Lactology Foundation

ABDOMINAL PAIN CHRONIC

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Most abdominal pain is localized, for example that due
to a renal stone or biliary stone, acute appendicitis
or peptic ulceration. There are, however, a number of
causes of generalized abdominal pain, the most
common of which are peritonitis and intestinal
obstructions.
A list of causes to be considered includes:
1.
General peritonitis
2. Tuberculous peritonitis
3. Intestinal obstruction
4. Lead colic (rare)
5. Gastric crises (rare)
6. Abdominal angina
7.
Functional abdominal pain
8. General medical diseases:
• Malaria
• Porphyria
• Diabetic ketosis
• Blood dyscrasias
• Henoch's purpura
• Sickle-cell anemia
• Hypercalcaemia
GENERAL PERITONITIS
Peritonitis must be secondary to a lesion that enables
some clue in the history to suggest the initiator
disease. Thus, the patient with established peritonitis
may give a history of onset that indicates acute
appendicitis or salpingitis as the source of origin.
Where the onset of peritonitis is sudden, one should
suspect an acute perforation of a hollow viscus.
The early features depend on the severity and the
extent of the peritonitis. Pain is always severe, and
typically the patient lies still on his account – in contrast
with the restlessness of a patient with abdominal colic.
An extensive peritonitis that involves the abdomen
aspect of the diaphragm may be accompanied by
shoulder-tip pain. Vomiting often occurs early in the
course of the disease. The patient is obviously ill, and
the temperature frequently elevated. If initially the
peritoneal exudate is not purulent, the temperature
may be normal. It is a good aphorism concerning
the two common causes of this condition that
peritonitis due to appendicitis is usually accompanied
by a temperature above 38 °C (100 °F), whereas the
temperature in peritonitis due to a perforation of a peptic ulcer rarely reaches this level. The pulse is
often raised and tends to increase from hour to hour.
Examination of the abdomen demonstrates
tenderness, which may be localized to the affected area
or is generalized if the peritoneal cavity is extensive
involved. There is marked guarding, which again may
be localized or generalized, and rebound tenderness
is present. The abdomen is silent on auscultation,
although sometimes the transmitted sounds of the
heart beat and respiration may be detected. Rectally,
there is tenderness of the pelvic peritoneum.
As the disease progresses, the abdomen becomes
distended, signs of free fluid may be detected, and
the pulse becomes more rapid and feeble. Vomiting is
now effortless and feculent, and the patient, although
still conscious and mentally alert, demonstrates the
Hippocratic facies with sunken eyes, pale, cold and
sweating skin, and cyanosis of the extremities.
An X-ray of the abdomen in the erect position may
reveal free subdiaphragmatic gas in peritonitis due to
hollow viscus perforation (e.g. perforated peptic ulcer),
but its absence by no means excludes the diagnosis (the photo below - abdominal radiograph showing the falciform ligament outlined by free intraperitoneal gas (arrowed).).

The main differential diagnoses are the colic of
intestinal obstruction or of ureteric or biliary stone.
Intraperitoneal haemorrhage, acute pancreatitis,
dissection or leakage of an aortic aneurysm, or a basal
pneumonia are also important differential diagnoses.
TUBERCULOUS PERITONITIS
In Great Britain, this is now a rare disease. When it
is encountered in the UK, the patient is usually an
immigrant from a developing country. Usually, there is
a feeling of heaviness rather than acute pain. The onset
of symptoms is gradual, with abdominal distension,
the presence of fluid within the peritoneal cavity, and
often the presence of a puckered, thickened omentum,
which forms a tumor lying transversely across the
middle of the abdomen.

INTESTINAL COLIC
INTESTINAL OBSTRUCTION
This is a common cause of generalized abdominal pain.
In peritonitis, there is no periodic rhythm, whereas
waves of pain interspersed with periods of completeness
relief or only a dull ache are typical of obstruction.
In contrast to the patients with peritonitis who wish
to remain completely still, the victim of intestinal
obstruction is restless and rolls about with the
spasms of colic. Usually, there are the accompaniments
of progressive abdominal distension, absolute
constipation, progressive vomiting (which becomes
faeculent), and the presence of noisy bowel sounds on
auscultation. An X-ray of the abdomen usually reveals
multiple fluid levels on the erect film, together with
distended loops of gas-filled bowel, which are obvious
on the supine radiograph.
The presence of a scar (or scars) of previous abdominal
surgery, performed no matter how long previously,
strongly suggests postoperative adhesions or bands as
the cause of the obstruction. Careful examination of the
hernial orifices – inguinal, femoral and umbilical – is
mandatory to diagnose a strangulated external hernia.
Surprisingly, the patient may be completely ignorant
of its presence. I has seen a distinguished
anesthetist who correctly diagnosed his own acute
bowel obstruction but had not noticed his strangulation
inguinal hernia.

LEAD COLIC
Lead colic may cause extremely severe attacks of
general abdominal pain. There may be preceding
anorexia, constipation and vague abdominal
discomfort. The severe pain is usually located in
the lower abdomen and radiates to both groins; it
may also sometimes be associated with wrist-drop (due to peripheral neuritis), and occasionally with lead
encephalopathy. There may be a blue 'lead line' on the
gums if oral sepsis is present, due to the precipitation
of lead sulphide. Frequently, there is a normocytic
hypochromic anemia with stippling of the red cells
(punctuate basophilia). Inquiry about the patient's
occupation may well be the first clue to the diagnosis.

GASTRIC CRISES
Gastric crises in neurosyphilis, although rare, may
causes general abdominal pain. The patient has other
evidence of tabes dorsalis, with Argyll Robertson
pupils, optic atrophy and ptosis, loss of deep sensation
(absence of pain on testicular compression or
squeezing the Achilles tendon), and loss of ankle and
knee jerks. The pain is severe and lasts for many hours
or even days. There may be accompanying vomiting,
and there may also be rigidity of the abdominal wall.
The crisis visceral may be the sole manifestation of
tabs. The mere fact that a patient has tabes dorsalis
does not, of course, mean that their abdominal pain
must necessarily be a gastric crisis. The author has
repaired a perforated duodenal ulcer in a patient with
all the classic features of well-documented tabs
dorsalis.

ABDOMINAL ANGINA
Abdominal angina occurs in elderly patients as a
result of progressive atheromatous narrowing of the
superior mesenteric artery. Colicky attacks of central
abdominal pain occurs after meals, and this is followed
by diarrhea. Complete occlusion with infarction of the
intestine is often preceded by attacks of this nature.
Occlusion of vessels to the small or large intestine - as
is seen in a number of vasculopathies such as systemic
lupus erythematosus (SLE) or polyarteritis nodosa –
may cause generalized abdominal pain and proceed to
gangrene, perforation and general peritonitis.

FUNCTIONAL ABDOMINAL PAIN
One of the most difficult problems is the patient (female
more often than male) who presents with severe chronic
generalized abdominal pains and in whom all clinical,
laboratory and radiological tests are negative. Inquiry
will often reveal features of depression or the presence
of some precipitating factor producing an anxiety state.
In some cases, the abdomen is covered with scars
previous laparotomies at which various organs have
been reposited, non-essential viscera removed, and real
or imaginary adhesions divided. Some of these patients
prove to be drug addicts, others are frank hysterics, and
others seek the security of the hospital environment,
but in still others the etiology remains mysterious.
This forms one type of the so-called 'Munchausen's'
syndrome', described by the late Dr. Richard Asher.

ABDOMINAL PAINS IN GENERAL DISEASE
Acute abdominal pain may occur in a number of
medical conditions not already considered. These
include sudden and severe pain complicating
malignant malaria, familial Mediterranean fever and
cholera, or the pain may accompany uncontrolled
diabetes with ketosis, that rare condition known
as porphyria and any of the blood dyscrasias; the
best examples are Henoch's purpura in children
and the abdominal colic of acute sickle-cell crisis. Bouts of abdominal pain may occur in the hypercalcaemia of hyperparathyroidism.