This is a UKMLA-centred history guide about abdominal pain.
Introduction
Causes of abdominal pain can range from surgical emergencies to mild self limiting gastroenteritis. Being able to take a thorough history to differentiate between possible causes is of vital importance.
Presenting Complaint
Site
Consider the anatomy that is underlying the different regions of the abdomen to generate differentials.
Right Upper Quadrant – Cholecystitis, hepatitis
Right Lower Quadrant – Appendicitis, inguinal hernia, IBD, and ovarian pathology
Left Upper Quadrant – Gastric ulcers and splenic causes (rupture + abscess)
Left Lower Quadrant – Diverticulitis, inguinal hernia, IBD, ovarian pathology
Right and Left Flanks – Pyelonephritis and renal/ureteric colic
Epigastric – Peptic ulcer disease, cholecystitis, GORD, pancreatitis, and MI
Peri-umbilical – Appendicitis (early), IBS, bowel obstruction and AAA
Suprapubic – UTI, urinary retention, pelvic inflammatory disease, testicular torsion and ovarian pathology
Radiation/Migration
Radiates from umbilicus to RIF e.g. appendicitis, Crohn’s can mimic this pattern
Radiates through to the back e.g. pancreatitis, abdominal aortic aneurysm
Radiating to shoulder tip e.g. ectopic pregnancy (and other pelvic pathology)
Loin to groin e.g. pyelonephritis, renal calculi
Quality/Character
Colicky (intermittent cramping/griping pain) – Renal colic, cholelithiasis, and any condition where an anatomical tube is trying to pass an obstruction such as a stone.
Burning (dyspepsia) e.g. reflux
Cramping e.g. appendicitis, IBS, IBD, Diverticulitis
Sharp e.g. pancreatitis
Tearing – AAA
Intensity
Ask to rate on scale of 1-10
Onset
Sudden e.g. ovarian/ testicular torsion, intussusception, volvulus, incarcerated hernia
Over hours (may suggest inflammatory or infective cause) e.g. appendicitis, gastroenteritis, pancreatitis, cholecystitis, and pyelonephritis
Days to Weeks – Chronic conditions such as IBD, IBS, PID, hepatitis, malignancy
Timing
Continuous or discrete episodes?
Has the pain changed over time?
How long does the pain last for?
Acute
Gastrointestinal: appendicitis, obstruction, flare of IBD incarcerated hernia
Pancreatic: acute pancreatitis
Genitourinary: UTI, testicular torsion
Gynaecological: ectopic pregnancy, PID, ovarian torsion/cyst
Others: DKA
Chronic (over weeks to months)
Gastrointestinal: IBD, Coeliac, Irritable Bowel Syndrome (IBS), Chronic constipation
Gynaecological: ovarian cyst (s), chronic pelvic pain, endometriosis
Other (medical causes): hypercalcaemia
Recurrent
e.g. IBS (often corresponds to stressful life events), functional abdominal pain, Coeliac pain
Associated Symptoms
Gastrointestinal symptoms
Fever (suggest an infective cause) e.g. gastroenteritis
Vomiting e.g. bowel obstruction/volvulus (bilious i.e. dark green), renal colic, pancreatitis
Constipation e.g. bowel obstruction, colon cancer
Diarrhoea e.g. IBD, diverticulitis (bloody diarrhoea), bowel obstruction, colon cancer (diarrhoea or constipation)
Jaundice e.g. hepatitis, cholangiocarcinoma, pancreatitis
Pallor e.g. GI bleed, malnutrition
PR bleeding e.g. colorectal cancer, IBD, diverticulitis
Urological symptoms
Dysuria, Flank pain, Urinary frequency, Haematuria e.g. UTI/pyelonephritis/nephrotic syndrome, sexually transmitted diseases ( STI)
Gynaecological symptoms
Vaginal discharge, Pelvic pain, Dyspareunia e.g. PID, ovarian cyst
Change to periods e.g. spotting or missed periods in ectopic pregnancy
Other symptoms:
Loss of consciousness, light-headedness e.g. ruptured ectopic pregnancy, ruptured AAA
Aggravating/Alleviating Factors
Worse before opening bowels e.g. gastroenteritis, IBS
Worse with movements e.g. appendicitis (walking, jumping/ bumps during a car journey)
Worsen by laying down e.g. Gastro-oesophageal reflux (dyspepsia)
Varying with Meals – Peptic ulcers and biliary colic (fatty foods)
Relief upon Sitting Forwards – Acute pancreatitis
Other
All women of childbearing age should be asked if they could be pregnant and when their last menstrual period was.
Differentials
Generally, the causes of abdominal pain can be categorised into gastrointestinal, urological, gynaecological and others.
It is important to demonstrate to the examiner that you are aware of this and establishing which system to click into.
Gastrointestinal Causes
Symptoms that suggest a gastrointestinal cause include abdominal distension, vomiting, change in bowel habit, weight loss, symptoms varying with meals and blood in stool.
| Differential | Features |
|---|---|
| Gastroenteritis | Diarrhoea, vomiting , crampy abdominal pain, fever |
| Appendicitis | Periumbilical pain radiating to RIF, fever |
| Biliary Colic | Colicky pain, fever RUQ/epigastric pain, exacerbated by fatty foods |
| Acute Pancreatitis | Epigastric pain radiating to back, relieved by sitting forwards, vomiting |
| Diverticulitis | LLQ pain, fever, diarrhoea, often elderly, PR bleeding |
| Peptic Ulcers | Epigastric pain varying with meals, risk factors in history (NSAIDs, spicy food). |
Urological Causes
Symptoms that suggest a urological cause include loin to groin pain, vomiting, rigors, change in urinary habit and blood in urine.
| Differential | Features |
|---|---|
| Renal colic | Colicky pain radiating from loin to groin, vomiting and rigors |
| Pyelonephritis | Same as renal colic with fever and recent lower urinary symptoms (pain on urination, burning, frequency) |
| UTI | Suprapubic pain, fevers, dysuria, malodourous urine, urinary retention, urinary frequency |
Gynaecological Causes
Symptoms that suggest a gynaecological cause include spotting, amenorrhea, sudden collapse (if childbearing age), pain varying with menstrual cycle and recent STI.
| Differential | Features |
|---|---|
| Pelvic Inflammatory Disease | Hypogastric pain, vaginal bleeding, amenorrhea, dizziness/fainting and breast tenderness |
| Early Pregnancy | Spotting, amenorrhea, morning sickness, breast tenderness, unprotected intercourse |
| Endometriosis | Pelvic/abdo pain varying with menstrual cycle, dysmenorrhea, pain during sex |
| Ectopic Pregnancy | Spotting, missed period, lower abdominal pain, dizziness/collapse |
Red Flags
There are serious causes of abdominal pain and it is important to demonstrate that you are considering them and asking red flag questions to screen for them:
Cancer
Fever, weight loss, night sweats, PR bleeding, melena and change in bowel habit (constipation or diarrhoea)
Ruptured Ectopic Pregnancy
Sudden collapse in a woman of childbearing age, amenorrhea
AAA
Tearing pain radiating to back, sudden collapse
Testicular Torsion
Severe groin/lower abdo pain, nausea and vomiting
Ovarian Torsion
Sudden colicky abdo pain, vomiting
Bowel Obstruction
Bowels not opening, not passing flatus, bilious vomiting.
Background
In any history you will ask about past medical history, medications, allergies, social history, and family history. In a history about abdominal pain, you can show how much you know about the various causes by explicitly asking about the following things:
Past Medical History
Previous abdominal surgery can lead to adhesions that cause abdominal pain and can alter the underlying anatomy thereby changing the possible differentials.
If suspecting a gynaecological cause you should ask about previous pregnancies, terminations, miscarriages, LMP and contraception.
Drug History
Laxatives – Can explain diarrhoea and will help you formulate a management plan for constipation.
Opiates – can cause constipation
NSAIDs – can cause peptic ulcers
Contraception – can change the likelihood of ectopic pregnancy and explain some gynae side effects.
Family History
Many conditions that cause abdominal pain have a genetic component. These include IBD, colorectal cancer, and coeliac disease. It is worth asking about other autoimmune conditions as these can share genetic predisposition for IBD and coeliac disease.
Social History
Smoking is protective in Crohn’s. Patients with Crohn’s who successfully reduce or stop smoking, may have a resulting flare of their condition.
Alcohol and diet can exacerbate conditions such as peptic ulcers, cholecystitis, and IBS.
Enquiring about dietary changes and patterns may uncover intolerances or be suggestive of the aforementioned conditions.
Anyone else at home with the same symptoms e.g. infective cause such as gastroenteritis.
Examination
When examining the patient, you should keep your differentials in mind and look for signs that confirm or refute your potential diagnoses.
Author – Dr Keiran Dey
Editor – Dr James Mackintosh
