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ABDOMINAL PAIN

There is a long list of causes of abdominal pain, including pain in lower left abdomen.

Common conditions which causes abdominal pain include:

1. Peptic ulcer disease / Gastritis - this usually occurs in in the upper abdomen. The pain may be relieved by antacids.

2. Gallstones - the pain is usually upper abdomen and to the right. Sometimes the pain is felt all the way round to the back as well. In the initial stages it is usually common not to be able to find any comfortable position at all. A fatty meal can sometimes trigger an atttack.

3. Appendicitis - the pain is initially central and then moves to the right side of the abdomen above the groin(the location is called the Right Iliac fossa - it is often abbreviated to RIF in medical notes). There is also often a loss of appetite and nausea.

4. Gynaecological pathology (eg Retrograde menstruation, bleeding ectopic pregnancy, twist of the ovary, rupture of an ovarian cyst/follicle, pelvic inflammatory disease, endometriosis) - the pain can be in either right or left iliac fossa but it is usually lower down and closer to the groin crease.

5. Urological pathology - Infection of the urinary tract (eg bladder) besides causing a stinging pain when passing urine may also cause pain above the pubic bone and also in the loin(if the infection spreads to the kidneys). Kidney stones can also cause pain in the loins going around into the groin. Testicular problems(eg torsion of testicle)/trauma may also cause pain to be felt around the belly button!

6. Diverticulitis - the pain is usually in the left iliac fossa. This is usually associated with fever.

7. Bowel blockage / obstruction (eg from adhesions or cancer or stuck hernia) - typically the pain comes and goes in waves, usually central or just above the pubic bone.

8. Complicated hernia - a hernia with its contents becoming stuck can become painful when the blood supply to the contents(eg fat or bowel) becomes compromised. It is important to check the groin for any inguinal or femoral hernia in anyone with abdominal pain.

9. Pain referred from elsewhere and other medical causes - Pneumonia affecting the lower lobes of the lungs, heart attack, metabolic causes (eg very high blood calcium levels, severe diabetes - diabetic ketoacidosis), back problems, shingles, Familial Mediterranean fever, vasculitis, sickle cell anaemia. In young children, mesenteric adenitis(inflammation of the lymph glands in the abdomen) can also cause abdominal pain. This is associated usually with a cold and high fever.

10. Pancreatitis - inflammation of the pancreas (usually from either alcohol or gallstones). This can cause pain in front going through to the back. Often assciated with vomiting which tends to relieve the pain.

11. Coeliac disease - this is a hereditary condition that is quite common(about 1 in 100 Australians suffer from it although aajority are undiagnosed. Often, there may not be a known family history. Coeliac disease can cause a wide range of synptoms including abdominal pain.

12. Inflammatory Bowel Disease - Ulcerative colitis, Crohn's disease

13. Cancer / Malignancy - This can occur in any abdominal organ. The common ones are colon cancer, stomach cancer, oesophageal cancer, liver cancer and pancreatic cancer. Generally cancer does not cause pain until it is quite advanced.

Sometimes, there are no causes found and this is labelled as non-specific abdominal pain or irritable bowel syndrome(if the pain is long-standing). Just as one can get headache without any specific cause being found, one can also get abdominal pain/colic/cramps without any specific cause being every found.

Causes of pain in lower left abdomen include:

1. Diverticular disease - sometimes this can be complicated by the development of acute diverticulitis, abscess and perforation.

2. Hernia - there can be pain in the left groin from an inguinal hernia or femoral hernia(especially if the hernia is strangulated).

3. Musculoskeletal injury - tear in the muscles/tendons in the area(eg Sportsperson's groin)

4. Pain from kidney stones (pain usually start in the flank and moves down into the groin)

5. Inflammation of underlying bowel - eg colitis in the sigmoid colon

6. Gynaecological pathology - eg rupture of an ovarian cyst, torsion of the ovary, endometriosis, ectopic pregnancy

MANAGEMENT

A detailed history and examination is required. This would help the doctor narrow down the differential diagnoses and select the most appropriate investigations if neccessary.

Investigations:

1. Full blood count - looking for evidence of increased white cells(as part of an inflammatory response)

2. Imaging - Abdominal X-ray althogh frequently ordered is not usually helpful(unless in bowel obstruction). Chest Xray excludes lung pathology and gas under the diaphragm(this can be due to perforation of the stomach/colon) An ultrasound to look for gallstones may also be needed.

3. A diagnostic laparoscopy may be performed (eg to look for appendicitis or gynaecological causes) The appendix may be removed even if it appears normal on the outside if no other clear cause is found(there can be microscopic appendicits with inflammation of the lining seen only under the microscope or blockage of the appendix eg by tumour or even worms!)

4. Endoscopy - depending on the symptoms, a gastroscopy and a colonoscopy may be indicated.

5. Admission. Sometimes, the diagnoses cannot be made immediately and admission for observation may be necessary. If that is the case, one would be asked to fast(in case condition deteriorates rapidly and emergency surgery is needed), given intravenous fluids, analgesics and reassesed.

Treatment

Treatment would depend on the specific cause of the abdominal pain.

 

Notable cases :

I remembered a case once when I was a registrar - I was called late in the middle of the night about a young woman with mild right sided abdominal pain and the ED resident wondered whether she had early appendicitis and had wanted to admit the patient overnight for observation. I decided to drive back to the hospital to see the patient. When examined, it turned out she had an incarcerated femoral hernia. The patient was taken to theatre immediately and an ischaemic but viable segment of small bowel was found stuck within it.

A junior surgical registrar had admitted a case overnight with abdominal pain and had organized for the patient to have a CT scan in the morning. On examination in the morning consultant ward round, the patient was found to have an incarcerated femoral hernia.

An obese middle-aged lady with generalized abdominal pain but not very specific signs. I had been referred the patient by the medical team. She also had a headache and high fever. I suggested doing a lumbar pucture and it turned out she had meningitis. I was worried the next few days whether I had contracted meningitis from the patient

Woman with abdominal pain on left side. Otherwise well. Few days later a few vesicles appeared followed by a rash in a band-like distribution. Shingles!

Young girl with pain in the lower abdomen - slightly tender above her pubic bone. I was asked to see her by the paediatric team to exclude a surgical pathology. As she had not had a period before, I suggested that an ultrasound scan be done for her looking for evidence of an imperforate vagina. To my suprise she had that!

Middle-aged man with chronic abdominal pain that has been labelled as irritable bowel presents with again to the emergency department. Diagnosis of  bowel obstruction is made. At surgery he is found to have small bowel cancer with spread to the liver.

2 young men who were both incarcerated - were referred for treatment of their appendiceal abscess after presenting with a long history of abdominal pain to their prison doctor.

Young girl presented with abdominal pain and was also noted to be anaemic. An upper GI endoscopy was performed and the duodenal biopsies showed changes consistent with coeliac disease

Middle-aged man presents with symptoms typical of apendicitis - at surgery, he had a very swollen and solid lump in the base of his appendix suggestive of being a tumour. He needed a bowel resection instead of just an appendicectomy. He turned out to have a carcinoid tumour.

Other conditions which I have come across causing RIF pain include: pinworms in the appendix, torsion of the omentum and also rectus sheath haematoma