BIOSOFT HELP FILES

Chronic abdominal pain is defined as continuous or intermittent abdominal discomfort lasting for at least 3 months.[1] Pain may arise from any system, including the genitourinary, gastrointestinal, and gynecologic tracts. The etiology of chronic abdominal pain is so wide that only the more common causes can be covered here. A clear relationship with an anatomic structure or underlying process may not always be present.

Diagnosis and management of patients with chronic abdominal pain is often challenging and can be a frustrating experience for both physicians and patients. Factors that contribute to this include poor sensitivity of the history and physical exam, a broad differential diagnosis that crosses several specialties, and an often negative diagnostic workup.

Classification
Chronic abdominal pain is divided into organic and functional etiologies.[2]​ Organic etiologies have a clear anatomic, physiologic, or metabolic cause. Chronic abdominal pain without a clear source, in spite of a thorough diagnostic evaluation, is usually termed a functional disorder.[3]​ Functional abdominal pain is thought to arise from multifactorial visceral hypersensitivity and dysmotility and altered function of the brain-gut axis.[4]

Chronic abdominal pain is less likely to reveal underlying organic pathology than acute abdominal pain. Acute abdominal pain often indicates a sudden physiologic change such as an obstructed or perforated hollow organ, infection, inflammation, or a sudden ischemic event.

Epidemiology
Chronic abdominal pain is a common complaint in primary care and subspecialty clinics.[3] The incidence of unspecified abdominal pain is 22.3 per 1000 person-years.[5] In an international meta-analysis, the primary care consultation prevalence for abdominal pain is 2.8%.[6]​ More than half of all patients presenting with the symptoms of abdominal pain do not have a causative diagnosis.[6][7][8]​​​​​​​​ One cross-sectional survey of US adults reported a prevalence of abdominal pain in 21.8% of the general population.[9] Women are more likely than men to report chronic abdominal pain.[3] In the US, abdominal pain is the most common symptom and diagnosis of gastrointestinal diseases to prompt a healthcare visit.​[10]​ ​However, in a US survey of adults with a history of abdominal pain, almost 40% did not seek medical care for their symptoms.[11]

Worldwide, the prevalence of functional gastrointestinal disorders (FGID, also known as disorders of gut-brain interaction) in adults is over 40%.[12]​ FGID conditions are heterogenous and irritable bowel syndrome and functional dyspepsia are the most common.[12] However, the pain associated with these disorders is nonspecific and can resemble or coexist with organic disorders.[13]​ A subset of patients with FGID do not respond to first-line therapy and have persistent chronic abdominal pain.[14]

The prevalence of chronic abdominal pain in children varies widely (4% to 53%).[15][16][17]​ ​​The prevalence of pediatric functional abdominal pain is 13.5%.[18]

Differentials
Common
GERD
Peptic ulcer disease
Infectious gastroenteritis
Lactase deficiency
Full details
Uncommon
Crohn disease
Ulcerative colitis
Subacute intestinal obstruction
Celiac disease
Full detail

https://bestpractice.bmj.com/topics/en-us/767 Accessed 2:00 AM 1/5/2024

1. Treede RD, Rief W, Barke A, et al. Chronic pain as a symptom or a disease: the IASP classification of chronic pain for the International Classification of Diseases (ICD-11). Pain. 2019 Jan;160(1):19-27. Abstract

2. Yarger E, Sandberg K. Updates in diagnosis and management of chronic abdominal pain. Curr Probl Pediatr Adolesc Health Care. 2020 Aug;50(8):100840.Full-text Abstract

3. Sabo CM, Grad S, Dumitrascu DL. Chronic abdominal pain in general practice. Dig Dis. 2021;39(6):606-14.Full-text Abstract

4. Korterink J, Devanarayana NM, Rajindrajith S, et al. Childhood functional abdominal pain: mechanisms and management. Nat Rev Gastroenterol Hepatol. 2015 Mar;12(3):159-71. Abstract

5. Wallander MA, Johansson S, Ruigomez A, et al. Unspecified abdominal pain in primary care: the role of gastrointestinal morbidity. Int J Clin Pract. 2007 Oct;61(10):1663-70. Abstract

6. Viniol A, Keunecke C, Biroga T, et al. Studies of the symptom abdominal pain--a systematic review and meta-analysis. Fam Pract. 2014 Oct;31(5):517-29.Full-text Abstract

7. Freeman TR, Stewart M, Léger D, et al. Natural history of abdominal pain in family practice: longitudinal study of electronic medical record data in southwestern Ontario. Can Fam Physician. 2023 May;69(5):341-51.Full-text Abstract

8. Price SJ, Gibson N, Hamilton WT, et al. Diagnoses after newly recorded abdominal pain in primary care: observational cohort study. Br J Gen Pract. 2022 Aug;72(721):e564-70.Full-text Abstract

9. Sandler RS, Stewart WF, Liberman JN, et al. Abdominal pain, bloating, and diarrhea in the United States: prevalence and impact. Dig Dis Sci. 2000 Jun;45(6):1166-71. Abstract

10. Peery AF, Crockett SD, Murphy CC, et al. Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: update 2021. Gastroenterology. 2022 Feb;162(2):621-44.Full-text Abstract

11. Lakhoo K, Almario CV, Khalil C, et al. Prevalence and characteristics of abdominal pain in the United States. Clin Gastroenterol Hepatol. 2021 Sep;19(9):1864-72.e5.Full-text Abstract

12. Sperber AD, Bangdiwala SI, Drossman DA, et al. Worldwide prevalence and burden of functional gastrointestinal disorders, results of Rome Foundation Global Study. Gastroenterology. 2021 Jan;160(1):99-114.e3.Full-text Abstract

13. Colombel JF, Shin A, Gibson PR. AGA clinical practice update on functional gastrointestinal symptoms in patients with inflammatory bowel disease: expert review. Clin Gastroenterol Hepatol. 2019 Feb;17(3):380-90.e1.Full-text Abstract

14. Keefer L, Ko CW, Ford AC. AGA clinical practice update on management of chronic gastrointestinal pain in disorders of gut-brain interaction: expert review. Clin Gastroenterol Hepatol. 2021 Dec;19(12):2481-8.e1.Full-text Abstract

15. King S, Chambers CT, Huguet A, et al. The epidemiology of chronic pain in children and adolescents revisited: a systematic review. Pain. 2011 Dec;152(12):2729-38. Abstract

16. Tutelman PR, Langley CL, Chambers CT, et al. Epidemiology of chronic pain in children and adolescents: a protocol for a systematic review update. BMJ Open. 2021 Feb 16;11(2):e043675.Full-text Abstract

17. ​World Health Organization. Guidelines on the management of chronic pain in children. Dec 2020 [internet publication].Full text

18. Korterink JJ, Diederen K, Benninga MA, et al. Epidemiology of pediatric functional abdominal pain disorders: a meta-analysis. PLoS One. 2015 May 20;10(5):e0126982.Full-text Abstract

1)      Acute gastroenteritis – ingestion of contaminated food and/or water, fever, diarrhea, vomiting, abdominal pain, dehydration mild-severe,

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

25)  Male pelvic pain syndrome – chronic prostatitis – alcohol excess, perineal injury, anal sex, UTI, urethritis, epididymitis, acute prostatitis, low back pain, lower abdominal pain, perineal pain, testicular pain, painful ejaculation, pain with bowel movements, IVS, OVS, Hematuria, incontinence, PR –tender enlarged prostate, tender groin lymphadenopathy, tender swollen scrotum, urethral discharge, Triple void specimen for UFR and Culture and ABST, FBC, Seminal fluid analysis, Tx – Bactrim, Cipro, Tetracycline, Carbenicillin, Erythromycin, Nitrofurantoin for 6-8 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,

31)  Acute viral hepatitis

32)  Alcoholic hepatitis – anorexia, weight loss, abdominal pain, distension, nausea, vomiting, hepatic encephalopathy, liver failure, hepatomegaly, jaundice, ascites, spider angiomas, fever, anemia, leucocytosis, elevated aminotransferases, hyperbilirubinemia, prolonged PT, hypoalbuminemia

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 2^nd 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 1^st trimester or 2^nd 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.

1)      Acute gastroenteritis

2)      Recurrent abdominal pain of childhood

3)      Atopic gastro enteropathy – recurrent abdominal pain, diarrhea, and vomiting in children with asthma, GIT symptoms usually predate asthma

4)      PFAPA Syndrome – See under fever.

5)      Non-Alcoholic Fatty Liver Disease or Non-Alcoholic SteatoHepatitis (NASH) – malaise, fatigue, vague recurrent abdominal pain, liver disease is progressive unless managed by weight reduction and treatment of hypertriglyceridemia

6)      Abdominal migraine – at least 3 or more attacks within the previous 1 yr comprising: a) acute, severe  periumbilical or midline abdominal pain lasting 2 hr to several days  with asymptomatic intervals lasting weeks to months  b) pain is associated with 2 or more of the following – anorexia, nausea, vomiting, headache, photophobia, pallor, family history of migraine, unilateral headache, aura c) pain is disabling d) Remissions lasts several weeks to months when the child is fully healthy e) no evidence for inflammatory, anatomic, metabolic, neoplastic process to explain the symptoms, Tx – pizotifen, propranolol, cyproheptadine,

7)      Functional Abdominal Pain Syndrome – FAPS – usually school-aged or adolescent, 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, psychological problems like unusual parental dependence, anxiety, depression, perfectionism, parental perception of the child as special (only child, male child in a family of girls, female child in a family male, youngest child, eldest child), parents anxious, overprotective, authoritarian, preoccupied with the child

8)      Functional dyspepsia – following symptoms for at least 12 weeks within the last 1 yr, persistent or recurrent upper abdominal area pain or discomfort above the umbilicus, no evidence for possible organic disease including UGIE (no red flags), no evidence for IBS

9)      IBS – following symptoms for at least 12 weeks within the last 1 yr, abdominal pain or discomfort that has at least 2 of following 3 characteristics – relieved by defecation, onset associated with a change of stool frequency, onset associated with a change in stool appearance, no evidence of following – no structural or metabolic abnormalities to explain the symptoms (that is no red flags)

10)  IBS is also suggested by the following symptoms – abnormal stool frequency of either > 3 bowel movements/day OR < 3 bowel movements/week, abnormal stool form (lumpy, hard, lose, watery), abnormal stool passage (straining, urgency, sense of incomplete evacuation), the passage of mucus with stools,. Abdominal distension

11)  Fod allergy – abdominal pain, vomiting, diarrhea, recurrent episodes, symptoms after ingestion of the suspected allergen (Children’s allergens : cow’s milk, hen’s eggs, pea nuts, tree nuts, seasame seeds, wheat and soy allergy.  Adults : shellfish, fish, pea nuts, tree nuts ), allergic response consistent, consistent response for avoidance of the allergen, positive food challenges, allergic reactions in other organs like skin (urticaria, flushing, angioedema, flare ups or worsening of eczema), respiratory (asthma, rhinitis, stridor), cardiovascular (anaphylaxis),  Mx – of the clinical situation, avoidance of the suspected food allergen, dietitian consultation when multiple food allergies present (wrong selfcare for presumed multiple food allegies can cause dietary defiiciencies, rickets, IDA, failure to thrive, impaired growth, osteoporosis), advice on selfcare with self adminsitred adrenaline, look for multiple food allergies, avoidance of vaccines containing the preseumed allergen (influenza vaccine in egg allergy), allergy specialist referral for allergic immunotherapy, oral desensitization, monoclonal anti-IgE.

1)      Severe abdominal pain and shock (generalized peritonitis, mesenteric infarction, severe pancreatitis)

2)      Collapse

3)      Shock

4)      Rigid abdomen

5)      Heavy vaginal bleeding

6)      Labor and complications of labor

7)      Very severe upper abdominal pain with cardiac ischemic symptoms (Exclude inferior MI)

8)      Fever, dyspnea (Pneumonia)

9)      Dyspnea and high-risk pulmonary embolism (Pulmonary embolism)

10)  Tachypnea, acidotic breathing, dehydration, high blood sugar, urinary ketones

11)  Period of amenorrhea

12)  Pregnancy early stages – ectopic pregnancy, incomplete abortion, genital tract trauma, pulmonary embolism, toxic shock syndrome

13)  Pregnancy late stages – placental abruption, placenta previa, pregnancy-induced hypertension (pre-eclampsia, eclampsia), pulmonary embolism

14)  Abnormal vital signs – hypotension, confusion,

15)  Pain requires opioid analgesia

16) The patient looks very ill

17)  Sudden sharp severe abdominal pain (ruptured or twisted ovarian cysts, perforated peptic ulcer, ruptured ectopic pregnancy, ruptured aortic aneurysm, ruptured spleen)

18)  Recent onset inability to pass stools, vomiting, abdominal distension (bowel obstruction)

19)  Elderly patient (> 65 yrs) – (minimal peritoneal signs so that fever, sepsis, and confusional states may be due to occult cholecystitis or cholangitis)

20)  Hematemesis, melena (peptic ulcer)

21)  Unintentional weight loss of > 5 kg (malignancy)

22)  Past abdominal surgery (adhesions)

23)  Diabetes (minimal peritoneal signs so that fever, sepsis, and confusional states may be due to occult cholecystitis or cholangitis)

24)  Unexplained upper abdominal pain and weight loss with or without backache (UGIE to exclude GIT Ca)

25)  Unexplained abdominal pain in a female with abdominal and/or VE mass (exclude ovarian Ca if not due to fibroids, GIT or GUS masses)

26)  Woman in reproductive age, bleeding PV, abdominal pain, POA +/-, shock out of proportion to blood loss, shoulder tip pain (immediate transfer with IV drip to maintain radial pulse, high flow oxygen)

27)  Woman undergoing IVF or any other assisted conception, collapse or shock or faintishness (Ovarian Hyperstimulation Syndrome – immediate referral to a gyn)

28)  Abdominal pain referral – right scapula (gall bladder), left shoulder (ruptured spleen, pancreatitis), pubis or vagina (renal pain), back (ruptured aortic aneurysm)

29)  HELLP syndrome – woman with a POA > 20/52 or 72-96 hrs after delivery, abdominal pain, RHC pain, malaise, weight gain, edema, nausea, vomiting, low BP, proteinuria, elevated liver enzymes, platelet count less than 100,000, microhemolytic anemia, elevated S. bilirubin,

30)  Late stages of pregnancy, hypertension, proteinuria, edema, upper abdominal pain, mostly epigastric or RHC, headache, nausea, vomiting, visual disturbances, hyperreflexia, reduced urine output, fits (Severe pre-eclampsia)  

31)  Constant severe abdominal pain, pregnancy more than 26 weeks, uterus hard and tender, bleeding per vaginam, shock out of proportion to the blood loss (due to internal uterine haemorrhage),  (Placental abruption)

32)  Abdominal pain, POA < 20/52, bleeding per vaginam, heavy bleeding, tachycardia, bradycardia, hypotension, passage of products of conception, severe abdominal pain (immediate gyn assessment for ectopic, incomplete abortion)

33)  Elderly patient with abdominal pain, vomiting, diarrhea – acute gastroenteritis is rare in the elderly, consider this as a non-specific presentation of any of following GIT lesions – gall bladder disease, acute appendicitis, diverticulitis, bowel obstruction, mesenteric ischemia

34)  Elderly patient with abdominal pain and AF, atherosclerotic markers (N), low ejection fraction – mesenteric ischemia

35)  Elderly patient with recent onset dyspepsia – dyspepsia never starts in the elderly, postprandial pain in the elderly with atherosclerotic markers may be intestinal  angina a sign of mesenteric ischemia, peptic ulcer disease

36)  Elderly patient with renal colic – exclude abdominal aortic aneurysm as renal colic in the elderly is uncommon

37)  Elderly patient with recent onset backache thought to be due to lumbar muscle sprain or musculoskeletal cause - remember musculoskeletal problems are less common among the elderly, exclude AAA as a cause of severe backache in the elderly

38)  Pregnancy < 22 weeks, palpable tender discrete mass in lower abdomen, light vaginal bleeding, adnexal mass on VE,  (Ovarian cyst)

39)  Pregnancy < 22 weeks, lower abdominal pain, low grade fever, rebound tenderness, abdominal distension, anorexia, nausea/vomiting, paralytic ileus, increased WBC, site of pain  right flank or RHC (Acute appendicitis)

40)  Pregnancy < 22 weeks, abdominal pain, dysuria, frequency, urgency, retropubic/suprapubic pain, (Acute cystitis)

41)  Pregnancy < 22 weeks, abdominal pain, dysuria, frequency, urgency, retropubic/suprapubic pain, spiking fever, chills, loin pain, loin tenderness, rib cage tenderness, anorexia, nausea, vomiting (Acute pyelonephritis)

42)  Pregnancy < 22 weeks, abdominal pain, low grade fever, chills, absent bowel sounds, rebound tenderness, abdominal distension, anorexia, nausea, vomiting, shock (Peritonitis)

43)  Pregnancy < 22 weeks, abdominal pain, light bleeding (takes longer than 5 min for a clean pad or cloth to be soaked), closed cervix, uterus slightly larger than normal, uterus softer than normal, fainting, tender adnexal mass, amenorrhea, cervical motion tenderness (Ectopic pregnancy)

44)  Pregnancy > 22 weeks, palpable contractions, blood stained mucus discharge, watery discharge usually before 37 weeks, cervical dilation and effacement, light vaginal bleeding (Preterm labour)

45)  Pregnancy > 22 weeks, palpable contractions, blood stained mucus discharge, watery discharge after 37 weeks, cervical dilation and effacement, light vaginal bleeding (Term labour)

46)  Pregnancy > 22 weeks, intermittent or constant abdominal pain, bleeding after 22 weeks of pregnancy, blood may be hidden in uterus rather than shown PV, shock, tense, tender, uterus, decreased, absent fetal movements, fetal distress or absent fetal heart sounds (Abruptio placentae)

47)  Pregnancy > 22 weeks, severe abdominal pain, bleeding intrabdominal or PV, shock, abdominal distension, free fluid, abnormal uterine contour, tender abdomen, easily palpable fetal parts, absent fetal movements, absent FHS, rapid maternal pulse (Ruptures uterus)

48)  Pregnancy > 22 weeks, foul smelling watery vaginal discharge, fever, chills, history of loss of fluid, tender uterus, rapid fetal heart rate, light vaginal bleeding (Amnionitis)

49)  Pregnancy > 22 weeks, dysuria, frequency, urgency, retropubic pain, suprapubic pain,  (Cystitis)

50)  Pregnancy > 22 weeks, abdominal pain, dysuria, frequency, urgency, retropubic/suprapubic pain, spiking fever, chills, loin pain, loin tenderness, rib cage tenderness, anorexia, nausea, vomiting (Acute pyelonephritis)

51)  Pregnancy > 22 weeks, lower abdominal pain, low grade fever, rebound tenderness, abdominal distension, anorexia, nausea/vomiting, paralytic ileus, increased WBC, site of pain  right flank or RHC (Acute appendicitis)

52)  Pregnancy > 22 weeks, lower abdominal pain, fever, chills, purulent foul smelling lochia, tender uterus, light vaginal bleeding, shock (Metritis)

53)  Pregnancy > 22 weeks, lower abdominal pain, abdominal distension, persistent spiking fever, chills, tender uterus, poor response for antibiotics, swelling in adnexa, swelling in pouch of Douglas, pus on culdocentesis (Pelvic abscess)

54)  Pregnancy > 22 weeks, abdominal pain, low grade fever, chills, absent bowel sounds, rebound tenderness, abdominal distension, anorexia, nausea, vomiting, shock (Peritonitis)

55)  Pregnancy < 22 weeks, palpable tender discrete mass in lower abdomen, light vaginal bleeding, adnexal mass on VE,  (Ovarian cyst)

56)  Pregnancy > 22 weeks, abdominal pain upper abdomen, headache, visual disturbance, generalized edema, brisk reflexes, reduced urine output, BP 140/90 or any rise in DBP from a previous reading, ankle edema, proteinuria, fitting, confusional state, (Preeclampsia)

57)  First episode of abdominal pain over 50 yrs person exclude gastric or pancreatic carcinoma

58)  Elderly patient, evidence of atherosclerosis markers (N), angina, intermittent claudication, epigastric or mid-abdominal pain, pain starts 15-20 min postprandial, lasts 2 hrs, weight loss, progressive loss of weight (Mesenteric angina)

59)  Abdominal pain, perianal fistulae, perianal sinuses, malabsorption syndrome (Abdominal pain without diarrhea as a presenting symptom of  IBD)

60)  Jaundice, anorexia, weight loss, recurrent abd pain, past gall stones, alcoholism (Pancreatic disease)

61)  Alcoholism

62)  Medical causes of abdominal pain – inferior myocardial infarction, pneumonia, pulmonary infarction, diabetic ketoacidosis, IBD, pyelonephritis

63)  Elderly patient with moderate to severe pain, any abnormality in vital signs, altered level of consciousness (Life threatening disease – admit immediately)

64)  Recent onset dyspepsia in elderly – PUD, mesenteric ischemia, bowel obstruction,

65)  Epigastric pain with cardiac risk factors (DM, HT, smoking, age above 55 yrs, past angina or unstable angina or MI, Hyperlipidemia, past strokes and CVA, F/H of cardiovascular disease before 50 yrs in male 60 yrs in female relatives, F/H suggestive of familial hyperlipidemia)

66)  Epigastric pain started at the chest

Epigastric pain radiating to the neck, arm, chest

1)      Failure to thrive – deceleration of linear growth

2)      Weight loss unintentional

3)      Patient age less than 4 years

4)      Nocturnal pain

5)      F/H Inflammatory Bowel Disease

6)      F/H Peptic ulcer disease

7)      Arthritis/arthralgia

8)      Aphthous ulcers/stomatitis

9)      Rashes, diarrhea, vomiting, fever, rectal bleeding

10)  Hemetemesis, bile-stained vomitus, GIT blood loss,

11)  Clubbing

12)  Hepatosplenomegaly

13)  Perianal disease

14)  Fecal occult blood, anemia, high ESR, hypoalbuminemia, high aminotransferases, dysuria, Hematuria, pyuria, eosinophilia, steatorrhea

15)  Pain away from the umbilicus

16)  Unexplained fever

17)  Changes in bowel function

18)  Intermittent fecal incontinence

19)  Right lower abdominal mass consistent with colonic origin (Urgent referral for colonoscopy)

20)  Obesity, hypertriglyceridemia

21)  Abdominal pain colicky in 3/12-6 yrs, episodes of inconsolable crying, stools red currant jelly, abdominal mass in the epigastrium or right upper quadrant, vomiting, bile stained vomitus, blood and mucus stools (Intussusception)

22)  Significant vomiting

23)  Severe chronic diarrhea

24)  Persistent right upper or lower quadrant pain

25)  Scrotal or testicular pain

26)  Recurrent cyclical monthly abdominal pain in females around puberty (imperforate hymen)

(Gray et.al. 2004)

 (NCC-PC Referral Guidelines for Suspected Cancer  in Adults and Children)

(MedlinePlus Medical Encyclopedia)

(Caffarelli et.al. 2000)

(Galankis E 2002)

(Tasher, Somekh and Dalal 2006)

(Rome II Criteria)

(Longstreth et.al. Rome III Criteria)

(Marion et.al. 2004)

(Clouse RE 2006 Rome III Criteria)

(Rasquin et.al. 2006 Rome III criteria)

(Andersson 2004)

(Fairbanks K 2004 at ClevelandClinic)

(Arulkumaran 2004)

(WHO 2003)

(AmericanAcademy of Pediatrics 2005)

(CDC – Sexually Transmitted Diseases Treatment Guidelines 2006)

(Mahomed 2006)

(Lack 2008)

(Meurer and Bower 2002)

(Buresh and Graber 2006)

This refers to the feeling of pain arising from normal visceral sensations.  For instance, if a patient has abnormal visceral nociception ordinary distension of viscera even may be perceived as pain.  Abnormal visceral nociception is believed to be the underlying reason for several common clinical states seen in primary care – recurrent anterior chest wall pain, IBS, heartburn, and dyspepsia.  It is believed that in abnormal visceral perception, the lesion may lie in any 1 or all of the following – gut lumen receptors, afferent neuron – excessive afferent neuronal impulse propagation, abnormal signal processing at the spinal cord, abnormal relay of signals to the cortex, efferent neuron – abnormal activation of the efferent limb of the sympathetic nervous system.

Importance There are a myriad of available treatment options for patients with frozen shoulder, which can be overwhelming to the treating health care professional.

Objective To assess and compare the effectiveness of available treatment options for frozen shoulder to guide musculoskeletal practitioners and inform guidelines.

Data Sources Medline, EMBASE, Scopus, and CINHAL were searched in February 2020.

Study Selection Studies with a randomized design of any type that compared treatment modalities for frozen shoulder with other modalities, placebo, or no treatment were included.

Data Extraction and Synthesis Data were independently extracted by 2 individuals. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Random-effects models were used.

Main Outcomes and Measures Pain and function were the primary outcomes, and external rotation range of movement (ER ROM) was the secondary outcome. Results of pairwise meta-analyses were presented as mean differences (MDs) for pain and ER ROM and standardized mean differences (SMDs) for function. Length of follow-up was divided into short-term (≤12 weeks), mid-term (>12 weeks to ≤12 months), and long-term (>12 months) follow-up.

Results From a total of 65 eligible studies with 4097 participants that were included in the systematic review, 34 studies with 2402 participants were included in pairwise meta-analyses and 39 studies with 2736 participants in network meta-analyses. Despite several statistically significant results in pairwise meta-analyses, only the administration of intra-articular (IA) corticosteroid was associated with statistical and clinical superiority compared with other interventions in the short-term for pain (vs no treatment or placebo: MD, −1.0 visual analog scale [VAS] point; 95% CI, −1.5 to −0.5 VAS points; P < .001; vs physiotherapy: MD, −1.1 VAS points; 95% CI, −1.7 to −0.5 VAS points; P < .001) and function (vs no treatment or placebo: SMD, 0.6; 95% CI, 0.3 to 0.9; P < .001; vs physiotherapy: SMD 0.5; 95% CI, 0.2 to 0.7; P < .001). Subgroup analyses and the network meta-analysis demonstrated that the addition of a home exercise program with simple exercises and stretches and physiotherapy (electrotherapy and/or mobilizations) to IA corticosteroid may be associated with added benefits in the mid-term (eg, pain for IA corticosteroid with home exercise vs no treatment or placebo: MD, −1.4 VAS points; 95% CI, −1.8 to −1.1 VAS points; P < .001).

Conclusions and Relevance The findings of this study suggest that the early use of IA corticosteroid in patients with frozen shoulders of less than 1-year duration is associated with better outcomes. This treatment should be accompanied by a home exercise program to maximize the chance of recovery.

Challoumas D, Biddle M, McLean M, Millar NL. Comparison of Treatments for Frozen Shoulder: A Systematic Review and Meta-analysis. JAMA Netw Open. 2020;3(12):e2029581. doi:10.1001/jamanetworkopen.2020.29581

Mild Acne
< 20 comedones or < 15 inflammatory papules or a lesion count of < 30, 15-50 papules and pustules with comedones and rare cysts. Total lesion count may range from 30-125.
Clinically mild acne has only white or black comedones
Treatment is adapalene 0.1% gel locally. The gel should be applied once a day to affected areas after washing in the evening before retiring. A thin film of the gel should be applied, avoiding eyes, lips, and mucous membranes.
To prevent the retinoid irritation advice patients to use mild soaps, soap substitutes like cetaphil lotion, avoid skin trauma like rubbing, scrubbing of face etc.

Moderate Acne
In between mild and moderate
Clinically in addition to white and black comedones, there are also inflammatory lesions like papules and pustules
Treatment is adapalene and Benzoyl peroxide 2.5%, 5% gel.
Azithromycin 500 mg initial dose and 250 mg daily for a further four days per month for 12 weeks
Azithromycin, 500 mg orally thrice weekly for 8 weeks ( 500 mg once-thrice weekly.)

Severe Acne
Azithromycin 500 mg initial dose and 250 mg daily for a further four days per month for 12 weeks
Azithromycin, 500 mg orally thrice weekly for 8 weeks ( 500 mg once-thrice weekly.)
Inflammatory nodules, comedones, papules, and pustules or total lesion count of greater than 125.
Dermatology referral for isotretinoin therapy

Other management considerations :
1) Management of QOL and emotional dysfunction of Acne
2) Indications for hormonal/contraceptive therapy
3) Indications for oral antibiotics

Microneedling is a common office-based procedure used
to manage post-acne atrophic scarring. Its clinical usefulness
is well established.4-6 A series of 3 to 5 treatment sessions at
2- to 4-week intervals typically results in improvement ranging
from50%to 70%.7 The efficacy of micro-needling has been
compared with other dermatological procedures for post-acne
scars, such as chemical peeling,8 cry rolling,9 or carbon
dioxide laser treatment,10 usually as combination therapies.
However, head-to-head comparative studies with home-based
medical management for acne scars is lacking.

Antibiotic therapy is a safe, efficient, feasible, and cost-effective alternative to appendectomy for patients with computed tomography (CT)–confirmed uncomplicated acute appendicitis at short-term and long-term follow-up.1-5 The World Society of Emergency Surgery 2020 guideline recommended discussing antibiotics as a safe alternative to surgery for uncomplicated acute appendicitis without appendicolith (high quality of evidence; strong recommendation).6 During the coronavirus disease 2019 (COVID-19) pandemic, this was also acknowledged by the American College of Surgeons (COVID-19 Guideline for Triage of Emergency General Surgery Patients).7

In the first APPAC trial, at the 5-year follow-up, 61% of 256 patients who initially presented with uncomplicated acute appendicitis were successfully treated with antibiotics, and those who ultimately developed recurrent appendicitis had no adverse outcomes related to the delay in appendectomy.2 Quality of life was also similar after these 2 treatment alternatives.8,9 In previous trials, the length of hospital stay for both antibiotics and appendectomy has been similar,10 but for antibiotics alone, hospitalization was required to administer broad-spectrum intravenous antibiotics to ensure patient safety.1,9,11 Successful outpatient treatment has since been reported.12 Despite prolonged hospitalizations, antibiotic therapy is associated with significantly lower treatment costs compared with appendectomy.3,4 A shorter hospital stay for antibiotic treatment could further enhance cost savings, patient satisfaction, and quality of life. Avoidance of hospitalizations during the COVID-19 pandemic is also a desirable potential benefit for the management of appendicitis using oral rather than intravenous antibiotics.

TRIAL DATA
Patients randomized to receive oral monotherapy (n = 295) received oral moxifloxacin (400 mg/d) for 7 days. Patients randomized to receive intravenous antibiotics followed by oral antibiotics (n = 288) received intravenous ertapenem (1 g/d) for 2 days followed by oral levofloxacin (500 mg/d) and metronidazole (500 mg 3 times/d) for 5 days.
Sippola S, Haijanen J, Grönroos J, et al. Effect of Oral Moxifloxacin vs Intravenous Ertapenem Plus Oral Levofloxacin for Treatment of Uncomplicated Acute Appendicitis: The APPAC II Randomized Clinical Trial. JAMA. Published online January 11, 2021. doi:10.1001/jama.2020.23525