YOUR ABDOMINAL PAIN DIAGNOSIS - MOST CLUES ARE IN THE HISTORY
Assessing your abdominal pain diagnosis can be as difficult as working on any equipment with an intermittent fault. Ask an electrician or mechanic.
If it is possible for your doctors to examine you when you have the pain, they will be better placed to offer you a likely explanation. Usually however, your account of the symptoms will be the most important guide to diagnosis.
Have you short term ( acute pain ), long term ( chronic pain ), or medium term pain ( stretching back weeks or months? ) For example, appendicitis is a painful short term disease, whereas irritable bowel syndrome is a long term disorder. This is the first essential bit of information needed for abdominal pain diagnosis.
Pain may come and go, either regularly (eg. with menstrual cycle,) at times of stress, or at random intervals ( duodenal ulcer with periodicity.) Pain associated with menses can start before bleeding ( spasmodic dysmenorrhea ), or with it ( endometriosis .) Thinking about it, can you identify anything which has coincided with the times you had pain?
On a day to day basis, the abdomen pain may precede or follow eating, using your bowels or passing urine. It is very usefull to tell your doctor if there is a pretty constant connection with one of these, or with any other bodily function.
Pain as you swallow is likely to originate in your esophagus. Stomach pain ( eg. gastritis or gastric ulcer ) is often within one hour of eating. Duodenal ulcer pain is later than one hour, often soon before the next meal.
Does your pain come on as you twist, straighten up or cough? Musculoskeletal causes or peritoeal irritation or some painfully distended organ, may hurt in these circumstances.
Think about your tummy as divided into four quarters or quadrants. Is the pain in the upper right ( gallstones ,) lower left (diverticulitis ) or other of these? Is the pain in the center rather than any quadrant (small bowel colic, as in gastroenteritis?) Urinary bladder pain is in the mid line of the lower abdomen.
The classical shift of pain in acute appendicitis is from central to right lower abdomen, as the disease progresses.
Kidney stone colic classically spreads around from the back, to the groin.
In abdominal pain diagnosis one has to consider extra-abdominal conditions as possible causes.
The source of your abdominal pain may be elsewhere. Lower abdominal pain can be testicle pain ( torsion of the testis, ) or ovary pain ( eg. ovarian cancer .) Abdominal and back pain may both be caused by the same spinal problem.
Abdominal conditions can cause referred pain elsewhere, as in right shoulder blade pain from your gall bladder and shoulder tip pain from bleeding in your peritoneal cavity (irritating the diaphragm.)
Do you have other symptoms such as stomach cramps, bloating, difficulty swallowing or burning discomfort? Has there been ANY change in your bowel habit or any other bodily function? Has your weight altered? Are you generally feeling well, or not?
Have you had dark urine after bouts of pain, suggesting bile from a gallstone obstructing your bile passages.
Acute hepatitis causes the same dark tea coloured urine. The pain under the right ribs is much milder here.
Infectious mononucleosis causes hepatitis, and can also cause enlargement of your spleen, with a rare complication of acute rupture (an obvious emergency with pain in the left upper abdomen.)
Urine initially clear but darkening on exposure to light for some time, is the classical finding in porphyria attacks.
Darker than usual urine may just be concentrated, due to dehydration from fever or reduced intake from nausea.
If you think of something and have a memory like mine, write it down immediately you think of it (and refresh your memory immediately before seeing the doctor.)
Aggravating and relieving factors
This is the "suck it and see" approach to abdominal pain diagnosis.
Relief by antacid or eating may suggest stomach acid is involved in causing your pain.
Relief by taking drugs such as ranatidine or proton pump inhibitors (PPIs) suggests the same.
The severe upper abdominal pain of pancreatitis may be eased by leaning forward posture, apparently.
Quality - words other than just "pain"
Pains can be burning, cutting, electric shock - like, gripping, heavy etc.
This sometimes is very useful...
Colicky pain makes one want to double over, wriggle or walk rather than stay still. This comes from some hollow organ going into spasm, as may happen after over indulgence in grapes or stone fruit.
Early shingles, before the rash, causes "neuropathic" pain. This may be burning (searing,) lancinating (cutting,) or electric shock like in quality.
Heart attacks can cause a heavy, crushing pain behind one's breastbone, but also in ones epigastrium.
AND SELF EXAMINATION IS ALSO USEFUL
Your doctor can only examine your abdomen a limited number of times, and has to assume it is the same at other times.
You can help your abdominal pain diagnosis greatly, by filling in this detail and reducing uncertainty.
Lay down on your back, with head and shoulders propped up on pillows to improve your view. Open your mouth widely and keep it open during this examination. Take deep breaths and examine your abdomen while you are breathing out each time. These measures are to help you relax your abdominal muscles.
Push in moderately firmly all over your abdomen, and note carefully the extent of any tender areas.
Record these areas on a simple diagram, cross hatching in the areas of tenderness. Repeat the examination over a period of time, but don't delay seeking medical attention while you're doing this.
You may feel lumps and bumps, especially down the mid line. Your pulse may be felt there, about half way down. Your doctor will be examining you, so I'm sticking to instructions about tenderness.
To check for tenderness of your liver and gallbladder, relax your tummy, dig your fingers in under your right ribs, and breath in deeply. Did it hurt more as you breathed in?
Your liver is a large organ, marked on the surface by a triangle between your nipples and the bottom of your ribs on the right side.
You can compare doing this test on right and left sides. if it is more tender on the left, the stomach is more likely to be the tender organ.
If you have found any area of tenderness, the next step in your abdominal pain diagnosis is to determine whether it is abdominal wall or visceral (internal organ) tenderness.
Laying on your back, ensure that the spot is consistently tender as you rub with a circular motion of your fingers, moving the skin over the deeper structures.
Your fingers don't slide over the skin, but stay on the exact same bit of skin as they make the circles.
Compare the tenderness using the same pressure, with your abdominal muscles alternately tightened and relaxed. Tighten them by starting to lift your legs off the bed, keeping them straight.
Take your time over this examination, and repeat it to see if you get consistent results.
If taking the pressure off your innards by lifting your legs, reduces the tenderness, then some organ in your abdomen is tender.
If the tenderness remains the same or increases, it is tenderness of the muscles of your abdominal wall. This is seldom due to anything wrong with the muscles, but usually because of one of your spine joints is stuck and sore.
Pain has spread (been "referred") from the back, and as always, tenderness accompanies the referred pain.
The nerves to your abdominal wall skin, come from spinal segments T6 to T12 in the upper back. Examination of this area is detailed on the
thoracic spine page
of this site.
This test is useful for checking any abdominal tenderness. If multiple areas of your tummy are tender, you can do this test on each of them.
If I find this indicates a back problem, I will treat the back and then come back and re-examine the persons tummy. It is not unusual to initially find tenderness unchanged by lifting the legs, and then on the re-check to find the reverse.
This indicates both a back problem plus an abdominal organ problem.
Carnett's sign is a variation on this test. The first description of my test was many years ago in a paper on intercostal neuralgia v. abdominal pain diagnosis.
Very localized abdominal wall tenderness plus a lump to feel here, may be due to a complicated hernia here. Abdominal pain diagnosis includes looking for lumps in your abdominal wall.
Use a circular motion with the pads of your middle 3 fingers.
Epigastric hernias may be fatty hernias of the linea alba. These are little bits of fat poking out between the 6 packs in the mid line of the upper abdomen.
These are often irreducible, there all the time. They may come and go, and be tender only when poking out.
Spigellian hernias are along the outer edge of the 6 pack. These come and go, and contain bowel. Bowel can become stuck in a hernia and swell up, obstructing the bowel. This causes severe colicy central abdominal pain as well as the sore hernia.
Umbilical hernias poke out through our tummy button, or just above or below it.
The flick test
It's not just for abdominal pain diagnosis, but also a treatment.
If you have griping abdominal pain especially, it's worth giving your tummy a few sharp flicks with your finger.
This is a technique used by surgeons to produce visible peristalsis, if they suspect a bowel obstruction. It makes the bowel contract, and if the person is thin enough, the wave of contraction can be seen through their abdominal wall.
If this relieves your pain, the pain was coming from your intestines - something to tell your doctor.
If you need a clear idea of the anatomy of your abdomen and its contents, very useful images are available at
Abdominal pain diagnosis gall bladder disease?
Is it your stomach, possibly gastritis pain?
Have you got diverticular disease?
Lower abdominal pain diagnosis - from your pelvic organs
Pregnancy abdomen pains
Abdominal pain can indicate celiac disease.
Notes on the obvious - gastroenteritis, travellers diarrhoea
Irritable bowel syndrome page here, here, here***
Notes on Crohn's disease
Possibly lactose intolerance ?
Wondering if you may have bowel cancer?
Some notes on intestinal parasites.
Baby screaming, drawing legs up to tummy?
A bit about your bugs - intestinal flora
About abdominal bloating
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