Chronic Abdominal Pain Causes - Differential Diagnosis Framework



Many patients with chronic abdominal pain have had prior evaluations that did not yield a diagnosis after history, physical and testing.

 • Could potentially be an acute exacerbation of a chronic problem.

 • Process: Accelerating vs plateaued? Long-standing vs intermittent



Chronic Abdominal Pain Red Flags:

 • Fever

 • Anorexia, weight loss

 • Pain that awakens the patient

 • Blood in stool

 • Jaundice

 • Edema

 • Abdominal mass/organomegaly

 • Vomiting, diarrhea

 • Back pain

 • Skin changes

 • Urinary symptoms

 • Family history of IBD



Chronic abdominal pain > 3 months

 • Recurrent: Consider tumor

 • Upper quadrant/Epigastric: Consider cardiac causes

 • Lower quadrant: Consider genitourinary causes



RUQ:

 • Biliary colic/Chronic cholecystitis

 • Functional biliary pain

 • Sphincter of Oddi dysfunction

 • PSC

 • Budd-Chiari syndrome

 • Chronic portal vein thrombosis

 • Hepatocellular carcinoma



Epigastric/LUQ Pain:

 • Cardiopulmonary disease/AMI

 • PUD

 • Gastric malignancy

 • Esophageal malignancy

 • GERD/Dyspepsia

 • Gastritis: H. pylori/NSAIDs

 • Chronic pancreatitis

 • Splenomegaly/Abscess

 • Splenic vein thrombus

 • Splenic infarction

 • Lymphoma/Leukemia



Lower Abdominal Pain:

 • Pregnancy

 • Diverticulitis

 • IBD

 • Intestinal obstruction

 • Colorectal CA

 • Urinary retention

 • Pyelonephritis

 • Nephrolithiasis

 • Femoral/Inguinal hernia

 • Epididymitis

 • Endometriosis

 • Fibroids

 • Ovulatory pain

 • Ectopic pregnancy

 • Ovarian CA



Diffuse Pain:

 • Constipation

 • Irritable bowel syndrome

 • Celiac disease

 • Inflammatory bowel disease

 • Chronic mesenteric ischemia

 • GI malignancy

 • Lactase malabsorption/intolerance

 • SIBO



Focal Pain:

 • Abdominal wall pain

 • Abdominal cutaneous nerve entrapment

 • Abdominal hernia

 • Rib fracture

 • Shingles



Poorly Localized Pain:

 • Abdominal aortic aneurysms

 • Acute intermittent porphyria

 • Hypercalcemia

 • Hypothyroidism

 • Lead poisoning

 • Celiac artery compression syndrome

 • Mesenteric ischemia

 • Chronic intestinal pseudoobstruction

 • Eosinophilic gastroenteritis

 • Epiploic appendages

 • FMF

 • Adult Still's disease

 • Necrotic bowel disease

 • Somatization



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