Causes of Abdominal Pain in Adults

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Causes of abdominal pain in adults

AUTHORS: Robert M Penner, BSc, MD, FRCPC, MSc, Mary B Fishman, MD
SECTION EDITORS: Andrew D Auerbach, MD, MPH, Mark D Aronson, MD
DEPUTY EDITOR: Jane Givens, MD, MSCE
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2024.

This topic last updated: Sep 12, 2023.
INTRODUCTION
The evaluation of abdominal pain requires an understanding of the possible mechanisms responsible for pain, a broad differential of
common causes, and recognition of typical patterns and clinical presentations. This topic reviews the etiologies of abdominal pain in
adults. The emergency and non-urgent evaluation of abdominal pain of adults discussed elsewhere. (See "Evaluation of the adult with
nontraumatic abdominal or flank pain in the emergency department" and "Evaluation of the adult with abdominal pain".)
Abdominal pain in pregnant and postpartum individuals is discussed elsewhere. (See "Approach to acute abdominal/pelvic pain in
pregnant and postpartum patients".)
PATHOPHYSIOLOGY OF ABDOMINAL PAIN
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● Neurologic basis for abdominal pain – Pain receptors in the abdomen respond to mechanical and chemical stimuli. Stretch is the
principal mechanical stimulus involved in visceral nociception, although distention, contraction, traction, compression, and torsion
are also perceived [1]. Visceral receptors responsible for these sensations are located on serosal surfaces, within the mesentery,
and within the walls of hollow viscera. Visceral mucosal receptors respond primarily to chemical stimuli, while other visceral
nociceptors respond to chemical or mechanical stimuli.
The events responsible for the perception of abdominal pain are not completely understood, but depend upon the type of stimulus
and the interpretation of visceral nociceptive inputs in the central nervous system. As an example, the gastric mucosa is insensitive
to pressure or chemical stimuli. However, in the presence of inflammation, these same stimuli can cause pain [2]. The threshold for
perceiving pain may vary among individuals and in certain diseases. (See "Evaluation of chronic non-cancer pain in adults", section
on 'Definition of pain'.)
● Localization – The type and density of visceral afferent nerves makes the localization of visceral pain imprecise. However, a few
general rules are useful:
• Most digestive tract pain is perceived in the midline because of bilaterally symmetric innervation [1,3]. Pain that is clearly
lateralized most likely arises from the ipsilateral kidney, ureter, ovary, or somatically innervated structures, which have
predominantly unilateral innervation. Exceptions to this rule include the gallbladder and ascending and descending colons
which, although bilaterally innervated, have predominant innervation located on their ipsilateral sides.
• Visceral pain is perceived in the spinal segment at which the visceral afferent nerves enter the spinal cord [4]. As an example,
afferent nerves mediating pain arising from the small intestine enter the spinal cord between T8 to L1. Thus, distension of the
small intestine is usually perceived in the periumbilical region.
● Referred pain – Pain originating in the viscera may sometimes be perceived as originating from a site distant from the affected
organ ( figure 1) [5-7]. Referred pain is usually located in the cutaneous dermatomes sharing the same spinal cord level as the
visceral inputs. As an example, nociceptive inputs from the gallbladder enter the spinal cord at T5 to T10. Thus, pain from an
inflamed gallbladder may be perceived in the scapula ( figure 1).

The quality of referred pain is aching and perceived to be near the surface of the body. In addition to pain, two other correlates of
referred pain can be detected: skin hyperalgesia and increased muscle tone of the abdominal wall (which accounts for the
abdominal wall rigidity sometimes observed in patients with an acute abdomen).
UPPER ABDOMINAL PAIN SYNDROMES
Upper abdominal pain syndromes typically have characteristic locations: right upper quadrant pain ( table 1), epigastric pain
( table 2), or left upper quadrant pain ( table 3).
Right upper quadrant pain — Biliary and hepatic etiologies cause right upper quadrant pain syndromes.
Biliary etiologies include ( table 1):
● Gallstones – Symptoms of biliary colic classically include an intense, dull discomfort located in the right upper quadrant,
epigastrium, or (less often) substernal area that may radiate to the back (particularly the right shoulder blade). Patients may have
associated nausea, vomiting, and diaphoresis. The pain generally lasts at least 30 minutes, plateauing within an hour. Patients have
an unremarkable abdominal examination. (See "Overview of gallstone disease in adults", section on 'Biliary colic'.)
● Acute cholecystitis – The clinical manifestations of acute cholecystitis include prolonged (more than four to six hours), steady,
severe right upper quadrant or epigastric pain, fever, abdominal guarding, a positive Murphy's sign, and leukocytosis. (See "Acute
calculous cholecystitis: Clinical features and diagnosis", section on 'Clinical manifestations'.)
● Acute cholangitis – Acute cholangitis occurs when a stone becomes impacted in the biliary or hepatic ducts, causing dilation of the
obstructed duct and bacterial superinfection. It is characterized by fever, jaundice, and abdominal pain, although this classic triad
(known as Charcot's triad) occurs in only 50 to 75 percent of cases [8]. The abdominal pain is typically vague and located in the right
upper quadrant. (See "Acute cholangitis: Clinical manifestations, diagnosis, and management", section on 'Clinical manifestations'.)
● Sphincter of Oddi dysfunction – Sphincter of Oddi dysfunction can be a cause of biliary pain in the absence of gallstones or biliary
inflammation. Typically the pain is located in the right upper quadrant or epigastrium and lasts from 30 minutes to several hours.

Hepatic etiologies include ( table 1):
● Hepatitis – Patients with acute hepatitis (eg, from hepatitis A, alcohol, or medications) may have fatigue, malaise, nausea,
vomiting, and anorexia in addition to right upper quadrant pain. Other symptoms include jaundice, dark urine, and light colored
stools. (See "Hepatitis A virus infection in adults: Epidemiology, clinical manifestations, and diagnosis", section on 'Clinical
manifestations' and "Alcoholic hepatitis: Clinical manifestations and diagnosis", section on 'Signs and symptoms' and "Drug-
induced liver injury", section on 'Clinical manifestations'.)
● Perihepatitis – The Fitz-Hugh-Curtis syndrome, or perihepatitis, is a cause of right upper quadrant pain in young females with
pelvic inflammatory disease (PID). It occurs in approximately 10 percent of patients with acute PID. It is characterized by right upper
quadrant pain with a distinct pleuritic component, sometimes referred to the right shoulder. (See "Pelvic inflammatory disease:
Clinical manifestations and diagnosis", section on 'Perihepatitis'.)
● Liver abscess – Liver abscess is the most common type of visceral abscess. Patients generally present with fever and abdominal
pain. Risk factors include diabetes, underlying hepatobiliary or pancreatic disease, or liver transplant. (See "Pyogenic liver abscess",
section on 'Epidemiology' and "Pyogenic liver abscess", section on 'Clinical manifestations'.)
● Budd-Chiari syndrome – Budd-Chiari syndrome is technically defined as hepatic venous outflow tract obstruction, independent of
the level or mechanism of obstruction, provided the obstruction is not due to cardiac disease, pericardial disease, or sinusoidal
obstruction syndrome (veno-occlusive disease). As commonly used, the Budd-Chiari syndrome implies thrombosis of the hepatic
veins and/or the intrahepatic or suprahepatic inferior vena cava. Symptoms include fever, abdominal pain, abdominal distention
(from ascites), lower extremity edema, jaundice, gastrointestinal bleeding, and/or hepatic encephalopathy. There are a variety of
causes, many of which are related to an underlying prothrombotic or hypercoagulable state ( table 4). (See "Budd-Chiari
syndrome: Epidemiology, clinical manifestations, and diagnosis", section on 'Clinical manifestations' and "Etiology of the Budd-
Chiari syndrome", section on 'Etiology'.)
● Portal vein thrombosis – Clinical manifestations of portal vein thrombosis vary depending on the extent of obstruction as well as
the speed of development (acute or chronic). It is common in patients with cirrhosis and is associated with the severity of liver
disease. Patients may be asymptomatic or have abdominal pain, dyspepsia, or gastrointestinal bleeding. (See "Acute portal vein

thrombosis in adults: Clinical manifestations, diagnosis, and management", section on 'Clinical manifestations' and "Chronic portal
vein thrombosis in adults: Clinical manifestations, diagnosis, and management", section on 'Clinical manifestations'.)
Epigastric pain — Pancreatic and gastric etiologies often cause epigastric pain ( table 2).
● Acute myocardial infarction – Epigastric pain can be the presenting symptom of an acute myocardial infarction. Patients may
have associated shortness of breath or exertional symptoms. (See "Approach to the patient with suspected angina pectoris".)
● Pancreatitis – Both acute and chronic pancreatitis are associated with abdominal pain that often radiates to the back. Most
patients with acute pancreatitis have acute onset of persistent, severe epigastric pain. The pain is steady and may be in the mid-
epigastrium, right upper quadrant, diffuse, or, infrequently, confined to the left side. (See "Clinical manifestations and diagnosis of
acute pancreatitis", section on 'Clinical features'.)
The two primary clinical manifestations of chronic pancreatitis are epigastric pain and pancreatic insufficiency. The pain is typically
epigastric, is occasionally associated with nausea and vomiting, and may be partially relieved by sitting upright or leaning forward.
(See "Chronic pancreatitis: Clinical manifestations and diagnosis in adults", section on 'Abdominal pain'.)
● Peptic ulcer disease – Upper abdominal pain or discomfort is the most prominent symptom in patients with peptic ulcers. Patients
most often have epigastric pain, but occasionally the discomfort localizes to one side. (See "Peptic ulcer disease: Clinical
manifestations and diagnosis", section on 'Clinical manifestations'.)
● Gastroesophageal reflux disease – Most patients with gastroesophageal reflux disease (GERD) complain of heartburn,
regurgitation, and dysphagia. However, some patients may also complain of epigastric and/or chest pain. (See "Clinical
manifestations and diagnosis of gastroesophageal reflux in adults", section on 'Clinical features'.)
● Gastritis/gastropathy – Gastritis refers to inflammation in the lining of the stomach. Gastritis is predominantly an inflammatory
process, while the term gastropathy denotes a gastric mucosal disorder with minimal to no inflammation. Acute gastropathy often
presents with abdominal discomfort/pain, heartburn, nausea, vomiting, and hematemesis. Gastropathy may be caused by a variety
of etiologies including alcohol and nonsteroidal antiinflammatory drugs (NSAIDs). (See "Acute hemorrhagic erosive gastropathy

and reactive gastropathy", section on 'Acute hemorrhagic erosive gastropathy' and "NSAIDs (including aspirin): Pathogenesis and
risk factors for gastroduodenal toxicity", section on 'COX-1 mediated NSAID injury'.)
● Functional dyspepsia – Functional dyspepsia is defined as the presence of one or more of the following symptoms: postprandial
fullness, early satiation, and epigastric pain or burning, with no evidence of structural disease (including at upper endoscopy) to
explain the symptoms. (See "Functional dyspepsia in adults".)
● Gastroparesis – Patients with gastroparesis can present with nausea, vomiting, abdominal pain, early satiety, postprandial fullness,
bloating, and, in severe cases, weight loss. The most common causes are idiopathic, diabetic, or postsurgical ( figure 2). (See
"Gastroparesis: Etiology, clinical manifestations, and diagnosis", section on 'Clinical manifestations'.)
Left upper quadrant pain — Left upper quadrant pain is often related to the spleen ( table 3).
● Splenomegaly – Splenomegaly can cause left upper quadrant pain or discomfort, referred pain to the left shoulder, and/or early
satiety. Splenomegaly has multiple causes ( table 5). (See "Splenomegaly and other splenic disorders in adults", section on
'Splenomegaly'.)
● Splenic infarction – Patients with splenic infarction classically present with severe left upper quadrant pain, though atypical
presentations are common. Splenic infarction is associated with a variety of underlying conditions (eg, hypercoagulable state,
embolic disease from atrial fibrillation, conditions associated with splenomegaly). (See "Splenomegaly and other splenic disorders
in adults", section on 'Abscess and infarction'.)
● Splenic abscess – Splenic abscesses are uncommon and typically are associated with fever and tenderness in the left upper
quadrant. They may also be associated with splenic infarction. (See "Splenomegaly and other splenic disorders in adults", section on
'Abscess and infarction'.)
● Splenic rupture – Splenic rupture is most often associated with trauma. The patient may complain of left upper abdominal, left
chest wall, or left shoulder pain (ie, Kehr's sign). Kehr's sign is pain referred to the left shoulder that worsens with inspiration and is
due to irritation of the phrenic nerve from blood adjacent to the left hemidiaphragm. (See "Management of splenic injury in the

adult trauma patient", section on 'History and physical examination' and "Splenomegaly and other splenic disorders in adults",
section on 'Trauma/rupture'.)
LOWER ABDOMINAL PAIN SYNDROMES
Lower abdominal pain syndromes ( table 6) often cause pain in either or both lower quadrants. Females may have lower abdominal
pain from disorders of the internal female reproductive organs ( table 7). (See 'Females' below.)
Lower abdominal pain syndromes that are generally localized to one side include ( table 6):
● Acute appendicitis – Acute appendicitis typically presents with periumbilical pain initially that radiates to the right lower quadrant.
It is associated with anorexia, nausea, and vomiting. However, occasionally patients present with epigastric or generalized
abdominal pain. The pain localizes to the right lower quadrant when the appendiceal inflammation begins to involve the peritoneal
surface. (See "Acute appendicitis in adults: Clinical manifestations and differential diagnosis", section on 'Clinical manifestations'.)
● Diverticulitis – The clinical presentation of diverticulitis depends upon the severity of the underlying inflammatory process and
whether or not complications are present. Left lower quadrant pain is the most common complaint, although right-sided
diverticulitis is not uncommon [9]. The pain is usually constant and is often present for several days prior to presentation. Patients
may also have nausea and vomiting. (See "Clinical manifestations and diagnosis of acute colonic diverticulitis in adults", section on
'Clinical manifestations'.)
Abdominal pain from some genitourinary etiologies may be localized to either side ( table 6):
● Kidney stones – Kidney stones usually cause symptoms when the stone passes from the renal pelvis into the ureter. Pain is the
most common symptom and varies from a mild to severe. Patients may have flank pain, back pain, or abdominal pain. (See "Kidney
stones in adults: Diagnosis and acute management of suspected nephrolithiasis", section on 'Clinical manifestations'.)
● Pyelonephritis – Patients with pyelonephritis may or may not have symptoms of cystitis (dysuria, frequency, urgency, and/or
hematuria). These patients also have fever, chills, flank pain, and costovertebral angle tenderness. (See "Acute simple cystitis in

adult and adolescent females", section on 'Clinical manifestations' and "Acute simple cystitis in adult and adolescent males", section
on 'Clinical manifestations'.)
Other etiologies of lower abdominal pain may not always be localized to one side ( table 6):
● Cystitis – Patients with cystitis may complain of suprapubic pain as well as dysuria, frequency, urgency, and/or hematuria. (See
"Acute simple cystitis in adult and adolescent females", section on 'Clinical manifestations' and "Acute simple cystitis in adult and
adolescent males", section on 'Clinical manifestations'.)
● Acute urinary retention – Patients with bladder outlet obstruction leading to acute urinary retention present with the inability to
pass urine. They may have associated lower abdominal and/or suprapubic pain or discomfort. (See "Acute urinary retention",
section on 'Initial evaluation'.)
● Infectious colitis – Patients with infectious colitis generally have diarrhea as the predominant symptom but may also have
associated abdominal pain, which may be severe. Patients with Clostridioides difficile infection can present with an acute abdomen
and peritoneal signs in the setting of perforation and fulminant colitis ( table 8). (See "Clostridioides difficile infection in adults:
Clinical manifestations and diagnosis", section on 'Clinical manifestations' and "Approach to the adult with acute diarrhea in
resource-abundant settings", section on 'Stool tests for bacterial pathogens'.)
DIFFUSE ABDOMINAL PAIN SYNDROMES
Abdominal pain syndromes may have diffuse, nonspecific, or variable patterns of pain ( table 9).
● Obstruction – Severe, acute diffuse abdominal pain can be caused by either partial or complete obstruction of the intestines.
Intestinal obstruction should be considered when the patient complains of pain, vomiting, and obstipation. Physical findings
include abdominal distention, tenderness to palpation, high-pitched or absent bowel sounds, and a tympanic abdomen. There are
many etiologies of obstruction ( table 10), with the most common etiologies in adults being postoperative adhesions, malignancy
related (eg, from colorectal cancer), and complicated hernias. Other less common etiologies include Crohn disease, gallstones,
volvulus, and intussusception. (See "Etiologies, clinical manifestations, and diagnosis of mechanical small bowel obstruction in
adults" and "Clinical presentation, diagnosis, and staging of colorectal cancer", section on 'Clinical presentation' and "Intestinal
malrotation in children" and "Gastric volvulus in adults" and "Cecal volvulus" and "Sigmoid volvulus".)
● Perforation of gastrointestinal tract – Perforation of the gastrointestinal tract can present acutely or in an indolent manner.
Patients complain of chest or abdominal pain to some degree. Sudden, severe chest or abdominal pain following instrumentation
or surgery is very concerning for perforation. Patients on immunosuppressive or antiinflammatory agents may have an impaired
inflammatory response, and some may have little or no pain and tenderness. Many patients will seek medical attention with the
onset or worsening of significant chest or abdominal pain, but a subset of patients will present in a delayed fashion. (See "Overview
of gastrointestinal tract perforation", section on 'Clinical features'.)
● Mesenteric ischemia – Acute mesenteric ischemia presents with the acute and severe onset of diffuse and persistent abdominal
pain, often described as pain out of proportion to examination. Several features of the pain and its presentation may provide clues
to the etiology of the ischemia and help distinguish small intestinal from colonic ischemia ( table 11). Chronic mesenteric
ischemia may be manifested by a variety of symptoms including abdominal pain after eating ("intestinal angina"), weight loss,
nausea, vomiting, and diarrhea. Ischemia that involves the celiac territory causes epigastric or right upper quadrant pain. Ischemia
may be from either arterial or venous disease. (See "Overview of intestinal ischemia in adults" and "Chronic mesenteric ischemia"
and "Mesenteric venous thrombosis in adults", section on 'Clinical presentations' and "Colonic ischemia", section on 'Clinical
features'.)
Patients with aortic dissection may have abdominal pain from mesenteric ischemia ( table 12). (See "Clinical features and
diagnosis of acute aortic dissection", section on 'Clinical features'.)
● Inflammatory bowel disease– Inflammatory bowel disease (IBD) is comprised of two major disorders: ulcerative colitis and Crohn
disease. IBD is also associated with a number of extraintestinal manifestations ( table 13). (See "Definitions, epidemiology, and
risk factors for inflammatory bowel disease".)
• Ulcerative colitis – Patients with ulcerative colitis usually present with diarrhea which may be associated with blood. Bowel
movements are frequent and small in volume as a result of rectal inflammation. Associated symptoms include colicky abdominal

pain, urgency, tenesmus, and incontinence. (See "Clinical manifestations, diagnosis, and prognosis of ulcerative colitis in adults",
section on 'Clinical manifestations'.)
• Crohn disease – The clinical manifestations of Crohn disease are more variable than those of ulcerative colitis. Patients can have
symptoms for many years prior to diagnosis. Fatigue, prolonged diarrhea with abdominal pain, weight loss, and fever, with or
without gross bleeding, are the hallmarks of Crohn disease. (See "Clinical manifestations, diagnosis, and prognosis of Crohn
disease in adults", section on 'Clinical features'.)
● Viral gastroenteritis – Patients with viral gastroenteritis often have diarrhea accompanied by nausea, vomiting, and abdominal
pain. (See "Acute viral gastroenteritis in adults", section on 'Clinical manifestations'.)
● Spontaneous bacterial peritonitis – Spontaneous bacterial peritonitis most often occurs in cirrhotics with advanced liver disease
with ascites. Patients present with fever, abdominal pain, and/or altered mental status. (See "Spontaneous bacterial peritonitis in
adults: Clinical manifestations", section on 'Clinical manifestations'.)
● Peritonitis in peritoneal dialysis patients – Peritonitis may develop in patients on peritoneal dialysis either from contamination
during dialysis or catheter related infection. The most common symptoms and signs are abdominal pain and cloudy peritoneal
effluent. Other symptoms and signs include fever, nausea, diarrhea, abdominal tenderness, rebound tenderness, and occasionally
systemic signs (eg, hypotension). (See "Clinical manifestations and diagnosis of peritonitis in peritoneal dialysis", section on 'Clinical
presentation'.)
● Malignancy – Gastrointestinal malignancies may be associated with abdominal discomfort. These are discussed in detail in specific
topics. As examples:
• Colorectal cancer – Patients with colorectal cancer may present with abdominal pain from partial obstruction, peritoneal
dissemination, or perforation. (See "Clinical presentation, diagnosis, and staging of colorectal cancer", section on 'Clinical
presentation'.)
• Gastric cancer – Patients with gastric cancer may have abdominal pain that is often epigastric pain. (See "Clinical features,
diagnosis, and staging of gastric cancer", section on 'Clinical features'.)
• Pancreatic cancer – The most common symptoms in patients with pancreatic cancer are pain, jaundice, and weight loss. (See
"Clinical manifestations, diagnosis, and staging of exocrine pancreatic cancer", section on 'Clinical presentation'.)
Additionally, patients may have pain as part of pain syndromes related to malignancy ( table 14). (See "Overview of cancer pain
syndromes", section on 'Tumor-related visceral pain syndromes'.)
● Celiac disease – Patients with celiac disease may complain of abdominal pain in addition to diarrhea with bulky, foul-smelling,
floating stools due to steatorrhea and flatulence. (See "Epidemiology, pathogenesis, and clinical manifestations of celiac disease in
adults", section on 'Clinical manifestations'.)
● Ketoacidosis – Patients with ketoacidosis (eg, from diabetes or alcohol) may have diffuse abdominal pain as well as nausea and
vomiting. (See "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Clinical features, evaluation, and diagnosis",
section on 'Abdominal pain in DKA' and "Fasting ketosis and alcoholic ketoacidosis", section on 'Clinical presentation'.)
● Adrenal insufficiency – Patients with adrenal insufficiency may have diffuse abdominal pain as well as nausea and vomiting.
Patients with adrenal crisis may present with shock and hypotension. Patients with chronic adrenal deficiency may also complain of
malaise, fatigue, anorexia, and weight loss. (See "Clinical manifestations of adrenal insufficiency in adults", section on 'Autoimmune
primary adrenal insufficiency' and "Clinical manifestations of adrenal insufficiency in adults", section on 'Gastrointestinal
complaints'.)
● Foodborne disease – A foodborne disease will typically manifest as a mixture of nausea, vomiting, fever, abdominal pain, and
diarrhea. Toxin-mediated illnesses can occur within hours of ingestion, but bacterial colitis generally requires 24 to 48 hours to
develop. Certain foods may be linked to particular pathogens ( table 15). (See "Causes of acute infectious diarrhea and other
foodborne illnesses in resource-abundant settings", section on 'Clinical clues to the microbial cause'.)
● Irritable bowel syndrome – Patients with irritable bowel syndrome (IBS) can present with a wide array of symptoms which include
both gastrointestinal and extraintestinal complaints. However, the symptom complex of chronic abdominal pain and altered bowel
habits remains the nonspecific yet primary characteristic of IBS. (See "Clinical manifestations and diagnosis of irritable bowel
syndrome in adults", section on 'Clinical manifestations'.)

● Constipation – Constipation may be associated with abdominal pain. Diseases associated with constipation include neurologic and
metabolic disorders; obstructing lesions of the gastrointestinal tract, including colorectal cancer; endocrine disorders such as
diabetes mellitus; and psychiatric disorders such as anorexia nervosa ( table 16). Constipation may also be due to a side effect of
drugs ( table 17). (See "Etiology and evaluation of chronic constipation in adults".)
● Diverticulosis – Uncomplicated diverticulosis is often asymptomatic and an incidental finding on colonoscopy or sigmoidoscopy.
Abdominal pain and constipation seen in patients with uncomplicated diverticulosis may be related to abnormal motility and
visceral hypersensitivity rather than to the diverticula themselves. (See "Colonic diverticulosis and diverticular disease:
Epidemiology, risk factors, and pathogenesis", section on 'Symptomatic uncomplicated diverticular disease'.)
● Lactose intolerance – Symptoms of lactose intolerance include abdominal pain, bloating, flatulence, and diarrhea. The abdominal
pain may be cramping in nature and is often localized to the periumbilical area or lower quadrants. (See "Lactose intolerance and
malabsorption: Clinical manifestations, diagnosis, and management", section on 'Clinical features'.)
LESS COMMON CAUSES
Less common causes of abdominal pain include ( table 18):
● Abdominal aortic aneurysm – Most patients with abdominal aortic aneurysm (AAA) have no symptoms. When patients with a
nonruptured AAA do have symptoms, abdominal, back, or flank pain is the most common clinical manifestation. Classically,
ruptured AAA is associated with severe pain, hypotension, and a pulsatile abdominal mass, but patients may have variable
presentations. (See "Clinical features and diagnosis of abdominal aortic aneurysm", section on 'Asymptomatic AAA' and "Clinical
features and diagnosis of abdominal aortic aneurysm", section on 'Symptomatic (nonruptured) AAA'.)
● Abdominal compartment syndrome – Abdominal compartment syndrome generally occurs in patients who are critically ill.
Patients have a tensely distended abdomen. (See "Abdominal compartment syndrome in adults".)
● Abdominal migraine – Recurrent abdominal pain may occur in patients with abdominal migraine [10]. These patients usually also
suffer from typical migraine headaches, although occasional patients present with gastrointestinal symptoms only [11]. Abdominal
migraines have also been linked to cyclic vomiting syndrome. (See "Pathophysiology, clinical manifestations, and diagnosis of
migraine in adults" and "Cyclic vomiting syndrome", section on 'Association with migraines'.)
● Acute hepatic porphyrias – The acute hepatic porphyrias, of which acute intermittent porphyria (AIP) is the most common, are a
rare cause of abdominal pain. The presentation of AIP is highly variable and patients have nonspecific symptoms. Abdominal pain is
the most common and often earliest symptom. (See "Porphyrias: An overview", section on 'Acute hepatic porphyrias (AHP)' and
"Acute intermittent porphyria: Pathogenesis, clinical features, and diagnosis", section on 'Acute attacks'.)
● Angioedema – Angioedema with abdominal pain may be caused by hereditary angioedema or related to angiotensin-converting
enzyme (ACE) inhibitor therapy. It can present with recurrent episodes of abdominal pain, accompanied by nausea, vomiting,
colicky pain, and diarrhea. (See "Hereditary angioedema: Epidemiology, clinical manifestations, exacerbating factors, and
prognosis" and "ACE inhibitor-induced angioedema", section on 'Intestine'.)
● Celiac artery compression syndrome – Celiac artery compression syndrome (also referred to as celiac axis syndrome, median
arcuate ligament syndrome, and Dunbar syndrome) is defined as chronic, recurrent abdominal pain related to compression of the
celiac artery by the median arcuate ligament. (See "Celiac artery compression syndrome".)
● Chronic abdominal wall pain – Chronic abdominal wall pain usually refers to anterior cutaneous nerve entrapment syndrome.
Pain associated with nerve entrapment is characteristically maximal in an area <2 cm in diameter. (See "Anterior cutaneous nerve
entrapment syndrome", section on 'Clinical features'.)
● Colonic pseudo-obstruction – Pseudo-obstruction is characterized by signs and symptoms of a mechanical obstruction of the
small or large bowel in the absence of a mechanical cause. The main clinical feature is abdominal distention, but patients may have
associated abdominal pain, nausea, and vomiting. Acute colonic pseudo-obstruction is also known as Ogilvie's syndrome. (See
"Acute colonic pseudo-obstruction (Ogilvie's syndrome)", section on 'Clinical manifestations' and "Chronic intestinal pseudo-
obstruction: Etiology, clinical manifestations, and diagnosis", section on 'Clinical manifestations'.)
● Eosinophilic gastroenteritis – Eosinophilic gastroenteritis belongs to a group of diseases that includes eosinophilic esophagitis,
gastritis, enteritis, and colitis. Symptoms depend on what part of the gastrointestinal tract is affected. (See "Eosinophilic

gastrointestinal diseases".)
● Epiploic appendagitis – Epiploic appendagitis (also known as appendicitis epiploica, hemorrhagic epiploitis, epiplopericolitis, or
appendagitis) is a benign and self-limited condition of the epiploic appendages. Patients with epiploic appendagitis most commonly
present with acute or subacute onset of lower abdominal pain. The pain is on the left side in 60 to 80 percent of patients but has
also been reported in the right lower quadrant. (See "Epiploic appendagitis".)
● Familial Mediterranean fever – The typical manifestations of familial Mediterranean fever are recurrent attacks of severe pain
(due to serositis at one or more sites) and fever, lasting one to three days and then resolving spontaneously. Most patients have
abdominal pain. In between attacks, patients feel entirely well. (See "Clinical manifestations and diagnosis of familial Mediterranean
fever".)
● Helminthic infections – Patients with helminthic infections can manifest with gastrointestinal symptoms, including abdominal
pain. The clinical manifestations for specific helminth infections are discussed in the appropriate topics.
● Herpes zoster – Herpes zoster neuropathic pain may precede the development of skin lesions. Depending on the dermatome
involved, this pain can be confused with other etiologies such as cholecystitis or renal colic. (See "Epidemiology, clinical
manifestations, and diagnosis of herpes zoster", section on 'Clinical manifestations'.)
● Hypercalcemia – Hypercalcemia can cause abdominal pain, either directly or as an etiology for pancreatitis or constipation. (See
"Clinical manifestations of hypercalcemia", section on 'Gastrointestinal'.)
● Hypothyroidism – Hypothyroidism can occasionally cause abdominal pain in the setting of constipation and ileus. (See "Clinical
manifestations of hypothyroidism", section on 'Gastrointestinal disorders'.)
● Lead poisoning – Abdominal pain is associated with acute lead poisoning. (See "Lead exposure, toxicity, and poisoning in adults",
section on 'Clinical manifestations'.)
● Meckel's diverticulum – Meckel's diverticulum is usually clinically silent and can be found incidentally or can present with a variety
of clinical manifestations including gastrointestinal bleeding or other acute abdominal complaints. Acute abdominal pain related to

Meckel's diverticulum can be the result of diverticular inflammation, similar to acute appendicitis, related to bowel obstruction or
perforation of the Meckel's or adjacent bowel. (See "Meckel's diverticulum", section on 'Abdominal symptoms'.)
● Narcotic bowel syndrome – The most common side effect of opioids is constipation, but some patients may have associated
abdominal pain. (See "Prevention and management of side effects in patients receiving opioids for chronic pain", section on 'Opioid
bowel dysfunction'.)
● Paroxysmal nocturnal hemoglobinuria – Paroxysmal nocturnal hemoglobinuria is a rare acquired hematopoietic stem cell
disorder. Up to 40 percent of patients with paroxysmal nocturnal hemoglobinuria may ultimately develop venous thrombosis, often
involving intraabdominal (mesenteric, portal, splenic, hepatic) vessels. Additionally, during acute hemolytic episodes, many patients
experience symptoms related to esophageal spasm and also complain of generalized cramping abdominal pain. (See "Clinical
manifestations and diagnosis of paroxysmal nocturnal hemoglobinuria", section on 'Abdominal pain/dysphagia' and "Clinical
manifestations and diagnosis of paroxysmal nocturnal hemoglobinuria", section on 'Thrombosis'.)
● Pseudoappendicitis – Acute yersiniosis or campylobacter infection can mimic appendicitis presenting with right lower abdominal
pain, fever, vomiting, leukocytosis, and mild diarrhea. (See "Yersiniosis: Infection due to Yersinia enterocolitica and Yersinia
pseudotuberculosis", section on 'Pseudoappendicitis' and "Campylobacter infection: Clinical manifestations, diagnosis, and
treatment", section on 'Pseudoappendicitis'.)
● Pulmonary etiologies – Lower lobe pulmonary pathologies (eg, pneumonia, pulmonary embolism) or inflammatory pleural
effusions (eg, empyema, pulmonary infarction) can present with what appears to be upper abdominal pain because they occur at
the threshold of the abdomen. Some patients with pneumonia (eg, Legionella) may also have abdominal pain and other
gastrointestinal symptoms as part of their illness. (See "Clinical manifestations and diagnosis of Legionella infection", section on
'Clinical features'.)
● Rectus sheath hematoma – Rectus sheath hematoma is a rare clinical entity that results from accumulation of blood within the
rectus sheath. Rectus sheath hematoma most often presents as acute onset of abdominal pain with a palpable abdominal wall
mass. (See "Spontaneous retroperitoneal hematoma and rectus sheath hematoma", section on 'Clinical presentations'.)

● Renal infarction – Renal infarction is rare. Patients with acute renal infarction typically complain of the acute onset of flank pain or
generalized abdominal pain, frequently accompanied by nausea, vomiting, and, occasionally, fever. (See "Renal infarction", section
on 'Clinical features'.)
● Rib pain – Patients may have upper abdominal pain from lower rib pain syndromes. (See "Major causes of musculoskeletal chest
pain in adults", section on 'Lower rib pain syndromes'.)
● Sclerosing mesenteritis – Sclerosing mesenteritis is part of a spectrum (including mesenteric lipodystrophy and mesenteric
panniculitis) of idiopathic primary inflammatory and fibrotic processes that affect the mesentery. The clinical manifestations of
sclerosing mesenteritis are varied but may include abdominal pain and other gastrointestinal symptoms. (See "Sclerosing
mesenteritis", section on 'Clinical presentation'.)
● Somatization – Patients with somatization may present with a wide array of symptoms including gastrointestinal symptoms. (See
"Somatic symptom disorder: Epidemiology and clinical presentation", section on 'Clinical presentation'.)
● Testicular torsion – This can cause male children and adolescents to present with lower abdominal pain, primarily on the
ipsilateral side. It is often associated with nausea and vomiting.
● Wandering spleen – The wandering (or ectopic) spleen is a rare condition where the spleen migrates from its normal site to
another location in the abdomen because of laxity or maldevelopment of the supporting ligaments [12]. Wandering spleen may be
congenital or acquired from weakened supporting splenic ligaments. Patients may be asymptomatic or present with acute, chronic,
or intermittent pain from torsion of the wandering spleen. Adults present with nonspecific abdominal pain associated with a
palpable abdominal mass while children most often present with acute abdominal pain.
● Thoracic duct–venous junction obstruction – This is an unusual cause of abdominal pain and bloating that can be detected on CT
scanning [13]. While rare, it is manageable with a bypass procedure.
SPECIAL POPULATIONS

In addition to the etiologies listed above, certain etiologies are specific to special populations of patients.
Females — Lower abdominal pain and/or pelvic pain in females is frequently caused by disorders of the internal female reproductive
organs ( table 7). The etiologies and evaluation of acute and chronic pelvic pain are discussed in detail separately. (See "Acute pelvic
pain in nonpregnant adult females: Evaluation" and "Chronic pelvic pain in nonpregnant adult females: Causes".)
● Pregnancy/pregnancy complications – Pregnancy and/or complications of pregnancy can lead to abdominal pain. This is
discussed in detail separately. (See "Approach to acute abdominal/pelvic pain in pregnant and postpartum patients", section on
'General approach'.)
● Ectopic pregnancy – The most common clinical presentation of ectopic pregnancy is first trimester vaginal bleeding and/or
abdominal pain. Clinical manifestations of ectopic pregnancy typically appear six to eight weeks after the last normal menstrual
period but can occur later, especially if the pregnancy is in an extrauterine site other than the fallopian tube. Individuals with
ruptured ectopic pregnancy can present with life-threatening hemorrhage. (See "Ectopic pregnancy: Clinical manifestations and
diagnosis", section on 'Abdominal pain'.)
● Pelvic inflammatory disease – Lower abdominal pain is the cardinal presenting symptom in females with pelvic inflammatory
disease (PID). Any sexually active female is at risk for PID. There is a wide-spectrum of clinical presentations. Acute symptomatic PID
is characterized by the acute onset of lower abdominal or pelvic pain, pelvic organ tenderness, and evidence of inflammation of the
genital tract. Individuals may also develop tuboovarian abscess as a complication. (See "Pelvic inflammatory disease: Clinical
manifestations and diagnosis" and "Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian abscess", section on
'Clinical presentation'.)
● Ovarian torsion – The classic presentation of ovarian torsion is the acute onset of moderate to severe pelvic pain, often with
nausea and possibly vomiting, in a woman with an adnexal mass. (See "Ovarian and fallopian tube torsion", section on 'Clinical
presentation'.)
● Ruptured ovarian cyst – Rupture of an ovarian cyst may be asymptomatic or associated with a sudden onset of unilateral lower
abdominal pain. The classic presentation is sudden onset of severe focal lower quadrant pain following sexual intercourse. (See

"Evaluation and management of ruptured ovarian cyst", section on 'Clinical presentation'.)
● Endometriosis – The classic symptoms of endometriosis are dysmenorrhea, pelvic pain, dyspareunia, and/or infertility, but other
symptoms may also be present (eg, bowel or bladder symptoms). Patients may present with one symptom or a combination of
symptoms.
● Endometritis – Endometritis refers to inflammation of the endometrium, the inner lining of the uterus. Acute endometritis is most
often preceded by PID. The diagnosis of acute endometritis is made clinically based upon criteria for the diagnosis of acute PID.
(See "Endometritis unrelated to pregnancy", section on 'Acute endometritis'.)
People with symptomatic chronic endometritis usually present with abnormal uterine bleeding, which may consist of
intermenstrual bleeding, spotting, postcoital bleeding, menorrhagia, or amenorrhea. Vague, crampy lower abdominal pain
accompanies the bleeding or may occur alone. (See "Endometritis unrelated to pregnancy", section on 'Chronic endometritis'.)
● Leiomyomas (fibroids) – Leiomyomas may cause pelvic pressure or pain. These symptoms may be related to bulk or infrequently
fibroids can cause acute pain from degeneration (eg, carneous or red degeneration) or torsion of a pedunculated tumor. Pain may
be associated with a low grade fever, uterine tenderness on palpation, elevated white blood cell count, or peritoneal signs.
● Ovarian hyperstimulation – Ovarian hyperstimulation syndrome can cause abdominal discomfort from enlarged ovaries in
individuals undergoing fertility treatment ( table 19). (See "Pathogenesis, clinical manifestations, and diagnosis of ovarian
hyperstimulation syndrome", section on 'Clinical manifestations'.)
● Ovarian cancer – Patients with ovarian cancer may present with bloating or abdominal or pelvic pain. (See "Epithelial carcinoma of
the ovary, fallopian tube, and peritoneum: Clinical features and diagnosis", section on 'Pelvic and abdominal symptoms'.)
Postoperative patients — A variety of postoperative complications can cause abdominal pain:
● Postoperative ileus (see "Postoperative ileus", section on 'Clinical features')
● Surgical site infections (see "Complications of abdominal surgical incisions", section on 'Hematoma and seroma' and "Overview of
the evaluation and management of surgical site infection")
● Hematoma/seroma formation and nerve injury (see "Complications of abdominal surgical incisions", section on 'Hematoma and
seroma' and "Complications of abdominal surgical incisions", section on 'Nerve injury')
Patients with sickle cell disease — Severe intermittent episodes of abdominal pain can occur with sickle cell disease, particularly after
an acute precipitant such as dehydration. (See "Evaluation of acute pain in sickle cell disease".)
Patients with sickle cell may also have right upper quadrant pain in the setting of hepatic involvement. The liver can be affected by a
number of complications due to the disease itself and its treatment. (See "Hepatic manifestations of sickle cell disease", section on
'Disorders associated with the sickling process' and "Hepatic manifestations of sickle cell disease", section on 'Disorders related to
coexisting conditions'.)
HIV-infected patients — Causes of abdominal pain in the HIV-infected patient include common etiologies seen in the general
population (eg, appendicitis, diverticulitis) but also opportunistic infections (eg, cytomegalovirus [CMV], Mycobacterium avium complex
[MAC], cryptosporidium) and neoplasms (eg, Kaposi sarcoma, lymphoma) if there is evidence of advanced immunodeficiency (CD4 cell
count <100 cells/microL). (See "AIDS-related cytomegalovirus gastrointestinal disease" and "Mycobacterium avium complex (MAC)
infections in persons with HIV" and "Cryptosporidiosis: Epidemiology, clinical manifestations, and diagnosis" and "AIDS-related Kaposi
sarcoma: Clinical manifestations and diagnosis" and "HIV-related lymphomas: Clinical manifestations and diagnosis".)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately.
(See "Society guideline links: Nontraumatic abdominal pain in adults".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are
written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about
a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond
the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade
reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients.
(You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topic (see "Patient education: Abdominal pain (The Basics)")
● Beyond the Basics topics (see "Patient education: Upset stomach (functional dyspepsia) in adults (Beyond the Basics)" and "Patient
education: Chronic pelvic pain in females (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
● Pathophysiology – Pain receptors in the abdomen respond to mechanical and chemical stimuli. The type and density of visceral
afferent nerves makes the localization of visceral pain imprecise. Pain originating in the viscera may also be perceived as
originating from a site distant from the affected organ (referred pain) ( figure 1). (See 'Pathophysiology of abdominal pain'
above.)
● Pain syndromes
• Upper abdominal pain typically has characteristic locations: right upper quadrant pain ( table 1), epigastric pain ( table 2), or
left upper quadrant pain ( table 3). (See 'Upper abdominal pain syndromes' above.)
• Lower abdominal pain syndromes ( table 6) often cause pain in either or both lower quadrants. Females may have lower
abdominal pain from disorders of the internal female reproductive organs ( table 7). (See 'Lower abdominal pain syndromes'
above and 'Females' above.)
• Abdominal pain syndromes may have diffuse or nonspecific pain ( table 9). (See 'Diffuse abdominal pain syndromes' above.)

● Less common causes – There are many other less common causes of abdominal pain ( table 18). (See 'Less common causes'
above.)
● Special populations – Certain etiologies are specific to special population of patients (females ( table 7), postoperative patients,
sickle cell patients, and HIV patients). (See 'Special populations' above.)
Use of UpToDate is subject to the Terms of Use.
REFERENCES
1. Ray BS, Neill CL. Abdominal Visceral Sensation in Man. Ann Surg 1947; 126:709.
2. Bentley FH. Observations on Visceral Pain : (1) Visceral Tenderness. Ann Surg 1948; 128:881.
3. CHAPMAN WP, HERRERA R, JONES CM. A comparison of pain produced experimentally in lower esophagus, common bile duct, and
upper small intestine with pain experienced by patients with diseases of biliary tract and pancreas. Surg Gynecol Obstet 1949;
89:573.
4. Brown FR. The Problem of Abdominal Pain. Br Med J 1942; 1:543.
5. Bloomfield AL, Polland WS. EXPERIMENTAL REFERRED PAIN FROM THE GASTRO-INTESTINAL TRACT. PART II. STOMACH, DUODENUM
AND COLON. J Clin Invest 1931; 10:453.
6. DWORKEN HJ, BIEL FJ, MACHELLA TE. Supradiaphragmatic reference of pain from the colon. Gastroenterology 1952; 22:222.
7. Ryle JA. Visceral pain and referred pain. Lancet 1926; 1:895.
8. Saik RP, Greenburg AG, Farris JM, Peskin GW. Spectrum of cholangitis. Am J Surg 1975; 130:143.
9. Tan KK, Wong J, Yan Z, et al. Colonic diverticulitis in young Asians: a predominantly mild and right-sided disease. ANZ J Surg 2014;
84:181.
10. Roberts JE, deShazo RD. Abdominal migraine, another cause of abdominal pain in adults. Am J Med 2012; 125:1135.
11. Angus-Leppan H, Saatci D, Sutcliffe A, Guiloff RJ. Abdominal migraine. BMJ 2018; 360:k179.

12. Gayer G, Hertz M, Strauss S, Zissin R. Congenital anomalies of the spleen. Semin Ultrasound CT MR 2006; 27:358.
13. O'Leary C, Nadolski G, Kovach SJ 3rd, et al. Thoracic Duct-Venous Junction Obstruction as Unknown Cause of Abdominal Pain:
Diagnosis and Treatment. Radiology 2023; 308:e230380.
Topic 6860 Version 57.0

GRAPHICS
Patterns of referred abdominal pain
Pain from abdominal viscera often (but not always) localizes according to the structure's embryologic origin, with foregut structures (mouth to
proximal one-half of duodenum) presenting with upper abdominal pain, midgut structures (distal one-half of duodenum to middle of the transverse
colon) presenting with periumbilical pain, and hind gut structures (remainder of colon and rectum, pelvic genitourinary organs) presenting with lower
abdominal pain. Radiation of pain may provide insight into the diagnosis. As examples, pain from pancreatitis may radiate to the back, while pain from
gallbladder disease may radiate to the right shoulder or subscapular region.

Graphic 61375 Version 8.0

Causes of right upper quadrant (RUQ) abdominal pain
RUQ Clinical features Comments
Biliary
Biliary colic Intense, dull discomfort located in the RUQ or Patients are generally well-appearing.
epigastrium. Associated with nausea, vomiting,
and diaphoresis. Generally lasts at least 30
minutes, plateauing within one hour. Benign
abdominal examination.
Acute cholecystitis Prolonged (>4 to 6 hours) RUQ or epigastric pain,

fever. Patients will have abdominal guarding and
Murphy's sign.
Acute cholangitis Fever, jaundice, RUQ pain. May have atypical presentation in older adults or
immunosuppressed patients.
Sphincter of Oddi dysfunction RUQ pain similar to other biliary pain. Biliary type pain without other apparent causes.
Hepatic
Acute hepatitis RUQ pain with fatigue, malaise, nausea, Variety of etiologies include hepatitis A, alcohol,
vomiting, and anorexia. Patients may also have and drug-induced.
jaundice, dark urine, and light-colored stools.
Perihepatitis (Fitz-Hugh-Curtis syndrome) RUQ pain with a pleuritic component, pain is Aminotransferases are usually normal or only
sometimes referred to the right shoulder. slightly elevated.
Liver abscess Fever and abdominal pain are the most common Risk factors include diabetes, underlying
symptoms. hepatobiliary or pancreatic disease, or liver
transplant.
Budd-Chiari syndrome Symptoms include fever, abdominal pain, Variety of causes.

abdominal distention (from ascites), lower

extremity edema, jaundice, gastrointestinal

bleeding, and/or hepatic encephalopathy.
Portal vein thrombosis Symptoms include abdominal pain, dyspepsia, or Clinical manifestations depend on extent of
gastrointestinal bleeding. obstruction and speed of development. Most
commonly associated with cirrhosis.

Causes of epigastric abdominal pain
Epigastric Clinical features Comments
Acute myocardial infarction May be associated with shortness of breath and Consider particularly in patients with risk factors
exertional symptoms. for coronary artery disease.
Acute pancreatitis Acute-onset, persistent upper abdominal pain

radiating to the back.
Chronic pancreatitis Epigastric pain radiating to the back. Associated with pancreatic insufficiency.
Peptic ulcer disease Epigastric pain or discomfort is the most Occasionally, discomfort localizes to one side.
prominent symptom.
Gastroesophageal reflux disease Associated with heartburn, regurgitation, and

dysphagia.
Gastritis/gastropathy Abdominal discomfort/pain, heartburn, nausea, Variety of etiologies including alcohol and
vomiting, and hematemesis. nonsteroidal antiinflammatory drugs (NSAIDs).
Functional dyspepsia The presence of one or more of the following: Patients have no evidence of structural disease.
postprandial fullness, early satiation, epigastric
pain, or burning.
Gastroparesis Nausea, vomiting, abdominal pain, early satiety, Most causes are idiopathic, diabetic, or
postprandial fullness, and bloating. postsurgical.

Causes of left upper quadrant (LUQ) abdominal pain
LUQ Clinical features Comments
Splenomegaly Pain or discomfort in LUQ, left shoulder pain, Multiple etiologies.

and/or early satiety.
Splenic infarct Severe LUQ pain. Atypical presentations common. Associated with
a variety of underlying conditions (eg,
hypercoagulable state, atrial fibrillation, and
splenomegaly).
Splenic abscess Associated with fever and LUQ tenderness. Uncommon. May also be associated with splenic
infarction.
Splenic rupture May complain of LUQ, left chest wall, or left Most often associated with trauma.
shoulder pain that is worse with inspiration.

Prothrombotic risk factors for BCS
A. Acquired thrombophilia
Myeloproliferative disease
Polycythemia vera
Essential thrombocytosis
Idiopathic myelofibrosis
JAK2 V617F mutation
Paroxysmal nocturnal hemoglobinuria
Behçet disease
Hyperhomocysteinemia
Antiphospholipid syndrome
B. Inherited thrombophilia
Factor V Leiden
Prothrombin gene G20210A mutation
MTHFR C677T mutation
Thalassemia
PC deficiency
Protein S deficiency
Antithrombin deficiency

C. Systemic factors
Sarcoidosis
Vasculitis
Behçet disease
Connective tissue disease
Inflammatory bowel disease
D. Hormonal factors
Recent oral contraceptive use
Pregnancy
BCS: Budd-Chiari syndrome; JAK2: janus kinase 2; MTHFR: methyltetrahydrofolate; PC: protein C.
From: Simonetto DA, Singal AK, Garcia-Tsao G, et et al. ACG Clinical guideline: Disorders of the hepatic and mesenteric circulation. Am J Gastroenterol 2020; 115:18. DOI:
10.14309/ajg.0000000000000486. Copyright © 2020 The American College of Gastroenterology. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of
this material is prohibited.

Neuromuscular disorders impairing gastric motor function
Several common neurologic disorders can affect gastrointestinal motility by altering the parasympathetic or sympathetic supply to the gut.
X: vagal nuceli; CNS: central nervous system; CVA: cerebrovascular accident; SCG: sympathetic chain ganglia.
Reproduced with permission from: Camilleri M, Prather CM. In: Sleisenger and Fordtran's Gastrointestinal Disease, 6th ed, Feldman M, Scharschmidt BF, Sleisenger MH (Eds), WB
Saunders, Philadelphia 1998. p.572.

Major causes of splenomegaly
Congestive
Cirrhosis
Heart failure
Thrombosis of portal, hepatic, or splenic veins
Malignancy
Lymphoma, usually indolent variants
Acute and chronic leukemias
Polycythemia vera
Multiple myeloma and its variants
Essential thrombocythemia
Primary myelofibrosis
Primary splenic tumors
Metastatic solid tumors
Infection
Viral – Hepatitis, infectious mononucleosis, cytomegalovirus
Bacterial – Salmonella, Brucella, tuberculosis
Parasitic – Malaria, schistosomiasis, toxoplasmosis, leishmaniasis
Infective endocarditis
Fungal
Inflammation
Sarcoid
Serum sickness
Systemic lupus erythematosus
Rheumatoid arthritis (Felty syndrome)
Infiltrative, nonmalignant
Gaucher disease
Niemann-Pick disease
Amyloid
Other lysosomal storage diseases (eg, mucopolysaccharidoses)
Langerhans cell histiocytosis
Hemophagocytic lymphohistiocytosis
Rosai-Dorfman disease
Hematologic (hypersplenic) states

Acute and chronic hemolytic anemias, all etiologies
Sickle cell disease (children)
Following use of recombinant human granulocyte colony-stimulating factor

Causes of lower abdominal pain
Lower abdomen Localization Clinical features Comments
Appendicitis Generally right lower quadrant Periumbilical pain initially that Occasional patients present with
radiates to the right lower quadrant. epigastric or generalized abdomina
Associated with anorexia, nausea, pain.
and vomiting.
Diverticulitis Generally left lower quadrant, Pain usually constant and present Clinical presentation depends on
although right-sided symptoms are for several days prior to severity of underlying inflammatory
not uncommon presentation. May have associated process and whether or not
nausea and vomiting. complications are present.
Nephrolithiasis Either Pain most common symptom, Cause symptoms as stone passes
varies from mild to severe. from renal pelvis to ureter.
Generally flank pain, but may have
back or abdominal pain.
Pyelonephritis Either Associated with dysuria, frequency,

urgency, hematuria, fever, chills,
flank pain, and costovertebral angle
tenderness.
Acute urinary retention Suprapubic Present with lower abdominal pain

and discomfort; inability to urinate.
Cystitis Suprapubic Associated with dysuria, frequency,

urgency, and hematuria.
Infectious colitis Either Diarrhea as the predominant Patients with Clostridioides difficile
symptom, but may also have infection can present with an acute
associated abdominal pain, which abdomen and peritoneal signs in
may be severe. the setting of perforation and
fulminant colitis.

Testicular torsion Can begin in lower abdomen, Often associated with nausea and Usually in boys or adolescents.
localizing to side ipsilateral to vomiting.
testicle

Pelvic causes of abdominal pain in women
Pelvic causes of
abdominal pain Lateralization Clinical features Comments
in women
Ectopic Either side or diffuse Vaginal bleeding with abdominal pain, typically six to eight weeks after last Patients can presen
pregnancy abdominal pain menstrual period. with life-threatening
hemorrhage if
ruptured.
Pelvic Lateralization Characterized by the acute onset of lower abdominal or pelvic pain, pelvic organ Wide spectrum of
inflammatory uncommon tenderness, and evidence of inflammation of the genital tract. Often associated clinical
disease with cervical discharge. presentations.
Ovarian torsion Localized to one Acute onset of moderate-to-severe pelvic pain, often with nausea and possibly Generally not
side vomiting, in a woman with an adnexal mass. associated with
vaginal discharge.
Ruptured ovarian Localized to one Sudden-onset unilateral lower abdominal pain. The classic presentation is sudden Generally not
cyst side onset of severe focal lower quadrant pain following sexual intercourse. associated with
vaginal discharge.
Endometriosis Associated with dysmenorrhea, pelvic pain, dyspareunia, and/or infertility, but Patients may
other symptoms may also be present (eg, bowel or bladder symptoms). present with one
symptom or a
combination of
symptoms.
Acute Most often preceded by pelvic inflammatory disease. Diagnostic criteria

endometritis the same as pelvic
inflammatory
disease.
Chronic Present with abnormal uterine bleeding, which may consist of intermenstrual
endometritis bleeding, spotting, postcoital bleeding, menorrhagia, or amenorrhea. Vague,

crampy lower abdominal pain accompanies the bleeding or may occur alone.
Leiomyomas Symptoms related to bulk or infrequently acute pain from degeneration or torsion
(fibroids) of pedunculate tumor. Pain may be associated with a low-grade fever, uterine
tenderness on palpation, elevated white blood cell count, or peritoneal signs.
Ovarian Abdominal distention/discomfort, nausea/vomiting, and diarrhea. More severe Women undergoing
hyperstimulation cases can have severe abdominal pain, ascites, intractable nausea, and vomiting. fertility treatment.
Ovarian cancer Abdominal or pelvic pain. May have associated symptoms of bloating, urinary
urgency or frequency, or difficulty eating/feeling full quickly.
Ovulatory pain Occurs mid-cycle, coinciding with timing of ovulation. May be right- or left
(Mittelsmerz) sided, depending on
site of ovulation
during that cycle.
Pregnancy and related complications*
* Refer to the UpToDate topics on abdominal pain.

Clinical manifestations of Clostridium difficile infection
Type of Physical
Diarrhea Other symptoms Sigmoidoscopic examination
infection examination
Diarrhea with • Multiple loose bowel Nausea, anorexia, fever, malaise, Abdominal distention, Diffuse or patchy nonspecific colitis
colitis movements per day dehydration, leukocytosis with left tenderness
shift
• Occult bleeding may be
seen
• Hematochezia rare
Fulminant • Diarrhea may be severe Lethargy, fever, tachycardia, May present as acute Sigmoidoscopy and colonoscopy
colitis OR diminished (due to abdominal pain; dilated abdomen; peritoneal contraindicated; flexible proctoscopy
paralytic ileus and colonic colon/paralytic ileus may be signs suggest perforation with minimal air insufflation may be
dilatation) demonstrated on plain abdominal diagnostic
film
• Surgical consult required;
colectomy can be life
saving
Asymptomatic Absent Absent Normal Normal

carriage

Causes of diffuse abdominal pain
Diffuse/poorly
Clinical features Comments
characterized
Bowel obstruction Most common symptoms are nausea, vomiting, crampy Multiple etiologies.
abdominal pain, and obstipation.
Distended, tympanic abdomen with high-pitched or absent

bowel sounds.
Perforation of the Severe abdominal pain, particularly following procedures. Can present acutely or in an indolent manner, particularly
gastrointestinal tract in immunosuppressed patients.
Acute mesenteric ischemia Acute and severe onset of diffuse and persistent abdominal May occur from either arterial or venous disease. Patients
pain, often described as pain out of proportion to with aortic dissection can have abdominal pain related to
examination. mesenteric ischemia.
Chronic mesenteric Abdominal pain after eating ("intestinal angina"), weight May occur from either arterial or venous disease.
ischemia loss, nausea, vomiting, and diarrhea.
Inflammatory bowel disease Associated with bloody diarrhea, urgency, tenesmus, bowel May have symptoms for years before diagnosis. Associated
(ulcerative colitis/Crohn incontinence, weight loss, and fevers. extraintestinal manifestations (eg, arthritis, uveitis).
disease)
Viral gastroenteritis Diarrhea accompanied by nausea, vomiting, and abdominal

pain.
Spontaneous bacterial Fever, abdominal pain, and/or altered mental status. Most often in cirrhotic patients with advanced liver disease
peritonitis and ascites.
Dialysis-related peritonitis Abdominal pain and cloudy peritoneal effluent. Other Only in peritoneal dialysis patients.
symptoms and signs include fever, nausea, diarrhea,
abdominal tenderness, and rebound tenderness.
Colorectal cancer Variable presentation, including obstruction and

perforation.

Other malignancy Vary depending on malignancy.
Celiac disease Abdominal pain in addition to including diarrhea with bulky,

foul-smelling, floating stools due to steatorrhea and
flatulence.
Ketoacidosis Diffuse abdominal pain and nausea and vomiting.
Adrenal insufficiency Diffuse abdominal pain and nausea and vomiting. Patients with adrenal crisis may present with shock and
hypotension.
Foodborne illness Mixture of nausea, vomiting, fever, abdominal pain and

diarrhea.
Irritable bowel syndrome Chronic abdominal pain with altered bowel habits.
Constipation Associated with a variety of neurologic and metabolic

disorders, obstruction lesions of the gastrointestinal tract,
endocrine disorders, psychiatric disorders, and side effect
of medications.
Diverticulosis May have symptoms of abdominal pain and constipation. Often an asymptomatic and incidental finding on
colonoscopy or sigmoidoscopy.
Lactose intolerance Associated with abdominal pain, bloating, flatulence, and

diarrhea. Abdominal pain may be cramping in nature.

Causes of bowel obstruction
Lesion Etiology Risk factors
Extrinsic lesions Adhesions Prior surgery, diverticulitis, Crohn disease, VP shunt,

peritonitis (eg, tuberculous peritonitis)
Hernia (congenital, acquired) Abdominal wall hernia, inguinal hernia, femoral hernia,
diaphragmatic hernia
Volvulus Chronic constipation, congenital abnormal mesenteric

attachments
Intra-abdominal abscess Diverticulitis, appendicitis, Crohn disease
Peritoneal carcinomatosis Ovarian cancer, colon cancer, gastric cancer
Endometriosis
Sclerosing mesenteritis Prior surgery, abdominal trauma, autoimmune disorders,

malignancy, neuroendocrine tumor
Desmoid tumor/other soft tissue sarcoma (rare)
Superior mesenteric artery syndrome Rapid weight loss
Intrinsic lesions Congenital malformations, atresia, duplication Refer to appropriate topic reviews
Large bowel neoplasm
Adenocarcinoma Hereditary colorectal cancer syndromes (HNPCC, FAP),

inflammatory bowel disease, bowel irradiation, others
(refer to appropriate topic reviews)
Desmoid
Carcinoid
Neuroendocrine tumor
Lymphoma

Small bowel neoplasm*
Adenocarcinoma Hereditary cancer syndromes (HNPCC, FAP, Peutz-Jeghers,

MUTYH-associated polyposis, attenuated FAP)
Leiomyosarcoma
Paraganglioma
Schwannoma
Metastatic disease Melanoma, breast cancer, cervical cancer, colon cancer

(refer to appropriate topic reviews)
Gastrointestinal stromal tumor
Neuroendocrine tumor
Lymphoma Chronic inflammation
Benign lesions Peutz-Jeghers polyps, xanthomatosis, leiomyoma
Anastomotic stricture Prior intestinal surgery
Inflammatory stricture Crohn disease, diverticular disease, NSAID enteropathy
Ischemic stricture Peripheral artery disease, aortic surgery, colon resection
Radiation enteritis/stricture Prior abdominal or pelvic irradiation
Intraluminal obstruction Intussusception* Small bowel tumor*

of normal bowel
Gallstones Cholecystitis
Congenital webs
Feces or meconium Cystic fibrosis, severe constipation
Bezoar (phytobezoar, pharmacobezoar) Intestinal motility disorders
Intramural hematoma
Traumatic Blunt abdominal trauma
Spontaneous Antithrombotic therapy

Foreign body
Ingested Psychiatric disturbance
Medical device migration PEG tube, jejunal tube
Parasites Ascaris lumbricoides, Strongyloides stercoralis
VP: ventriculoperitoneal; HNPCC: hereditary nonpolyposis colorectal cancer; FAP: familial adenomatous polyposis; NSAID: nonsteroidal anti-
inflammatory drug; PEG: percutaneous endoscopic gastrostomy.
* May be due to an intrinsic lesion serving as a lead point.

Features of acute small bowel versus acute colonic ischemia
Acute small bowel ischemia Acute colonic ischemia
Age varies with etiology of ischemia 90 percent of patients over age 60 years
Acute precipitating cause is typical Acute precipitating cause is rare
Patients appear severely ill Patients do not appear severely ill
Pain is usually severe, tenderness is not prominent early Mild abdominal pain, tenderness present
Bleeding uncommon until very late Rectal bleeding, bloody diarrhea typical
MRA or MDCT angiography may be considered as the initial diagnostic test; Colonoscopy is procedure of choice
angiography is recommended if there is strong clinical suspicion
MRA: magnetic resonance angiography; MDCT: multidetector row computed tomography.
Data from: Reinus JF, Brandt LJ, Boley SJ. Ischemic diseases of the bowel. Gastroenterol Clin North Am 1990; 19:319.

Presentations of aortic dissection based on affected structures
Clinical findings Artery or structure involved
Aortic insufficiency or heart failure Aortic valve
Myocardial infarction Coronary artery (often right)
Cardiac tamponade Pericardium
Hemothorax Thorax
Horner syndrome (ptosis, miosis, anhidrosis) Superior cervical sympathetic ganglion
Stroke or syncope Brachiocephalic, common carotid, or left subclavian arteries
Upper extremity pulselessness, hypotension pain Subclavian artery
Paraplegia Intercostal arteries (give off spinal and vertebral arteries)
Back or flank pain; renal failure Renal artery
Abdominal pain; mesenteric ischemia Celiac or mesenteric arteries
Lower extremity pain, pulselessness, weakness Common iliac artery

Extraintestinal manifestations of inflammatory bowel disease
Common extraintestinal manifestations
Musculoskeletal
Arthritis – Colitic type, ankylosing spondylitis, isolated joint involvement such as sacroiliitis.
Hypertrophic osteoarthropathy – Clubbing, periostitis, metastatic Crohn disease.
Miscellaneous – Osteoporosis, aseptic necrosis, polymyositis, osteomalacia.
Skin and mouth
Reactive lesions – Erythema nodosum, pyoderma gangrenosum, aphthous ulcers, vesiculopustular eruption, cutaneous vasculitis, neutrophilic
dermatosis, metastatic Crohn disease, epidermolysis bullosa acquisita.
Specific lesions – Fissures and fistulas, oral Crohn disease, drug rashes.
Nutritional deficiency – Acrodermatitis enteropathica (zinc), purpura (vitamins C and K), glossitis (vitamin B), hair loss and brittle nail (protein).
Associated diseases – Vitiligo, psoriasis, amyloidosis, epidermolysis bullosa acquisita.
Hepatobiliary
Specific complications – Sclerosing cholangitis (large-duct or small-duct), bile duct carcinoma, cholelithiasis.
Associated inflammation – Autoimmune chronic active hepatitis, pericholangitis, portal fibrosis and cirrhosis, granuloma in Crohn disease.
Metabolic – Fatty liver, gallstones associated with ileal Crohn disease.
Ocular
Uveitis iritis, episcleritis, scleromalacia, corneal ulcers, retinal vascular disease, retrobulbar neuritis, Crohn keratopathy.
Metabolic
Growth retardation in children and adolescents, delayed sexual maturation.
Less common extraintestinal manifestations
Blood and vascular

Anemia due to iron, folate, or vitamin B12 deficiency or autoimmune hemolytic anemia, anemia of chronic disease, thrombocytopenic purpura;
leukocytosis and thrombocytosis; thrombophlebitis and thromboembolism, arteritis and arterial occlusion, polyarteritis nodosa, Takayasu arteritis,
cutaneous vasculitis, anticardiolipin antibody, hyposplenism.
Renal and genitourinary tract
Urinary calculi (oxalate stones in ileal disease), local extension of Crohn disease involving ureter or bladder, amyloidosis, drug-related
nephrotoxicity.
Renal tubular damage with increased urinary excretion of various enzymes (eg, beta N-acetyl-D-glucosaminidase).
Neurologic
Up to 3% of patients may have non-iatrogenic neurologic involvement, including peripheral neuropathy, myelopathy, vestibular dysfunction,
pseudotumor cerebri, myasthenia gravis, and cerebrovascular disorders. Incidence equal in ulcerative colitis and Crohn disease. These disorders
usually appear 5 to 6 years after the onset of inflammatory bowel disease and are frequently associated with other extraintestinal manifestations.
Airway and parenchymal lung disease
Pulmonary fibrosis, vasculitis, bronchitis, necrobiotic nodules, acute laryngotracheitis, interstitial lung disease, sarcoidosis. Abnormal pulmonary
function tests without clinical symptoms are common (up to 50% of cases).
Cardiac
Pericarditis, myocarditis, endocarditis, and heart block – More common in ulcerative colitis than in Crohn disease; cardiomyopathy, cardiac failure
due to anti-TNF therapy.
Pericarditis may also occur from sulfasalazine/5-aminosalicylates.
Pancreas
Acute pancreatitis – More common in Crohn disease than in ulcerative colitis. Risk factors include 6-mercaptopurine and 5-aminosalicylate therapy,
duodenal Crohn disease.
Autoimmune
Drug-induced lupus and autoimmune diseases secondary to anti-TNF-alpha therapy.
Positive ANA, anti-double-stranded DNA, cutaneous and systemic manifestations of lupus.

TNF: tumor necrosis factor; ANA: antinuclear antibody; DNA: deoxyribonucleic acid.
Modified from: Das KM. Relationship of extraintestinal involvements in inflammatory bowel disease: New insights into autoimmune pathogenesis. Dig Dis Sci 1999; 44:1.

Chronic pain syndromes directly related to cancer
Nociceptive pain syndromes: Somatic
Tumor-related bone pain
Multifocal bone pain
Bone metastases
Bone marrow expansion (hematologic malignancies)
Oncogenic hypophosphatemic osteomalacia
Vertebral syndromes
Atlanto-axial destruction and odontoid fracture
C7-T1 syndrome
T12-L1 syndrome
Sacral syndrome
Back pain secondary to spinal cord compression
Pain syndromes related to pelvis and hip
Pelvic metastases
Hip joint syndrome
Malignant piriformis syndrome
Base of skull metastases
Orbital syndrome
Parasellar syndrome
Middle cranial fossa syndrome
Jugular foramen syndrome

Occipital condyle syndrome
Clivus syndrome
Sphenoid sinus syndrome
Tumor-related soft tissue pain
Headache and facial pain
Ear and eye pain syndromes
Pleural pain
Paraneoplastic pain syndromes
Muscle cramps
Hypertrophic osteoarthropathy
Tumor-related gynecomastia (eg, in testicular neoplasms that secrete human chorionic gonadotropin)
Paraneoplastic pemphigus
Paraneoplastic Raynaud phenomenon
Nociceptive pain syndromes: Visceral

Hepatic distention syndrome
Midline retroperitoneal syndrome
Chronic intestinal obstruction
Peritoneal carcinomatosis
Malignant perineal pain
Adrenal pain syndrome
Ureteric obstruction
Neuropathic pain syndromes

Leptomeningeal metastases

Malignant painful radiculopathy
Painful cranial neuralgias
Glossopharyngeal neuralgia
Trigeminal neuralgia
Radiculopathies
Lumbosacral radiculopathy
Cervical radiculopathy
Thoracic radiculopathy
Plexopathies
Cervical plexopathy
Malignant brachial plexopathy
Malignant lumbosacral plexopathy
Lower lumbosacral plexopathies, including sacral and coccygeal plexopathy and panplexopathy
Painful peripheral mononeuropathies
Paraneoplastic sensory neuropathy

Differential diagnosis of foodborne disease by item consumed
Item Commonly associated microbes*
Raw seafood Norwalk-like virus, Vibrio spp, hepatitis A
Raw eggs Salmonella spp
Undercooked meat or poultry Salmonella spp, Campylobacter spp, STEC, Clostridium perfringens
Unpasteurized milk or juice Salmonella spp, Campylobacter spp, STEC, Yersinia enterocolitica
Unpasteurized soft cheeses Salmonella spp, Campylobacter spp, STEC, Y. enterocolitica, Listeria monocytogenes
Homemade canned goods Clostridium botulinum
Raw hot dogs, deli meat L. monocytogenes
STEC: shiga toxin-producing Escherichia coli.
* This association lists the commonly associated organisms and is not fully comprehensive.

Causes of chronic constipation
Neurogenic disorders Non-neurogenic disorders
Peripheral Hypothyroidism
Diabetes mellitus Hypokalemia
Autonomic neuropathy Anorexia nervosa
Hirschsprung disease Pregnancy
Chagas disease Panhypopituitarism
Intestinal pseudoobstruction Systemic sclerosis
Central Myotonic dystrophy
Multiple sclerosis Idiopathic constipation

Spinal cord injury Normal colonic transit
Parkinson disease Slow transit constipation
Irritable bowel syndrome Dyssynergic defecation
Drugs
See separate table

Drugs associated with constipation
Analgesics
Anticholinergics
Antihistamines
Antispasmodics
Antidepressants
Antipsychotics
Cation-containing agents
Iron supplements
Aluminum (antacids, sucralfate)
Barium
Neurally active agents

Opiates
Antihypertensives
Ganglionic blockers
Vinca alkaloids
Calcium channel blockers
5HT3 antagonists

Less common causes of abdominal pain
Abdominal aortic aneurysm
Abdominal compartment syndrome
Abdominal migraine
Acute hepatic porphyrias (eg, acute intermittent porphyria)
Angioedema (either hereditary or angiotensin-converting enzyme [ACE] inhibitor-related)
Celiac artery compression syndrome
Chronic abdominal wall pain
Colonic pseudo-obstruction (acute or chronic)
Eosinophilic gastroenteritis
Epiploic appendagitis
Familial Mediterranean fever
Helminthic infections
Herpes zoster
Hypercalcemia
Hypothyroidism
Lead poisoning
Meckel's diverticulum
Narcotic bowel syndrome
Paroxysmal nocturnal hemoglobinuria
Pseudoappendicitis
Pulmonary etiologies

Rectus sheath hematoma
Renal infarction
Rib pain
Sclerosing mesenteritis
Somatization
Thoracic duct-venous junction obstruction
Wandering spleen

Classification of OHSS: Clinical and biochemical features [1]
Clinical features Biochemical features
Mild Abdominal distention/discomfort No clinically important laboratory findings

Mild nausea/vomiting
Diarrhea
Enlarged ovaries
Moderate Presence of mild features plus: Elevated Hct (>41%)

Ultrasonographic evidence of ascites Elevated WBC (>15,000/microL)
Hypoproteinemia
Severe Presence of mild and moderate features plus: Hemoconcentration (Hct >55%)
Clinical evidence of ascites (can be tense ascites) WBC >25,000/microL
Severe abdominal pain Serum creatinine >1.6 mg/dL
Intractable nausea and vomiting Creatinine clearance <50 mL/min
Rapid weight gain (>1 kg in 24 hours) Hyponatremia (Na + <135 mEq/L)
Pleural effusion Hyperkalemia (K + >5 mEq/L)
Severe dyspnea Elevated liver enzymes
Oliguria/anuria
Low blood/central venous pressure
Syncope
Venous thrombosis
Critical Presence of severe features plus: Worsening of biochemical findings seen with severe
Anuria/acute renal failure OHSS
Arrhythmia
Pericardial effusion
Massive hydrothorax
Thromboembolism

Arterial thrombosis
ARDS
Sepsis
OHSS: ovarian hyperstimulation syndrome; Hct: hematocrit; WBC: white blood cell; Na: sodium; K: potassium; ARDS: acute respiratory distress
syndrome.
Reference:
1. Navot D, Bergh PA, Laufer N. Ovarian hyperstimulation syndrome in novel reproductive technologies: prevention and treatment. Fertil steril 1992; 58:249.
From: Fiedler K, Ezcurra D. Predicting and preventing ovarian hyperstimulation syndrome (OHSS): the need for individualized not standardized treatment. Reprod Biol Endocrinol 2012;
10:32. Copyright © 2012 Fiedler and Ezcurra. Reproduced from BioMed Central Ltd.

Contributor Disclosures
Robert M Penner, BSc, MD, FRCPC, MSc Consultant/Advisory Boards: AbbVie [Inflammatory bowel disease]; Janssen [Inflammatory bowel disease];
Takeda [Inflammatory bowel disease]. Speaker's Bureau: AbbVie [Inflammatory bowel disease]; Janssen [Inflammatory bowel disease]; Takeda
[Inflammatory bowel disease]. All of the relevant financial relationships listed have been mitigated. Mary B Fishman, MD No relevant financial
relationship(s) with ineligible companies to disclose. Andrew D Auerbach, MD, MPH Equity Ownership/Stock Options: Kuretic [Digital health app
marketplace]. All of the relevant financial relationships listed have been mitigated. Mark D Aronson, MD No relevant financial relationship(s) with
ineligible companies to disclose. Jane Givens, MD, MSCE No relevant financial relationship(s) with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level
review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

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16/03/2024, 21:20 Causes of abdominal pain in adults - UpToDate

Official reprint from UpToDate®

Literature review current through: Feb 2024.

PATHOPHYSIOLOGY OF ABDOMINAL PAIN

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UPPER ABDOMINAL PAIN SYNDROMES

Biliary etiologies include ( table 1):

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Hepatic etiologies include ( table 1):

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LOWER ABDOMINAL PAIN SYNDROMES

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DIFFUSE ABDOMINAL PAIN SYNDROMES

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LESS COMMON CAUSES

Less common causes of abdominal pain include ( table 18):

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"Evaluation and management of ruptured ovarian cyst", section on 'Clinical presentation'.)

Postoperative patients — A variety of postoperative complications can cause abdominal pain:

● Postoperative ileus (see "Postoperative ileus", section on 'Clinical features')

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

● Basics topic (see "Patient education: Abdominal pain (The Basics)")

SUMMARY AND RECOMMENDATIONS

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Use of UpToDate is subject to the Terms of Use.

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Patterns of referred abdominal pain

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Graphic 61375 Version 8.0

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Causes of right upper quadrant (RUQ) abdominal pain

RUQ Clinical features Comments

Acute cholecystitis Prolonged (>4 to 6 hours) RUQ or epigastric pain,

Budd-Chiari syndrome Symptoms include fever, abdominal pain, Variety of causes.

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extremity edema, jaundice, gastrointestinal

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Causes of epigastric abdominal pain

Epigastric Clinical features Comments

Acute pancreatitis Acute-onset, persistent upper abdominal pain

Gastroesophageal reflux disease Associated with heartburn, regurgitation, and

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Causes of left upper quadrant (LUQ) abdominal pain

LUQ Clinical features Comments

Splenomegaly Pain or discomfort in LUQ, left shoulder pain, Multiple etiologies.

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