Bedside Logic in Diagnostic Gastroenterology
James Christensen, M.D.
Peer Review Status: Internally Peer Reviewed
INTRODUCTION
Pain in the abdomen is a very common symptom. Many different organs and processes can produce abdominal pain. If you explore all the details you will often be able to get quite an accurate idea of the source of such pain.
THE SPECIFIC FEATURES OF ABDOMINAL PAIN
The Character of Abdominal Pain
How to Get Patients to Describe Abdominal Pain
Pains in general are difficult to describe, but the description of abdominal pain is very important. The quality or character of abdominal pain can be very useful to you as you try to interpret such pain and you should explore the character as far as you can.
There are many ways to describe the quality of pain in the abdomen. Patients often use descriptive terms voluntarily but some patients will not volunteer descriptions. I find it useful to ask first, "What is the pain like?" The answer to this question may be quite specific like "a sharp pain," or the patient may refuse to answer, saying "just a pain." In either case you should press for a further description and it is always fruitful to do so. Do this by offering terms or descriptions from which the patient can choose. Ask, "Does the pain feel hot, burning, like a knife, like something sharp, like something moving around, like something squeezing, like something too big, or like a cramp?" Offered such choices, most patients will select one of these terms and you then can explore the description further. Sometimes after considering such a set of terms, a patient will refuse them all. Pains in the abdomen can be classified usefully in three categories: bright pains, dull pains, and undifferentiated pains. These three categories have different implications. In this chapter I use "dull" to mean "not sharp" rather than "mild": I use dull to refer to the character rather than to the severity of pain.
Bright Pains
The bright pains are those that patients describe with terms like "hot," "burning," "sharp," "knifelike," "stabbing," "sour," or "sore." Such terms denote a quality that most patients find relatively easy to describe and they will often select several of the terms that you offer as accurately descriptive. Bright pain in the upper abdomen is usually mucosal in origin. It signifies inflammatory disease although malignancy in a hollow organ can also produce bright pain, presumably because malignancy often has some associated inflammation. In organs that cause pain in the lower abdomen (the distal ileum and colon), mucosal inflammation does not produce a bright pain. It may be that the mucosa there lacks an innervation by pain fibers that can produce the sensation of that quality.
Dull Pains
The dull pains are those that patients describe as "dull," "squeezing," "cramping," "colicky," "like something too big," or "like something moving around." Such terms denote qualities of dull pain that patients find relatively more difficult to describe than those of bright pain, and they will usually select only one of these terms as accurate, and that with some reluctance. Dull pain is much less specific than bright pain as to cause. I think of it as arising from pain fibers that are not mucosal but deeper in hollow organs or in solid masses. Squeezing or crampy pain and pain that feels like something moving around usually represent an origin in the muscular walls of the gut. Such pain seems to represent some degree of obstruction to flow along the gut. Presumably it arises from abnormally forceful contractions above the obstruction. But such dull pain also occurs in nonobstructive disease like intestinal ischemia, for example. It seems to me that the fundamental cause of all such pain may be a relative ischemia of muscle.
When a patient describes a pain as feeling like something too big, he is usually right -- you will usually find an enlarged organ.
Undifferentiated Pains (Aching Pains)
Pains that patients cannot describe or call an "ache" are undifferentiated pains. Of course some patients are not very verbal and they will not select a descriptive term for that reason. But when a patient of normal intelligence and understanding cannot find words to describe his pain adequately, it usually means that the pain is not arising from the mucosa or the muscle of the gut. This leaves the solid organs as the source. The pancreas, for example, is a common source of abdominal pain, and pancreatic pain nearly always seems to be indescribable. Pain referred to the abdomen from the chest, as occurs in pneumonia or myocardial infarction, is also often indescribable, as is pain of abdominal wall origin.
The Severity of Pain
You should always try to discover the general severity of abdominal pain although the answers you get can be misleading. Very sensitive people perceive a pain as severe that other people might consider mild. Anxiety about the pain always makes it seem worse, while a patient who is preoccupied often perceives the pain as milder. An inquiry as to severity is a most useful way for you to open an exploration of the feelings of the patient about his pain. It can also suggest to you the magnitude of the causative lesion. You can get an idea of severity by asking what limitations the pain imposes on daily activities, whether it has led to lost workdays, for example.
The Location of Abdominal Pain
How to Get Patients to Locate Pain
The location of an abdominal pain strongly suggests its origin. For each organ the pain is usually most severe at its primary site and is variably perceived at secondary sites (also called areas of referred pain or projections of pain). A patient will usually volunteer to you only that location where the pain is most severe, the primary site. You must ask him directly about secondary sites. I ask "Do you feel the pain anywhere else or does it shoot or move to some other spot?"
Often the pain is perceived at secondary sites only when it is severe, being restricted to the primary site when it is mild. Also, in an exacerbation, the pain may appear first at the primary site and later at the secondary site. These generalizations are, however, not constant. Occasionally a pain may appear first or most severely at a secondary site.
The Meaning of Projection of Pain
The locations of sites of referral of pain are related to two factors. In many instances referred pain is related to a shared sensory innervation of various parts of the body. In other cases projection of a pain away from a primary site occurs because of the nature of the process itself. Thus, for example, when there is gastric obstruction from inflammatory disease at the gastric outlet the pain at the primary site (in the epigastrium) may be perceived as extending to the left quadrant.
The primary sites of pain in the viscera are usually immediately over or very near those viscera. The secondary sites due to a shared sensory innervation are quite specific and so they are very useful in interpreting specific sources of pain. These primary and secondary sites are shown in Figures 3-1 and 3-2.
Primary Pain in the Epigastrium
When the primary site is in the epigastrium the source usually is the pancreas, stomach, duodenum, or liver. Pancreatic pain commonly projects straight through to the midline over the lumbar spine. Pain from the stomach or duodenum infrequently projects through to this area and when it does it usually signifies that the lesion is on the posterior wall of the organ. The sudden projection of an established epigastric pain straight through to the midline lumbar region always suggests that a chronic disease (usually a duodenal ulcer) has extended to involve the pancreas, for the midline lumbar region is the posterior secondary site for pancreatic pain, while the secondary sites for duodenal and gastric pains seem to be slightly higher in the midline of the back (Figure 3-3). Pain from the liver sometimes projects into the chest, especially on the right side. This may occur when the cause is generalized throughout the liver (as in hepatitis) or when a localized lesion is at the dome of the right or left lobe. Pain of distal esophageal origin is sometimes perceived in the epigastrium. The pain of myocardial infarction sometimes radiates there and it may be felt primarily in the epigastrium.
Primary Pain in the Right Upper Quadrant
When the primary site is in the right upper quadrant the source usually is the gallbladder or duodenum, sometimes the liver, and rarely the colon. Pain arising from the gallbladder frequently projects straight through to the right posterior thorax in a discrete area just below the tip of the right scapula. It is usually said that gallbladder pain may also project to the lateral supraclavicular area on the right side. This is not common. Because this area is a common site of projection of pain arising from the right diaphragm such a pattern of referral always suggests to me that the diaphragm is involved in whatever process in the right upper quadrant is responsible. Pain referred to the right lateral supraclavicular area is often prominent with a right subdiaphragmatic abscess, for example.
Hepatic pain commonly radiates across the upper abdomen and sometimes to the chest or into the right flank.
Primary Pain in the Left Upper Quadrant
A primary site in the left upper quadrant usually signifies a source in the spleen, sometimes in the stomach, and rarely in the left hepatic lobe or the colon. As in the case of the right upper quadrant, left upper quadrant pain is sometimes referred to the lateral supraclavicular area on the left and this signifies left diaphragmatic involvement in the pathologic process. This radiation is common in pain from the spleen, since that organ is in close contact with the diaphragm. Splenic pain also often radiates into the left flank. Gastric pain often radiates from the midline to the left. Left hepatic lobe pain (which is rare) can radiate across the upper abdomen and into the left flank, into the left chest, or to the left lateral supraclavicular area. Pain in this quadrant of left pulmonary or cardiac origin usually also occurs in the chest. Left upper quadrant lesions do not so commonly produce pain referred to the lateral supraclavicular area as do those on the right. This is because there is so much more potential space for expansion in the left hypochondriac fossa than there is in the right.
Primary Pain in the Periumbilical Region
When the primary site of pain is periumbilical you should consider the small intestine as the major source, less often the aorta and pancreas. Small-intestinal pain is diffuse anteriorly and frequently projects into the lower quadrants; it is not perceived in the back. Often pancreatic pain is primarily felt over a broad epigastric and periumbilical area anteriorly, and it frequently projects to the midline lumbar region posteriorly where it is often just as severe as it is anteriorly. Such pain goes straight through without lateral radiation. This pattern is very consistent and specific for retroperitoneal pain of pancreatic origin. Aortic pain (arising from an aneurysm) is usually felt over a more narrow area anteriorly and is nearly always felt posteriorly in the lumbar midline as well, commonly being more severe posteriorly. It is the general rule that significant projection of a periumbilical pain to the midline lumbar area suggests a source in retroperitoneal structures.
Primary Pain in the Flanks
Primary pain in the flanks usually comes from the kidneys, but it may arise as well from the gallbladder on the right or the colon on either side. Renal pain is often more severe posteriorly than anteriorly and it seems to extend from the front to the back of the flank by radiating around the side rather than straight through (Figure 3-4). Sometimes musculoskeletal pain follows a similar pattern. When there is ureteral disease (as in the passage of a kidney stone) the pain radiates down over the abdomen toward or into the genitalia (Figure 3-1). Gallbladder pain may be perceived quite laterally in the right flank. This location of pain may result from a lateral position of the gallbladder, this being one of the anatomic variations sometimes encountered. Pain arising from the ascending or descending colon may occur mainly in the flanks, but it usually spreads diffusely into the lower quadrants as well.
Primary Pain in the Lower Quadrants and Suprapubic Region
The colon is the usual gastrointestinal source of pain in these regions but pain of ureteral, renal, adnexal, and rarely gastric origins may be felt there as well. Colonic pain is commonly diffuse, radiating fairly widely in the abdomen; it does not radiate to the back unless the pathologic process has extended retroperitoneally, which is rare. Ureteral pain is usually easy to identify from its radiation obliquely from the flank to the genitalia. Adnexal pain is easily confused with colonic pain in its location, but patients usually feel it as being deeper in the pelvis.
The Chronology of Abdominal Pain
The Date of Onset of the Pain
When an abdominal pain has been present for only a short time, most patients will fully recall the date and details of onset. When an abdominal pain is more than a month or two old, the exact date and circumstances of its onset are easily forgotten. Precise dating of the onset of the pain is important in dating the onset of the process; also, asking about this is a useful way to get a patient to start talking about the circumstances of its beginning and its nature when it began. When a patient cannot remember the date of onset, you should offer him some recent landmark dates -- seasonal changes, secular or religious holidays, political events or birthdays -- to help him to remember. This may well lead him to tell you things he had forgotten -- that it was first noticed or was particularly noticeable after a feast or after a fast, for example.
The Circumstances of the Onset of Pain
The circumstances surrounding the beginning of an abdominal pain sometimes suggest the cause. Patients will recall these circumstances voluntarily only if they themselves perceive the circumstances as being important. If your attempt to establish the date of onset does not yield a discussion of the circumstances of onset, you should ask if anything special occurred about that time. You should suggest some things that are appropriate -- a forgotten injury or accident, a period of physical or emotional stress, an operation, the use of some drug of unusual nature or in unusual dosage, an unusually large meal or a period of fasting. Symptoms of inflammatory disease of the stomach and duodenum sometimes seem to start in periods of physical or emotional stress, or during periods of heavy dosage with aspirin or nonsteroidal anti-inflammatory drugs. Chronic relapsing pancreatitis can begin with abdominal trauma that may have occurred in an accident where the pancreatic injury was eclipsed by fractures, head injury, or coma. Bowel obstruction from adhesions or hepatitis from transfusion often follow long enough after an abdominal operation that the patient does not suspect an association.
Character and Location at Onset of Pain
When you are exploring the onset of a pain, it is important for you to find out about the character and location at onset, for these may have changed as the illness developed. The character and location of a pain do not change much unless the pathological process itself has changed. For example, a bright pain to the right of the midepigastrium (suggestive of duodenal ulcer) may have evolved to include or to be eclipsed by an undifferentiated diffuse epigastric pain in the periumbilical and posterior lumbar regions if the ulcer has penetrated into the pancreas. The severity of a pain also often changes as the illness develops.
The Progress of Abdominal Pain
Abdominal pain is not often truly constant; most abdominal pain is characterized by exacerbations and remissions. You need to find out whether the pain is indeed periodic, to discover the rhythm of its period and to discover patterns in severity during exacerbations.
You should ask, "Is the pain always there or does it come and go?" If the response is that it is always there, that does not mean that it is constant. Ask "Do you mean that you have it every day, all day and all night?" Almost always the answer will be negative. The commonest abdominal pain that approaches absolute constancy is that of pancreatic carcinoma. Constancy is also a feature of the pain of dissecting abdominal aneurysm and the referred pains of pneumonia and myocardial infarction.
When a patient acknowledges that his pain is periodic you must explore the periodicity. A pain that comes and goes with a daily or diurnal period is very likely to do that because its source is affected by a process that shows a diurnal rhythm -- like eating, sleeping, and exercise. I call this a daily pain. It may not occur every day though, and I ask a patient how many days of the week he estimates that he has the pain. A constant pathologic process characterized by daily pain will usually manifest itself on at least 5 days a week. This is the case with many pains arising in diseases of the stomach, duodenum, and pancreas, less so in those coming from the colon and even less in those of splenic or hepatic origin. This is because secretory and motor processes of the proximal gut are those most likely to fluctuate with daily activities.
Other pains may be described by the patient as a single episode when, in fact, they are recurrent pains: He may have forgotten previous episodes if they occurred far apart, or he may be ashamed to tell you that he had the problem before and did nothing about it. You should always ask "Have you ever had a pain like this before?" This may reveal a pain that is characterized by discrete attacks and remissions. I call these episodic pains. With episodic pains you need to find out the frequency of attacks. Many causes of abdominal pain are episodic in nature, but the episodes may be weeks to months apart. Episodic pain suggests an episodic disease. The pains of relapsing pancreatitis and symptomatic gallstones, for example, occur classically as very similar attacks recurring at intervals of weeks, months, or even years. You must ask if the attacks are identical one to another or if they have changed appreciably with recurrences, and if their temporal spacing is changing. This will reveal to you whether or not the pathologic process is an evolving one.
With such episodic pain you should discover if remissions are truly asymptomatic periods or if they are periods when the pain is still present but so mild in comparison to attacks that the patient feels that he is well. In the periodic passage of gallstones, for example, the intervals of remission are usually completely pain-free. In gastric and duodenal ulcer, on the other hand, intervals of apparent remission are usually only periods of relative easing of pain, the mild pain in those intervals probably representing that of the more general inflammation which nearly always accompanies ulceration.
With episodic pain you should discover how the episodes begin and how they end. Ask "Do the attacks begin suddenly so that the pain quickly rises to its maximum, or does the pain take hours to develop?" Passage of a gallstone, for example, begins very suddenly and is quickly maximal, while an attack of relapsing pancreatitis or cholecystitis takes one to several hours to reach its greatest intensity.
You should ask about fluctuations in intensity of pain during episodes or attacks (Figure 3-5). For most patients the term "crampy" implies such fluctuations but this is not always so. Some patients use the term to mean "squeezing" in character. You should ask "When the pain develops, is it perfectly constant or does it rise and fall in intensity?" The pain of cholecystitis is nearly always constant during attacks despite the widespread description of this pain as "colicky," as is also the pain of an attack of relapsing pancreatitis. The pain of passage of a gallstone, on the other hand, usually fluctuates during an attack.
Aggravating Factors in Abdominal Pain
Pains of abdominal origin are frequently made worse by certain activities, and knowledge of a relationship can be very useful to you in interpreting such pain. The most important of the aggravating factors that you should ask about are eating and drinking in general, the taking of specific foods and beverages, the taking of medicines, defecation, body position, and physical activity.
When eating and drinking in general aggravate the pain, the pain is nearly always arising from the stomach, pancreas, biliary tract, small intestine, or colon. When the pain comes on immediately or intensifies within 45 minutes after the initiation of eating or drinking, the pain is usually of gastric origin. This may occur either because the stimulus to gastric secretion is very prompt or because some component of the food or beverage excites pain fibers in the inflamed gastric mucosa which it reaches immediately. When the pain does not intensify until an hour or more has passed the physiologic process is one that requires more time. In the case of pain arising in the pancreas or biliary tract this can be attributed to the fact that the release of enteric hormones in response to foods is slow. The effects of such hormones on the functions of the diseased gallbladder or pancreas produce the pain. In the case of the small intestine and colon the aggravation of pain by eating or drinking usually represents some degree of obstruction and it takes some time for the ingested foods to reach or affect the lower regions of the bowel. In intestinal ischemia the pain is always clearly precipitated by eating and it is usually very severe, but undifferentiated in character.
Often patients will have noticed that specific foods and beverages aggravate the pain. This is especially true in inflammatory disease of the stomach and duodenum. The most common offenders in such cases are coffee, alcohol, hot spicy foods, and fruit juices. You should ask about specific foods -- Mexican or Italian foods, pizza, and specific fruit juices. Reconstituted frozen orange juice is a very common offender. Prompt exacerbation of a bright pain in an appropriate location with the ingestion of such things is classical in gastritis and gastric ulcer, and it is present in some cases of duodenal ulcer. In some cases of pain due to partial distal small- bowel obstruction I have heard patients complain that the ingestion of large amounts of foods with a high fiber content clearly exacerbates the pain. Some such foods are obvious, bran cereals and celery, for example, but patients rarely gorge on these. I have also heard oranges, mushrooms, and water chestnuts mentioned by patients with partial intestinal obstruction; these are foods that people may sometimes consume in large quantities and which they do not recognize as high-fiber foods.
Specific medicines may aggravate the pain of inflammatory disease of the upper gut. The most common offenders are aspirin, nonsteroidal anti-inflammatory drugs, erythromycin, and elixirs of various sorts (all of which may contain alcohol). The mechanism is the same as that in the ingestion of irritating foods.
Defecation may occasionally aggravate a left lower quadrant abdominal pain. You should ask "Does moving your bowels affect the pain?" Because defecation involves contraction mainly of the distal parts of the colon such a relationship suggests obstructive disease in that part of the bowel. Do not let patients confuse normal defecation with straining at stool. Such straining commonly aggravates pain of origin in the abdominal wall, in which case the pain is often located in some other part of the abdomen than the left lower quadrant.
Certain body positions often aggravate abdominal pain. The dull pains that occur in a partially obstructed viscus seem often to be worse with the torso fully extended. In pain due to an enlarged solid organ or a completely obstructed bowel or gastric outlet, pressure on the abdomen is intolerable, lying on the stomach is avoided, and "doubling-up" makes the pain worse.
Certain pains often prompt avoidance of certain body activities. In pain due to pancreatitis, for example, any activity that jars the pancreas is avoided. These may include walking, climbing stairs, and riding in a car, especially over a rough road. Sometimes patients will describe restlessness with pain. Patients unsuccessfully seek a body position that gives relief. This restlessness is fairly common but it is not specific. The absence of restlessness is often a feature of pancreatic pain. When coughing, sneezing, or deep breathing aggravate an abdominal pain it usually signifies that the pain arises in part from the abdominal wall or diaphragm or from some organ that is moved by diaphragmatic motion, like the liver or spleen. Pain of gastric origin alone is not often aggravated by diaphragmatic motion because the stomach is deformed rather than displaced by diaphragmatic descent. Pain arising in the abdominal wall is usually aggravated by coughing and sneezing more than by deep breathing.
Relieving Factors in Abdominal Pain
While patients may tell you a great deal about the things that they have observed that make abdominal pain worse, they are rarely very forthcoming about relieving factors. You must therefore make an extra effort to find out about them, for knowledge about them can be helpful in interpreting pain. Of course patients seek relief by avoiding the aggravating factors that they recognize, so in reviewing aggravating factors you will already have discovered many things that produce relief. Certain other things that patients do are positive actions, like taking medicine. It is important to know what things patients have tried to get relief without success.
In getting at this matter you should ask simply what the patient has tried to get relief. Because he may not remember without prompting, you should offer him a series of matters to consider. These are eating and drinking in general, the taking of specific foods and beverages, the taking of medicines, defecation, and body position.
Eating and drinking in general do not often relieve any abdominal pain except for that arising from gastritis or uncomplicated duodenal ulcer. The eating and drinking of specific foods is also important in relation to gastritis and duodenal ulcer, when things that patients perceive as soothing -- like milk products -- often produce a particularly notable degree of relief.
Many patients with abdominal pain try common medicines to get relief. For upper-abdominal pain they commonly try buffer antacids. When these are effective the pain probably arises from inflammatory disease of the stomach or duodenum. Such antacids are sometimes ineffective in such cases, either because the dose is insufficient or because patients often use tablet antacids which may not be adequately dispersed or dissolved in the stomach. Patients commonly try salicylates; these are rarely very effective in relieving any cause of abdominal pain and they often worsen the bright pain of gastric or duodenal inflammation.
Defecation sometimes relieves left lower quadrant abdominal pain and this suggests that the pain arises in the distal colon.
The body position that gives relief is quite useful in distinguishing pancreatic pain from pains of other origins. The patient with pancreatic pain or any other retroperitoneal source of pain prefers to lie quietly with his back slightly flexed, often on his side, sometimes on his back. This position may relieve pains of other origins as well but less consistently so. Patients with pancreatic pain sometimes like to press a pillow into the abdomen, sitting up and doubling over to do so, but such a position is not tolerable to the patient with cholecystitis or inflammatory disease of the upper gut. Some patients with abdominal pain find relief with the application of heat to the abdomen. I tend to interpret relief by external heat as suggestive of an origin in the abdominal wall, but this is no more than a suggestion.
Associated Symptoms in Abdominal Pain
A few associated complaints have quite specific meanings and so they are useful in the interpretation of abdominal pain. The most important ones are weight loss, nausea and vomiting, diarrhea, constipation, blood in the stools, jaundice, and bloating.
Weight Loss
Significant loss of weight occurs in many gastrointestinal disorders. When pain is the principal complaint, weight loss of much magnitude is associated with relatively few disorders. Weight loss can signify a reduction in caloric intake, an increase in caloric loss, or malignancy.
Any intra-abdominal disease in which the pain is exacerbated by eating leads to weight loss. Most patients attempt to get around the problem by eating frequent small meals, by avoiding offending foods and beverages, and by eating soothing foods like milk products which are calorically dense. These maneuvers work quite well when the source of pain is gastritis or gastric ulcer so that weight loss is relatively slow and small in those disorders. A patient with a duodenal ulcer often gains weight because such foods generally relieve the pain quite well. When the source of pain is the pancreas or biliary tree these maneuvers do not work, so that weight loss is more severe. The most extreme degree of weight loss associated with abdominal pain is that which occurs in carcinoma of the pancreas; this reflects the combined effects of a reduced caloric intake and of the malignancy. An equally extreme degree of weight loss occurs in intestinal ischemia because eating anything inevitably causes pain.
Nausea and Vomiting
The medullary nausea center is activated by both somatic and autonomic inputs so you must establish that the nausea is indeed related to the abdominal pain by asking about a temporal relationship.
Nausea accompanies many causes of abdominal pain. It occurs with both malignant and inflammatory disease of the intra-abdominal organs but it is more common with disease of the upper gastrointestinal tract than the lower. It is rare in esophageal disease, very common in gastric and small -intestinal disease, and uncommon in colonic disease. Nausea also accompanies diseases of the solid organs and peritoneum.
Nausea seems to be particularly associated with distension of the gut. Thus the development of nausea during the course of a well-established abdominal pain suggests that an initially nonobstructive lesion has extended to produce obstruction.
In the enlargement of the solid organs nausea accompanies rapid enlargement more than slow enlargement. Thus, it is common with hepatitis and pancreatitis, but uncommon in cirrhosis and pancreatic cancer.
Diarrhea
When diarrhea accompanies abdominal pain it signifies disordered function of the small intestine and colon. Partial or intermittent obstruction can produce episodes of loose stools. The most common lesions that do this are carcinoma of the right colon and regional enteritis. In both cases the diarrhea is rarely of much magnitude; it is often so eclipsed by the pain that patients may not mention it.
The pains of gastritis, gastric ulcer, and duodenal ulcer often cause patients to take large doses of antacids with a consequent diarrhea if those antacids contain magnesium compounds.
Constipation
Constipation accompanies abdominal pain in some situations. It may be a sign of ileus and it occurs in obstructing lesions of the distal colon like neoplasms. In diverticulitis there is often some constipation with the pain. In the irritable bowel syndrome the constipation is usually more complained about than the pain.
Blood in the Stool
The presence of gross or microscopic blood in the stool in association with abdominal pain means only that the lesion is mucosal. It can occur with all neoplastic and inflammatory lesions. The absence of observed blood from the stool does not speak against such disease. Some lesions bleed only intermittently and the tests for microscopic blood are not infallible.
Jaundice
Jaundice accompanying abdominal pain usually means that the source of pain is in the biliary tree or pancreas. There are some exceptions. An episode of hemolysis, as occurs in sickle cell disease, produces both acute abdominal pain, and jaundice. Also patients with Gilbert's syndrome may develop mild jaundice with fasting or fever along with pain from abdominal disease that is not related to the biliary tract or liver.
Bloating
When a patient with abdominal pain complains of bloating he is describing the sensation of abdominal distension. This usually represents obstruction of the gut at some point and it indicates that the lesion causing pain is also obstructive. It may also represent an ileus related to peritonitis or reflex ileus from pain referred to the abdomen from a thoracic disease like pulmonary infarction, pneumonia, or myocardial infarction.
A SUMMARY -- WHAT YOU CAN LEARN FROM ANALYSIS OF THE SPECIFIC FEATURES OF ABDOMINAL PAIN
Character of Abdominal Pain
What it Can Tell You
This information can suggest to you if the origin is in the mucosa, in the muscle, or at some other tissue level.
Reliability
Very reliable.
Problems
"Sharp" means "sharp" to some, "severe" to others; "dull" means "not sharp" to some, "mild" to others; cramping means "squeezing" to some, "rhythmic" to others; "stabbing" means "knifelike" to some, "momentary" to others. You have to make certain what patients mean by such terms.
Location of Pain
What it Can Tell You
This information can tell you which organ is the source of pain. The commonest causes of pain in certain specific areas of the abdomen are shown in Figures 3-6, 3-7, 3-8, 3-9, 3-10, and 3-11.
Reliability
Very reliable.
Problems
Primary organ-associated pain sites are not always quite consistent. The most common variants are: The gallbladder primary site is sometimes far to the right -- almost in the flank; the pancreatic primary site is sometimes very high in the epigastrium rather than nearer the umbilicus, or even in the left upper quadrant; the splenic primary site is sometimes very far to the left, even posterior. Secondary organ-related pain sites are only sometimes involved. When they are it is very helpful; when they are not that fact does not exclude the organ that you suspect from the primary site. Certain locations of secondary pain are very suggestive of specific diseases.
Chronology of Abdominal Pain
What it Can Tell You
This information can tell you the nature of the progression of the pathologic process. The progress of the symptom accurately reflects the progress of the process.
Reliability
Very reliable.
Problems
Patients often cannot recall remote events well. You have to help them by offering secular or religious holidays or other special events when you want the remote chronology of the pain. Patients may not tell you of previous episodes of the pain unless you ask them.
Aggravating Factors in Abdominal Pain
What They Can Tell You
This information can support what you have already decided about the mucosal or muscular (or other) origin of the pain and the organ of origin.
Reliability
Very reliable.
Problems
Patients usually volunteer only the most notable aggravating factors and only then when the aggravation is severe. You have to ask about all the factors that you can think of to ask about. Positive answers are very helpful; negative answers are relatively useless. The pain of gastric ulcer, for example, is not always made worse by eating spicy foods.
Relieving Factors in Abdominal Pain
What They Can Tell You
This information can support what you have already concluded about the mucosal, muscular (or other) origin of the pain and the organ of origin.
Reliability
Very reliable.
Problems
Patients will rarely tell you how they get relief from the pain: You have to ask. Patients will almost never tell you what they have tried that did not work yet this can be very useful to you as you interpret the pain. Positive answers are very helpful; negative answers are less so.
Associated Symptoms in Abdominal Pain
What They Can Tell You
This information can support what you have already concluded about the organ of origin.
Reliability
Only moderately reliable.
Problems
Associated symptoms have inconsistent meanings. For example, some people get nauseated very easily, others not at all; some people stop eating (and so lose weight) very readily, others very reluctantly; some people with inflammatory or malignant disease of the colon have diarrhea or constipation while others do not, or do not notice or mention it. Some people with obstructing lesions (perhaps those who wear tight clothes) complain intensely about trivial bloating while others (perhaps those who wear loose clothes) scarcely notice extreme bloating.
SOME COMMENTS ABOUT THE FUNCTIONAL OR IRRITABLE BOWEL SYNDROME
Many patients with abdominal pain of undiscovered origin receive a diagnosis of the functional or irritable bowel syndrome. I have not considered this syndrome in this chapter until now, largely because the application of bedside logic cannot often point specifically to such a diagnosis. The reason is that the syndrome is only vaguely defined in terms of symptoms and lacks any definition whatsoever in functional or structural terms. Indeed, the entity is undefined, and so it cannot be shown to exist and the diagnosis cannot be made logically. Still, many experienced clinicians use the term to describe a situation found in certain patients with abdominal pain and other gastrointestinal symptoms that cannot be explained in any other way, attributing the symptom-complex to emotional stress or anxiety.
The syndrome is characterized mainly by chronic abdominal pain. The character of the pain is nearly always described in terms that denote pain of dull character, like cramping, squeezing or colicky. The location of the pain is more in the lower quadrants, perhaps more on the left than the right, but it may be quite generalized. It does not radiate to the back or more remote points. The chronology of the pain is perhaps a little more consistent. It begins in the second or third decades of life and persists for years. It is a vaguely episodic pain, the episodes having no predictability or consistency as to onset, duration, or severity. The pattern of pain in an episode is inconsistent. There are no consistent aggravating factors or relieving factors. The associated symptoms usually (but not always) include some alteration in bowel habit (constipation, diarrhea, or alternating constipation and diarrhea) and this may be severe. Nausea and vomiting may or may not be present. Weight loss is not usually present. Bloating is a frequent complaint.
It is commonly taught that there are certain bedside clues to the diagnosis of anxiety-induced abdominal pain. These include inappropriate affective responses during the interview or examination as discussed in Chapter 1, the keeping of a complex symptom diary, and your discovery of secondary gain. All these clues are fallible. Deciding what is an appropriate affective response to the interview depends on many variables -- your experience, the emotional volatility of the patient, and the character of the interview. Patients who are naturally compulsive or introspective may keep symptom diaries. And the discovery of secondary gain -- the fact that some limitation of activity imposed by the pain is in fact the avoidance of an unconsciously undesired responsibility on the part of the patient -- can require a very extensive probing and careful interpretation of patients' attitudes to themselves and to their diseases.
Those who make this diagnosis do so when they can find no other explanation for the symptoms. It is thus a diagnosis of exclusion. Of course what you look for depends upon what you think of to look for.
There is an intellectual trap in this. As soon as you have named a disease ("made a diagnosis") not only do you stop thinking of other possible explanations for symptoms but you also begin to think that you understand the process denoted by the diagnostic term you have chosen. Thus to make this diagnosis is to risk self-delusion, and worse, to risk missing another diagnosis that you didn't think of.
I do not deny that there are patients with chronic abdominal pain and altered bowel habit that defy analysis. I know perfectly well that emotional stress and anxiety can produce these symptoms, for that has been the nearly universal experience of every normal but terrified school child or soldier. I know also that the physiologic mechanism of this effect is not known. It seems to me that when anxiety seems to explain symptoms you should simply say so, calling them anxiety-related symptoms. To use a term like the functional bowel syndrome is to risk creating a defined disease where none exists.
I have seen many errors committed by physicians who made a diagnosis of the functional bowel syndrome too hastily. You may avoid such errors if you avoid thinking that abdominal pain has its origin in chronic anxiety when:
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See related Provider Topics Abdominal Pain, Brain and Nervous System, Pain or Symptoms and Manifestations.
See related Patient Topics Abdominal Pain, Brain and Nervous System, Pain or Symptoms and Manifestations.
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