in IBS but not part of the criteria list include : constipation (< 3 bowel movements/week), diarrhea (> 3 bowel movements/day, lumpy-hard-lose-watery stools, defecation straining, urgency, sense of incomplete evacuation of the rectum, mucus passage, bloating).
9) Functional Abdominal Pain Syndrome – FAPS – abdominal pain, pain expressed in emotional terms, at least continued for 6 months, constant or nearly constant abdominal pain or at least very frequently recurring pain, pain unrelated to meals, defecation, urination, sex, menses, absence of red flags, interference with daily activities common, co-morbid with other chronic pain disorders like headache, backache, etc., most likely a somatoform pain disorder, pain is not likely to be explained by IBS nor dyspepsia, the constellation of symptom related behaviors (N), in the absence of red flags investigations should be kept to a minimum, prominent psychosocial features – past physical or sexual abuse, unresolved loss events like death, divorce, abortions, evidence of personality disorders, family history of chronic somatic symptoms. Tx – tricyclics, assessment of pain beliefs and coping strategies, management of comorbid depression and/or anxiety, SNRIs like venlafaxine or duloxetine, anticonvulsants like gabapentin, carbamazepine, lamotrigine.
10) Myofascial pain syndrome (N) – epigastric pain spreading to RHC or LHC in external oblique MFPS, iliac fossa pain spreading all over the abdomen towards the opposite side of the abdomen in lateral abdominals MFPS, midline strip of pain between the navel and the pubis symphysis in pyramidalis MFPS and iliac fossa pain in the rectus abdominis MFPS. See the notes under MFPS for diagnosis and treatment
11) Abdominal Migraines – recurrent abdominal pain with complete asymptomatic periods in between, the prodrome of nausea, pallor, diaphoresis, anorexia, and headache, past history of migraine and/or family history of migraine positive, past history of cyclical vomiting syndrome to may be seen, usually in the same age group as migraine but slightly earlier, most patients develop migraine later, Mx – antimigraine therapy.
12) Somatic anxiety symptoms – abdominal pain symptoms with symptoms suggestive of somatic anxiety syndrome, all symptoms co-occurring,
13) Peptic ulcer disease – duodenal ulcer - epigastric abdominal pain, mild to moderate, vague, gnawing, discomfort, boring, aching, pressure, triggered by meals, usually 1-3 hrs after a meal, so that pain causes night wakeups, relieved by antacids, snacks, insidious onset, usually pain for many months, recurrent and periodic pain typical, usually localized to epigastrium, but can spread to back, to the LHC later in the course, localized tenderness at the epigastrium, Mx – if ALARM symptoms positive refer for urgent UGIE, if definite GERD start acid suppression therapy, if no past UGIE do a H. pylori serology testing (blood for H. pylori IgG antibodies, Stools for H. pylori antigens, Urea breath test for ureases activity, Urine ELISA or Salivary ELISA for H. pylroi IgG antobodeis) and treat if positive, if UGIE is done and no ulcer documented then treat as for non-ulcer dyspepsia, Triple therapy for H. pylroi infection – regime 1 (Omeprazole 20 mg bid + Amoxicillin 1 G bid + Clarithromycin 500 mg bid ), regime 2 (Ranitidine bismuth citrate 400 mg bid + Clarithromycin 500 mg bid + Amoxicillin 1 G bid ) or regime 3 (Bismuth subsalicilate 525 mg qid + Metronidazole 250 mg qid + Teteracycline 500 mg qid + H2RA for 28 days), treatment recommended for 10-14 days.
14) Peptic ulcer disease – gastric ulcer - epigastric abdominal pain, mild to moderate, vague, gnawing, discomfort, boring, aching, pressure, triggered by meals, meal related pain, hunger pains complained, pain immediately after a meal, relieved by antacids, snacks, insidious onset, usually pain for many months, recurrent and periodic pain typical, usually localized to epigastrium, but can spread to back, to the LHC later in the course, localized tenderness at the epigastrium, usually associated nausea and or vomiting, Mx – See above.
15) Acute gastritis – usually recent onset and lasts a few days to weeks, epigastric pain, anorexia, vomiting, vomiting blood or coffee-ground like vomitus, melena, hiccups, usually caused by alcohol, smoking, drugs, H. pylori infection of the stomach, erosions of the gastric mucosa, stress, viral infections, Tx – domperidone, PPI, avoidance of gastric irritants
16) Chronic constipation – See under constipation.
17) Lactose intolerance – abdominal pain, watery diarrhea, distension, excessive flatus, symptoms improve with stopping milk and milk products, diagnosis confirmed by breath hydrogen test, lactose tolerance test, symptom expression of lactose intolerance depends on many factors – amount of milk ingested, mixture of dairy products (this is why not all milk products cause symptoms – while some can digest skim milk or ice cream, cannot take powdered milk, many can take yogurt).
18) Food allergy
19) Hernias – obstructed inguinal, femoral, paraumbilical hernias, or any other abdominal hernias.
20) Renal colic – unilateral, abdominal pain, loin to groin radiation, loin to urethral meatus radiation, moderate to severe usually but can sometimes be mild, colicky, but can also be constant, usually lasts few days, associated irritative urinary symptoms, hematuria, nausea, and vomiting particularly if severe.
21) UTI – lower urinary tract, upper tract
22) Parasitic infections
23) Pelvic pain – in male or females pelvic pain refers to the lower abdominal and pain felt as arising from deep inside the pelvis, usually a dull ache, but can also be severe and sharp, mild to moderate to severe, aggravating factors are spinal movements, sex, bowel movements, passing urine, can be shortlasting to longlasting, monoepisodic to multiepisodic depending on the cause, pain may ease off with rest,
24) Male pelvic pain syndrome – acute prostatitis - fever, chills, rigors, low back pain, perineal pain, dysuria, urinary retention, pain with ejaculation, pain with bowel movements, IVS, OVS, testicular pain, hematuria, blood-stained seminal fluid, foul smelling urine, PR – warm, soft, swollen, tender prostate, groin tender lymphadenopathy, swollen tender scrotum, urethral discharge, FBC, Urinalysis, PSA, Seminal Fluid Analysis, Tx – STD prostatitis Ceftriaxone 250 mg IM with a 10 day course of doxycycline or ofloxacin PO. Non-STD bacterial prostatitis Bactrim, Cipro or Floxin for 4-8 weeks
26) Female pelvic pain syndrome – abdominal pain concurrent with urinary symptoms (UTI), recurrent monthly abdominal pain with menses (Dysmenorrhea), abdominal pain, dysmenorrheal, subfertility and menorrhagia (Endometriosis), ovulation pain (midpoint of normal menstrual cycle, few days of symptoms, usually unilateral lower abdominal pain, jarring pain).
27) Female pelvic pain syndrome – probable – a young woman of reproductive age, unilateral lower abdominal pain, mild-moderate pain, possible ovarian pain (pain in the RIF or LIF, the pain worsens with jarring, pain with walking, pain in the mid-cycle), recent onset pain, shortlasting illness, may radiate to the anterior inner thigh, Ix – US scan for any ovarian signs, Mx – NSAIDs and watchful waiting.
28) Biliary colic, acute cholecystitis – RHC pain, radiation to shoulder or right scapular region or back, pain develops after a fatty meal, nausea, vomiting, pleuritic pain and fever may occur in acute cholecystitis, US scan investigation of choice.
29) Acute appendicitis – abdominal pain, periumbilical and then RIF, vomiting, localized tenderness at RIF or right side of the abdomen, variables identified as of diagnostic value in a meta-analytic study are (Andersson ) neutrophil count, white blood cell count, proportion of polymorphonuclear cells, CRP concentration, rebound peritoneal irritation, peritoneal percussion tenderness and history of pain migration.
30) Unilateral abdominal pain with ipsilateral scrotal pain, swelling,
33) Spontaneous abortion – loss of pregnancy before 20 weeks, abdominal pain mild, bleeding PV+, if bleeding is heavy, tachycardia or bradycardia, hypotension, products of conception passed, very severe abdominal pain – immediate gyn referral, otherwise early gyn review.
34) Pelvic Inflammatory Disease – IUCD use, past ectopic, past subfertility, lower abdominal pain, vaginal discharge, in a sexually active woman of reproductive age, deep dyspareunia, dysmenorrhea, menstrual irregularity, lower abdominal tenderness, bilateral adnexal tenderness, cervical motion tenderness, uterine tenderness, no other likely cause for symptoms, varying spectrum of severity from asymptomatic, mild abdominal pain, moderate symptoms of abdominal pain and vaginal discharge to the most severe of fever, abdominal pain, pelvic peritonitis and adnexal masses, exclude gonococcal, chlamydial infections as a cause, start empiric treatment in a woman with risk factors if there is 1 one or more of cervical motion tenderness, uterine tenderness, adnexal tenderness, and the diagnostic specificity is increased in the presence of oral temperature greater than 101* F, abnormal cervical or vaginal mucopurulent discharge, presence of many WBC on saline microscopy of vaginal secretions (absence of WBC excludes PID as a cause for symptoms), elevated ESR, elevated CRP, lab evidence of N. gonorrhoea or C. trachomatis infection, Tx – severe infections admit for IV antibiotics, other indications for gyn referral include pregnancy, non-response for oral antibiotics, presence of tubovarian abscess, diagnostic uncertainty, mild – moderate infections cefuroxime, amoxicillin, metronidzole, Levofloxacin 500 mg orally once daily for 14 days OR Ofloxacin 400 mg orally twice daily for 14 days with or without Metronidazole 500 mg orally twice daily for 14 days, alternative treatment regimens include Ceftriaxone 250 mg IM single dose AND Doxycyline 100 mg bid for 14 days WITH or WITHOUT Metronidazole 500 mg bid orally for 14 days, clinical improvement should be seen within 3 days, any sexual contacts within 60 days of symptom development traced and investigated, sex partners needs treatment symptomatic or not for potential C. trachomatis and N. gonorrhoeae infections, screen for C. trachomatis, N.gonorrhoeae, HIV and syphilis
35) Spontaneous abortion – POA < 12/52, mild abdominal pain, mild bleeding PV (less than a normal period), pt is well and stable – refer to a Gyn unit for early pregnancy assessment
36) Pregnancy – False labor – during 2nd or 3 rd trimester, pain worse usually during the times of monthly menses, pains stop when walking, cramps come irregularly,
37) Pregnancy – Labor pains – after 37 weeks of pregnancy, lower abdominal pain in cramps, starting from the back and spreading to the lower abdomen, pain starts at a frequency of every 10 min, but gets stronger and closer, heaviness and pressure felt at the pelvis, increased vaginal discharge, blood-stained vaginal discharge – Mx labor
38) Pregnancy – Preterm labor – before 37 weeks of pregnancy, abdominal pain every 10 min or so, abdominal pain in cramps, pressure in the lower abdomen (baby being pushed down into pelvis), waves of cramps gets stronger and closer, increasing vaginal discharge, blood-stained vaginal discharge, backache – Mx admission.
39) Pregnancy – other common causes of abdominal pain in pregnancy are GERD, dyspepsia, constipation,
40) Pregnancy-associated abdominal pain – Round Ligament Pain – usually in the lower abdomen, crampy or stabbing, worsens with movements, postural changes, spreading to the groin, seen in the end of 1st trimester or 2nd trimester, in multigravida, Mx – usually reassurance, simple analgesics and rest
41) Pregnancy-associated abdominal pain – Braxton Hicks Contraction – abdominal pain in the second half of pregnancy, intensity usually mild but variable and frequency irregular, Mx – usually reassurance, simple analgesics and rest
42) Epiploic Appendagitis – comes into differential diagnosis of acute appendicitis, diverticulitis, cholecystitis, younger patients around thirties, usually rapid onset severe abdominal pain in the LIF, very localized, non-spreading, symptoms may last 1-4 weeks, no other GIT symptoms than pain, well looking patient for the amount of pain, abdominal exam soft and non tender without any guarding and/or rigidity, uncommon features are vomiting (because of severe pain), guarding on the left side (because of the pain), palpable masses in the LIF. Ix – lab investigations normal, imaging studies with US equivocal, CT may have some diagnostic features. Mx – NSAIDS and symptomatic treatment.