ABDOMINAL PAIN - Full
Hans is an eight year old boy whose father was recently transferred from Germany to set up a printing plant in Melbourne. They had only been in Australia a few weeks when Hans became unwell.
Hans had what seemed like a typical tummy upset and was unable to go to school. He had been vomiting a few times overnight and complained of vague pains in the abdomen. He also had a slight fever. During the day the pains became worse. Initially they were colicky pains that came and went. Now they were almost constant and had shifted in position to the lower part of the abdomen.
Hans' mother rang the surgery and was advised to bring him straight down. It was obvious that he was not well. He was reluctant to lie down flat and seemed more comfortable with his knees bent up a little. His tongue was a little dry and his pulse was faster than normal. His abdomen was very tender to the touch, especially lower down on the right side. When I felt in that area, Hans winced in pain and seemed to tighten his abdominal muscles.
There was little doubt that he had acute appendicitis. I explained this to Hans and his mother and then contacted a paediatric surgeon at the children's hospital. Hans' mother was very concerned about the whole thing. Hans just wanted to get rid of that awful pain in the tummy. Later that evening Hans had his appendix removed and he went on to make a speedy recovery. He was home from hospital within a few days and soon back at his new school.
Abdominal pains can really knock you about. They can be very severe and may be associated with other symptoms like nausea and vomiting. Frequently there is the added concern that there could be an underlying problem like appendicitis or something more serious.
The abdominal cavity extends from the diaphragm to the pelvis and has a lining called the peritoneum. It contains many organs, any of which can malfunction and cause pain. On the upper left side is the stomach which enters into the duodenum and then the rest of the bowel. The pancreas sits in the curve of the duodenum and empties into it via a duct. Just under the right ribs are the liver and gallbladder that also drain into the duodenum, via the bile duct. Two kidneys sit fairly high on the back wall, each with a ureter that passes down to the bladder. Running down the back of the abdomen is the main arterial trunk called the aorta. There are several other structures, and the female pelvis also contains the uterus, tubes and ovaries.
Aside from the severity of the pain and its precise location, several features give a clue to the underlying cause. Is the pain constant or does it come and go? Colicky pains suggest spasm in a muscular tube, due to such things as bowel cramps, gallstones or kidney stones. Is it a sudden, acute pain or did it just gradually develop? The pain of appendicitis usually develops gradually. Does the pain radiate anywhere? The pain from kidney stones frequently travels from the back around to the groin. Is there a fever or any bowel or urinary symptoms? What about other symptoms like indigestion, poor appetite or weight loss? With a good history the doctor can usually narrow down the cause of abdominal pain to a couple of possibilities.
On examination, the blood pressure, pulse and temperature are checked. Then the abdomen is examined, looking for signs of any tenderness or distension. An internal examination may also be required. The urine is then tested for the presence of blood or other abnormalities. Blood tests, X-rays or ultrasounds may be necessary to confirm a diagnosis and assist with treatment.
There are a number of causes of abdominal pain that should be kept in mind...
Appendicitis is the condition that always comes to mind first. It can occur in people of any age but may be difficult to diagnose in the very young and the elderly. Frequently the pain is non-specific to start with. There may be vomiting and perhaps a fever. The pain tends to gradually get worse and then usually becomes localized in the lower right side of the abdomen. The diagnosis may not be initially clear.
Gallstones are usually an adult condition. Frequently they cause severe colicky pain high up on the right side of the abdomen. Sometimes the pain can be felt in the back or even the chest, and may be triggered off by a fatty meal.
Kidney stones also are more common in adults. Often they cause very severe pain, usually felt initially in the loin area. The pain may travel around to the front or to the groin. People often thrash about, unable to get any relief. While women put the pain in the childbirth category, men often compare it in severity to a kick in the testicles.
Duodenal ulcer pain is like severe indigestion. It is often a burning pain just below the breastbone and it may be relieved with antacid. It may wake the person from sleep. Gastric ulcer pain is quite similar but tends to come on with eating. Ulcers are uncommon in children.
Abdominal aneurysm - The aorta is the main arterial trunk that carries blood from the heart. Sometimes its wall can become weak, and an aneurysm, or bubble may occur. This is more likely to happen in older people with vascular disease. An abdominal aortic aneurysm can cause severe pain, sometimes also felt in the back. If blood is leaking into the abdominal cavity the blood pressure may drop sharply and the person may look sweaty and pale. A leaking or ruptured abdominal aortic aneurysm is a surgical emergency. Immediate ambulance transport to a major hospital is necessary if a leaking aneurysm is suspected.
In both children and adults, abdominal pains often turn out to be no more than a tummy upset with some cramping bowel spasms. However, there are clues to suggest that abdominal pain might be due to something more significant:
* Persistent or severe abdominal pain always needs a medical check, even in the middle of the night. If you are not sure, it is better to err on the safe side and ask your doctor for advice.
Dr. Andrew Pattison: Common Consultations
North East Valley Division General Practice, Melbourne, Australia. Disclaimer
- Last modified: September 14, 2000