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Evaluation of the adult with abdominal pain
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opic Outline
● SUMMARY & RECOMMENDATIONS ❍ Large
● INTRODUCTION
● EVALUATION
❍ History ● Bookmark
■ Acute versus chronic

■ Description
●
■ Associated symptoms

■ Other medical history

❍ Physical examination

❍ Studies

● DIAGNOSTIC APPROACH TO ACUTE

ABDOMINAL PAIN
❍ Urgent/emergent evaluation and/or surgical

abdomen
❍ Nonurgent evaluation

■ Right upper quadrant pain

■ Epigastric pain

■ Left upper quadrant pain

■ Lower abdominal pain

■ Diffuse abdominal pain

● DIAGNOSTIC APPROACH TO CHRONIC ABDOMINAL PAIN

❍ Initial workup

❍ Subsequent work-up

● SPECIAL POPULATIONS
❍ Women

❍ Older adults

❍ Sickle cell

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 Evaluation of the adult with abdominal pain - UpToDate

HIV-infected patients
❍

● SOCIETY GUIDELINE LINKS

● INFORMATION FOR PATIENTS
● SUMMARY AND RECOMMENDATIONS
● ACKNOWLEDGMENT
● REFERENCES

RAPHICS
●
Algorithms
❍ Evaluation of acute diarrhea

●
Tables
❍ Causes of left upper quadrant (LUQ) abdominal pain

❍ Causes of epigastric abdominal pain

❍ Causes of right upper quadrant (RUQ) abdominal pain

❍ Less common causes of abdominal pain

❍ Differential diagnosis of foodborne disease by item consumed

❍ Extraintestinal manifestations of inflammatory bowel disease

❍ Drugs causing constipation

❍ Causes of lower abdominal pain

❍ Differential diagnosis of dyspepsia

❍ Pelvic causes of abdominal pain in women

❍ Causes of acute pelvic pain by organ system

❍ Causes of diffuse abdominal pain

❍ Major symptoms and signs of hypothyroidism

ELATED TOPICS
● AIDS-related Kaposi sarcoma: Clinical manifestations and diagnosis
● AIDS-related cytomegalovirus gastrointestinal disease
● Acute calculous cholecystitis: Clinical features and diagnosis
● Acute cholangitis: Clinical manifestations, diagnosis, and management
● Acute complicated urinary tract infection (including pyelonephritis) in adults
● Acute simple cystitis in men
● Acute simple cystitis in women
● Acute viral gastroenteritis in adults
● Angina pectoris: Chest pain caused by coronary artery obstruction
● Approach to acute abdominal pain in pregnant and postpartum women
● Approach to the adult with acute diarrhea in resource-rich settings
● Approach to the adult with chronic diarrhea in resource-rich settings
● Approach to the adult with dyspepsia
● Auscultation of cardiac murmurs in adults
● Auscultation of heart sounds
● Causes and diagnosis of iron deficiency and iron deficiency anemia in adults

● Causes of abdominal pain in adults

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 Evaluation of the adult with abdominal pain - UpToDate

● Causes of chronic pelvic pain in nonpregnant women

● Clinical manifestations and diagnosis of acute diverticulitis in adults
● Clinical manifestations and diagnosis of chronic pancreatitis in adults
● Clinical manifestations and diagnosis of familial Mediterranean fever
● Clinical manifestations and diagnosis of irritable bowel syndrome in adults
● Clinical manifestations and diagnosis of sphincter of Oddi dysfunction
● Clinical manifestations of adrenal insufficiency in adults
● Clinical manifestations of hypercalcemia
● Clinical manifestations, diagnosis and prognosis of Crohn disease in adults
● Clinical manifestations, diagnosis, and prognosis of ulcerative colitis in adults
● Clinical presentation, diagnosis, and staging of colorectal cancer
● Clostridioides (formerly Clostridium) difficile infection in adults: Epidemiology, microbiology,
and pathophysiology
● Definitions, epidemiology, and risk factors for inflammatory bowel disease in adults
● Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Clinical features,
evaluation, and diagnosis
● Diagnosis of and screening for hypothyroidism in nonpregnant adults
● Diagnostic approach to community-acquired pneumonia in adults
● Endoscopic retrograde cholangiopancreatography: Indications, patient preparation, and
complications
● Epidemiology and etiology of peptic ulcer disease
● Epidemiology, clinical features, and diagnosis of mechanical small bowel obstruction in
adults
● Epidemiology, clinical manifestations, and diagnosis of cryptosporidiosis
● Evaluation of acute pelvic pain in nonpregnant adult women
● Evaluation of chronic pelvic pain in women
● Evaluation of splenomegaly and other splenic disorders in adults
● Evaluation of the HIV-infected patient with diarrhea
● Evaluation of the HIV-infected patient with odynophagia and dysphagia
● Evaluation of the adult with abdominal pain in the emergency department
● Functional dyspepsia in adults
● HIV-related lymphomas: Clinical manifestations and diagnosis
● Hepatic manifestations of sickle cell disease
● Hereditary angioedema: Epidemiology, clinical manifestations, exacerbating factors, and
prognosis
● Magnetic resonance cholangiopancreatography
● Mycobacterium avium complex (MAC) infections in persons with HIV
● Outpatient evaluation of the adult with chest pain
● Overview of acute pulmonary embolism in adults
● Overview of upper gastrointestinal endoscopy (esophagogastroduodenoscopy)
● Patient education: Chronic pelvic pain in women (Beyond the Basics)
● Patient education: Chronic pelvic pain in women (The Basics)
● Patient education: Severe abdominal pain (The Basics)
● Patient education: Stomach ache and stomach upset (The Basics)
● Patient education: Upper endoscopy (Beyond the Basics)
● Patient education: Upper endoscopy (The Basics)

● Patient education: Upset stomach (functional dyspepsia) in adults (Beyond the Basics)

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 Evaluation of the adult with abdominal pain - UpToDate

● Peptic ulcer disease: Clinical manifestations and diagnosis

● Prenatal care: Initial assessment
● Screening for sexually transmitted infections
● Society guideline links: Nontraumatic abdominal pain in adults
● The gynecologic history and pelvic examination
● Traumatic gastrointestinal injury in the adult patient

Evaluation of the adult with abdominal pain

Authors:Robert M Penner, BSc, MD, FRCPC, MScMary B Fishman, MDSection Editors:Andrew D
Auerbach, MD, MPHMark D Aronson, MDDeputy Editor:Lisa Kunins, MD
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2019. | This topic last updated: Jun 07, 2019.

INTRODUCTION
Abdominal pain can be a challenging complaint for both primary care and specialist
clinicians because it is frequently a benign complaint, but it can also herald serious
acute pathology.

Clinicians are responsible for trying to determine which patients can be safely
observed or treated symptomatically and which require further investigation or
specialist referral. This task is complicated by the fact that abdominal pain is often a
nonspecific complaint that presents with other symptoms [1].

This topic reviews a diagnostic approach to nontraumatic abdominal pain in adults.

The causes of abdominal pain and its pathophysiology, the evaluation of the adult
with abdominal pain in the emergency department, and the evaluation of abdominal
pain related to trauma is discussed elsewhere. (See "Causes of abdominal pain in
adults" and "Evaluation of the adult with abdominal pain in the emergency
department" and "Traumatic gastrointestinal injury in the adult patient".)

EVALUATION
Abdominal pain is a common problem. Most patients have a benign and/or self-limited
etiology, and the initial goal of evaluation is to identify those patients with a serious
etiology that may require urgent intervention. A history and focused physical
examination will lead to a differential diagnosis of abdominal pain, which will then
inform further evaluation with laboratory evaluation and/or imaging.

History — The history of a patient with abdominal pain includes determining whether
the pain is acute or chronic and a detailed description of the pain and associated
symptoms, which should be interpreted with other aspects of the medical history.

The overall sensitivity and specificity of the history and physical examination in

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diagnosing the different causes of abdominal pain is poor [2], particularly for benign
conditions [3,4]. Fortunately, studies of the accuracy of history and physical
examination for the more serious causes of abdominal pain (eg, acute appendicitis),
alone or in combination with focused investigations, have yielded better results [5-7].

Acute versus chronic — There is no strict time period that will classify the
differential diagnosis unfailingly. A clinical judgment must be made that considers
whether this is an accelerating process, one that has reached a plateau, or one that is
longstanding but intermittent. Patients with chronic abdominal pain may present with
an acute exacerbation of a chronic problem or a new and unrelated problem.

Pain of less than a few days’ duration that has worsened progressively until the time
of presentation is clearly "acute." Pain that has remained unchanged for months or
years can be safely classified as chronic. Pain that does not clearly fit either category
might be called subacute and requires consideration of a broader differential than
acute and chronic pain.

Description — Pain should be characterized according to location, chronology,

severity, aggravating and alleviating factors, and associated symptoms. It is also
important to note if the patient has recurring episodes of similar pain as this may
narrow the differential.
● Location and radiation – The location of abdominal pain helps narrow the
differential diagnosis as different pain syndromes typically have characteristic
locations (table 1A-D). For example, pain involving the liver or biliary tree is
generally located in the right upper quadrant, but it may radiate to the back or
epigastrium. Because hepatic pain only results when the capsule of the liver is
"stretched," most pain in the right upper quadrant is related to the biliary tree.
Pain radiation is also important: the pain of pancreatitis classically bores to the
back, while renal colic radiates to the groin.
● Temporal elements – The onset, frequency, and duration of the pain are
helpful features. The pain of pancreatitis may be gradual and steady, while
perforation and resultant peritonitis begins suddenly and is maximal from the
onset.
● Quality – The quality of the pain includes determining whether the pain is
burning or gnawing, as is typical of gastroesophageal reflux and peptic ulcer
disease, or colicky, as in the cramping pain of gastroenteritis or intestinal
obstruction.
● Severity – The severity of the pain generally is related to the severity of the
disorder, especially if acute in onset. For example, the pain of biliary or renal
colic or acute mesenteric ischemia is of high intensity, while the pain of
gastroenteritis is less marked. Age and general health may affect the patient's
clinical presentation. A patient taking corticosteroids may have significant
masking of pain, and older adult patients often present with less intense pain.
● Precipitants or palliation – Determining what precipitates or palliates the
pain can help narrow the differential. The pain of chronic mesenteric ischemia
usually starts within one hour of eating, while the pain of duodenal ulcers may
be relieved by eating and recur several hours after a meal. The pain of

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pancreatitis is classically relieved by sitting up and leaning forward. Peritonitis

often causes patients to lie motionless on their backs because any motion
causes pain. Obtaining a history of pain occurring in relationship to eating
lactose- or gluten-containing foods may be helpful in identifying sensitivities to
these food constituents. Patients with foodborne illness may become ill after
eating certain foods (table 2).

Associated symptoms — Symptoms that occur in relation to abdominal pain may

give important information.
● Other gastrointestinal symptoms – We ask about associated nausea,
vomiting, diarrhea, constipation, hematochezia, melena, and changes in stool
(eg, change in caliber). For patients with right upper quadrant pain or concern
for liver disease, we also ask about jaundice and changes in the color of urine
and stool. The bowel habit is an important part of the history for chronic
abdominal pain. While many organic lesions can result in chronic diarrhea,
irritable bowel syndrome (IBS) often presents with swings between diarrhea and
constipation, a pattern that is much less likely with organic disease.
● Genitourinary symptoms – Patients with symptoms such as dysuria,
frequency, and hematuria are more likely to have a genitourinary cause for their
abdominal pain.
● Constitutional symptoms – Symptoms such as fevers, chills, fatigue,
weight loss, and anorexia would be concerning for infection, malignancy, or
systemic illnesses (eg, inflammatory bowel disease [IBD]).
● Cardiopulmonary symptoms – Symptoms such as cough, shortness of
breath, orthopnea, and exertional dyspnea suggest a pulmonary or cardiac
etiology. Orthostatic hypotension may indicate early shock or be associated with
adrenal insufficiency.
● Other – Patients with diabetic ketoacidosis will have symptoms of polyuria and
thirst. Patients with suspected IBD should be asked about extraintestinal
manifestations (table 3).

Other medical history — Other aspects of the history help narrow the differential.
● Specific questions for women – Women should be screened for sexually
transmitted diseases and risks for pelvic inflammatory disease (eg, new or
multiple partners). (See "Screening for sexually transmitted infections", section
on 'Assessing risk'.)

Premenopausal women should be asked about their menstrual history (last

menstrual period, last normal menstrual period, previous menstrual period, cycle
length) and use of contraception. They should also be asked about vaginal
discharge or bleeding, dyspareunia or dysmenorrhea, as these symptoms
suggest a pelvic pathology. (See "Prenatal care: Initial assessment" and
"Evaluation of acute pelvic pain in nonpregnant adult women" and "Evaluation of
chronic pelvic pain in women".)

● Past medical history – A history of surgeries and procedures should be

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obtained to assess risk for differing etiologies (eg, a history of abdominal

surgery is a risk factor for obstruction). A history of cardiovascular disease
(CVD) or multiple risk factors for CVD in a patient with epigastric pain raises
concern for a myocardial ischemia. (See "Outpatient evaluation of the adult with
chest pain", section on 'Differential Diagnosis'.)

● Medications – A comprehensive medication list (including over the counter

medications and medications that cause constipation (table 4)) should be
elicited as this can inform the differential. For example, patients taking high
doses of nonsteroidal antiinflammatory drugs (NSAIDs) are at risk for
gastropathy and peptic ulcer disease. Patients with recent antibiotics use or
hospitalization are at risk for Clostridioides (formerly Clostridium) difficile.
Patients on chronic steroids are at risk for adrenal insufficiency and may be
immunosuppressed with atypical presentations of abdominal pain. (See
"Epidemiology and etiology of peptic ulcer disease", section on 'NSAIDs,
including aspirin' and "Peptic ulcer disease: Clinical manifestations and
diagnosis", section on 'Assessment of NSAID use' and "Clostridioides (formerly
Clostridium) difficile infection in adults: Epidemiology, microbiology, and
pathophysiology", section on 'Risk factors'.)

● Other history

• Alcohol – It is important to ask about alcohol intake to assess for the

possibility of liver disease and pancreatitis.

• Family history – Family history should be asked as appropriate based

on other history. For example, patients with history concerning for IBD or
cancer should also be asked about family history. (See "Definitions,
epidemiology, and risk factors for inflammatory bowel disease in adults".)

• Travel history – A travel history is important to elicit in patients with

symptoms consistent with gastroenteritis or colitis (eg, nausea, vomiting,
and diarrhea) to consider infectious etiologies [8].

• Sick contacts – Often patients are in contact with someone with

gastroenteritis before having similar symptoms. Patients with foodborne
illness may also have close contacts with similar illness.

Physical examination — All patients should have vital signs and an abdominal
examination. Other physical examination will depend on the history. Patients with
chronic abdominal pain should have a thorough physical examination.
● Vital signs – Unstable vital signs are an indication for immediate referral to
the emergency department. (See "Evaluation of the adult with abdominal pain in
the emergency department".)

Vital signs may inform further evaluation. Weight and any changes should be
noted for patients seen over multiple visits. Patients with hypoxemia should be
evaluated for pulmonary etiologies of abdominal pain. Fever raises suspicion for
infectious disease. Orthostatic vital signs may be indicative of dehydration or a

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sign of adrenal insufficiency.

● Abdominal examination – The abdominal examination includes inspection,
auscultation, percussion, and palpation. In patients with suspected psychogenic
abdominal pain, it is important to perform the abdominal examination while the
patient is distracted.

• Inspection – The general appearance and level of comfort or discomfort

should be noted. Inspection of the abdomen should include attention to the
position assumed by the patient when in pain; strict immobility is typical of
a patient with peritonitis, while patients with biliary or renal colic writhe in
agony. Patients with peritonitis will have worsening pain when the
examiner lightly bumps the stretcher.

• Auscultation – The abdomen should be auscultated for bowel sounds.

Auscultation is a useful physical finding, particularly in detecting ileus
[9,10]. Abnormal bowel sounds are highly predictive of a small bowel
obstruction in patients with acute abdominal pain. Abnormally active, high-
pitched bowel sounds are a feature of early bowel obstruction, while a
friction rub in the appropriate area might be heard in a patient with a
splenic infarct.

• Percussion – We start with gentle percussion (rather than palpation).

Patients with peritonitis will have pain with gentle percussion. Percussion
is also used to identify ascites and hepatomegaly. Tympany signifies a
distended bowel, while dullness may signify a mass. Shifting dullness is a
reliable and fairly accurate sign for the detection of ascites.

• Palpation – Palpation is used to evaluate tenderness of the abdomen

and for enlarged organs (eg, hepatomegaly or splenomegaly) or masses.
We start by examining the quadrant of the abdomen where the patient is
experiencing the least pain.

Muscular rigidity or "guarding" is an important and early sign of peritoneal

inflammation; it can be unilateral in a patient with a focal inflammatory
mass such as a diverticular abscess or diffuse in peritonitis. Guarding is
typically absent with deeper sources of pain such as renal colic and
pancreatitis.

Rebound tenderness may reflect peritonitis. If testing for rebound

tenderness is appropriate, we begin with gentle palpation and release. If
the patient has no rebound tenderness with gentle palpation, we then
proceed to deeper palpation and release.

The patient should be examined for signs of nerve and muscle wall injury
and hernia. Pain in a dermatomal distribution and hyperesthesia are both
signs of nerve involvement as in herpes zoster or nerve root impingement.
Abdominal wall pathology may be found by palpation or by noting
exacerbation of the pain when using the abdominal wall muscles (eg,
sitting up).

● Rectal examination – Most patients with abdominal pain should have a

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rectal examination. Fecal impaction might be the explanation for signs and
symptoms of obstruction in older adults, while tenderness on rectal examination
may be the only abnormal finding in a patient with retrocecal appendicitis.
However, some patients with localized upper abdominal pain (eg, right upper
quadrant pain) or abdominal pain that is likely from a non-gastrointestinal cause
(eg, suspected cystitis) may not require a rectal examination.
● Pelvic examination – A pelvic examination should be done whenever pelvic
pathology is in the differential diagnosis. Unless the patient has another etiology
of abdominal pain, all women with acute lower abdominal pain should have a
pelvic examination. (See "The gynecologic history and pelvic examination" and
"Causes of abdominal pain in adults", section on 'Women'.)

● Other – The eyes should be examined for scleral icterus and the skin for
jaundice. Patients with pulmonary or cardiac symptoms should have pulmonary
and cardiac exams. Patients with history concerning for IBD should be
examined for extraintestinal manifestations of IBD (table 3). (See "Auscultation
of cardiac murmurs in adults" and "Auscultation of heart sounds".)

Studies — Laboratory studies are determined by the history and physical and will
vary depending on the suspected etiology. Pregnancy should be excluded in all
women of childbearing age with abdominal pain. (See 'Diagnostic approach to acute
abdominal pain' below and 'Diagnostic approach to chronic abdominal pain' below.)

Patients with abdominal pain will often have imaging as part of their evaluation. The
imaging modality chosen will depend on suspected etiologies. Imaging modalities that
may be used to evaluate abdominal pain include ultrasound, computed tomography
(CT) scan, magnetic resonance imaging (MRI; including magnetic resonance
cholangiopancreatography), endoscopy, and endoscopic retrograde
cholangiopancreatography. (See "Magnetic resonance cholangiopancreatography"
and "Overview of upper gastrointestinal endoscopy (esophagogastroduodenoscopy)"
and "Endoscopic retrograde cholangiopancreatography: Indications, patient
preparation, and complications".)

DIAGNOSTIC APPROACH TO ACUTE ABDOMINAL PAIN

The diagnostic approach to acute abdominal pain will depend on whether or not the
pain is localized. The location of abdominal pain helps narrow the differential
diagnosis as different pain syndromes typically have characteristic locations (table 1A-
C, 1E). Some patients with acute abdominal pain will need urgent or emergency
evaluation.

Urgent/emergent evaluation and/or surgical abdomen — Patients in

whom there are concerns for life-threatening causes of abdominal pain should be
referred to the emergency department. (See "Evaluation of the adult with abdominal
pain in the emergency department".)

These include those with:

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● Unstable vital signs

● Signs of peritonitis on abdominal exam (eg, abdominal rigidity, rebound
tenderness, and/or pain that worsens when the examiner lightly bumps the
stretcher)
● Concern that the abdominal pain is from a life-threatening condition (eg, acute
bowel obstruction, acute mesenteric ischemia, perforation, acute myocardial
infarction, ectopic pregnancy)

These patients may require analgesics, which can be administered without

compromising their assessment. (See "Evaluation of the adult with abdominal pain in
the emergency department", section on 'Analgesia'.)

Patients with concern for infection on initial evaluation (eg, fever, jaundice, and right
upper quadrant pain) should also be evaluated promptly, often requiring referral to the
emergency department for expedited evaluation. (See "Acute cholangitis: Clinical
manifestations, diagnosis, and management".)

Patients with less acute illnesses may require consultation or referral for further
management following a more detailed history and initial assessment, as described
below.

Nonurgent evaluation — In patients with localized pain, the differential diagnosis

can be considered in terms of "symptom clusters" in order to guide further
management and investigation. Patients with diffuse abdominal pain may need a
broader evaluation.

Right upper quadrant pain — Pain involving the liver or biliary tree is generally
located in the right upper quadrant, but it may radiate to the back or epigastrium (table
1C). Because hepatic pain only results when the capsule of the liver is "stretched,"
most pain in the right upper quadrant is related to the biliary tree. Patients with right
upper quadrant pain should have the following laboratory studies:
● Complete blood count with differential
● Electrolytes, blood urea nitrogen (BUN), creatinine, and glucose
● Aminotransferases, alkaline phosphatase, and bilirubin
● Lipase and/or amylase

Patients should also have an abdominal ultrasound to evaluate for hepatobiliary

etiologies.

Further evaluation will depend on the results of laboratory studies and ultrasound
results. Patients in whom there is concern for hepatobiliary infection, particularly acute
cholangitis and acute cholecystitis, should be referred for prompt evaluation. (See
"Acute cholangitis: Clinical manifestations, diagnosis, and management" and "Acute
calculous cholecystitis: Clinical features and diagnosis".)

Epigastric pain — Patients with epigastric pain and cardiac risk factors and/or
other symptoms concerning for angina (eg, shortness of breath, exertional symptoms)
should have appropriate cardiac evaluation. (See "Angina pectoris: Chest pain caused
by coronary artery obstruction", section on 'Diagnosis'.)

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Other patients with epigastric pain should be evaluated for pancreatitis as well as
gastric etiologies (table 1B). Patients should have the following laboratory studies:

● Complete blood count with differential

● Electrolytes, BUN, creatinine, and glucose
● Aminotransferases, alkaline phosphatase, and bilirubin
● Lipase and/or amylase

If there is concern for hepatobiliary pain (table 1C), patients should have an
abdominal ultrasound for evaluation. Patients with concern for other etiologies should
have appropriate evaluation (eg, if concern for peptic ulcer disease, endoscopy may
be indicated). (See "Peptic ulcer disease: Clinical manifestations and diagnosis",
section on 'Upper endoscopy'.)

Pain limited to the epigastrium, which may be associated with bloating, abdominal
fullness, heartburn, or nausea can be classified as dyspepsia (table 5). The evaluation
of dyspepsia is discussed in detail elsewhere. (See "Approach to the adult with
dyspepsia", section on 'Initial evaluation'.)

Left upper quadrant pain — Left upper quadrant pain can be caused by splenic
etiologies (table 1A). Patients with left upper quadrant pain should therefore be
evaluated for splenomegaly and other disorders of the spleen. Most patients will have
imaging with either ultrasound or computed tomography (CT) scan.

However, the causes of epigastric abdominal pain are more common than splenic
etiologies (table 1B), and pain from these disorders may atypically present as left
upper quadrant pain.

The evaluation of patients with splenomegaly is discussed separately. (See

"Evaluation of splenomegaly and other splenic disorders in adults", section on
'Evaluation (splenomegaly)'.)

Lower abdominal pain — Pain in the lower abdomen can be associated with the
distal intestinal tract, but it may also radiate down from upper abdominal structures or
up from the pelvis (table 1E). Diagnostic evaluation will depend on suspected
etiologies based on the history and physical examination.

Women of childbearing age should have a pregnancy test. Women with suspected
pelvic etiologies (table 6 and table 7) should have appropriate evaluation, which is
discussed elsewhere. (See "Evaluation of acute pelvic pain in nonpregnant adult
women".)

Patients with suspected genitourinary etiologies should have appropriate evaluation

(eg, patients with lower abdominal pain and concern for cystitis or pyelonephritis
should have a urinalysis and culture). (See "Acute simple cystitis in women", section
on 'Diagnostic approach' and "Acute simple cystitis in men", section on 'Diagnostic
approach' and "Acute complicated urinary tract infection (including pyelonephritis) in
adults", section on 'Diagnostic approach'.)

Patients thought to have lower abdominal pain from gastrointestinal causes should

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have a complete blood count with differential. Further diagnostic testing will depend
on suspected etiology. As examples:
● Patients with lower abdominal pain and acute diarrhea may have self-limited
presentations and can be managed expectantly depending on severity of illness
and other risk factors (algorithm 1). This is discussed in detail elsewhere. (See
"Approach to the adult with acute diarrhea in resource-rich settings".)

● Subacute right lower quadrant pain with diarrhea is the most characteristic
presentation of ileal Crohn disease, although the presentation of inflammatory
bowel disease (IBD) can be highly variable. (See "Approach to the adult with
chronic diarrhea in resource-rich settings", section on 'Initial evaluation'.)

● Acute left lower quadrant pain with fever and elevated white blood cell count is
suggestive of diverticulitis. (See "Clinical manifestations and diagnosis of acute
diverticulitis in adults", section on 'Diagnosis'.)

● Patients with anemia should have evaluation for iron deficiency anemia. In older
patients, iron deficiency anemia is concerning for colorectal cancer. (See
"Causes and diagnosis of iron deficiency and iron deficiency anemia in adults"
and "Clinical presentation, diagnosis, and staging of colorectal cancer", section
on 'Symptoms from the local tumor'.)

● In older patients, abdominal pain and a change in bowel habits can be the first
sign of colon cancer. Presentations of colonic neoplasia are highly variable, so
risk factors for colon cancer (particularly age and family history) should be
considered in patients with lower abdominal pain. (See "Clinical presentation,
diagnosis, and staging of colorectal cancer".)

Diffuse abdominal pain — Patients with diffuse or nonspecific abdominal pain

may have pain from etiologies that lead to diffuse abdominal pain (table 8) or those
that tend to be more localized (table 1A-C, 1E). Diagnostic evaluation will depend on
suspected etiologies based on the history and physical examination.

Patients with suspected acute infectious gastroenteritis or toxin-mediated food

poisoning may not need further evaluation. The most useful diagnostic tool will often
be watchful waiting for spontaneous recovery. Multisystem symptoms, such as upper
respiratory tract involvement or myalgias, may suggest a viral etiology. A history of
family members or other contacts developing a similar illness is valuable, not only
because it points towards a likely diagnosis, but because the patient's illness is likely
to mimic the course of their contact's illness. Depending on their degree of systemic
illness, patients with self-limited symptoms may need only reassurance or may require
significant supportive care. (See "Acute viral gastroenteritis in adults", section on
'Treatment'.)

Patients with diffuse upper abdominal pain may have pleural or pulmonary pathology,
particularly when the patient also had associated pulmonary symptoms (eg, cough,
shortness of breath). Lower lobe pulmonary pathologies (eg, pneumonia, pulmonary
embolism) or inflammatory pleural effusions (eg, empyema, pulmonary infarction) can
present with what appears to be abdominal pain because they occur at the threshold
of the abdomen. In patients with diffuse upper abdominal pain and associated

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pulmonary symptoms, chest imaging should be done to evaluate for thoracic

etiologies. The modality will depend on suspected etiology. For example, patients with
suspected pneumonia should have chest radiography, while patients with suspected
pulmonary embolism should have a chest CT scan. (See "Diagnostic approach to
community-acquired pneumonia in adults", section on 'Radiologic evaluation' and
"Overview of acute pulmonary embolism in adults", section on 'Diagnostic approach to
patients with suspected PE'.)

In patients with diffuse or nonspecific abdominal pain with unknown etiology, we

check the following laboratory studies:
● Electrolytes, with calculation of an anion gap
● BUN, creatinine, blood glucose
● Calcium
● Complete blood count with differential
● Lipase and/or amylase
● Pregnancy test in women of childbearing age
● In older adult or immunosuppressed patients who may have atypical
presentations of biliary tree infection, we also check aminotransferases, alkaline
phosphatase, and bilirubin

Further evaluation will depend on results from the initial evaluation. As examples:
● Patients with history concerning for IBD with extraintestinal manifestations (table
3) and/or family history should be evaluated as appropriate. (See "Clinical
manifestations, diagnosis, and prognosis of ulcerative colitis in adults", section
on 'Diagnosis' and "Clinical manifestations, diagnosis and prognosis of Crohn
disease in adults", section on 'Diagnosis'.)

● The combination of metabolic acidosis and an elevated blood glucose strongly

suggests diabetic ketoacidosis (DKA) as the etiology of the symptoms. It is
important to keep in mind that an intraabdominal infection could precipitate DKA
in a patient with diabetes. (See "Diabetic ketoacidosis and hyperosmolar
hyperglycemic state in adults: Clinical features, evaluation, and diagnosis".)

● Patients with hyponatremia or hyperkalemia and symptoms of fatigue, malaise,

nausea and vomiting, and symptoms of hypotension may have adrenal
insufficiency. (See "Clinical manifestations of adrenal insufficiency in adults".)

● Hypercalcemia can cause abdominal pain, either directly or as an etiology for

pancreatitis or constipation. (See "Clinical manifestations of hypercalcemia",
section on 'Gastrointestinal abnormalities'.)

DIAGNOSTIC APPROACH TO CHRONIC ABDOMINAL PAIN

Chronic abdominal pain is a common complaint, and the vast majority of patients will
have a functional disorder, most commonly irritable bowel syndrome (IBS) [11,12].

The evaluation of chronic lower abdominal pain (pelvic pain) in women is discussed

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separately. (See "Clinical manifestations and diagnosis of irritable bowel syndrome in

adults", section on 'Chronic abdominal pain' and "Causes of chronic pelvic pain in
nonpregnant women".)

Initial workup — Initial workup is focused on differentiating benign functional

illness from organic pathology. Features that suggest organic illness include weight
loss, fever, hypovolemia, electrolyte abnormalities, symptoms or signs of
gastrointestinal blood loss, anemia, or signs of malnutrition. Laboratory studies should
be normal in patients with functional abdominal pain.

The following laboratory measurements should be performed in most patients with

chronic abdominal pain:
● Complete blood count with differential
● Electrolytes, blood urea nitrogen (BUN), creatinine, and glucose
● Calcium
● Aminotransferases, alkaline phosphatase, and bilirubin
● Lipase and/or amylase
● Serum iron, total iron binding capacity, and ferritin
● Anti-tissue transglutaminase

Further evaluation with imaging will depend on the differential diagnosis based on the
history, physical, and laboratory studies. For example:
● Laboratory studies suggestive of iron deficiency should raise the suspicion of
celiac disease, inflammatory bowel disease (IBD), or malignancy (eg, colorectal
cancer). (See "Causes and diagnosis of iron deficiency and iron deficiency
anemia in adults" and "Clinical manifestations, diagnosis and prognosis of Crohn
disease in adults", section on 'Clinical manifestations' and "Clinical
manifestations, diagnosis, and prognosis of ulcerative colitis in adults", section
on 'Clinical manifestations' and "Clinical presentation, diagnosis, and staging of
colorectal cancer".)

● In patients where IBD remains in the differential diagnosis but index of suspicion
is low, fecal calprotectin, which is sensitive for detection of intestinal
inflammation, may be used to select patients for colonoscopy. (See "Approach
to the adult with chronic diarrhea in resource-rich settings", section on 'General
laboratory tests'.)

● A history of recurrent pancreatitis or excessive alcohol intake should raise

suspicion for chronic pancreatitis. (See "Clinical manifestations and diagnosis of
chronic pancreatitis in adults".)

● Abdominal pain is not a common presentation of hypothyroidism, but when

additional symptoms (table 9) suggest abnormalities of thyroid function, a
thyroid-stimulating hormone should be measured. Hypothyroidism can
occasionally cause abdominal pain in the setting of constipation and ileus. (See
"Diagnosis of and screening for hypothyroidism in nonpregnant adults", section
on 'Clinical features'.)

● While the hallmark of IBS is pain associated with changes in bowel habit, other
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related functional disorders may present with isolated pain (such as functional
abdominal pain syndrome) or with pain mimicking upper gastrointestinal organic
pathology (such as functional dyspepsia). (See "Clinical manifestations and
diagnosis of irritable bowel syndrome in adults" and "Functional dyspepsia in
adults".)

Subsequent work-up — At the conclusion of the initial workup, young patients

with no evidence of organic disease can be treated symptomatically. The use of
further invasive testing should be directed at ruling in or out specific diseases and not
as a general screen.

However, a diagnosis of new-onset functional illness should be made only with great
caution in patients over 50 years of age. These patients, by virtue of their increased
risk of malignancy, will likely require abdominal imaging as their symptoms and signs
dictate.

Some patients have a history of pain that is likely organic, based on historical features
or laboratory abnormalities, but may be difficult to definitively diagnose because the
symptoms are intermittent. Less common causes of abdominal pain (table 1D) should
be considered in patients with repeated visits for the same complaint without a definite
diagnosis, in an ill-appearing patient with minimal or nonspecific findings, in patients
with pain out of proportion to clinical findings, and in immunocompromised patients.
Examples of such cases include:
● Right upper quadrant pain after cholecystectomy that mimics biliary colic and
could be functional biliary pain; it could also arise from intermittent passage of
stones that have formed in the bile ducts, passage of sludge, or sphincter of
Oddi dysfunction. (See "Clinical manifestations and diagnosis of sphincter of
Oddi dysfunction".)

● Chronic, partial small bowel obstruction may occur in some patients. Patients
usually present with chronic postprandial abdominal discomfort and variable
nausea. Abdominal distention and tympany may be present, but usually without
any fluid or electrolyte derangements. (See "Epidemiology, clinical features, and
diagnosis of mechanical small bowel obstruction in adults", section on 'Chronic,
partial obstruction'.)

● Very rare causes of intermittent acute severe abdominal pain should be

considered in view of a positive family history (eg, familial Mediterranean fever,
hereditary angioedema). (See "Clinical manifestations and diagnosis of familial
Mediterranean fever" and "Hereditary angioedema: Epidemiology, clinical
manifestations, exacerbating factors, and prognosis".)

SPECIAL POPULATIONS
Pelvic etiologies of abdominal pain (table 6) should be considered in women. Other
populations of patients, including older adults [13], and patients with human

immunodeficiency virus (HIV) [14] may present with unusual causes of abdominal

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pain or may have unusual presentations of common disorders.

Women — Lower abdominal pain in women must be considered as a spectrum with

causes of pelvic pain (table 6). The evaluation of pelvic pain in women is discussed
separately. (See "Evaluation of acute pelvic pain in nonpregnant adult women" and
"Evaluation of chronic pelvic pain in women".)

Acute abdominal pain in pregnant and postpartum women may or may not be related
to pregnancy. (See "Approach to acute abdominal pain in pregnant and postpartum
women".)

Older adults — Older adult patients often do not present with the same signs and
symptoms of disease characteristic of younger individuals. Older patients may not
have fever or abnormal laboratory values with infectious etiologies for abdominal pain
[15]. The frequency of misdiagnosis of the acute abdomen in older patients is high
and associated with higher mortality rates than in younger patients [16].

A particularly high level of suspicion should be maintained for severe pathology in

immunosuppressed patients (including those taking immunosuppressive agents or
having comorbidities affecting immune function, such as diabetes or renal failure) and
older adults, where classic signs of peritoneal inflammation may be attenuated.

Sickle cell — Patients with sickle cell may have right upper quadrant pain in the
setting of hepatic involvement. The liver can be affected by a number of complications
due to the disease itself and its treatment. (See "Hepatic manifestations of sickle cell
disease", section on 'Disorders associated with the sickling process' and "Hepatic
manifestations of sickle cell disease", section on 'Disorders related to coexisting
conditions'.)

HIV-infected patients — Diagnostic evaluation of abdominal pain in the HIV-

infected patient is similar to that in the general population, but it is also guided by the
immunologic function as represented by the CD4 cell count. The differential diagnosis
includes common etiologies seen in the general population (eg, appendicitis,
diverticulitis) but also opportunistic infections (eg, cytomegalovirus [CMV],
Mycobacterium avium complex [MAC], cryptosporidium) and neoplasms (eg, Kaposi
sarcoma, lymphoma) if there is evidence of advanced immunodeficiency (CD4 cell
count <100 cells/microL). In this context, there should be a lower threshold for
radiologic imaging and obtaining tissue culture and/or biopsy where appropriate. (See
"AIDS-related cytomegalovirus gastrointestinal disease" and "Mycobacterium avium
complex (MAC) infections in persons with HIV" and "Epidemiology, clinical
manifestations, and diagnosis of cryptosporidiosis" and "AIDS-related Kaposi
sarcoma: Clinical manifestations and diagnosis" and "HIV-related lymphomas: Clinical
manifestations and diagnosis".)

Evaluation of odynophagia and dysphagia and diarrhea in the HIV-infected patient are
discussed elsewhere. (See "Evaluation of the HIV-infected patient with odynophagia
and dysphagia" and "Evaluation of the HIV-infected patient with diarrhea".)

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SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and
regions around the world are provided separately. (See "Society guideline links:
Nontraumatic abdominal pain in adults".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond
the Basics." The Basics patient education pieces are written in plain language, at the
5th to 6th grade reading level, and they answer the four or five key questions a patient
might have about a given condition. These articles are best for patients who want a
general overview and who prefer short, easy-to-read materials. Beyond the Basics
patient education pieces are longer, more sophisticated, and more detailed. These
articles are written at the 10th to 12th grade reading level and are best for patients who
want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage
you to print or e-mail these topics to your patients. (You can also locate patient
education articles on a variety of subjects by searching on "patient info" and the
keyword(s) of interest.)
● Basics topics (see "Patient education: Stomach ache and stomach upset (The
Basics)" and "Patient education: Chronic pelvic pain in women (The Basics)"
and "Patient education: Upper endoscopy (The Basics)" and "Patient education:
Severe abdominal pain (The Basics)")

● Beyond the Basics topics (see "Patient education: Upset stomach (functional
dyspepsia) in adults (Beyond the Basics)" and "Patient education: Chronic pelvic
pain in women (Beyond the Basics)" and "Patient education: Upper endoscopy
(Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

● Abdominal pain is a common problem. Most patients have a benign and/or self-
limited etiology, and the initial goal of evaluation is to identify those patients with
a serious etiology for their symptoms that may require urgent intervention. (See
'Evaluation' above.)

The history of a patient with abdominal pain includes determining whether the
pain is acute or chronic and a detailed description of the pain and associated
symptoms. (See 'History' above.)

All patients should have vital signs and an abdominal examination. Other
physical examination will depend on the history. Patients with chronic abdominal
pain should have a thorough physical examination. (See 'Physical examination'
above.)

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● Patients with unstable vital signs, signs of peritonitis on abdominal exam, or in

whom there are concerns for life-threatening causes of abdominal pain (eg,
acute bowel obstruction, acute mesenteric ischemia, perforation, acute
myocardial infarction, ectopic pregnancy) should be referred to the emergency
department. Patients with concern for infection on initial evaluation (eg, fever,
jaundice, and right upper quadrant pain) should also be evaluated promptly,
often requiring referral to the emergency department for expedited evaluation.
(See 'Urgent/emergent evaluation and/or surgical abdomen' above.)

● In patients with acute localized abdominal pain, the differential diagnosis can be
considered in terms of "symptom clusters" (table 1A-C, 1E) in order to guide
further management and investigation. Patients with diffuse or nonspecific
abdominal pain may have pain from etiologies that lead to diffuse abdominal
pain (table 8) or those that tend to be more localized. Pelvic etiologies of
abdominal pain (table 6) should be considered in women with lower abdominal
pain. (See 'Nonurgent evaluation' above and 'Women' above.)

● Most patients with chronic abdominal pain have a benign functional disorder
such as irritable bowel syndrome (IBS) or functional dyspepsia. Initial workup is
focused on differentiating benign functional illness from organic pathology. (See
'Initial workup' above.)

At the conclusion of the initial workup, young patients with no evidence of

organic disease can be treated symptomatically. However, a diagnosis of new-
onset functional illness should be made only with great caution in patients over
50 years of age. These patients, by virtue of their increased risk of malignancy,
will likely require abdominal imaging as their symptoms and signs dictate. (See
'Subsequent work-up' above.)

● Specific populations of patients, including older adults and patients with human
immunodeficiency virus (HIV) may present with unusual causes of abdominal
pain or may have unusual presentations of common disorders. (See "Evaluation
of acute pelvic pain in nonpregnant adult women" and "Evaluation of chronic
pelvic pain in women" and 'Special populations' above.)

ACKNOWLEDGMENT
We are saddened by the death of Sumit Majumdar, MD, MPH, who passed away in
January 2018. UpToDate wishes to acknowledge Dr. Majumdar's past work as an
author for this topic.

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES
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generally specific to one organ system? Am J Manag Care 2001; 7:299.

2. Yamamoto W, Kono H, Maekawa M, Fukui T. The relationship between

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3. Heikkinen M, Pikkarainen P, Eskelinen M, Julkunen R. GPs' ability to diagnose

dyspepsia based only on physical examination and patient history. Scand J Prim
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4. Thomson AB, Barkun AN, Armstrong D, et al. The prevalence of clinically

significant endoscopic findings in primary care patients with uninvestigated
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6. Eskelinen M, Ikonen J, Lipponen P. Usefulness of history-taking, physical

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7. Trowbridge RL, Rutkowski NK, Shojania KG. Does this patient have acute
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11. Drossman DA, Li Z, Andruzzi E, et al. U.S. householder survey of functional

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14. Thuluvath PJ, Connolly GM, Forbes A, Gazzard BG. Abdominal pain in HIV
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