Abdominal pain, chronic or recurrent in adults

Probability diagnosis

Irritable bowel syndrome

Mittelschmerz/dysmenorrhoea

Constipation

Peptic ulcer/gastritis

Serious disorders not to be missed

Vascular:

• mesenteric artery ischaemia

• AAA

Cancer/neoplasia:

• bowel/stomach cancer

• pancreatic cancer

• ovarian tumours

Infection:

• hepatitis

• recurrent PID

Pitfalls (often missed)

Adhesions

Appendicitis

Biliary disease: gallstones, sludge

Food allergies

Hernia

Lactase deficiency (i.e. lactose intolerance)

Constipation/faecal impaction

Chronic pancreatitis

Coeliac disease

Inflammatory bowel disease

Crohn disease

Endometriosis

Diverticular disease

Subacute obstruction (cancer, adhesions, etc.)

Rarities:

• tropical infections (e.g. hydatids, melioidosis, strongyloides)

• uraemia

• lead poisoning

• porphyria

• sickle cell anaemia

• hypercalcaemia

• Addison disease

Masquerades checklist

Depression

Drugs

Spinal dysfunction

UTI

Is the patient trying to tell me something?

A strong possibility: consider hypochondriasis, anxiety, sexual dysfunction, Munchausen syndrome.

Key history

This includes a detailed pain analysis, especially associated features such as micturition, bowel function, menstruation, diet and psychological features. Note relevant past history (incl. abdominal surgery), drug intake, travel, family history. Enquire about ‘red flags’ for organic disease (e.g. weight loss, fever, nocturnal pain or diarrhoea, progressive symptoms).

Key examination

• General appearance including psyche and vital parameters

• Abdominal examination: inspection, auscultation, palpation, percussion (in that order)

• Rectal examination

• Vaginal examination (if appropriate)

• Office urine test

Key investigations

• Urinalysis including MCU

• FBE

• ESR/CRP

• Lipase/amylase

• LFTs

• U&E

• Plain abdominal X-ray

• Other imaging (e.g. ultrasound, IVU) according to findings and intuition

• Endoscopy as appropriate

Consider

• H. pylori testing

• coeliac disease

Diagnostic tips

• Consider gallstones and duodenal ulcer if the patient is woken (e.g. at 2–3 am) with abdominal pain.

• Be very mindful of constipation, especially in the elderly, and be skilled at digital rectal examination.

• Avoid repeated investigations unless a new symptom develops and the patient becomes unwell.