Abdominal pain, chronic or recurrent

Question 1

Probability diagnosis

Answer 1

Irritable bowel syndrome

Mittelschmerz/dysmenorrhoea

Constipation

Peptic ulcer/gastritis

Question 2

Serious disorders not to be missed

Answer 2

Vascular:

• mesenteric artery ischaemia
• AAA

Cancer/neoplasia:

• bowel/stomach cancer
• pancreatic cancer
• ovarian tumours

Infection:

• hepatitis
• recurrent PID

Question 3

Pitfalls (often missed)

Answer 3

1. Adhesions
2. Appendicitis
3. Biliary disease: gallstones, sludge
4. Food allergies
5. Hernia
6. Lactase deficiency (i.e. lactose intolerance)
7. Constipation/faecal impaction
8. Chronic pancreatitis
9. Coeliac disease
10. Inflammatory bowel disease
11. Crohn disease
12. Endometriosis
13. Diverticular disease
14. Subacute obstruction (cancer, adhesions, etc.)
15. Rarities:

• tropical infections (e.g. hydatids, melioidosis, strongyloides)
• uraemia
• lead poisoning
• porphyria
• sickle cell anaemia
• hypercalcaemia
• Addison disease

Question 4

Masquerades checklist

Answer 4

Depression

Drugs

Spinal dysfunction

UTI

Question 5

Is the patient trying to tell me something?

Answer 5

A strong possibility: consider;

1. hypochondriasis
2. anxiety
3. sexual dysfunction
4. Munchausen syndrome.

Question 6

Key history

Answer 6

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).

Question 7

Key examination

Answer 7

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

Question 8

Key investigations

Answer 8

Urinalysis including MCU

• FBC
• 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

Question 9

Diagnostic tips

Answer 9

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.