Diagnosing abdominal pain

In the presence of acute intense abdominal pain, the general practitioner is faced with the task not so much of establishing a nosological diagnosis, but of immediately assessing the degree of urgency of the disease and the need for urgent surgical care. The solution to this issue is the surgeon's prerogative, but a preliminary conclusion is made by the general practitioner. If the urgency of the situation is not obvious, it is necessary to establish a presumptive diagnosis, provide assistance and outline a plan for additional diagnostic measures, possible in an outpatient setting or in a hospital, judging by the patient's condition.

The solution to these questions should be, first of all, based on questioning and physical examination.

When questioning the patient, the following questions should be asked:

1. when the abdominal pain occurred, its duration;
2. how the disease developed - suddenly or gradually;
3. what are the possible causes of pain - poor quality food, injury, medication, previous diseases of the abdominal organs, chest, spine;
4. what is the localization, irradiation and prevalence of abdominal pain (local, diffuse);
5. what is the intensity and nature of abdominal pain: sharp, dull, colicky, short-term, long-term, constant, etc.;
6. what are the accompanying symptoms: fever, vomiting, diarrhea, constipation and gas.

During an objective examination, the general condition of the patient should be assessed: position in bed and behavior, face, tongue, skin color, respiratory rate and pulse, blood pressure; auscultation of the lungs, heart, and blood vessels should be performed. When examining the abdomen, its configuration, size, participation in the act of breathing, soreness, muscle tension, peritoneal symptoms, and peristaltic sounds should be determined. Soft, careful palpation should be used, using more rational techniques, for example, the Shchetkin-Blumberg symptom can be replaced by light percussion of the abdomen, and the identification of muscle protection - by coughing. Questioning and objective examination allow us to distinguish visceral pain from diseases of hollow organs, and somatic pain from irritation of the parietal peritoneum.

When examining a patient, diagnostic methods should be used that would ensure sufficient reliability, i.e. reliability of results from the standpoint of sensitivity and specificity of the method; low risk for the patient, low time costs. The latter is especially important in emergency situations. These requirements are met, first of all, by a detailed questioning and objective examination, which are considered more valuable in comparison with any instrumental and laboratory studies and, in most cases, resolve the diagnosis or determine the tactics of patient management.

The main, most informative methods of additional examination of such patients are currently considered to be endoscopic (with possible biopsy), ultrasound and laboratory tests. The latter include a general blood test (leukocytosis!), blood for amylase, alkaline phosphatase, sugar, bilirubin. X-ray studies often provide only probable data, and therefore it is better to use them for special indications: if there is a suspicion of mechanical ileus (sensitivity of the method is 98%), perforation of a hollow organ (60%), stones (64%) - only positive results are taken into account.

Based on the clinical examination of a patient with acute abdominal pain, there are 3 possible alternative solutions:

• emergency hospitalization;
• planned hospitalization;
• outpatient observation and examination.

All patients with signs of peritonitis, intestinal obstruction or mesenteric thrombosis are subject to urgent hospitalization in the surgical department first of all. Then come patients with severe, prolonged or recurrent pain, especially with signs of inflammation and/or cardiovascular disorders, including suspected acute appendicitis, cholecystitis, pancreatitis.

The remaining patients have a lower degree of "urgency" and are subject to planned hospitalization, usually in therapeutic departments, or, as with chronic pain, are examined on an outpatient basis. This group includes patients with gallstones or urolithiasis, acute gastroenteritis, and extra-abdominal diseases that can cause acute pain, but not acute abdomen.

To prevent many unnecessary studies, it is important to take into account anamnestic information that allows us to differentiate between organic and functional intestinal pathology.

The rapid development of symptoms and their progression indicate an organic disease. With irritable bowel syndrome, diarrhea or simply frequent bowel movements with pain, as well as visible bloating, are observed significantly more often than with organic diseases. Symptoms such as a feeling of fullness in the abdomen, incomplete emptying, and mucus in the stool are on the verge of reliability. Taking these signs into account helps to establish a diagnosis of young and middle-aged people. In elderly people, a complete gastroenterological examination is always required in accordance with the anamnesis and examination data.

Differential diagnostics of functional and organic intestinal pathology

Sign	Irritable bowel syndrome	Organic bowel disease
Age	Less than 50 years old	Over 50 years old
Duration of anamnesis	Years	Months
Features of pain	Diffuse, variable localization and intensity	Clearly localized, often paroxysmal, nocturnal, short-term
Connection	With psycho-emotional factors	With food
Defecation	In the morning	At night
There is blood in the stool too	No	May be
Weight loss	No	Available
Psychovegetative disorders	There are	Usually no
Blood test	No special features	Anemia, increased ESR

If there are signs of organic bowel disease, bowel cancer, nonspecific ulcerative colitis, terminal ileitis (Crohn's disease), and colon diverticulitis should be excluded. All of these diseases have some common symptoms: weakness, weight loss, fever, blood in the stool, anemia, leukocytosis, and increased ESR.

Non-specific ulcerative colitis and terminal ileitis have characteristic extra-abdominal manifestations: arthritis, skin lesions (nodular or multiple exudative erythema, exanthema), iritis, enlarged lymph nodes. In ulcerative colitis and diverticulitis, the descending colon is predominantly affected, which is painful and thickened upon palpation, and there are often tenesmus and perianal inflammatory changes. Digital rectal examination, rectoscopy and irrigoscopy are important for diagnosis. In diverticulitis, there may be narrowing of the intestinal lumen, filling defects, which requires a biopsy of the mucous membrane to exclude a tumor.

Terminal ileitis is more often accompanied by local symptoms in the ileocecal region in young people: painful conglomerate, fistulas, diarrhea, steatorrhea, malabsorption syndrome. The diagnosis is established based on X-ray examination (rigidity and narrowing of the intestinal lumen) and colonoscopy with targeted biopsy.

Intestinal tumors manifest similar symptoms, but are more common in elderly patients and require detailed X-ray and endoscopic examination.

Differential diagnosis of abdominal pain includes the following diseases: gastric and duodenal ulcers, esophagitis, stomach cancer, pancreatitis, pancreatic carcinoma, gallbladder disease, helminthic infestation, abuse of laxatives, tumors of the small and large intestines.

When making differential diagnoses of chronic abdominal pain, it is necessary to take into account its localization, as well as the presence or absence of dyspepsia, intestinal disorders, and other accompanying symptoms.

It should be emphasized that the guideline for the selection and sequence of diagnostic tests for bowel diseases are the data from the anamnesis and objective examination, which every doctor should have, regardless of specialty.

When diagnosing abdominal pain, one should not forget about the existence of pain associated with viscerovisceral, visceromuscular and viscerocutaneous reflexes. They arise as a result of switching afferent impulses from sympathetic fibers from the affected organ to the corresponding segments of the somatic nervous system. The diagnostic significance of the appearance of such reflected pain was first described by A. Zakharyin and G. Ged (1989) and their zones were presented in the form of a diagram. By establishing pain zones and comparing their boundaries with the given diagram, one can make an assumption about which internal organ is affected. However, pain in the same zones can occur in diseases of various organs.

Thus, diagnosis and differential diagnosis of abdominal pain syndrome is a very difficult task.

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