Types of abdominal pain

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"abdominal pain"[MeSH Terms] AND "diagnosis"

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abdominal pain referred pain visceral afferent dermatomes diagram

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Types of abdominal pain

1. By neuroanatomical mechanism

Type	Source	Character	Localization
Visceral	Stretch, spasm or ischaemia of hollow organ walls or solid organ capsules (autonomic fibers, entering the cord bilaterally)	Dull, aching, cramping, vague	Poor, usually midline
Somatic (parietal)	Irritation of the parietal peritoneum (ipsilateral spinal nerves to dorsal root ganglia)	Sharp, constant, intense	Well localized, over the affected area. Worse with movement or coughing
Referred	Shared central pathways for afferents from distant sites	Felt at a site away from the source	Distant dermatome

Visceral pain follows embryological origin (Rosen's Emergency Medicine, Ch. 23, Pathophysiology, p. 267):

Foregut (stomach, duodenum, liver, gallbladder, pancreas): epigastric pain.
Midgut (small bowel, proximal colon, appendix): periumbilical pain.
Hindgut (distal colon, genitourinary tract): lower abdominal or suprapubic pain.

Appendicitis is the classic example of visceral pain followed by somatic pain. Periumbilical dull pain becomes sharp right lower quadrant pain once the inflamed appendix irritates the parietal peritoneum.

Examples of referred pain:

Epigastric pain from inferior MI.
Shoulder-tip pain from diaphragmatic irritation (ruptured spleen or liver, free blood).
Upper abdominal pain from lower lobe pneumonia.
Biliary pain to the right scapula.
Renal or ureteric pain to the groin.
Pancreatic pain to the back.

Bailey & Love notes that visceral pain is referred to the somatic distribution of nerve roots T1 to L2. Once an inflamed organ touches the parietal peritoneum, pain localizes to the segmental dermatome of the abdominal wall (Bailey and Love's Short Practice of Surgery, 28th ed., Specific characteristics of abdominal pain).

2. By pattern and character

Colicky pain comes in waves, caused by peristalsis against an obstruction (Bailey and Love's Short Practice of Surgery, 28th ed., Summary box 63.6):
- Small bowel colic: central, comes in waves and disappears completely within minutes.
- Biliary colic: insidious onset, peaks in about 30 minutes and does not ease off completely between spasms. It is usually a steady pain rather than a true colic.
- Ureteric colic: intense, lasting 1-2 minutes, along the line of the ureter.
Constant or steady pain suggests inflammation or peritonitis (appendicitis, cholecystitis, diverticulitis).
Sudden, severe, "tearing" pain suggests perforation or vascular catastrophe (perforated ulcer, ruptured AAA, aortic dissection, mesenteric ischaemia).
Burning pain suggests peptic ulcer disease or reflux.

3. By duration

Acute: hours to days. This is the surgical or emergency presentation.
Subacute: days to weeks.
Chronic or recurrent: more than 3 months, for example IBS, chronic pancreatitis, functional dyspepsia, IBD, abdominal migraine and adhesions.

4. By location (quadrant or region)

Region	Common causes
Right upper	Biliary colic, cholecystitis, hepatitis, hepatic abscess, duodenal ulcer
Epigastric	Peptic ulcer, gastritis, pancreatitis, MI, GERD
Left upper	Splenic pathology, gastric ulcer, pancreatitis
Periumbilical	Early appendicitis, small bowel obstruction, mesenteric ischaemia, AAA
Right lower	Appendicitis, Crohn's ileitis, ovarian torsion, ectopic pregnancy, right ureteric stone
Left lower	Diverticulitis, sigmoid volvulus, ovarian or ectopic causes, left ureteric stone
Suprapubic	Cystitis, urinary retention, PID, uterine pathology
Diffuse	Peritonitis, obstruction, gastroenteritis, DKA, mesenteric ischaemia

5. By cause

Intra-abdominal inflammatory or infective: appendicitis, cholecystitis, pancreatitis, diverticulitis.
Obstructive: bowel obstruction, biliary or ureteric stones.
Perforation or rupture: peptic ulcer, ectopic pregnancy, AAA.
Vascular or ischaemic: mesenteric ischaemia, aortic dissection.
Gynaecological: ectopic pregnancy, ovarian torsion, PID.
Extra-abdominal or systemic: MI, lower lobe pneumonia, DKA, Addisonian crisis, herpes zoster, spinal pathology.
Functional: IBS, functional dyspepsia, abdominal migraine.

Rosen's emphasizes higher-risk groups, who often present atypically: the elderly, pregnant women and the immunosuppressed (Rosen's Emergency Medicine, Ch. 23, p. 267-268).

Recent evidence check

A PubMed search of the last 2 years found no recent meta-analyses or systematic reviews that contradict the textbook classification above. Recent reviews cover narrower topics:

Chronic abdominal pain after bariatric surgery (PMID 41514128).
Clinical features of abdominal migraine (PMID 41695619).
Standardized ED pain management protocols for acute abdominal pain (PMID 40967062).

I can go deeper on any one area, such as the acute abdomen workup, a quadrant-wise differential, or chronic functional pain.

What to take in HOPI of obg

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What to include in the HOPI (history of presenting illness) in OBG

The library had no chapter on the HOPI for OBG as such. I've combined the textbook elements it did have with standard clinical practice, and I mark which is which below.

1. Start with the chief complaint

Record the complaints in the patient's own words, in chronological order, each with its duration. For example: "Amenorrhoea for 8 weeks, pain in lower abdomen for 2 days, spotting per vaginum for 1 day."

2. Core HOPI for every symptom

Use the standard framework for each complaint:

Onset (sudden or gradual) and duration
Progression (static, worse or better)
Character and severity
Site and radiation (for pain)
Aggravating and relieving factors
Associated symptoms, including relevant negatives
Treatment taken so far and its response
Impact on daily life

3. If it is an obstetric case

Always establish at the start:

Gravida, parity, living children, abortions (G P L A)
LMP, EDD (Naegele's rule) and period of gestation
Booked or unbooked, and where the antenatal care was done

Tintinalli's says the obstetric history should include parity, complications with prior deliveries, history of precipitous deliveries, prenatal care in this pregnancy and the estimated date of delivery (Tintinalli's Emergency Medicine, History section).

Symptom-based HOPI:

Complaint	Points to ask
Pain abdomen or labour pains	Onset, frequency, duration and regularity of contractions. Show or bloody discharge. Fetal movements
Leaking per vaginum	Time of onset, amount, colour (clear, meconium-stained, blood-stained), smell, fever. This points to PROM or PPROM
Bleeding per vaginum	Amount (number of pads), colour, clots, painful or painless (placenta praevia versus abruption), trauma or coitus, passage of tissue (abortion), shock symptoms
Decreased or absent fetal movements	Since when, and the kick count
Headache, visual disturbance, epigastric pain, swelling, fits	Pre-eclampsia or eclampsia. Ask about BP records and urine protein
Vomiting	Frequency, ability to tolerate fluids, weight loss (hyperemesis)
Fever, burning micturition, discharge	Infection
Itching	Intrahepatic cholestasis of pregnancy
Postpartum or post-abortal presentations	Bleeding, fever, foul lochia, breast problems, mood, calf swelling or breathlessness

Also ask in the HOPI or past history for this pregnancy:

Conception details (spontaneous or assisted)
First trimester symptoms
Antenatal visits, scans and screening
Folic acid, iron and tetanus toxoid
Complications such as GDM, hypertension, anaemia or infections

4. If it is a gynaecology case

Menstrual complaints (AUB, amenorrhoea, dysmenorrhoea):

Cycle length and regularity, and duration of flow
Amount (pads per day, clots, flooding)
Intermenstrual, post-coital or postmenopausal bleeding
Dysmenorrhoea (spasmodic or congestive)
Onset of the problem and any weight, stress or drug change
Anticoagulants, hormones, aspirin or herbal products
Symptoms of anaemia (fatigue, breathlessness, palpitations)

Vaginal discharge:

Colour, odour, amount, itching
Association with menses and with partner symptoms

Pain (pelvic or abdominal):

Cyclical or acyclical
Dyspareunia (superficial or deep)
Dysuria and bowel symptoms
Relation to menses and intercourse

Mass per abdomen or per vaginum, or prolapse:

Duration and rate of growth
Pressure symptoms
Urinary symptoms (stress incontinence, urgency, retention)
Bowel symptoms

Infertility:

Duration of attempts, frequency of intercourse
Previous investigations and treatment
Partner's semen analysis

Postmenopausal patient:

Age at menopause
Hot flushes, bleeding, discharge, urinary complaints

5. Key elements of a gynaecological history

Schwartz's lists these as the key elements (Schwartz's Principles of Surgery, 11th ed., Elements of a Gynecologic History, p. 1814-1815):

Date of last menstrual period
Contraceptive and postmenopausal hormone use
Obstetric history
Age at menarche and menopause
Menstrual bleeding pattern
Pelvic assessments, including cervical smear and HPV results
Pelvic infections, including HPV and HIV status
Sexual history
Prior gynaecologic surgery

It also advises asking about medications and about any personal or family history of prolonged bleeding.

6. Pertinent negatives to always document

Bleeding case: syncope, fever, pain
Pregnancy: danger signs (headache, blurred vision, bleeding, leaking, reduced movements)
Gynae case: weight loss, bowel or bladder changes, postmenopausal bleeding, and symptoms of anaemia

7. Where each part is recorded

The HOPI covers only the current illness. Record the rest in separate sections:

Menstrual history
Obstetric history (past pregnancies)
Contraceptive history
Past medical and surgical history
Family history
Personal history
Marital and sexual history

A one-line summary of a good OBG HOPI: LMP and gestation (or menstrual pattern) + each complaint with onset, duration, character and associated symptoms + treatment taken + pertinent negatives.

I can write a sample HOPI for a specific case, such as APH, PROM, AUB or pre-eclampsia.

Define HOPI

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HOPI stands for History of Present Illness. It is also written HPI, or HOPI in Indian usage.

It is the part of the clinical history that gives a chronological account of the patient's current problem. It runs from the first symptom to the day of presentation. The textbooks place it directly after the chief complaint in the standard history and physical (Kaplan & Sadock's Comprehensive Textbook of Psychiatry, Chief Complaint; Neuroanatomy through Clinical Cases, 3rd ed., The General History and Physical Exam). A standard history runs as follows (Campbell-Walsh Urology, Overview):

Chief complaint
History of present illness
Past medical and surgical history
Allergies
Family and social history
Review of systems

What it contains:

The onset, duration, progression and character of each symptom
Aggravating and relieving factors
Associated symptoms, and pertinent negatives
Treatment taken so far and the response to it

HOPI versus review of systems (ROS): The HOPI covers the symptoms of the presenting problem. The ROS picks up symptoms the HOPI did not cover or missed (Goldman-Cecil Medicine, Review of Systems).

In OBG, the HOPI also records the LMP, gestational age and the menstrual pattern alongside each complaint, as in my previous answer.

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