Abdominal pain various site with causes
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abdominal pain location site causes differential diagnosis diagram
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I now have rich textbook content and two excellent diagrams. Let me compile a comprehensive, well-organized answer.
Abdominal Pain by Site and Causes
Here is a complete breakdown of abdominal pain organized by anatomical location, drawn from authoritative medical textbooks (Tintinalli's Emergency Medicine, Sleisenger & Fordtran's GI Disease, Goldman-Cecil Medicine, Yamada's Gastroenterology).
Visual Reference Diagrams
The 9-region diagram (Lecturio):
The Tintinalli's Emergency Medicine quadrant diagram:
Diffuse / Generalized Abdominal Pain
These conditions tend to involve the entire peritoneum or produce pain that is not well-localized:
| Cause | Notes |
|---|---|
| Peritonitis (any cause) | Rigid abdomen, board-like |
| Bowel obstruction | Colicky, diffuse, with distension and vomiting |
| Early appendicitis | Starts periumbilical before localizing to RLQ |
| Pancreatitis | Can be diffuse or epigastric; radiates to back |
| Gastroenteritis | Crampy, associated with diarrhea/vomiting |
| Mesenteric ischemia | Severe pain out of proportion to signs |
| Aortic aneurysm (leaking/ruptured) | Sudden severe pain, pulsatile mass |
| Perforated bowel | Sudden onset, peritoneal signs |
| Volvulus | Crampy colicky pain, massive distension |
| Sickle cell crisis | Known history, systemic features |
| Metabolic disorders | Diabetic ketoacidosis (DKA), Addisonian crisis, porphyria, uremia |
| Familial Mediterranean fever | Recurrent episodic attacks |
| Heavy metal poisoning | Lead, arsenic |
| Hereditary angioedema | Episodic, no urticaria |
| Narcotic withdrawal | Drug history |
| Malaria | Fever, travel history |
| Abdominal compartment syndrome | Post-trauma/surgery setting |
Right Upper Quadrant (RUQ) / Right Hypochondriac Pain
The liver, gallbladder, and right lobe of the diaphragm are the main structures here.
| Cause | Key Features |
|---|---|
| Biliary colic | Colicky RUQ, radiates to right scapula, after fatty meals; resolves in <6 hours |
| Acute cholecystitis | Persistent RUQ pain, positive Murphy's sign, fever, nausea |
| Cholangitis | Charcot's triad: RUQ pain + fever + jaundice |
| Hepatitis (viral, alcoholic, autoimmune) | RUQ dull ache, jaundice, elevated LFTs |
| Hepatic abscess | Fever, tender hepatomegaly |
| Hepatic congestion (right heart failure) | Dull RUQ, raised JVP, peripheral edema |
| Duodenal ulcer | Epigastric-RUQ, relieved by food, worse at night |
| Subphrenic abscess | Post-surgical, shoulder tip pain |
| Myocardial ischemia / infarction | Referred pain - especially inferior MI; ECG mandatory |
| Pneumonia (right lower lobe) | Pleuritic, respiratory signs present |
| Pulmonary embolism | Pleuritic chest/right side pain, hypoxia |
| Herpes zoster | Dermatomal pain before rash |
Epigastric Pain
The stomach, duodenum, pancreas, and aorta are the main sources.
| Cause | Key Features |
|---|---|
| Peptic ulcer disease (gastric/duodenal) | Burning, relationship to meals, H. pylori |
| Perforated peptic ulcer | Sudden severe "knife-like" pain, peritonitis |
| Gastritis / esophagitis | Burning, worse with food/alcohol/NSAIDs |
| GERD | Burning, worse lying down, regurgitation |
| Acute pancreatitis | Severe, radiates to back, relieved leaning forward; elevated lipase/amylase |
| Aortic aneurysm | Pulsatile epigastric mass, radiates to back |
| Myocardial infarction | Do not miss - get ECG in all epigastric pain |
| Mesenteric ischemia | Severe pain out of proportion to exam |
Left Upper Quadrant (LUQ) / Left Hypochondriac Pain
The stomach, spleen, left kidney, pancreatic tail, and left lung are here.
| Cause | Key Features |
|---|---|
| Gastric ulcer / gastritis | Burning, worse with food |
| Splenic rupture | Trauma history, Kehr's sign (referred to left shoulder) |
| Splenomegaly / splenic abscess | Fullness, dull ache |
| Pancreatitis (tail) | Radiates to left back |
| Pneumonia (left lower lobe) | Respiratory signs, pleuritic |
| Pulmonary embolism | Pleuritic left-sided pain |
| Myocardial ischemia | Referred pain to epigastrium/LUQ |
| Herpes zoster | Dermatomal |
Right Lumbar (Right Flank) Pain
| Cause | Key Features |
|---|---|
| Ureteric colic (renal stone) | Severe colicky pain radiating to groin/scrotum/labia; hematuria in 85-90%; peak age 30-40 |
| Pyelonephritis | Dull aching flank pain + fever + dysuria + CVA tenderness |
| Hepatitis | Can extend to right flank |
| Mesenteric ischemia | |
| Small bowel obstruction | Colicky, associated with vomiting |
Left Lumbar (Left Flank) Pain
| Cause | Key Features |
|---|---|
| Ureteric colic | Same features as right, contralateral side |
| Pyelonephritis | Flank tenderness, fever, dysuria |
| Inflammatory bowel disease | Crohn's disease, associated diarrhea |
Umbilical / Periumbilical Pain
| Cause | Key Features |
|---|---|
| Early appendicitis | Begins periumbilical, then migrates to RLQ over 12-24 hours - classic presentation |
| Mesenteric lymphadenitis | Children, viral illness, no migration |
| Meckel's diverticulitis | Children/young adults; mimics appendicitis |
| Umbilical hernia | Visible/palpable |
| Aortic aneurysm | Mid-abdominal pulsatile mass |
| Intestinal obstruction | Colicky |
| Lymphoma | Painless mass, may cause obstruction |
Right Iliac Fossa (RLQ) Pain
This is one of the most clinically important regions.
| Cause | Key Features |
|---|---|
| Appendicitis | Most common surgical cause in young adults; RLQ tenderness, rebound, Rovsing's sign |
| Crohn's disease (terminal ileitis) | Chronic, diarrhea, weight loss, skip lesions |
| Cecal obstruction / volvulus | Colicky, distension |
| Ovarian cyst (ruptured/torsion) | Sudden severe pain, adnexal mass on exam |
| Ectopic pregnancy | Missed period, positive hCG; can rupture causing hemodynamic instability |
| Pelvic inflammatory disease (PID) | Cervical motion tenderness, vaginal discharge, bilateral/unilateral |
| Inguinal hernia (incarcerated/strangulated) | Visible groin bulge, severe pain |
| Endometriosis | Cyclic pain, dysmenorrhea |
| Mittelschmerz | Mid-cycle, brief |
| Psoas abscess | Flexion deformity of hip, fever |
| Ureteral calculi | Radiates to groin, hematuria |
| Herpes zoster | Dermatomal rash |
| Ischemic colitis | Older patients, post-prandial pain |
| Testicular torsion | Adolescents, sudden scrotal/lower abdominal pain |
Left Iliac Fossa (LLQ) Pain
| Cause | Key Features |
|---|---|
| Diverticulitis | Older adults, "left-sided appendicitis," fever, altered bowel habit |
| Ulcerative colitis | Bloody diarrhea, urgency, tenesmus |
| Constipation | Often overlooked, most common cause in primary care |
| Ovarian cyst / torsion | Same as RLQ contralateral |
| Ectopic pregnancy | |
| PID / endometriosis | |
| Inguinal hernia (incarcerated) | |
| Ischemic colitis | |
| Sigmoid volvulus | Elderly/institutionalized; massive distension |
| Ureteral calculi | |
| Aortic aneurysm | Can extend to LLQ |
| Regional enteritis (Crohn's) |
Hypogastric / Suprapubic Pain
| Cause | Key Features |
|---|---|
| Cystitis (UTI) | Burning, frequency, urgency, pyuria |
| Urinary retention | Inability to void, distended bladder, elderly male (BPH) |
| Testicular torsion | Adolescents; also may feel suprapubic |
| Ovarian pathology (bilateral cysts, torsion) | |
| Uterine causes (fibroids, endometriosis) | |
| Placental abruption / obstetric causes | Pregnant patient |
| PID | Bilateral pelvic tenderness |
| Bladder outlet obstruction / BPH | |
| Prostatitis | Perineal and suprapubic ache, dysuria |
Referred Pain - Important Clinical Pitfalls
Some extra-abdominal conditions present as abdominal pain:
| Extra-abdominal Source | Location of Referred Pain |
|---|---|
| Inferior MI / coronary ischemia | Epigastric or RUQ |
| Right lower lobe pneumonia | RUQ / right flank |
| Left lower lobe pneumonia | LUQ / left flank |
| Pulmonary embolism | Either upper quadrant |
| Diaphragmatic irritation (any cause) | Shoulder tip (Kehr's sign) |
| Testicular pathology | Lower abdominal / groin |
| Hip/spine pathology | Lower abdominal or inguinal |
| Diabetic ketoacidosis | Diffuse |
| Acute MI in elderly/diabetics | Epigastric (silent ischemia) |
Key clinical principle (Goldman-Cecil Medicine): "The site of the abdominal pain has a significant correlation with the organ involved" - but the history must also cover acuity, severity, radiation, duration, pattern (colicky vs. constant), and relationship to food and bowel movements.
A Quick Aide-Memoire: Mnemonic by Quadrant
- RUQ = Gall bladder, Hepatitis, Hepatic abscess, Duodenal ulcer, Cardiac (inferior MI)
- Epigastric = Pancreatitis, Peptic ulcer, Perforated ulcer, GERD, MI
- LUQ = Spleen, Stomach, Pancreatitis (tail)
- Periumbilical = Early appendicitis, Mesenteric ischemia, Aortic aneurysm
- RLQ = Appendicitis, Crohn's, Ovarian (right), Ectopic (right)
- LLQ = Diverticulitis, Ulcerative colitis, Constipation, Ovarian (left)
- Suprapubic = Cystitis, Uterine, Bladder obstruction
Sources: Tintinalli's Emergency Medicine (9e), Sleisenger & Fordtran's GI and Liver Disease, Goldman-Cecil Medicine (2-vol set), Yamada's Textbook of Gastroenterology (7e), Lecturio Differential Diagnosis Diagram
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