Abdominal pain history
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Taking a History in Abdominal Pain
Based on Sleisenger and Fordtran's Gastrointestinal and Liver Disease
Why History Matters
History taking remains the most important component of the initial evaluation of a patient with acute abdominal pain. Characteristic features of the pain, combined with a careful history, often allow the clinician to narrow the differential diagnosis substantially before any investigations are ordered.
Key Dimensions to Explore
1. Onset
- Sudden/instantaneous ("thunderclap"): suggests catastrophic events — ruptured aortic aneurysm, perforated viscus, mesenteric ischemia
- Rapid onset (minutes): volvulus, intussusception, ureteral/biliary colic, superior mesenteric artery (SMA) occlusion
- Gradual (hours): appendicitis, cholecystitis, bowel obstruction, pancreatitis
2. Character and Quality
| Character | Suggests |
|---|---|
| Colicky (waves, comes and goes) | Obstruction of a hollow viscus (bowel, ureter, bile duct) |
| Constant, dull, aching | Inflammation of a solid organ (e.g., cholecystitis, pancreatitis) |
| Sharp, tearing, ripping | Aortic dissection |
| Burning | Peptic ulcer, GERD |
| Cramping | IBD, gastroenteritis |
3. Location and Radiation
- RUQ → biliary, hepatic, right lower lobe pneumonia
- Epigastric → peptic ulcer, pancreatitis, AMI (referred)
- LUQ → splenic, gastric, tail of pancreas
- Periumbilical → early appendicitis (visceral), small bowel, AAA
- RLQ → appendicitis, Crohn's, ovarian pathology, inguinal hernia
- LLQ → diverticulitis, sigmoid volvulus, ovarian pathology
- Suprapubic → bladder, uterus, pelvic structures
- Radiation to back → pancreatitis, aortic aneurysm, posterior peptic ulcer
- Radiation to right shoulder/scapula → biliary colic, subphrenic irritation
- Radiation to groin → ureteral colic, testicular torsion (referred)
4. Severity
Rate on a 0–10 scale. Extremely severe pain disproportionate to physical findings raises concern for mesenteric ischemia ("pain out of proportion to exam").
5. Time Course and Pattern
- Constant since onset vs. intermittent/colicky
- Progressive worsening vs. improving
- Prior similar episodes: suggests recurrent conditions (biliary colic, renal colic, IBS, IBD)
6. Modifying Factors
| Factor | Implication |
|---|---|
| Relieved by eating | Duodenal ulcer |
| Worsened by eating | Gastric ulcer, mesenteric ischemia (intestinal angina), gastroparesis |
| Relieved by defecation | IBS, colitis |
| Worsened by movement | Peritoneal irritation (peritonitis) |
| Relieved by bending forward (knee-chest) | Pancreatitis |
| Worsened by lying flat | Pancreatitis, aortic pathology |
7. Associated Symptoms
- Nausea/vomiting: onset relative to pain matters — vomiting before pain suggests gastroenteritis; vomiting after pain onset suggests surgical causes (e.g., appendicitis)
- Anorexia: classic in appendicitis
- Fever/chills: infection, perforation, cholangitis
- Diarrhoea: IBD, infectious gastroenteritis, Clostridium difficile
- Constipation/obstipation: bowel obstruction (complete obstipation = no gas, no stool)
- Haematuria: urolithiasis, renal/bladder pathology
- Vaginal discharge or bleeding: ectopic pregnancy, PID, ovarian torsion
- Jaundice: biliary obstruction, hepatitis
- Haematemesis / malaena / rectal bleeding: GI haemorrhage
Past Medical History
- Previous similar episodes: partial SBO, renal calculi, PID — prior episodes raise likelihood of recurrence
- Prior abdominal surgery: adhesions are the most common cause of SBO
- Known IBD, PUD, gallstones, hernias, diverticulosis, AAA
- Cardiovascular disease: raises suspicion for mesenteric ischemia or referred cardiac pain
- Malignancy: obstruction, perforation, metastatic involvement
- Immunosuppression: atypical presentations, opportunistic infections
- Diabetes: gastroparesis, DKA (which causes pseudoperitoneum), autonomic neuropathy masking pain
Medication History
- NSAIDs / steroids: peptic ulcer, masked peritoneal signs
- Anticoagulants: retroperitoneal or intramural haematoma
- Antibiotics: C. difficile colitis
- Immunosuppressants: atypical infections
- Opioids: constipation, ileus, chronic opioid-induced bowel dysfunction
- OCP / HRT: mesenteric venous thrombosis, hepatic adenoma, IBD exacerbation
Gynaecological and Obstetric History (Women)
- LMP — always ask: ectopic pregnancy must be excluded in any woman of reproductive age with lower abdominal pain
- Menstrual irregularity, dysmenorrhoea, dyspareunia → endometriosis, ovarian pathology
- STI history / vaginal discharge → PID, tubo-ovarian abscess
- Pregnancy test is mandatory when in doubt
Social History
- Alcohol use: pancreatitis, alcoholic hepatitis, gastritis
- Travel history: infectious causes (amebiasis, typhoid, tropical infections)
- Diet: constipation, gallstones (rapid weight loss), food intolerances
- Smoking: Crohn's disease, peptic ulcer, vascular disease
- IV drug use: hepatitis, endocarditis with septic emboli
Family History
- IBD, colorectal cancer, polyposis syndromes (FAP, Lynch)
- AAA: strong heritable component
- Hereditary pancreatitis, haemochromatosis
Special Populations
Elderly
- Presentations are frequently atypical and blunted — fever may be absent, pain may be mild even with severe pathology (e.g., perforation). High index of suspicion required. Vascular causes (mesenteric ischemia, AAA) are more common.
Immunocompromised
- Peritoneal signs and fever may be absent. Atypical organisms (CMV colitis, fungal infection, neutropenic enterocolitis/typhlitis) must be considered.
Children
- A complete history is especially important. Causes vary with age: intussusception in infants, mesenteric adenitis and appendicitis in older children.
Red Flags Warranting Urgent Evaluation
- Sudden-onset severe pain ("worst pain of life")
- Pain out of proportion to physical findings
- Known AAA or vascular disease
- Peritoneal signs on exam
- Haemodynamic instability (hypotension, tachycardia)
- Fever with rigors
- Pregnancy (to exclude ectopic)
- Immunosuppression
— Sleisenger and Fordtran's Gastrointestinal and Liver Disease
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