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Evaluation of the adult with abdominal pain

Authors: Robert M Penner, BSc, MD, FRCPC, MSc, Mary B Fishman, MD
Section Editors: Andrew D Auerbach, MD, MPH, Mark D Aronson, MD
Deputy Editor: Lisa Kunins, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Aug 2022. | This topic last updated: May 10, 2021.

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

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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 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

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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 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]).

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● 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 females – Females 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 individuals 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 "Chronic pelvic pain in adult females: Evaluation".)

● Past medical history – A history of surgeries and procedures should be 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
difficile. Patients on chronic steroids are at risk for adrenal insufficiency and may be
immunosuppressed with atypical presentations of abdominal pain. (See "Peptic ulcer
disease: Epidemiology, etiology, and pathogenesis", section on 'NSAIDs, including
aspirin' and "Peptic ulcer disease: Clinical manifestations and diagnosis", section on
'Evaluate for nonsteroidal anti-inflammatory drug (NSAID) and corticosteroid use' and
"Clostridioides difficile infection in adults: Epidemiology, microbiology, and

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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".)

• 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 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

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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).

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● Rectal examination – Most patients with abdominal pain should have a 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 females 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 'Females'.)

● 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 females 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 "Overview of upper
gastrointestinal endoscopy (esophagogastroduodenoscopy)" and "Overview of endoscopic
retrograde cholangiopancreatography (ERCP) in adults".)

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

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acute abdominal pain will need urgent or emergency evaluation.

Urgent 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:

● 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

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● 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 fixed epicardial
coronary artery obstruction", section on 'Diagnosis'.)

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

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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.

Females of childbearing age should have a pregnancy test. Females 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 adult males", 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 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-abundant 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

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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 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 "Clinical evaluation and diagnostic testing for community-acquired
pneumonia in adults", section on 'Chest imaging' and "Overview of acute pulmonary
embolism in adults", section on 'Diagnostic approach to patients with suspected PE'.)

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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 females 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 'Diagnostic evaluation'.)

● 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

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functional disorder, most commonly irritable bowel syndrome (IBS) [11,12]. The evaluation of
chronic lower abdominal pain (pelvic pain) in females is discussed separately. (See "Clinical
manifestations and diagnosis of irritable bowel syndrome in adults", section on 'Chronic
abdominal pain' and "Chronic pelvic pain in nonpregnant adult females: Causes".)

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 features' 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-abundant settings", section on 'General laboratory tests'.)

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

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chronic pancreatitis. (See "Chronic pancreatitis: Clinical manifestations and diagnosis 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 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 workup — 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

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electrolyte derangements. (See "Etiologies, clinical manifestations, 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
the setting of a positive family history (eg, familial Mediterranean fever, hereditary
angioedema, acute intermittent porphyria [AIP]); in the case of AIP, the diagnosis may
be considered even without a family history of the disease. (See "Clinical manifestations
and diagnosis of familial Mediterranean fever" and "Hereditary angioedema:
Epidemiology, clinical manifestations, exacerbating factors, and prognosis" and
"Porphyrias: An overview", section on 'Acute hepatic porphyrias (AHP)' and "Acute
intermittent porphyria: Pathogenesis, clinical features, and diagnosis".)

SPECIAL POPULATIONS

Pelvic etiologies of abdominal pain ( table 6) should be considered in females. Other

populations of patients, including older adults [13], and patients with human
immunodeficiency virus (HIV) [14] may present with unusual causes of abdominal pain or
may have unusual presentations of common disorders.

Females — Lower abdominal pain in females must be considered as a spectrum with causes
of pelvic pain ( table 6). The evaluation of pelvic pain in females is discussed separately.
(See "Evaluation of acute pelvic pain in nonpregnant adult women" and "Chronic pelvic pain
in adult females: Evaluation".)

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

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.

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Sickle cell — Patients with sickle cell disease 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
"Cryptosporidiosis: Epidemiology, clinical manifestations, and diagnosis" 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 patient with HIV, odynophagia, and dysphagia"
and "Evaluation of the patient with HIV and diarrhea".)

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

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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 females (The Basics)" and "Patient
education: Upper endoscopy (The Basics)" and "Patient education: 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

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

• The history includes determining whether the pain is acute or chronic as well as
obtaining a detailed description of the pain (eg, location, radiation, temporal
description, quality, severity, and precipitating and palliating features) and any
associated symptoms. (See 'History' above.)

• All patients with abdominal pain should have measurement of vital signs and a
complete abdominal examination, including inspection, auscultation, percussion,
and palpation. Other physical examination will depend upon the patient's history.
Patients with chronic abdominal pain should have a thorough physical examination.
(See 'Physical examination' above.)

● Indications for urgent and/or surgical evaluation of acute abdominal pain –

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

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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 evaluation and/or surgical abdomen'
above.)

● Acute abdominal pain: Etiologies and differential diagnosis (See 'Nonurgent

evaluation' above.)

• Localized pain – 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.

• Diffuse or nonspecific 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). (See 'Diffuse abdominal
pain' above.)

• Females with lower abdominal pain – Pelvic etiologies ( table 6) should be

considered in females who have lower abdominal pain. (See 'Females' above.)

● Evaluation of chronic abdominal pain – Most patients with chronic abdominal pain
have a benign functional disorder such as irritable bowel syndrome (IBS) or functional
dyspepsia.

• Initial evaluation – Initial workup is focused on differentiating benign functional

illness from organic pathology. (See 'Initial workup' above.)

• Additional evaluation in certain patients – Young patients with no evidence of

organic disease can be treated symptomatically, although 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. Less common causes of
abdominal pain ( table 1D) should be considered in patients with repeated visits
for the same complaint, in an ill-appearing patient with minimal or nonspecific
findings, in patients with pain out of proportion to clinical findings, and in
immunocompromised patients. (See 'Subsequent workup' above.)

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● Etiologies of abdominal pain in special populations – Specific populations of

patients, including older adults, females, and patients with HIV and sickle cell disease
may present with unusual causes of abdominal pain or may have unusual presentations
of common disorders. (See 'Special populations' above.)

ACKNOWLEDGMENT

The UpToDate editorial staff acknowledges Sumit Majumdar, MD, MPH, now deceased, who
contributed to an earlier version of this topic review.

Use of UpToDate is subject to the Terms of Use.

REFERENCES

1. Fleischer AB Jr, Gardner EF, Feldman SR. Are patients' chief complaints 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 abdominal pain

regions and specific diseases: an epidemiologic approach to clinical practice. J Epidemiol
1997; 7:27.

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 Health Care 2000;
18:99.

4. Thomson AB, Barkun AN, Armstrong D, et al. The prevalence of clinically significant
endoscopic findings in primary care patients with uninvestigated dyspepsia: the
Canadian Adult Dyspepsia Empiric Treatment - Prompt Endoscopy (CADET-PE) study.
Aliment Pharmacol Ther 2003; 17:1481.

5. Böhner H, Yang Q, Franke C, et al. Simple data from history and physical examination
help to exclude bowel obstruction and to avoid radiographic studies in patients with
acute abdominal pain. Eur J Surg 1998; 164:777.

6. Eskelinen M, Ikonen J, Lipponen P. Usefulness of history-taking, physical examination

and diagnostic scoring in acute renal colic. Eur Urol 1998; 34:467.

7. Trowbridge RL, Rutkowski NK, Shojania KG. Does this patient have acute cholecystitis?
JAMA 2003; 289:80.

8. Becker SL, Vogt J, Knopp S, et al. Persistent digestive disorders in the tropics: causative
infectious pathogens and reference diagnostic tests. BMC Infect Dis 2013; 13:37.

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9. Gu Y, Lim HJ, Moser MA. How useful are bowel sounds in assessing the abdomen? Dig
Surg 2010; 27:422.

10. Eskelinen M, Ikonen J, Lipponen P. Contributions of history-taking, physical examination,

and computer assistance to diagnosis of acute small-bowel obstruction. A prospective
study of 1333 patients with acute abdominal pain. Scand J Gastroenterol 1994; 29:715.

11. Drossman DA, Li Z, Andruzzi E, et al. U.S. householder survey of functional

gastrointestinal disorders. Prevalence, sociodemography, and health impact. Dig Dis Sci
1993; 38:1569.

12. Talley NJ, Zinsmeister AR, Van Dyke C, Melton LJ 3rd. Epidemiology of colonic symptoms
and the irritable bowel syndrome. Gastroenterology 1991; 101:927.

13. de Dombal FT. Acute abdominal pain in the elderly. J Clin Gastroenterol 1994; 19:331.

14. Thuluvath PJ, Connolly GM, Forbes A, Gazzard BG. Abdominal pain in HIV infection. Q J
Med 1991; 78:275.

15. Parker LJ, Vukov LF, Wollan PC. Emergency department evaluation of geriatric patients
with acute cholecystitis. Acad Emerg Med 1997; 4:51.

16. Lyon C, Clark DC. Diagnosis of acute abdominal pain in older patients. Am Fam Physician
2006; 74:1537.
Topic 6862 Version 59.0

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GRAPHICS

Causes of left upper quadrant (LUQ) abdominal pain

LUQ Clinical features Comments

Splenomegaly Pain or discomfort in LUQ, left Multiple etiologies.

shoulder pain, and/or early
satiety.

Splenic infarct Severe LUQ pain. Atypical presentations

common. Associated with a
variety of underlying
conditions (eg,
hypercoagulable state, atrial
fibrillation, and splenomegaly).

Splenic abscess Associated with fever and LUQ Uncommon. May also be
tenderness. associated with splenic
infarction.

Splenic rupture May complain of LUQ, left Most often associated with
chest wall, or left shoulder trauma.
pain that is worse with
inspiration.

Graphic 106201 Version 2.0

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Causes of epigastric abdominal pain

Epigastric Clinical features Comments

Acute myocardial infarction May be associated with Consider particularly in

shortness of breath and patients with risk factors for
exertional symptoms. coronary artery disease.

Acute pancreatitis Acute-onset, persistent upper

abdominal pain radiating to
the back.

Chronic pancreatitis Epigastric pain radiating to the Associated with pancreatic

back. insufficiency.

Peptic ulcer disease Epigastric pain or discomfort is Occasionally, discomfort

the most prominent symptom. localizes to one side.

Gastroesophageal reflux Associated with heartburn,

disease regurgitation, and dysphagia.

Gastritis/gastropathy Abdominal discomfort/pain, Variety of etiologies including

heartburn, nausea, vomiting, alcohol and nonsteroidal
and hematemesis. antiinflammatory drugs
(NSAIDs).

Functional dyspepsia The presence of one or more Patients have no evidence of

of the following: postprandial structural disease.
fullness, early satiation,
epigastric pain, or burning.

Gastroparesis Nausea, vomiting, abdominal Most causes are idiopathic,

pain, early satiety, diabetic, or postsurgical.
postprandial fullness, and
bloating.

Graphic 106200 Version 2.0

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Causes of right upper quadrant (RUQ) abdominal pain

RUQ Clinical features Comments

Biliary

Biliary colic Intense, dull discomfort Patients are generally well-

located in the RUQ or appearing.
epigastrium. Associated with
nausea, vomiting, and
diaphoresis. Generally lasts at
least 30 minutes, plateauing
within one hour. Benign
abdominal examination.

Acute cholecystitis Prolonged (>4 to 6 hours) RUQ

or epigastric pain, fever.
Patients will have abdominal
guarding and Murphy's sign.

Acute cholangitis Fever, jaundice, RUQ pain. May have atypical presentation
in older adults or
immunosuppressed patients.

Sphincter of Oddi RUQ pain similar to other Biliary type pain without other
dysfunction biliary pain. apparent causes.

Hepatic

Acute hepatitis RUQ pain with fatigue, Variety of etiologies include

malaise, nausea, vomiting, and hepatitis A, alcohol, and drug-
anorexia. Patients may also induced.
have jaundice, dark urine, and
light-colored stools.

Perihepatitis (Fitz-Hugh- RUQ pain with a pleuritic Aminotransferases are usually

Curtis syndrome) component, pain is sometimes normal or only slightly
referred to the right shoulder. elevated.

Liver abscess Fever and abdominal pain are Risk factors include diabetes,
the most common symptoms. underlying hepatobiliary or
pancreatic disease, or liver
transplant.

Budd-Chiari syndrome Symptoms include fever, Variety of causes.

abdominal pain, abdominal
distention (from ascites), lower
extremity edema, jaundice,
gastrointestinal bleeding,

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and/or hepatic
encephalopathy.

Portal vein thrombosis Symptoms include abdominal Clinical manifestations depend

pain, dyspepsia, or on extent of obstruction and
gastrointestinal bleeding. speed of development. Most
commonly associated with
cirrhosis.

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Less common causes of abdominal pain

Abdominal aortic aneurysm

Abdominal compartment syndrome

Abdominal migraine

Acute hepatic porphyrias (eg, acute intermittent porphyria)

Angioedema (either hereditary or angiotensin-converting enzyme [ACE] inhibitor-related)

Celiac artery compression syndrome

Chronic abdominal wall pain

Colonic pseudo-obstruction (acute or chronic)

Eosinophilic gastroenteritis

Epiploic appendagitis

Familial Mediterranean fever

Helminthic infections

Herpes zoster

Hypercalcemia

Hypothyroidism

Lead poisoning

Meckel's diverticulum

Narcotic bowel syndrome

Paroxysmal nocturnal hemoglobinuria

Pseudoappendicitis

Pulmonary etiologies

Rectus sheath hematoma

Renal infarction

Rib pain

Sclerosing mesenteritis

Somatization

Wandering spleen

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Differential diagnosis of foodborne disease by item consumed

Item Commonly associated microbes*

Raw seafood Norwalk-like virus, Vibrio spp, hepatitis A

Raw eggs Salmonella spp

Undercooked meat or Salmonella spp, Campylobacter spp, STEC, Clostridium perfringens

poultry

Unpasteurized milk or Salmonella spp, Campylobacter spp, STEC, Yersinia enterocolitica

juice

Unpasteurized soft Salmonella spp, Campylobacter spp, STEC, Y. enterocolitica, Listeria

cheeses monocytogenes

Homemade canned goods Clostridium botulinum

Raw hot dogs, deli meat L. monocytogenes

STEC: shiga toxin-producing Escherichia coli.

* This association lists the commonly associated organisms and is not fully comprehensive.

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Extraintestinal manifestations of inflammatory bowel disease

Common extraintestinal manifestations

Musculoskeletal

Arthritis – Colitic type, ankylosing spondylitis, isolated joint involvement such as sacroiliitis.

Hypertrophic osteoarthropathy – Clubbing, periostitis, metastatic Crohn disease.

Miscellaneous – Osteoporosis, aseptic necrosis, polymyositis, osteomalacia.

Skin and mouth

Reactive lesions – Erythema nodosum, pyoderma gangrenosum, aphthous ulcers,

vesiculopustular eruption, cutaneous vasculitis, neutrophilic dermatosis, metastatic Crohn
disease, epidermolysis bullosa acquisita.

Specific lesions – Fissures and fistulas, oral Crohn disease, drug rashes.

Nutritional deficiency – Acrodermatitis enteropathica (zinc), purpura (vitamins C and K),

glossitis (vitamin B), hair loss and brittle nail (protein).

Associated diseases – Vitiligo, psoriasis, amyloidosis, epidermolysis bullosa acquisita.

Hepatobiliary

Specific complications – Sclerosing cholangitis (large-duct or small-duct), bile duct

carcinoma, cholelithiasis.

Associated inflammation – Autoimmune chronic active hepatitis, pericholangitis, portal

fibrosis and cirrhosis, granuloma in Crohn disease.

Metabolic – Fatty liver, gallstones associated with ileal Crohn disease.

Ocular

Uveitis iritis, episcleritis, scleromalacia, corneal ulcers, retinal vascular disease, retrobulbar
neuritis, Crohn keratopathy.

Metabolic

Growth retardation in children and adolescents, delayed sexual maturation.

Less common extraintestinal manifestations

Blood and vascular

Anemia due to iron, folate, or vitamin B12 deficiency or autoimmune hemolytic anemia,
anemia of chronic disease, thrombocytopenic purpura; leukocytosis and thrombocytosis;
thrombophlebitis and thromboembolism, arteritis and arterial occlusion, polyarteritis
nodosa, Takayasu arteritis, cutaneous vasculitis, anticardiolipin antibody, hyposplenism.

Renal and genitourinary tract

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Urinary calculi (oxalate stones in ileal disease), local extension of Crohn disease involving
ureter or bladder, amyloidosis, drug-related nephrotoxicity.

Renal tubular damage with increased urinary excretion of various enzymes (eg, beta
N-acetyl-D-glucosaminidase).

Neurologic

Up to 3% of patients may have non-iatrogenic neurologic involvement, including peripheral

neuropathy, myelopathy, vestibular dysfunction, pseudotumor cerebri, myasthenia gravis,
and cerebrovascular disorders. Incidence equal in ulcerative colitis and Crohn disease. These
disorders usually appear 5 to 6 years after the onset of inflammatory bowel disease and are
frequently associated with other extraintestinal manifestations.

Airway and parenchymal lung disease

Pulmonary fibrosis, vasculitis, bronchitis, necrobiotic nodules, acute laryngotracheitis,

interstitial lung disease, sarcoidosis. Abnormal pulmonary function tests without clinical
symptoms are common (up to 50% of cases).

Cardiac

Pericarditis, myocarditis, endocarditis, and heart block – More common in ulcerative colitis
than in Crohn disease; cardiomyopathy, cardiac failure due to anti-TNF therapy.

Pericarditis may also occur from sulfasalazine/5-aminosalicylates.

Pancreas

Acute pancreatitis – More common in Crohn disease than in ulcerative colitis. Risk factors
include 6-mercaptopurine and 5-aminosalicylate therapy, duodenal Crohn disease.

Autoimmune

Drug-induced lupus and autoimmune diseases secondary to anti-TNF-alpha therapy.

Positive ANA, anti-double-stranded DNA, cutaneous and systemic manifestations of lupus.

TNF: tumor necrosis factor; ANA: antinuclear antibody; DNA: deoxyribonucleic acid.

Modified from: Das KM. Relationship of extraintestinal involvements in inflammatory bowel disease: New insights into
autoimmune pathogenesis. Dig Dis Sci 1999; 44:1.

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Drugs associated with constipation

Analgesics

Anticholinergics
Antihistamines

Antispasmodics

Antidepressants

Antipsychotics

Cation-containing agents
Iron supplements

Aluminum (antacids, sucralfate)

Barium

Neurally active agents

Opiates

Antihypertensives

Ganglionic blockers

Vinca alkaloids

Calcium channel blockers

5HT3 antagonists

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Causes of lower abdominal pain

Lower abdomen Localization Clinical features Comments

Appendicitis Generally right lower Periumbilical pain Occasional patients

quadrant initially that radiates present with
to the right lower epigastric or
quadrant. Associated generalized
with anorexia, nausea, abdominal pain.
and vomiting.

Diverticulitis Generally left lower Pain usually constant Clinical presentation

quadrant; right lower and present for depends on severity of
quadrant more several days prior to underlying
common in Asian presentation. May inflammatory process
patients have associated and whether or not
nausea and vomiting. complications are
present.

Nephrolithiasis Either Pain most common Cause symptoms as

symptom, varies from stone passes from
mild to severe. renal pelvis to ureter.
Generally flank pain,
but may have back or
abdominal pain.

Pyelonephritis Either Associated with

dysuria, frequency,
urgency, hematuria,
fever, chills, flank pain,
and costovertebral
angle tenderness.

Acute urinary Suprapubic Present with lower

retention abdominal pain and
discomfort; inability to
urinate.

Cystitis Suprapubic Associated with

dysuria, frequency,
urgency, and
hematuria.

Infectious colitis Either Diarrhea as the Patients with

predominant Clostridioides
symptom, but may difficile infection can
also have associated present with an acute
abdominal pain, which abdomen and

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may be severe. peritoneal signs in the

setting of perforation
and fulminant colitis.

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Differential diagnosis of dyspepsia

Diagnosis
Functional dyspepsia

Dyspepsia caused by structural or biochemical disease

Peptic ulcer disease

Helicobacter pylori gastritis

Gastroesophageal reflux disease (GERD)

Biliary pain

Chronic abdominal wall pain

Gastric or esophageal cancer

Gastroparesis

Pancreatitis

Carbohydrate malabsorption

Medications (including potassium supplements, digitalis, iron, theophylline, oral antibiotics

[especially ampicillin and erythromycin], nonsteroidal antiinflammatory drugs [NSAIDs],
glucocorticoids, niacin, gemfibrozil, narcotics, colchicine, quinidine, estrogens, levodopa)

Infiltrative diseases of the stomach (eg, Crohn disease, sarcoidosis)

Metabolic disturbances (hypercalcemia, hyperkalemia)

Hepatocellular carcinoma

Ischemic bowel disease, celiac artery compression syndrome, superior mesenteric artery
syndrome

Systemic disorders (diabetes mellitus, thyroid and parathyroid disorders, connective tissue
disease)

Intestinal parasites (Giardia, Strongyloides)

Abdominal cancer, especially pancreatic cancer

Adapted from:
1. Talley NJ, Silverstein MD, Agreus L, et al. American Gastroenterological Association (AGA) technical review:
evaluation of dyspepsia. Gastroenterology 1998; 114:582.
2. Fisher RS, Parkman HP. Management of nonulcer dyspepsia. N Engl J Med 1998; 339:1376.

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Pelvic causes of abdominal pain in women

Pelvic causes of
abdominal pain Lateralization Clinical features Comments
in women

Ectopic Either side or Vaginal bleeding with abdominal pain, Patients can
pregnancy diffuse typically six to eight weeks after last present with
abdominal pain menstrual period. life-
threatening
hemorrhage
if ruptured.

Pelvic Lateralization Characterized by the acute onset of Wide

inflammatory uncommon lower abdominal or pelvic pain, pelvic spectrum of
disease organ tenderness, and evidence of clinical
inflammation of the genital tract. Often presentations.
associated with cervical discharge.

Ovarian torsion Localized to one Acute onset of moderate-to-severe Generally not

side pelvic pain, often with nausea and associated
possibly vomiting, in a woman with an with vaginal
adnexal mass. discharge.

Ruptured Localized to one Sudden-onset unilateral lower Generally not

ovarian cyst side abdominal pain. The classic associated
presentation is sudden onset of severe with vaginal
focal lower quadrant pain following discharge.
sexual intercourse.

Endometriosis Associated with dysmenorrhea, pelvic Patients may

pain, dyspareunia, and/or infertility, present with
but other symptoms may also be one symptom
present (eg, bowel or bladder or a
symptoms). combination
of symptoms.

Acute Most often preceded by pelvic Diagnostic

endometritis inflammatory disease. criteria the
same as
pelvic
inflammatory
disease.

Chronic Present with abnormal uterine

endometritis bleeding, which may consist of
intermenstrual bleeding, spotting,
postcoital bleeding, menorrhagia, or

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amenorrhea. Vague, crampy lower

abdominal pain accompanies the
bleeding or may occur alone.

Leiomyomas Symptoms related to bulk or

(fibroids) infrequently acute pain from
degeneration or torsion of
pedunculate tumor. Pain may be
associated with a low-grade fever,
uterine tenderness on palpation,
elevated white blood cell count, or
peritoneal signs.

Ovarian Abdominal distention/discomfort, Women

hyperstimulation nausea/vomiting, and diarrhea. More undergoing
severe cases can have severe fertility
abdominal pain, ascites, intractable treatment.
nausea, and vomiting.

Ovarian cancer Abdominal or pelvic pain. May have

associated symptoms of bloating,
urinary urgency or frequency, or
difficulty eating/feeling full quickly.

Ovulatory pain Occurs mid-cycle, coinciding with May be right-

(Mittelsmerz) timing of ovulation. or left-sided,
depending on
site of
ovulation
during that
cycle.

Pregnancy and related complications*

* Refer to the UpToDate topics on abdominal pain.

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Causes of acute pelvic pain in adult women by organ system

Reproductive tract Gastrointestinal

Gynecologic: Infectious Appendicitis

!"Pelvic inflammatory disease Irritable bowel syndrome

Diverticulitis
!"Endometritis
Inflammatory bowel disease
!"Salpingitis
Fecal impaction or constipation
!"Tubo-ovarian abscess
Gastroenteritis
Gynecologic: Noninfectious
Mesenteric lymphadenitis
!"Dysmenorrhea Abdominopelvic adhesions

!"Ovarian cyst (ruptured or intact) Perforated viscus

!"Endometriosis Bowel obstruction

Incarcerated or strangulated hernia

!"Uterine leiomyoma (fibroid):
Degenerating or not Ischemic bowel

Hirschsprung disease [1]

!"Adenomyosis
Intussusception [2]
!"Mittelschmerz (midcycle ovulatory
pain) Meckel's diverticulum [3]

Volvulus [4]
!"Adnexal torsion (ovary and/or
fallopian tube) Urinary tract

!"Ovarian hyperstimulation syndrome Cystitis

Pyelonephritis
!"Endosalpingiosis
Painful bladder syndrome
!"Uterine perforation (in women who
have undergone a uterine procedure) Kidney stones

Urinary retention
!"Asherman's syndrome
Malignancy (bladder cancer)
!"Neoplasm
Vascular
Pregnancy-related
Abdominal aortic aneurysm and dissection
First trimester
Sickle cell disease crisis
!"Threatened abortion
Septic pelvic thrombophlebitis

Ovarian vein thrombosis

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!"Ectopic pregnancy, including Pelvic congestion syndrome

heterotopic pregnancy
Musculoskeletal
!"Corpus luteum hematoma Muscular strain or sprain

!"Incomplete abortion Abdominal wall hematoma or infection

!"Septic abortion Hernia (inguinal or femoral)

Pelvic fracture
!"Uterine impaction
Myofascial pain
Second and third trimesters
Neurologic
!"Preterm labor
Herpes zoster
!"Chorioamnionitis
Anterior cutaneous nerve entrapment
!"Placental abruption syndrome

Abdominal epilepsy [5]

!"Degenerating uterine leiomyoma
(fibroid) Abdominal migraine [6]

!"Medical complications during Psychiatric

pregnancy, such as appendicitis
Depression
!"Round ligament stretch Somatization disorder

Postpartum Narcotic seeking

!"Endometritis Sexual and interpersonal

!"Wound infection (cesarean section, Domestic violence

laceration, or episiotomy repair) Sexual abuse

!"Ovarian vein thrombosis or septic Other

pelvic thrombophlebitis
Familial Mediterranean Fever

Porphyria [7]

Lead poisoning

TNF receptor-associated periodic syndrome

(ie, TRAPS)

This table presents common etiologies but is not meant to be exhaustive.

TNF: tumor necrosis factor; TRAPS: tumor necrosis factor receptor-associated periodic syndrome.

References:
1. Qiu JF, Shi YJ, Hu L, et al. Adult Hirschsprung's disease: report of four cases. Int J Clin Exp Pathol 2013; 6:1624.

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2. Lu T. Adult Intussusception. Perm J 2015; 19:79.

3. Dumper J, Mackenzie S, Mitchell P, et al. Complications of Meckel's diverticula in adults. Can J Surg 2006; 49:353.
4. Li X, Zhang J, Li B, et al. Diagnosis, treatment and prognosis of small bowel volvulus in adults: A monocentric
summary of a rare small intestinal obstruction. PLoS One 2017; 12:e0175866.
5. Harshe DG, Harshe SN, Harshe GR, Harshe GG. Abdominal Epilepsy in an Adult: A Diagnosis Often Missed. J Clin
Diagn Res 2016; 10:VD01.
6. Kunishi Y, Iwata Y, Ota M, et al. Abdominal Migraine in a Middle-aged Woman. Intern Med 2016; 55:2793.
7. Klobucic M, Sklebar D, Ivanac R, et al. Differential diagnosis of acute abdominal pain - acute intermittent
porphyria. Med Glas (Zenica) 2011; 8:298.
Adapted from: Lipsky AM, Hart D. Acute pelvic pain. In: Rosen's Emergency Medicine: Concepts and Clinical Practice, 9th
ed, Walls RM, Hockberger RS, Gausche M, et al (Eds), Elsevier, Philadelphia 2018.

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Evaluation of acute diarrhea in adults

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This algorithm outlines an approach to the work-up and initial management of adults with acute diarrhea acquire
on infectious etiologies, which are the most common causes. Refer to UpToDate content on acute diarrhea in reso

STEC: Shiga toxin-producing Escherichia coli; HIV: human immunodeficiency virus.

* Routine stool culture will identify Salmonella, Campylobacter, and Shigella. If other bacterial organisms (eg,
suspected based on exposures, the laboratory should be notified for specific plating of the specimen. Some labora
testing of stool to test for multiple organisms simultaneously; the indications for such testing are similar to those

¶ Individuals who have had antibiotic use or hospitalization within the prior three months should be tested for
often performed in patients with inflammatory bowel disease. Testing for parasites (microscopy, antigen testing, m
warranted for acute diarrhea but is appropriate in patients with persistent diarrhea (>7 days), in patients with adv
<200 cells/microL), in men who have sex with men, in the setting of a community waterborne outbreak, and if stoo
patients with bloody diarrhea.

Δ Empiric antibiotic therapy can reduce the duration of diarrhea and other symptoms by several days, but the ben
potential drawbacks in most patients with acute diarrhea. For these select patients (with or at high risk for severe
persistent disease) empiric antibiotic treatment is reasonable, as symptom reduction may have a greater relative
indicated, azithromycin or a fluoroquinolone is used for empiric antibiotic therapy. In particular, azithromycin is pr
dysentery, or risk factors for fluoroquinolone-resistant infection. Empiric antibiotic therapy should be tailored to re

◊ We withhold empiric antibiotic therapy until stool testing has ruled out STEC or Shiga toxin production in stable
higher (eg, bloody diarrhea in the setting of an outbreak or in an afebrile patient). However, for adults with highly
the benefits of antibiotic therapy may outweigh the low risk of potential complications from treating STEC.

§ Loperamide and bismuth salicylates are both effective in reducing the duration and frequency of diarrhea, but lo
However, we avoid loperamide in patients with evidence of dysentery (fever, bloody or mucous stools) unless antib
concern for exacerbation of disease. Loperamide is also often avoided when C. difficile is suspected. Patients takin
to exceed the maximum daily dose.

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Causes of diffuse abdominal pain

Diffuse/poorly
Clinical features Comments
characterized

Bowel Most common symptoms are nausea, Multiple etiologies.

obstruction vomiting, crampy abdominal pain,
and obstipation.

Distended, tympanic abdomen with

high-pitched or absent bowel sounds.

Perforation of the Severe abdominal pain, particularly Can present acutely or in an indolent
gastrointestinal following procedures. manner, particularly in
tract immunosuppressed patients.

Acute mesenteric Acute and severe onset of diffuse and May occur from either arterial or
ischemia persistent abdominal pain, often venous disease. Patients with aortic
described as pain out of proportion dissection can have abdominal pain
to examination. related to mesenteric ischemia.

Chronic Abdominal pain after eating May occur from either arterial or
mesenteric ("intestinal angina"), weight loss, venous disease.
ischemia nausea, vomiting, and diarrhea.

Inflammatory Associated with bloody diarrhea, May have symptoms for years before
bowel disease urgency, tenesmus, bowel diagnosis. Associated extraintestinal
(ulcerative incontinence, weight loss, and fevers. manifestations (eg, arthritis, uveitis).
colitis/Crohn
disease)

Viral Diarrhea accompanied by nausea,

gastroenteritis vomiting, and abdominal pain.

Spontaneous Fever, abdominal pain, and/or altered Most often in cirrhotic patients with
bacterial mental status. advanced liver disease and ascites.
peritonitis

Dialysis-related Abdominal pain and cloudy Only in peritoneal dialysis patients.

peritonitis peritoneal effluent. Other symptoms
and signs include fever, nausea,
diarrhea, abdominal tenderness, and
rebound tenderness.

Colorectal cancer Variable presentation, including

obstruction and perforation.

Other Vary depending on malignancy.

malignancy

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Celiac disease Abdominal pain in addition to

including diarrhea with bulky, foul-
smelling, floating stools due to
steatorrhea and flatulence.

Ketoacidosis Diffuse abdominal pain and nausea

and vomiting.

Adrenal Diffuse abdominal pain and nausea Patients with adrenal crisis may
insufficiency and vomiting. present with shock and hypotension.

Foodborne illness Mixture of nausea, vomiting, fever,

abdominal pain and diarrhea.

Irritable bowel Chronic abdominal pain with altered

syndrome bowel habits.

Constipation Associated with a variety of

neurologic and metabolic disorders,
obstruction lesions of the
gastrointestinal tract, endocrine
disorders, psychiatric disorders, and
side effect of medications.

Diverticulosis May have symptoms of abdominal Often an asymptomatic and

pain and constipation. incidental finding on colonoscopy or
sigmoidoscopy.

Lactose Associated with abdominal pain,

intolerance bloating, flatulence, and diarrhea.
Abdominal pain may be cramping in
nature.

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Major symptoms and signs of hypothyroidism

Mechanism Symptoms Signs

Slowing of metabolic Fatigue and weakness Slow movement and slow

processes speech
Cold intolerance
Delayed relaxation of tendon
Dyspnea on exertion
reflexes
Weight gain
Bradycardia
Cognitive dysfunction
Carotenemia
Intellectual disability (infantile
onset)

Constipation

Growth failure

Accumulation of matrix Dry skin Coarse skin

substances
Hoarseness Puffy facies and loss of
eyebrows
Edema
Periorbital edema

Enlargement of the tongue

Other Decreased hearing Diastolic hypertension

Myalgia and paresthesia Pleural and pericardial

effusions
Depression
Ascites
Menorrhagia
Galactorrhea
Arthralgia

Pubertal delay

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Contributor Disclosures
Robert M Penner, BSc, MD, FRCPC, MSc Consultant/Advisory Boards: AbbVie [Inflammatory bowel
disease]; Janssen [Inflammatory bowel disease]; Takeda [Inflammatory bowel disease]. Speaker's
Bureau: AbbVie [Inflammatory bowel disease]; Janssen [Inflammatory bowel disease]; Takeda
[Inflammatory bowel disease]. All of the relevant financial relationships listed have been
mitigated. Mary B Fishman, MD No relevant financial relationship(s) with ineligible companies to
disclose. Andrew D Auerbach, MD, MPH No relevant financial relationship(s) with ineligible companies
to disclose. Mark D Aronson, MD No relevant financial relationship(s) with ineligible companies to
disclose. Lisa Kunins, MD No relevant financial relationship(s) with ineligible companies to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.

Conflict of interest policy

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