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Chapter 31. Abdominal Pain

Thomas E. Baudendistel, MD; Amarpreet Sandhu, DO

A 62-year-old man with a history of hyperlipidemia, hypertension, and coronary artery disease presents to your primary care practice with abdominal pain for 6 months. His pain gets worse after eating meals.

  • What are the other important questions to ask this patient?
  • What is the differential diagnosis of acute and chronic abdominal pain?
  • Can you make a definite diagnosis through an open-ended history followed by focused questions?

Abdominal pain is a commonly encountered clinical problem, accounting for nearly 10% of all visits to emergency departments. Nearly 25% of all patients evaluated for abdominal pain in such settings require hospitalization. What is the reason for such a high rate of hospitalization? The etiology of abdominal pain is often, at least initially, uncertain. Approximately 25% of the patients leave the emergency setting without a definite diagnosis. The frequency of this clinical problem and the associated diagnostic uncertainty mandate a further discussion of abdominal pain. A better understanding of the historical features associated with different causes of abdominal pain will expedite appropriate diagnosis and treatment.

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Acute abdomenAn abdominal condition that requires immediate surgical intervention.1,2 Patients with an acute abdomen represent only a fraction of those with acute abdominal pain.
Acute abdominal painAcute abdominal pain has an onset over minutes but can persist for days.3 Sometimes, very severe abdominal pain is described as acute, which is appropriate only if the pain is a new problem. An acute exacerbation of chronic abdominal pain should not be described as acute abdominal pain.
Biliary colicPain caused by acute transient obstruction of the cystic duct, usually due to the passage of a gallstone. Patients commonly describe the pain as occurring "in waves." This may be due to peristaltic contractions against a fixed obstruction.
Chronic abdominal painAbdominal pain that is present for at least 6 months without a diagnosis despite an appropriate evaluation.
Nonspecific abdominal painPain poorly localized to a specific area of the abdomen. It is often inadequately explained by any specific diagnosis.
PeritoneumThe membrane derived from embryonic mesoderm that covers the viscera and lines the walls of the abdominal and pelvic cavities. The part of the peritoneum that lines the viscera is called the visceral peritoneum. The parietal peritoneum lines the abdominal and pelvic cavities. Autonomic nerves innervate the visceral peritoneum, whereas spinal somatic nerves innervate the parietal peritoneum.1
Referred painReferred pain is experienced distant from the site of origin.4 The referral of visceral pain to distant sites is not well understood but may involve both somatic and visceral input to the dorsal horn of the spinal cord.
Somatic painSomatic pain emanates from the parietal peritoneum. The somatic nerves innervating the parietal peritoneum contain A-delta neurons.1 These nerves are fast transmitters and typically produce very sharp, localized pain.
Visceral painPain emanating from the visceral peritoneum. The visceral peritoneum contains C fibers, which transmit ...

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