Digestive Problems
Common Symptoms: Abdominal Pain
Pain is an important symptom of abdominal disease. Its position and characteristics give important clues to the likely causes. However, it is important to emphasize that many abdominal illnesses are not painful, at least in the early stages. This is because the lining of the gut has no nerve endings. Some inflammations and even cancers can develop and grow without provoking pain, unless the problem spreads through the wall of the gut to its outer lining, or causes narrowing. The intestine is sensitive to distention, which occurs upstream of any partial or complete obstruction.
Abdominal pains usually occur where you might expect from the anatomical location of the involved organ. Thus, problems in the stomach, biliary tree and pancreas usually cause pain in the upper abdomen below the breast bone (in the case of the gallbladder, somewhat to the right). Pain from the colon can be felt anywhere around the abdomen, but often in the flanks, whereas problems in the small intestine tend to be felt more centrally in the abdomen. There is some truth in the saying that pains further from the middle of the abdomen are likely to be more important than those near the umbilicus (navel).
We make a distinction between sudden and severe "acute abdominal pains," and those which are less severe, and more longlasting (maybe intermittent). Attacks of "acute abdominal pain" drive patients immediately to seek emergency aid; many need urgent surgical treatment – the so called "acute abdomen." Causes include acute appendicitis (and ruptured appendix), perforated gastric or duodenal ulcer, sudden loss of blood supply to the gut (mesenteric infarction), acute cholecystitis (inflammation of the gallbladder), and a ruptured aortic aneurysm (the major blood vessel). Sudden obstruction to the intestine can be caused by adhesions, kinking, hernias, tumors and local inflammation. Pains are initially "colicky," i.e. come and go like squeezing, and are associated with rapid abdominal swelling (distention) and vomiting. Women may present acutely with ruptured ectopic pregnancy or ovarian cysts.
Other abdominal diseases cause pains which are usually somewhat less severe, and may come and go. Understanding the sources can puzzle both patients and doctors.
Acid refluxing back from the stomach into the lower esophagus typically causes heartburn, felt behind the breast bone in the chest. However, in some patients, this acid reflux provokes spasm of the lower esophagus which is felt as a sharper pain at the lower tip of the breast bone. Because of their position, these pains cause a lot of anxiety, since patients may think they come from the heart. Heart pains (angina) typically start during exercise, and may be felt also in the neck and upper arms.
The epigastrium describes the upper part of the abdomen between the breast bone and the navel. Indigestion (dyspepsia) caused by ulcers and gastritis can sometimes be bad enough to be described as a "pain." Typically, it is more a continuous gnawing feeling, which starts about 30 minutes after food, and can be relieved (at least partially) by any medicine which reduces stomach acids. It may feel like a "hunger pain," and (paradoxically) can be helped temporarily by eating. Ulcer pain is more severe if the ulcer penetrates through the wall of the stomach or duodenum into another organ, and produces an "acute abdomen" if it penetrates into the peritoneal cavity (to cause peritonitis).
Diseases of the pancreas (chronic pancreatitis and cancer) cause upper abdominal "epigastric" pain; it is often felt also in the mid back, since the pancreas lies across the spine. The pain ofpancreatic cancer is continuous and progressive. That due to chronic pancreatitis is usually intermittent, with no clear relation to eating. Upper abdominal pain and weight loss (along with lack of appetite) are typical symptoms of stomach cancer.
Stones in the gallbladder cause pain in the epigastrium and "right upper quadrant" of the abdomen. The pain is due to stones blocking the exit to the gallbladder (the cystic duct), and/or infection within the gallbladder. A typical attack gallstone pain (biliary colic) is severe and lasts for several hours. It is usually continuous (rather than waxing and waning like a labor pain), and may also be felt under the right shoulder blade. Gallstone pain can be particularly severe when a stone passes through the cystic duct into the bile duct, and gets stuck near its exit at the papilla of Vater. The pain is caused by distention of the bile duct, and the obstruction is often followed by infection. Because the stone is blocking the bile duct, there is a buildup of bile in the blood; the patient may notice yellowing of the eyes or skin (jaundice) in association with the pains, and the stools may become pale. Lesser degrees of obstruction will show up on blood tests of the liver (liver function tests). The full blown syndrome of bile duct obstruction is called "acute cholangitis" – the association of pain, jaundice, and fever.
Complete loss of blood supply to the intestine causes a sudden "acute abdomen." Less complete interruption of the blood supply results in "mesenteric ischemia"; the intestine is starved of blood, but survives. Epigastric and mid abdominal pain occurs after eating, especially after larger meals, and the patient characteristically loses weight quickly.
Any part of the intestines can become inflamed. The most common painful inflammatory condition is diverticulitis – inflammation of an outpocket (diverticulum) of the colon. This usually occurs in the left lower quadrant of the abdomen, and is associated with some disturbance of bowel function – diarrhea and/or constipation. This combination (along with a change in the diameter of the stools) can be seen also in patients with cancer of the lower bowel.
Crohn's disease is another inflammatory condition of the intestine. This can cause pain wherever the inflammation occurs, and may result in obstruction to the bowel.
The pains described so far tend to have characteristic positions, which can point to their origin. By far the most common cause of abdominal pain in the general population is the so-called "irritable bowel syndrome." It can effect all parts of the gut; thus the pain may be felt in different places on different occasions. Pains are due to distention of areas of the gut (behind areas of spasm); they feel like a balloon being blown up inside. Pains are characteristically "colicky," which means that they come and go in periods of minutes. They are often associated with a feeling of abdominal distention or bloating, and a disturbance of bowel function (diarrhea and/or constipation) with excessive gas. The stomach sometimes sounds noisy.
Kidney stones can cause intense pain when they get stuck in the urinary passages; this pain is usually felt in the flank on one or either side, and may radiate down into the groin. Pain in the groin itself may result from a hernia (rupture); the pain can be intense when the hernia becomes stuck (incarcerated).
In general, it is fair to say that abdominal pains which move around and last only for a few minutes at the time are unlikely to be serious, however bothersome. Pains which are fixed in position, continuous and progressive usually signify serious underlying disease. The important thing to remember is, despite how low you may feel the pain is, if the pain persists over an extended period of time, go see your physician. That dull pain may be an early warning signal of something more serious.