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Chronic abdominal pain

Medicine > Gastrointestinal

Differential Diagnosis Schema 🧠

Gastrointestinal Causes

  • Peptic Ulcer Disease: Epigastric pain, often relieved by eating or antacids, associated with NSAID use.
  • Irritable Bowel Syndrome (IBS): Alternating constipation and diarrhea, pain relieved by defecation, often associated with stress.
  • Inflammatory Bowel Disease (Crohn’s Disease/Ulcerative Colitis): Chronic diarrhea, rectal bleeding, weight loss, family history.
  • Gastroesophageal Reflux Disease (GERD): Heartburn, regurgitation, worse after eating or lying down.
  • Gallstones (Cholelithiasis/Cholecystitis): Right upper quadrant pain radiating to the shoulder, often triggered by fatty meals.
  • Pancreatitis: Epigastric pain radiating to the back, associated with alcohol use or gallstones, elevated serum lipase/amylase.
  • Colorectal Cancer: Altered bowel habits, rectal bleeding, weight loss, family history.
  • Diverticular Disease: Left lower quadrant pain, bloating, and change in bowel habits, more common in older adults.

Genitourinary Causes

  • Kidney Stones (Nephrolithiasis): Flank pain radiating to the groin, hematuria, nausea and vomiting.
  • Urinary Tract Infection (UTI): Suprapubic pain, dysuria, frequency, urgency.
  • Chronic Pelvic Pain (Endometriosis, PID): Pelvic pain, dysmenorrhea, dyspareunia, infertility.
  • Ovarian Cysts or Torsion: Sudden-onset lower abdominal pain, nausea, often associated with menstrual irregularities.

Cardiovascular Causes

  • Chronic Mesenteric Ischemia: Postprandial abdominal pain, weight loss, food aversion, history of cardiovascular disease.
  • Abdominal Aortic Aneurysm (AAA): Pulsatile abdominal mass, back pain, hypotension in rupture, more common in older males and smokers.

Metabolic and Endocrine Causes

  • Diabetic Ketoacidosis (DKA): Diffuse abdominal pain, nausea, vomiting, polyuria, polydipsia, altered mental status.
  • Hypercalcemia: Constipation, abdominal pain, polyuria, psychiatric disturbances (“stones, bones, abdominal groans, and psychic moans”).
  • Porphyria: Intermittent severe abdominal pain, neurological symptoms, family history.
  • Thyroid Disorders (Hyperthyroidism/Hypothyroidism): Altered bowel habits, weight loss or gain, lethargy, goiter.

Psychogenic Causes

  • Functional Abdominal Pain: Pain without an identifiable cause, often associated with anxiety or depression.
  • Somatization Disorder: Multiple unexplained physical symptoms, including abdominal pain, often with a history of psychiatric illness.

Key Points in History 🥼

Pain Characteristics

  • Onset: Sudden vs. gradual, acute vs. chronic, may suggest different pathologies (e.g., sudden pain could suggest torsion or rupture).
  • Location: Epigastric, periumbilical, right upper quadrant, left lower quadrant, or diffuse can guide towards specific diagnoses.
  • Quality: Sharp, dull, cramping, burning, or colicky. Cramping pain may suggest bowel obstruction, while burning pain suggests GERD.
  • Radiation: Pain radiating to the back may suggest pancreatitis or AAA, while shoulder pain could indicate diaphragmatic irritation (e.g., gallstones).
  • Aggravating/Relieving Factors: Eating, defecation, position changes, medications (e.g., antacids relieve peptic ulcer pain).
  • Associated Symptoms: Nausea, vomiting, diarrhea, constipation, weight loss, fever, jaundice, bloating, rectal bleeding, dysuria.

Background

  • Past Medical History: Previous gastrointestinal surgeries, chronic conditions like diabetes or cardiovascular disease.
  • Drug History: NSAIDs (suggests peptic ulcer disease), corticosteroids (suggests adrenal insufficiency), recent antibiotics (suggests C. difficile).
  • Family History: Gastrointestinal diseases (e.g., IBD, colorectal cancer), metabolic disorders.
  • Social History: Alcohol use (suggests pancreatitis), smoking (suggests peptic ulcer disease or cardiovascular issues), diet, stress, recent travel.

Possible Investigations 🌡️

Laboratory Tests

  • Full Blood Count (FBC): May show anemia (suggests bleeding), leukocytosis (suggests infection or inflammation).
  • C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR): Elevated in inflammation or infection.
  • Liver Function Tests (LFTs): Assess for hepatobiliary pathology (e.g., hepatitis, biliary obstruction).
  • Amylase/Lipase: Elevated in pancreatitis.
  • Urinalysis: Check for hematuria (suggests nephrolithiasis) or infection.
  • Serum Calcium: Elevated in hypercalcemia.
  • Thyroid Function Tests: Assess for thyroid disorders.
  • Stool Tests: Occult blood, pathogens, and fat (suggests malabsorption).

Imaging

  • Abdominal Ultrasound: First-line for gallstones, liver pathology, renal stones.
  • CT Abdomen/Pelvis: Useful for assessing malignancy, bowel obstruction, pancreatitis, diverticulitis.
  • MRI: Preferred for detailed imaging of the liver, pancreas, and biliary tree, or in pregnancy.
  • Endoscopy (Upper GI, Colonoscopy): For direct visualization and biopsy of the gastrointestinal tract.

Special Tests

  • Helicobacter pylori Testing: Urea breath test, stool antigen, or serology to diagnose peptic ulcer disease.
  • Barium Studies: Barium swallow or enema for structural abnormalities like strictures or diverticula.
  • Laparoscopy: Diagnostic for unclear chronic pain, endometriosis, adhesions.

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Gastrointestinal