Assessing Stomach Pain and Cramps

Key questions to narrow it down

• Location: epigastric, periumbilical, RLQ/RUQ/LLQ/LUQ, diffuse/generalized, suprapubic
• Onset and duration: sudden vs. gradual, acute (hours-days) vs. chronic/recurrent (weeks-months)
• Character: crampy/colicky (comes in waves) vs. constant/sharp vs. burning
• Associated symptoms: fever, vomiting, diarrhea or constipation, blood in stool/vomit, bloating, jaundice, urinary symptoms, weight loss
• Modifying factors: relation to meals, bowel movements, menstrual cycle (if female), medications (NSAIDs, antibiotics)
• Age: causes and risk of serious pathology shift a lot with age

Common causes by pattern

• Crampy, periumbilical or diffuse pain with diarrhea/nausea - gastroenteritis (viral most common), food poisoning, IBS
• Epigastric burning, worse/better with food - peptic ulcer disease, gastritis, GERD. Per Harrison's Principles of Internal Medicine, dyspepsia that becomes constant or radiates to the back can suggest a penetrating ulcer, while sudden severe generalized pain raises concern for perforation - Harrison's Principles of Internal Medicine, 22E.
• RLQ pain, worsening, with fever/anorexia - appendicitis (surgical emergency)
• RUQ colicky pain after fatty meals - biliary colic/cholecystitis
• Crampy pain with bloating, altered bowel habits, relieved by defecation, chronic/recurrent - irritable bowel syndrome (a common cause of "cramps")
• Lower abdominal/pelvic cramping in a woman - dysmenorrhea, ovarian cyst, PID, ectopic pregnancy (must rule out if any possibility of pregnancy)
• Diffuse colicky pain with constipation/distension - bowel obstruction
• Flank-to-groin colicky pain - renal colic (kidney stone)

Red flags that warrant urgent evaluation

• Sudden onset of severe, generalized, or "board-like" abdominal pain (possible perforation)
• Pain with rigidity, guarding, or rebound tenderness
• Fever with abdominal pain
• Persistent vomiting, inability to keep fluids down
• Blood in vomit or stool, or black/tarry stools
• Unintentional weight loss
• Signs of GI bleeding or hypovolemia (tachycardia, dizziness, pallor)
• Pain in an older adult: presentations are often deceptively subtle in the elderly (lack of guarding/rebound despite serious pathology), and this group carries a higher risk of a surgical abdomen and death - ROSEN's Emergency Medicine, Concepts and Clinical Practice. Also, in older adults (especially women), abdominal pain alone can be the presenting symptom of acute coronary syndrome rather than chest pain.
• Any possibility of pregnancy with lower abdominal pain (rule out ectopic)

What generally helps in the meantime (if no red flags)

• Clear fluids, small bland meals (BRAT-type diet), rest
• Avoid NSAIDs, alcohol, caffeine, and fatty/spicy foods until cause is clear
• OTC antispasmodics or simethicone for gas/cramping if no contraindication
• Track symptoms: timing relative to meals/bowel movements, stool character, temperature