ABDOMINAL PAIN, CHRONIC RECURRENT

Ask the following questions:

1. Is there a family history of migraine or epilepsy? Migraine and epilepsy both present with abdominal pain.
2. Is the pain colicky or persistent? Chronic colicky abdominal pain may be due to chronic cholecystitis, cholelithiasis, renal calculus, or partial intestinal obstruction.
3. What is the location of the pain? If the pain is located in the upper abdomen, then one should consider peptic ulcer disease, pancreatitis, cholecystitis, and cholelithiasis. If the pain is located in the flanks, one should consider renal calculus and pyelonephritis. If the pain is located in the lower abdomen, one should consider diverticulitis, salpingitis, endometritis, and chronic appendicitis. Regional ileitis also may be located in the lower abdomen, particularly in the right lower quadrant.
4. What is the relationship to meals? Abdominal pain relieved by food may be due to a peptic ulcer. Abdominal pain brought on by food may be due to abdominal angina. If the pain comes on 2 to 3 hr after a meal, it may be due to a peptic ulcer. On the other hand, pain that comes on 1 to 2 hr after meals, especially if it's a fatty meal, may be related to cholecystitis and cholelithiasis.
5. Is there fever associated with the abdominal pain? Fever and abdominal pain may be due to pyelonephritis, diverticulitis, or appendicitis.
6. Is there a history of chronic alcoholism? The history of chronic alcoholism suggests acute and chronic pancreatitis.
7. Is there blood in the stool? The presence of blood in the stool would, of course, suggest peptic ulcer disease and diverticulitis.
8. Is there an abdominal mass? The presence of an abdominal mass, particularly in the midepigastrium, suggests a pancreatic cyst related to chronic pancreatitis. A mass in the right lower quadrant might be related to regional ileitis or salpingitis. A mass in the left lower quadrant may be related to diverticulitis and salpingitis.

DIAGNOSTIC WORKUP

Routine laboratory tests include a CBC, sedimentation rate, urinalysis, urine culture, sensitivity, colony count, chemistry panel, serum amylase and lipase, pregnancy test, stool for occult blood, and stools for ovum and parasites. A chest x-ray, EKG, and flat plate of the abdomen should also be done. A urine porphobilinogen will help exclude porphyria.

If these tests are negative, then an upper gastrointestinal (GI) series, esophagogram, and gallbladder ultrasound would be done for upper abdominal pain; an IVP would be done for flank pain; and a barium enema and sigmoidoscopy would be performed for lower abdominal pain.

If these studies are inconclusive, a gastroenterologist should be consulted for endoscopic procedures. If there is upper abdominal pain, esophagoscopy, gastroscopy, and duodenoscopy would be performed. Endoscopic retrograde cholangiopancreatography (ERCP) may be required to diagnose cholangitis or common duct stones. If there is lower abdominal pain, colonoscopy would be performed. A CT scan of the abdomen and pelvis is a useful diagnostic tool also. Gallium scans may detect a diverticular abscess or other localized area of chronic inflammation. Pelvic ultrasound may be useful in lower abdominal pain, especially in females. Aortography and angiography will be useful in abdominal angina. Lymphangiography can be helpful in discovering retroperitoneal tumors. Ultimately, exploratory laparotomy may still be necessary in some cases.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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More About This Book: Title: Algorithmic Diagnosis of Symptoms and Signs Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 0-7817-3805-9

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