What is abdominal pain?

         Abdominal pain is pain that is felt in the abdomen. The abdomen is an anatomical area that is
    bounded by the lower margin of the ribs above, the pelvic bone (pubic ramus) below, and the flanks
    on each side. Although abdominal pain can arise from the tissues of the abdominal wall that surround
    the abdominal cavity (i.e., skin and abdominal wall muscles), the term abdominal pain generally is used
    to describe pain originating from organs within the abdominal cavity (i.e., beneath the skin and muscles).
    These organs include the stomach, small intestine, colon, liver, gallbladder, and pancreas

     Occasionally, pain may be felt in the abdomen even though it is arising from organs that are close to but
    not within the abdominal cavity, for example, the lower lungs, the kidneys, and the uterus or ovaries. This 
    latter type of pain is called "referred" pain because the pain, though originating outside the abdomen, is
    being referred to (felt) in the abdominal area.

What causes abdominal pain?

          Abdominal pain is caused by inflammation (i.e.- appendicitis, diverticulitis, colitis), by stretching
    or distention of an organ (e.g., obstruction of the intestine, blockage of a bile duct by gallstones, swelling of
    the liver with hepatitis), or by loss of the supply of blood to an organ (e.g., ischemic colitis). To complicate
    matters, however, abdominal pain also can occur without inflammation, distention or loss of blood supply.
    An important example of this latter type of pain is theirritable bowel syndrome (IBS).It is not clear what
    causes the abdominal pain in IBS, but it is believed to be due either to abnormal contractions of the
    intestinal muscles (e.g., spasm) or abnormally sensitive nerves within the intestines that give rise to painful
    sensations inappropriately (visceral hyper-sensitivity).

COMMON CAUSES OF FEMALE ABDOMINAL PAIN

                OVARIAN CYSTS     ENDOMETRIOSIS         PELVIC INFECTION – PERITONITIS

           UTERINE INFECTION    UTERINE CANCER      CERVICAL CANCER    COLON CANCER

            HERNIAS OF THE STOMACH WALL – FEMORAL,  UMBILICAL                                                                                        

                   IRRITABLE BOWEL SYNDROME      DIVERTICULITIS     APPENDICITIS      

Upper Abdominal Pain


Biliary disease - Cholecystitis ( Inflammation of the gallbladder) and gallstones typically cause pain in the right upper quadrant of the abdomen. The pain can be recurrent in nature and be related to  food ingestion. Patients may complain of of nausea, vomiting, and anorexia in addition to the pain. 

Acute pancreatitis - this often causes severe epigastric( upper , middle, abdomen) pain at the outset that radiates ( spreads) to the back. Vomiting and sometimes shock are typical associated features.

Peptic ulcer disease - ulcers are sores in the lining of the stomach caused by irritating acids eroding the lining of the stomach.

Gastro-esophageal reflux disease- stomach acids constantly flowing into the lower esophagus causing chronic heartburn and irritation, especially after eating.

Pneumonia - of the lower areas of the lung can cause abdominal pain by irritating the  diaphragm ( the muscular structure separating the chest from the abdomen) This can mimic gallbladder disease.

Heart Attack - may present with upper abdominal pain mimicking a gastric ulcer. If you are considered a high risk cardiac patient you may need to be monitored with an ECG.

Damage  to the Spleen - this organ is situated near the stomach and is mainly involved in filtering blood. It can be damaged by trauma to the stomach or by blood clots entering its circulation, both of which cause pain in the left upper quadrant of the abdomen. 
                   
     
                    
  Lower abdominal pain  

  Acute Appendicitis - is a common surgical condition in all age groups. Appendicitis 
  causes   vague central abdominal pain that localizes to the right lower stomach and often 
  radiates down the groin. Nausea, vomiting and diarrhea  may be associated features. Your 
  doctor can often determine the cause of pain by the site of tenderness and signs on physical 
  examination.

  Diverticular disease - Diverticulitis occurs when abnormal out-pouching of the bowel get obstructed   
  and inflamed by fecal matter. It normally produces pain on the left side of the  abdomen.

             Inflammatory Bowel Disease - Crohn's disease and Ulcerative colitis ( chronic ulcers in the colon)
             can cause  episodes of abdominal pain .

             Kidney Stones - can cause very severe back pain and severe stomach pain.

             Hernias of the abdominal wall ( Umbilical - at the belly button / Inguinal - at the lower right or left
             of the  stomach)  can cause severe pain .

             Bladder distension - may be caused by blockage of the bladder outlet and cause the bladder to
             enlarge like a ballon. Prostate infection and benign prostate muscular swelling ( hypertrophy).

             Gastroenteritis - or a Urinary tract / Bladder infection are common causes of abdominal pain.

             Pelvic Inflammatory Disease - infection of the fallopian tubes, uterus and pelvis are very common
             causes of lower abdominal pain in young sexually active women and in all females. 
 
            Ovarian cysts and masses in the ovaries often cause sharp pain or a dull aching pain on the side of
              the cyts or mass lesion.   

             Ectopic pregnancy - is a pregnancy inside the fallopian tube,  ovary or abdomen. It causes dull
             aching  pain initially, then as the pregnancy expands more sharp stabbing severe pain is
             experienced. If the pregnancy continues to grow it may cause severe bleeding and immediate
             surgery is often required.   
       
             Endometriosis - is a chronic condition where tissue from the lining of the uterus is present
             outside the uterus often on the ovary, bowel, pelvic nerves, tubes or other abdominal sites
             causing mild to severe  pain.
           
            Fibroids- are normally benign growths on the wall of the uterus that cause pain, bleeding and
             pressure. Heavy bleeding during the menstrual cycle is a common early sign of fibroids. Fibroids
             often are inherited by daughters from their mothers through some yet to be discovered genetic
             process. 


     Diffuse Abdominal Pain


           Bowel Obstruction- Small bowel obstruction ( blockage of the intestines) is commonly due to
           adhesions (scarring) from previous infection, surgery while large bowel obstruction is often due to a
           mass or twisting  of the bowel. Nausea, vomiting, bloating and an inability to pass stool or gas are
          often  symptoms in patients with obstuction.

           Abdominal Aortic Aneurysm - is a dilatation ( balloon like) or out-pouching of the wall of the main and
           biggest blood vessel  running through the abdomen. These areas are weak and prone to rupture or
           burst. If this rupture or leakage ocuurs, severe abdominal pain, severe back pain and severe blood
           loss and shock often occur. this is a true surgical emergency and many patients do not survive this
           condition.
  
           Peritonitis - is the generalized inflammation of the lining of the abdominal cavity. When the abdomen is
           pushed in and then released, severe pain often occurs. This is often seen with acute pelvic infection,
           appendicitis, and leaking bowel disorders.

    Other less common causes of Abdominal Pain   


           Metabolic Disorders-  Diabetes mellitus, porphyrias, and lead poisoning are medical causes of
           acute abdominal pain.

   
           Abdominal Malignancies - Colon cancer, stomach,  and pancreatic cancers may cause
           abdominal  pain.

           Lactose Intolerance  

           Tropical Infections 

           Psychogenic causes - Abdominal pain is often a feature of somatoform



    Diseases Presenting with Abdominal Pain

          Hepatitis C viral infection ( HCV)

          Peptic Ulcer Disease  ( PUD )

          Ulcerative Colitis  ( UC )

          Gastro-Esophageal Reflux Disease ( GERD )

          Crohn's Disease

          Pancreatitis - Acute  and Chronic Pancreatitis

          Gallstone Disease

          Choledocholithiasis ( including - Cholangitis and Obstructive Jaundice)          

        While the history and physical examination are vitally important in determining the cause of abdominal
     pain, testing often is necessary to determine the cause.

     Laboratory tests. Laboratory tests such as the complete blood count (CBC), liver enzymes,
     pancreatic  enzymes (amylase and lipase), and urinalysis are frequently performed in the evaluation
     of abdominal pain. An elevated white count suggests inflammation or infection (as with appendicitis,
     pancreatitis, diverticulitis, or colitis). Amylase and lipase (enzymes produced by the pancreas) commonly
     are elevated in pancreatitis. Liver enzymes may be elevated with gallstone attacks. Blood in the urine
     suggests kidney stones. When there is diarrhea, white blood cells in the stool suggest intestinal 
     inflammation.

    Plain x-rays of the abdomen. Plain abdominal x-rays of the abdomen also are referred to as a KUB
    (because they include the Kidney, Ureter, and Bladder). The KUB may show enlarged loops of intestines
    filled with copious amounts of fluid and air when there is intestinal obstruction. Patients with a perforated 
    ulcer may have air escape from the stomach into the abdominal cavity. The escaped air often can be seen
    on a KUB on the underside of the diaphragm. Sometimes a KUB may reveal a calcified kidney stone that
    has passed into the ureter and resulted in referred abdominal pain.

    Radiographic studies. Abdominal ultrasound is useful in diagnosing gallstones, cholecystitis
    appendicitis, or ruptured ovarian cysts as the cause of the pain. Computerized tomography (CT) of the
    abdomen is useful in diagnosing pancreatitis, pancreatic cancer, appendicitis, and diverticulitis, as well as
    in diagnosing abscesses in the abdomen. Special CT scans of the abdominal blood vessels can detect
    diseases of the arteries that block the flow of blood to the abdominal organs. Magnetic resonance imaging 
    MRI ) is useful in diagnosing gallstones that have passed out of the gallbladder and are obstructing the bile
    ducts. Barium x-rays of the stomach and the intestines (upper gastrointestinal series or UGI with a small
   bowel follow-through) can be helpful in diagnosing ulcers, inflammation, and blockage in the intestines.

    Computerized tomography (CT) of the small intestine can be helpful in diagnosing diseases in the small
    bowel such as Crohn's disease. Capsule enteroscopy, a small camera the size of a pill swallowed by the
    patient, can take pictures of the entire small bowel and transmit the pictures onto a portable receiver. The
    small bowel images can be downloaded from the receiver onto a computer to be inspected by a doctor
    later. Capsule enteroscopy can be helpful in diagnosing Crohn's disease, small bowel tumors, and
    bleeding lesions not seen on x-rays or CT scans

    
     Endoscopic procedures.  Esophagogastroduodenoscopyor EGD is useful for detecting ulcers,
     gastritis (inflammation of the stomach), or stomach cancer.Colonoscopy or flexible sigmoidoscopy is
     useful for diagnosing infectious colitis, ulcerative colitis, or colon cancer. Endoscopic ultrasound (EUS)
     is useful for diagnosing pancreatic cancer or gallstones if the standard ultrasound or CT or MRI scans fail
     to detect them.


    Surgery - Sometimes the diagnosis requires the examination of the abdominal cavity by placing a
    camera through the belly button ( laparoscopy ) or by opening the stomach surgically ( laparotomy).

                                                   
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                               KENNETH GOODRICH, M.D.  -  OBSTETRICIAN- GYNECOLOGIST  
     
                                           Certified by the American Board of Obstetrics and Gynecology

           Specializing in General Obstetrics and Gynecology, Minimally Invasive Gynecological Surgery- Hysterectomies
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