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An Index For The Clinical Diagnosis of Abdominal Pain

(This is an excerpt from an e book 'All About Abdominal Pain'. This blog is for the reference of Homeopathy World Community members only)
© 2009 Copyright Dr Muhammed Rafeeque, BHMS.

Pain felt any where between the chest and the groin is regarded as abdominal pain. Synonymously different terms are used to denote abdominal pain such as stomach pain, bellyache, abdominal cramps, acute abdomen etc. It is a usual complaint in clinical practice and is basically due to conditions like inflammation, infection, irritation, obstruction, perforation and functional causes. Abdominal pain may be visceral pain, parietal pain or referred pain. Nerves, both motor and sensory, richly supply the abdominal wall and the organs. The sensory nerves carry the sensation of pain. Any pathological lesion in the organs or abdominal wall stimulates these nerves and the person feels a pain in the affected area. The main cause for abdominal pain is due to intra abdominal causes and less commonly due to abdominal wall lesions. Rarely, extra abdominal causes can produce abdominal pain due to common nerve supply.

Here, probable causes of abdominal pain are given under the headings such as Location, Radiation, Sensation - type, Aggravation, Amelioration and Associated symptoms. However, it should be kept in mind that diagnosis is confirmed only by correlating the clinical findings, history and all investigatory reports. In case of diagnostic dilemma, a second opinion is needed for the safety of the patient as well as the doctor.

1. Location of pain

Costovertebral angle: Obstruction in uretero pelvic junction.

Epigastria: Pain in this area may be due to any lesion in lower esophagus, stomach, duodenum, jejunum, left lobe of liver, biliary tree, pancreas, transverse colon.

Hypogastria: Lesions in uterus, urinary bladder, sigmoid colon and rectum.

Left hypochondria: Pain in this area indicates lesions in fundus of stomach, spleen, tail of pancreas and splenic flexure of colon.

Left iliac fossa: Left ovary, left fallopian tube, lower part of descending colon, sigmoid colon.

Left lumbar region: Left kidney, left adrenal gland, left ureter, descending colon.

Pain changing location frequently: May be psychogenic.

Pain in dermatome segments: Pain in the peripheral nerve originating from the spinal cord.

Perineum and low back: Uterine pain.

Right hypochondria: Pain in this region may be due to lesions in biliary tree, right lobe of liver, gall bladder, hepatic flexure of colon.

Right iliac fossa: Lower part of ascending colon, ceacum, appendix, right ovary, right fallopian tube.

Right lumbar region: Right kidney, right adrenal gland, right ureter, ascending colon.

Umbilical region: Pain in this region may be due to lesions in abdominal aorta, inferior vena cava, part of stomach, head and body of pancreas, duodenal loop, mesentery, loop of small intestine

Xiphisternal region: May be due to abdominal, cardiac, pulmonary causes.

2. Radiation of pain

Back to anteriorly, worse on bending or moving: Spinal pain.

Epigastria to back on both sides of spine: Pancreatitis, rupture of abdominal aortic aneurism.

Epigastria to localized area on the back: Duodenal ulcer.

First in the affected site and later spreads all over the abdomen: Spreading peritonitis.

From epigastria to back of spine: Pancreatitis.

Lower abdomen to perineum and urethra: Bladder pain.

Lumbar region to testicles or vulva: Ureteric colic.

Pain initially in umbilical region later shift to right iliac fossa: Acute appendicitis.

Pain radiates along the course of nerve: Herpes zoaster, spinal pain, and neuralgia.

Pain radiating to sacral region, flanks, and genitalia: Rupture of abdominal aneurysm.

Right hypochondria to right iliac fossa: Peptic ulcer perforation.

Right hypochondria to right infra scapular region: Biliary colic.

Right upper quadrant to tip of scapula: Gall bladder pain.

3. Sensation--Type – frequency of pain

Colicky pain: Renal colic, intestinal obstruction, biliary colic, ureteric colic, appendicular colic etc.

Chronic pains: Ulcer pain, chronic pancreatitis, chronic cholecystitis, tuberculosis, inflammatory bowel disorders, chronic intestinal obstruction etc.

Colicky pain becomes burning: Intestinal obstruction becoming strangulated.

Constant aching: Pain in the abdominal wall.

Constant burning pain: Peritonitis, acid peptic disease, perforated peptic ulcer.

Daily pain: Peptic ulcer.

Diminution of pain: Appendicitis perforation, 2nd stage of peptic ulcer perforation.

Dull supra pubic pain: Urinary bladder obstruction.

Exaggeration of symptoms: Functional pain.

Gradual onset and reaches a high intensity: Acute intestinal obstruction.

Intermittent colicky pain: Obstruction.

Intermittent colicky, poorly localized: Obstruction of viscera.

Lancinating pain: Neurogenic or spinal pain.

Non-colicky pain: Peritonitis, perforation, pancreatitis etc.

Non-specific pain: In uremia and diabetes.

Pain comes and goes suddenly: Neurogenic.

Pain once a week or once a month: Intestinal, biliary, renal colics.

Severe pain for hours: Peritonitis, pancreatitis.

Sharp, intermittent griping, comes and goes suddenly: Colicky pain due to obstruction.

Steady aching, throbbing: Peritoneal inflammation.

Severe agonizing pain: Acute pancreatitis, torsion.

Sudden and catastrophic: Pain due to vascular occlusion.

Sudden onset: Inflammation, perforation, occlusion, obstruction, torsion.

Throbbing pain: Inflammation.

Varies in type: Psychogenic.

4. Aggravation of pain

Alcohol, spicy food, and aspirin: Peptic ulcer.

Coughing, sneezing, and straining: Peritoneal, spinal.

Deep inspiration & coughing: Diaphragmatic pleurisy.

During the act of urination: Ureteric colic, pelvic appendicitis, pelvic abscess.

Fatty food: Cholecystitis.

Food: Esophageal pain, gastritis, gastric ulcer.

Lying down: Pancreatic obstruction.

Movement, pressure, prolonged standing: Abdominal wall lesions.

Movements of spine: Spinal.

Pain only in presence of others: Hysterical.

Pressing the affected area: Inflammatory.

Pressing the testis: Orchitis, torsion of testis.

Stooping: Hiatus hernia, reflux esophagitis.

Walking & jolting: Cholecystitis, appendicitis, ureteric colic.

5. Amelioration of pain

Fat free diet: Cholecystitis.

Food: Duodenal ulcer.

Lying still: Peritoneal inflammation.

Pressure: Colicky pain.

Rolling on bed: Peritonitis.

Sitting upright: Acute pancreatitis.

Taking alkaline substance: Peptic ulcer.

Vomiting: Gastric ulcer.

Vomiting temporarily relieves pain but appear immediately: Colic.

6. Symptoms associated with pain

Absence of vomiting with marked abdominal distension and gurgling: Ileal or large bowel obstruction.

Absent peristaltic sounds with clear respiratory and heart sounds heard in abdomen: Diffuse peritonitis, paralytic ileus.

Alternate constipation and diarrhoea: Rectal cancer, diverticulitis, ileocaecal tuberculosis.

Arrest of feces and flatus (Absolute constipation): Intestinal obstruction, peritonitis.

Bilious vomiting: Biliary colic, gastric and duodenal irritation.

Blood with putrid stools: Mesenteric thrombosis.

Blood or pus in stools: Colonic disease, dysentery.

Bloody stools with mucus without straining on stools: Pelvic abscess.

Brown vomiting: Uremia.

Chronic pain with loss of weight and appetite: Cancer, tuberculosis of intestine, inflammatory bowel disease, mal absorption syndromes.

Clay colored stools: Obstructive jaundice.

Colicky pains with bloody stools, defecation relieves pain: Dysentery.

Complaints in the order of pain, vomiting and fever (PVF): Acute appendicitis.

Constant vomiting: Gastritis, gall bladder disease, pancreatitis.

Cyanosis: Hemorrhagic pancreatitis, cardiac or pulmonary lesions, poisoning.

Dark brown vomiting: Peritonitis.

Distention of flanks: Ascites.

Distention of upper abdomen: Pyloric stenosis.

Distention restricted to periphery of abdomen: Large bowel obstruction.

Doughy feeling on palpation: Tuberculosis of abdomen.

Evening rise of fever for few weeks with weight loss and anorexia: Abdominal TB

Extreme pallor with gasping respiration in a woman with missed periods: Ruptured tubal gestation.

Fall in temperature with increase of pulse: Intestinal bleeding, perforation, shock.

Fear of eating: Gastric ulcer.

Features of intestinal obstruction with discharge of mucus &blood in the anus in a child: Intussusception.

Fever: Gastroenteritis, appendicitis, cholecystitis, diverticulitis, salpingitis, peritonitis.

Fever with right hypochondriac pain radiating to right shoulder: Amoebic liver abscess.

Fever with rigors and chills and jaundice: Stone in common bile duct causing obstruction.

Fever (periodic) with rigors and abdominal and back pain lasting few days: Retroperitoneal filarial lymphangitis.

Frequent stools only while at home: Irritable bowel syndrome.

Hippocratic facies (Anxious look, bright eyes, pinched face, cold sweat): Terminal stage of peritonitis.

History of abdominal operation: Intestinal obstruction due to adhesions, Presence of any foreign material accidentally kept during surgery (Scissors, cotton swabs, forceps etc).

History of alcoholism: Gastritis, pancreatitis, hepatitis.

Histories of biliary colic, high temperature and jaundice: Cholecystitis.

History of coronary and valvular heart disease: Embolic occlusion of abdominal vessels.

History of diabetes mellitus and chronic renal failure: Metabolic cause.

History of gall stones: Gall stone ileus, pancreatitis.

History of thrombotic disease: Vascular occlusion.

Intense pain with rigidity of abdominal and back muscles: Bite of black widow spider.

Jaundice and biliary colic: Cholelithiasis.

Large fatty and offensive stools: Chronic pancreatitis.

Localised guarding: Appendicitis, cholecystitis etc.

Metallic tinkles or borborygmi heard on auscultation: Intestinal obstruction.

Mild hypochondriac pain with fever for few days: Viral hepatitis.

Mild hypochondriac pain with fever for few weeks or more: Amoebic liver abscess.

Missed periods with pain in abdomen: Ectopic pregnancy.

Moderate fever: Acute cholecystitis.

Muscle spasm with hyperesthesia and pain of dermatome: Spinal pain.

Operative scars: Adhesions.

Pain in lower abdomen with change in bowel habit: Cancer of colon.

Pain with shifting dullness due to fluid collection in abdomen: Seen in peptic ulcer perforation, acute pancreatitis, ruptured ectopic gestation.

Pain with absence of liver dullness on percussion due to gas under diaphragm: Perforation of the gastrointestinal tract.

Pain with fever: Infection.

Pain with normal appetite: Peptic ulcer.

Periodic vomiting: Peptic ulcer.

Peristaltic sounds increased, heard even without stethoscope: Obstruction.

Persistent vomiting without abdominal distension or gurgling sounds: Duodenal obstruction.

Previous history of ulcer pain: Perforation of peptic ulcer.

Projectile vomiting: High intestinal obstruction, toxic enteritis.

Pulse rate becomes high: Inflammatory causes.

Pulse becomes rapid immediately with gasping and pallor: Internal bleeding.

Quick and small volume pulse: Peritonitis.

Quiet regurgitation of mouth full: Peptic ulcer, perforation, and peritonitis.

Reflex spasm of abdominal muscles: Peritoneal inflammation.

Reluctant to move in bed: Pancreatitis.

Rigidity of abdominal muscles: Continuously present in abdominal conditions whereas in thoracic conditions rigidity in the abdomen will be diminished during expiration.

Silent abdomen on auscultation: Paralytic ileus, diffuse peritonitis.

Stools frequent without blood or pus: Irritable bowel syndrome.

Stool with high fecal fat: Chronic pancrestitis , mal absorption.

Tarry stools: Bleeding from upper gastro intestinal tract.

Typical facial expression called abdominal facies: Seen only in acute abdomen. (Absent in abdominal pain due to extra abdominal causes)

Visible peristralsis from left to right on upper abdomen: Duodenal stenosis.

Visible peristalsis in different directions: Small or large bowel obstruction.

Visible pulsation in the midline of abdomen: Aneurysm.

Vomiting absent or late: Large bowel obstruction.

Vomiting, daily: Duodenal stenosis.

Vomiting and pain together: High intestinal obstruction.

Vomiting of blood: Chronic & acute peptic ulcer, erosions, esophageal varices due to portal obstruction, and cancer of stomach.

Vomiting of gastric contents: Peptic ulcer.

Vomiting of stomach contents then bilious vomiting followed by fecal vomiting:
Intestinal obstruction
Vomitus with bile: Upper small bowel obstruction.

Vomitus without bile: Gastric outlet obstruction.

Vomiting without abdominal pain or discomfort: Extra abdominal causes.

Weight loss: Abdominal TB, diabetes mellitus, malignancy, mal absorption, thyrotoxicosis etc.

Wide variety of unrelated symptoms: Functional pain.

With pain patient tossing in bed, doubled up or rolls: Colic.


Final disease diagnosis is done by correlating the clinical findings with lab investigation reports and the history of the patient.

Remedial diagnosis and plan of treatment changes from system to system. Similarly there is a difference in opinion regarding surgical and medical diseases. However, conditions like perforation, strangulation, torsion etc. are considered as purely surgical by all systems of medicine.

© 2009 Copyright Dr Muhammed Rafeeque, BHMS

An e book that deals with:

124 Causes of abdominal pain.

Different conditions presented with abdominal pain.

Clinical features and lab investigations.

Index for clinical diagnosis.

Published by:

Views: 27732


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Comment by Dr Muhammed Rafeeque on November 8, 2009 at 11:10pm
Really true. But we have an aversion to nosological diagnosis. Hahnemann has told us to give more importance to the individual charectiristic symptoms rather than selecting a drug on the basis of nosological diagnosis. True that when we diagnose a disease, a few drugs will come to our mind. May be because of this issue, most of the homoeopaths are having an aversion to disease diagnosis.
Comment by Dr Muhammed Rafeeque on November 6, 2009 at 10:46pm
Comment by Dr Muhammed Rafeeque on November 6, 2009 at 6:01am
PVF (pain followed by vomiting and fever comes last)is the order of appearance of symptoms in classical appendicitis. but nowadays we dont get the cases that follow this order. some times right sided renal colic is "diagnozed" as appendicitis. I feel appendicitis is overdiagnosed in many cases, but missing to diagnose this can be dangerous, both for the doctor and the patient.
Comment by Dr Muhammed Rafeeque on November 5, 2009 at 5:23am
Thanks Dr Nishant.

Debby, You can use some text-to-speech software to read blogs.
Comment by Dr. Nishant on November 5, 2009 at 4:20am
thank you so much .. very good sir .. extremely useful
Comment by Dr Muhammed Rafeeque on November 4, 2009 at 11:17pm
Fantabulous comment!!!!!!!!!!!!!!!!!!
Comment by Debby Bruck on November 4, 2009 at 11:59am
Thank you. I will need a mentor to take me through all this information.

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