Chronic/Recurrent Abdominal Pain

Differential Overview

❑ Irritable bowel syndrome

❑ Peptic ulcer disease

❑ Cholecystitis

❑ Chronic pancreatitis

❑ Inflammatory bowel disease

❑ Intermittent mesenteric ischemia

❑ Pancreatic cancer

❑ Gastric cancer

❑ Endometriosis

❑ Recurrent intestinal obstruction

❑ Sickle cell anemia

❑ Radiculopathy

❑ Adrenal insufficiency

❑ Lead poisoning

❑ Porphyria

Diagnostic Approach

Examining a patient during an episode of pain is important for diagnosis. A significant proportion of patients with chronic abdominal pain will remain undiagnosed despite extensive testing. For these patients, repeated history and examination, during which one looks for new symptoms or any change in the pattern of symptoms, may eventually yield a formulation.

Clinical Findings

Irritable bowel syndrome  Typically, pain is experienced as cramping relieved by a bowel movement. The pain often changes in location, but the hepatic and splenic flexures and the sigmoid colon are frequent sites. Bowel movements may be either loose or constipated. Gaseous abdominal distension is often reported and can be appreciated on examination.

Peptic ulcer disease  A typical presentation will be chronic dyspepsia with an epigastric gnawing or hunger pain, both of which are temporarily relieved by food or antacids.

Cholecystitis  Biliary colic appears with repeated episodes of steady right upper quadrant pain that lasts 15 minutes to hours and then is com-
pletely relieved. Acute cholecystitis has acute progressive pain with a tender
gallbladder.

Chronic pancreatitis  A sequela of recurrent bouts of acute pancreatitis, usually alcoholic in origin. At this phase, there is often a pancreatic malabsorptive syndrome with steatorrhea. A pseudocyst may be palpable.

Inflammatory bowel disease  Crohn disease in particular may be confined to the terminal ileum, producing right lower quadrant pain. There will be concomitant fever, localized tenderness, and mucous, bloody, or diarrheal stools.

Intermittent mesenteric ischemia  Ischemia presents as episodes of cramping or dull midabdominal pain that comes 15 to 30 minutes after a meal and lasts as long as 2 to 3 hours. Considerable weight loss can be caused by avoidance of eating. Mesenteric artery luminal compromise is usually atherosclerotic in origin and found in patients with other atherosclerotic symptoms such as claudication or angina.

Pancreatic cancer  Pain occurs in 75% of patients, especially with involvement of the body or tail of the pancreas, with deep abdominal pain radiating into the back. There is a vaguely palpable, deep, fixed mass in the left upper quadrant. Wasting, jaundice, clay-colored stools, dark urine, and migratory thrombophlebitis (Trousseau sign) are other indicators.

Gastric cancer  It presents with continuous epigastric pain, anorexia, and nausea.

Endometriosis  Pelvic pain, which cycles in intensity with the period, is typical.

Recurrent intestinal obstruction  There is often a history of prior abdominal surgery giving rise to adhesions. The pain is midabdominal with distension. Vomiting ensues if obstruction is severe.

Sickle cell anemia  Recurrent, episodic, acute abdominal pain (sickle crisis) occurs in a patient with known sickle cell anemia.

Radiculopathy  The underlying process may be postherpetic, diabetic mononeuritis, or osteophyte impingement on a nerve root. The pain is neuritic (burning, sharp, electric), follows a dermatomal pattern, and does not cross the midline.

Adrenal insufficiency  Vague abdominal pain—sometimes severe—is associated with the insidious onset of weakness, nausea, weight loss, orthostatic hypotension, and hyperpigmentation, especially of the mucous membranes.

Lead poisoning  A wandering, poorly localized, colicky pain is associated with encephalopathy and peripheral neuropathy. A blue-black “lead line” on the gum, due to precipitation of lead salts, is a helpful clue.

Porphyria  It presents with recurrent symptoms of generalized, severe, colicky abdominal pain.

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

Other Book Chapters Related to Abdominal symptoms

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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Abdominal symptoms: Introduction (review 3124 causes)
• Next Book Extract About Abdominal symptoms: Abdominal/Pelvic Mass (Field Guide to Bedside Diagnosis)
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More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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