A Diagnostic Approach to Chronic Abdominal Pain

Abstract

Chronic abdominal pain is a condition routinely encountered in clinical practice. The differential diagnosis for chronic abdominal pain is broad and can be categorized using a location- and character-based approach. The evaluation begins with a thorough history, comprehensive exam, and thoughtful diagnostic approach. If warning signs are absent and no obvious underlying etiology is identified, patients should be stratified into low-risk versus high-risk categories based on age and associated symptoms. Low-risk patients (age <60 years and without alarm symptoms) may be offered empiric pharmacologic and/or psycho-behavioral treatment directed at the principal underlying symptom without further investigation. High-risk patients (age ≥60 years or with alarm features) may require additional evaluation prior to treatment.

Self-Test

• Question 1. A 40-year-old woman presents with a 4-year history of epigastric burning and fullness that typically occurs 1 hour after eating. She has a prior history of fibromyalgia and depression. Prior work-up, including an esophagogastroduodenoscopy, Helicobacter pylori stool antigen, and right upper quadrant ultrasound, have all been negative or normal. She denies any constipation, diarrhea, heartburn, or weight loss and has found no relief with over-the-counter antacid medications.

  What is the most likely diagnosis?

  • (a) Irritable bowel syndrome

  • (b) Functional dyspepsia

  • (c) Gastroesophageal reflux disease

  • (d) Peptic ulcer disease

  • (e) Biliary colic

• Question 2. A 70-year-old man presents with a 4-month history of worsening abdominal pain. He notes that his abdominal pain starts within 30 min of eating and resolves over the next 2 hours. He has developed a fear of eating and has lost 15 pounds of weight during this time. He has a history of hypertension, hyperlipidemia, and 40-pack-year tobacco use. He denies a history of alcohol use. He underwent coronary angiogram with drug-eluting stent placement to his left anterior descending artery 6 months ago for unstable angina. His medications include aspirin, clopidogrel, atorvastatin, metoprolol, and lisinopril. He denies diarrhea, melena, or hematochezia. A complete blood count and fasting glucose are within normal limits. An esophagogastroduodenoscopy was performed 6 months ago in the evaluation of nausea, around the time of his coronary angiogram, and was found to be normal.

  What is the most likely diagnosis?

  • (a) Gastric malignancy

  • (b) Medication side effect

  • (c) Chronic mesenteric ischemia

  • (d) Chronic pancreatitis

  • (e) Peptic ulcer disease

• Question 3. A 61-year-old man presents with a 6-month history of epigastric pain. He describes the pain as burning and achy. It starts several hours after eating a meal and lasts for 1–2 hours. The pain also awakens him from sleep. He has lost 10 pounds of weight unintentionally during this time. He denies any melena or hematochezia. His past medical history is notable for osteoarthritis and benign prostatic hypertrophy. His only medications are over-the-counter analgesics for joint pain. His complete blood count reveals a microcytic anemia. His last colonoscopy at age 60 was unremarkable.

  What is the next best step in management?

  • (a) Computed tomography of the abdomen

  • (b) Colonoscopy

  • (c) Abdominal ultrasound

  • (d) Helicobacter pylori stool antigen

  • (e) Esophagogastroduodenoscopy

• Question 4. A 30-year-old woman presents with a 3-year history of diffuse abdominal pain. She has a lifelong history of constipation with one bowel movement per week. She also describes a sense of incomplete evacuation, excessive straining, and occasional bloating. Several times per month, she has to manually evacuate stool using her fingers. She has seen two providers previously for the same complaint, and an esophagogastroduodenoscopy, colonoscopy, and computed tomography scan of the abdomen and pelvis have been unremarkable. She consumes 60 ounces of water daily and has found no benefit with fiber supplementation, which tends to worsen symptoms of chronic bloating. Her menstrual periods are regular, and her past medical history is unremarkable other than two uneventful vaginal deliveries. Abdominal examination reveals mild diffuse tenderness, and rectal examination reveals limited perineal descent and paradoxical contraction on simulated defecation, with hard stool palpable in the rectal vault.

  What is the next best step in management?

  • (a) Anorectal manometry with balloon expulsion

  • (b) Increasing doses of stimulant laxatives

  • (c) Defecating proctogram

  • (d) Colonic transit study

  • (e) Subtotal colectomy