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Official reprint from UpToDate


www.uptodate.com 2016 UpToDate

Causes of abdominal pain in adults


Authors
Robert M Penner, BSc, MD,
FRCPC, MSc
Mary B Fishman, MD
Sumit R Majumdar, MD, MPH

Section Editors
Andrew D Auerbach, MD, MPH
Mark D Aronson, MD

Deputy Editor
Lee Park, MD, MPH

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2016. | This topic last updated: Feb 22, 2016.
INTRODUCTION The evaluation of abdominal pain requires an understanding of the possible mechanisms
responsible for pain, a broad differential of common causes, and recognition of typical patterns and clinical
presentations. This topic reviews the etiologies of abdominal pain in adults. The emergent and non-urgent
evaluation of abdominal pain of adults discussed elsewhere. (See "Evaluation of the adult with abdominal pain in
the emergency department" and "Evaluation of the adult with abdominal pain".)
Abdominal pain in pregnant and postpartum women and patients with HIV is discussed elsewhere. (See
"Approach to abdominal pain and the acute abdomen in pregnant and postpartum women" and "Evaluation of
abdominal pain in the HIV-infected patient".)
PATHOPHYSIOLOGY OF ABDOMINAL PAIN
Neurologic basis for abdominal pain Pain receptors in the abdomen respond to mechanical and
chemical stimuli. Stretch is the principal mechanical stimulus involved in visceral nociception, although
distention, contraction, traction, compression, and torsion are also perceived [1]. Visceral receptors
responsible for these sensations are located on serosal surfaces, within the mesentery, and within the walls
of hollow viscera. Visceral mucosal receptors respond primarily to chemical stimuli, while other visceral
nociceptors respond to chemical or mechanical stimuli.
The events responsible for the perception of abdominal pain are not completely understood, but depend
upon the type of stimulus and the interpretation of visceral nociceptive inputs in the central nervous system
(CNS). As an example, the gastric mucosa is insensitive to pressure or chemical stimuli. However, in the
presence of inflammation, these same stimuli can cause pain [2]. The threshold for perceiving pain may
vary among individuals and in certain diseases. (See "Definition and pathogenesis of chronic pain", section
on 'Pathogenesis of pain'.)
Localization The type and density of visceral afferent nerves makes the localization of visceral pain
imprecise. However, a few general rules are useful:
Most digestive tract pain is perceived in the midline because of bilaterally symmetric innervation [1,3].
Pain that is clearly lateralized most likely arises from the ipsilateral kidney, ureter, ovary, or somatically
innervated structures, which have predominantly unilateral innervation. Exceptions to this rule include
the gallbladder and ascending and descending colons which, although bilaterally innervated, have
predominant innervation located on their ipsilateral sides.
Visceral pain is perceived in the spinal segment at which the visceral afferent nerves enter the spinal
cord [4]. As an example, afferent nerves mediating pain arising from the small intestine enter the
spinal cord between T8 to L1. Thus, distension of the small intestine is usually perceived in the
periumbilical region.
Referred pain Pain originating in the viscera may sometimes be perceived as originating from a site
distant from the affected organ (figure 1) [5-7]. Referred pain is usually located in the cutaneous
dermatomes sharing the same spinal cord level as the visceral inputs. As an example, nociceptive inputs
from the gallbladder enter the spinal cord at T5 to T10. Thus, pain from an inflamed gallbladder may be
perceived in the scapula (figure 1).

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The quality of referred pain is aching and perceived to be near the surface of the body. In addition to pain,
two other correlates of referred pain can be detected: skin hyperalgesia and increased muscle tone of the
abdominal wall (which accounts for the abdominal wall rigidity sometimes observed in patients with an
acute abdomen).
UPPER ABDOMINAL PAIN SYNDROMES Upper abdominal pain syndromes typically have characteristic
locations: right upper quadrant pain (table 1), epigastric pain (table 2), or left upper quadrant pain (table 3).
Right upper quadrant pain Biliary and hepatic etiologies cause right upper quadrant pain syndromes.
Biliary etiologies include (table 1):
Gallstones Symptoms of biliary colic classically include an intense, dull discomfort located in the right
upper quadrant, epigastrium, or (less often) substernal area that may radiate to the back (particularly the
right shoulder blade). Patients may have associated nausea, vomiting, and diaphoresis. The pain generally
lasts at least 30 minutes, plateauing within an hour. Patients have an unremarkable abdominal
examination. (See "Uncomplicated gallstone disease in adults", section on 'Biliary colic'.)
Acute cholecystitis The clinical manifestations of acute cholecystitis include prolonged (more than four
to six hours), steady, severe right upper quadrant or epigastric pain, fever, abdominal guarding, a positive
Murphy's sign, and leukocytosis. (See "Acute cholecystitis: Pathogenesis, clinical features, and diagnosis",
section on 'Clinical manifestations'.)
Acute cholangitis Acute cholangitis occurs when a stone becomes impacted in the biliary or hepatic
ducts, causing dilation of the obstructed duct and bacterial superinfection. It is characterized by fever,
jaundice, and abdominal pain, although this classic triad (known as Charcot's triad) occurs in only 50 to 75
percent of cases [8]. The abdominal pain is typically vague and located in the right upper quadrant. (See
"Acute cholangitis", section on 'Clinical manifestations'.)
Sphincter of Oddi dysfunction Sphincter of Oddi dysfunction can be a cause of biliary pain in the
absence of gallstones or biliary inflammation. Typically the pain is located in the right upper quadrant or
epigastrium and lasts from 30 minutes to several hours. (See "Clinical manifestations and diagnosis of
sphincter of Oddi dysfunction".)
Hepatic etiologies include (table 1):
Hepatitis Patients with acute hepatitis (eg, from hepatitis A, alcohol, or medications) may have fatigue,
malaise, nausea, vomiting, and anorexia in addition to right upper quadrant pain. Other symptoms include
jaundice, dark urine, and light colored stools. (See "Overview of hepatitis A virus infection in adults", section
on 'Clinical evaluation' and "Alcoholic hepatitis: Clinical manifestations and diagnosis", section on 'Signs
and symptoms' and "Drug-induced liver injury", section on 'Clinical manifestations'.)
Perihepatitis The Fitz-Hugh-Curtis syndrome, or perihepatitis, is a cause of right upper quadrant pain in
young women with pelvic inflammatory disease (PID). It occurs in approximately 10 percent of patients with
acute PID. It is characterized by right upper quadrant pain with a distinct pleuritic component, sometimes
referred to the right shoulder. (See "Pelvic inflammatory disease: Clinical manifestations and diagnosis",
section on 'Perihepatitis'.)
Liver abscess Liver abscess is the most common type of visceral abscess. Patients generally present
with fever and abdominal pain. Risk factors include diabetes, underlying hepatobiliary or pancreatic
disease, or liver transplant. (See "Pyogenic liver abscess", section on 'Epidemiology' and "Pyogenic liver
abscess", section on 'Clinical manifestations'.)
Budd-Chiari syndrome Budd-Chiari syndrome is defined as hepatic venous outflow tract obstruction,
independent of the level or mechanism of obstruction, provided the obstruction is not due to cardiac
disease, pericardial disease, or sinusoidal obstruction syndrome (veno-occlusive disease). Symptoms
include fever, abdominal pain, abdominal distention (from ascites), lower extremity edema, jaundice,
gastrointestinal bleeding, and/or hepatic encephalopathy. There are a variety of causes (table 4). (See
"Budd-Chiari syndrome: Epidemiology, clinical manifestations, and diagnosis", section on 'Clinical
manifestations' and "Etiology of the Budd-Chiari syndrome", section on 'Etiology'.)

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Portal vein thrombosis Clinical manifestations of portal vein thrombosis vary depending on the extent of
obstruction as well as the speed of development (acute or chronic). It is common in patients with cirrhosis
and is associated with the severity of liver disease. Patients may be asymptomatic or have abdominal pain,
dyspepsia, or gastrointestinal bleeding. (See "Acute portal vein thrombosis in adults: Clinical
manifestations, diagnosis, and management", section on 'Clinical manifestations' and "Chronic portal vein
thrombosis in adults: Clinical manifestations, diagnosis, and management", section on 'Clinical
manifestations'.)
Epigastric pain Pancreatic and gastric etiologies often cause epigastric pain (table 2).
Acute myocardial infarction Epigastric pain can be the presenting symptom of an acute myocardial
infarction. Patients may have associated shortness of breath or exertional symptoms. (See "Angina
pectoris: Chest pain caused by myocardial ischemia", section on 'History'.)
Pancreatitis Both acute and chronic pancreatitis are associated with abdominal pain that often radiates
to the back. Most patients with acute pancreatitis have acute onset of persistent, severe epigastric pain.
The pain is steady and may be in the mid-epigastrium, right upper quadrant, diffuse, or, infrequently,
confined to the left side. (See "Clinical manifestations and diagnosis of acute pancreatitis", section on
'Clinical features'.)
The two primary clinical manifestations of chronic pancreatitis are epigastric pain and pancreatic
insufficiency. The pain is typically epigastric, is occasionally associated with nausea and vomiting, and may
be partially relieved by sitting upright or leaning forward. (See "Clinical manifestations and diagnosis of
chronic pancreatitis in adults", section on 'Clinical manifestations'.)
Peptic ulcer disease Upper abdominal pain or discomfort is the most prominent symptom in patients
with peptic ulcers. Patients most often have epigastric pain, but occasionally the discomfort localizes to one
side. (See "Peptic ulcer disease: Clinical manifestations and diagnosis", section on 'Clinical
manifestations'.)
Gastroesophageal reflux disease (GERD) Most patients with GERD complain of heartburn,
regurgitation, and dysphagia. However, some patients may also complain of epigastric and/or chest pain.
(See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults", section on 'Clinical
features'.)
Gastritis/gastropathy Gastritis refers to inflammation in the lining of the stomach. Gastritis is
predominantly an inflammatory process, while the term gastropathy denotes a gastric mucosal disorder
with minimal to no inflammation. Acute gastropathy often presents with abdominal discomfort/pain,
heartburn, nausea, vomiting, and hematemesis. Gastropathy may be caused by a variety of etiologies
including alcohol and non-steroid anti-inflammatory medications. (See "Acute hemorrhagic erosive
gastropathy and chronic chemical gastropathy", section on 'Acute hemorrhagic erosive gastropathy' and
"NSAIDs (including aspirin): Pathogenesis of gastroduodenal toxicity", section on 'Gastric damage'.)
Functional dyspepsia Functional dyspepsia is defined as the presence of one or more of the following
symptoms: postprandial fullness, early satiation, and epigastric pain or burning, with no evidence of
structural disease (including at upper endoscopy) to explain the symptoms. (See "Functional dyspepsia in
adults".)
Gastroparesis Patients with gastroparesis can present with nausea, vomiting, abdominal pain, early
satiety, postprandial fullness, bloating, and, in severe cases, weight loss. The most common causes are
idiopathic, diabetic, or postsurgical (figure 2). (See "Gastroparesis: Etiology, clinical manifestations, and
diagnosis", section on 'Clinical manifestations'.)
Left upper quadrant pain Left upper quadrant pain is often related to the spleen (table 3).
Splenomegaly Splenomegaly can cause left upper quadrant pain or discomfort, referred pain to the left
shoulder, and/or early satiety. Splenomegaly has multiple causes (table 5). (See "Approach to the adult
patient with splenomegaly and other splenic disorders", section on 'Symptoms' and "Approach to the adult
patient with splenomegaly and other splenic disorders", section on 'Causes of splenomegaly'.)

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Splenic infarction Patients with splenic infarction classically present with severe left upper quadrant
pain, though atypical presentations are common. Splenic infarction is associated with a variety of
underlying conditions (eg, hypercoagulable state, embolic disease from atrial fibrillation, conditions
associated with splenomegaly). (See "Approach to the adult patient with splenomegaly and other splenic
disorders", section on 'Splenic infarction'.)
Splenic abscess Splenic abscesses are uncommon and typically are associated with fever and
tenderness in the left upper quadrant. They may also be associated with splenic infarction. (See "Approach
to the adult patient with splenomegaly and other splenic disorders", section on 'Splenic abscess'.)
Splenic rupture Splenic rupture is most often associated with trauma. The patient may complain of left
upper abdominal, left chest wall, or left shoulder pain (ie, Kehr's sign). Kehr's sign is pain referred to the left
shoulder that worsens with inspiration and is due to irritation of the phrenic nerve from blood adjacent to the
left hemidiaphragm. (See "Approach to the adult patient with splenomegaly and other splenic disorders",
section on 'Splenic rupture' and "Management of splenic injury in the adult trauma patient", section on
'History and physical examination'.)
LOWER ABDOMINAL PAIN SYNDROMES Lower abdominal pain syndromes (table 6) often cause pain in
either or both lower quadrants. Women may have lower abdominal pain from disorders of the internal female
reproductive organs (table 7). (See 'Women' below.)
Lower abdominal pain syndromes that are generally localized to one side include (table 6):
Acute appendicitis Acute appendicitis typically presents with periumbilical pain initially that radiates to
the right lower quadrant. It is associated with anorexia, nausea, and vomiting. However, occasionally
patients present with epigastric or generalized abdominal pain. The pain localizes to the right lower
quadrant when the appendiceal inflammation begins to involve the peritoneal surface. (See "Acute
appendicitis in adults: Clinical manifestations and differential diagnosis", section on 'Clinical
manifestations'.)
Diverticulitis The clinical presentation of diverticulitis depends upon the severity of the underlying
inflammatory process and whether or not complications are present. Left lower quadrant pain is the most
common complaint in Western countries, occurring in 70 percent of patients. Right-sided diverticulitis is
more common in Asian patients. The pain is usually constant and is often present for several days prior to
presentation. Patients may also have nausea and vomiting. (See "Clinical manifestations and diagnosis of
acute diverticulitis in adults", section on 'Clinical manifestations'.)
Abdominal pain from some genitourinary etiologies may be localized to either side (table 6):
Kidney stones Kidney stones usually cause symptoms when the stone passes from the renal pelvis into
the ureter. Pain is the most common symptom and varies from a mild to severe. Patients may have flank
pain, back pain, or abdominal pain. (See "Diagnosis and acute management of suspected nephrolithiasis in
adults", section on 'Clinical manifestations'.)
Pyelonephritis Patients with pyelonephritis may or may not have symptoms of cystitis (dysuria,
frequency, urgency, and/or hematuria). These patients also have fever, chills, flank pain, and costovertebral
angle tenderness. (See "Acute uncomplicated cystitis and pyelonephritis in women", section on 'Clinical
manifestations' and "Acute uncomplicated cystitis and pyelonephritis in men", section on 'Clinical
manifestations'.)
Other etiologies of lower abdominal pain may not always be localized to one side (table 6):
Cystitis Patients with cystitis may complain of suprapubic pain as well as dysuria, frequency, urgency,
and/or hematuria. (See "Acute uncomplicated cystitis and pyelonephritis in women", section on 'Clinical
manifestations' and "Acute uncomplicated cystitis and pyelonephritis in men", section on 'Clinical
manifestations'.)
Acute urinary retention Patients with bladder outlet obstruction leading to acute urinary retention
present with the inability to pass urine. They may have associated lower abdominal and/or suprapubic pain
or discomfort. (See "Acute urinary retention", section on 'Clinical presentation'.)

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Infectious colitis Patients with infectious colitis generally have diarrhea as the predominant symptom but
may also have associated abdominal pain, which may be severe. Patients with clostridium difficile infection
can present with an acute abdomen and peritoneal signs in the setting of perforation and fulminant colitis
(table 8). (See "Clostridium difficile infection in adults: Clinical manifestations and diagnosis", section on
'Clinical manifestations' and "Approach to the adult with acute diarrhea in resource-rich countries", section
on 'Indications for diagnostic evaluation'.)
DIFFUSE ABDOMINAL PAIN SYNDROMES Abdominal pain syndromes may have diffuse, non-specific
abdominal or variable presentations of pain (table 9).
Obstruction Severe, acute diffuse abdominal pain can be caused by either partial or complete
obstruction of the intestines. Intestinal obstruction should be considered when the patient complains of
pain, vomiting, and obstipation. Physical findings include abdominal distention, tenderness to palpation,
high-pitched or absent bowel sounds, and a tympanic abdomen. There are many etiologies of obstruction
(table 10), with the most common etiologies in adults being postoperative adhesions, malignancy related
(eg, from colorectal cancer), and complicated hernias. Other less common etiologies include Crohn
disease, gallstones, volvulus, and intussusception. (See "Epidemiology, clinical features, and diagnosis of
mechanical small bowel obstruction in adults" and "Clinical presentation, diagnosis, and staging of
colorectal cancer", section on 'Clinical presentation' and "Intestinal malrotation in children" and "Gastric
volvulus in adults" and "Cecal volvulus" and "Sigmoid volvulus".)
Perforation of gastrointestinal tract Perforation of the gastrointestinal tract can present acutely or in an
indolent manner. Patients complain of chest or abdominal pain to some degree. Sudden, severe chest or
abdominal pain following instrumentation or surgery is very concerning for perforation. Patients on
immunosuppressive or anti-inflammatory agents may have an impaired inflammatory response, and some
may have little or no pain and tenderness. Many patients will seek medical attention with the onset or
worsening of significant chest or abdominal pain, but a subset of patients will present in a delayed fashion.
(See "Overview of gastrointestinal tract perforation", section on 'Clinical features'.)
Mesenteric ischemia Acute mesenteric ischemia presents with the acute and severe onset of diffuse
and persistent abdominal pain, often described as pain out of proportion to examination. Several features of
the pain and its presentation may provide clues to the etiology of the ischemia and help distinguish small
intestinal from colonic ischemia (table 11). Chronic mesenteric ischemia may be manifested by a variety of
symptoms including abdominal pain after eating ("intestinal angina"), weight loss, nausea, vomiting, and
diarrhea. Ischemia that involves the celiac territory causes epigastric or right upper quadrant pain. Ischemia
may be from either arterial or venous disease. (See "Overview of intestinal ischemia in adults" and "Chronic
mesenteric ischemia" and "Mesenteric venous thrombosis in adults", section on 'Clinical presentations' and
"Colonic ischemia", section on 'Clinical manifestations'.)
Patients with aortic dissection may have abdominal pain from mesenteric ischemia (table 12). (See "Clinical
features and diagnosis of acute aortic dissection", section on 'Clinical features'.)
Inflammatory bowel disease (IBD) IBD is comprised of two major disorders: ulcerative colitis and Crohn
disease. IBD is also associated with a number of extraintestinal manifestations (table 13). (See "Definition,
epidemiology, and risk factors in inflammatory bowel disease".)
Ulcerative colitis (UC) Patients with UC usually present with diarrhea which may be associated
with blood. Bowel movements are frequent and small in volume as a result of rectal inflammation.
Associated symptoms include colicky abdominal pain, urgency, tenesmus, and incontinence. (See
"Clinical manifestations, diagnosis, and prognosis of ulcerative colitis in adults", section on 'Clinical
manifestations'.)
Crohn disease (CD) The clinical manifestations of CD are more variable than those of UC. Patients
can have symptoms for many years prior to diagnosis. Fatigue, prolonged diarrhea with abdominal
pain, weight loss, and fever, with or without gross bleeding, are the hallmarks of CD. (See "Clinical
manifestations, diagnosis and prognosis of Crohn disease in adults", section on 'Clinical
manifestations'.)

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Viral gastroenteritis Patients with viral gastroenteritis often have diarrhea accompanied by nausea,
vomiting, and abdominal pain. (See "Acute viral gastroenteritis in adults", section on 'Clinical
manifestations'.)
Spontaneous bacterial peritonitis (SBP) SBP most often occurs in cirrhotics with advanced liver
disease with ascites. Patients present with fever, abdominal pain, and/or altered mental status. (See
"Spontaneous bacterial peritonitis in adults: Clinical manifestations", section on 'Clinical manifestations'.)
Peritonitis in peritoneal dialysis patients Peritonitis may develop in patients on peritoneal dialysis
either from contamination during dialysis or catheter related infection. The most common symptoms and
signs are abdominal pain and cloudy peritoneal effluent. Other symptoms and signs include fever, nausea,
diarrhea, abdominal tenderness, rebound tenderness, and occasionally systemic signs (eg, hypotension).
(See "Clinical manifestations and diagnosis of peritonitis in peritoneal dialysis", section on 'Clinical
manifestations'.)
Malignancy Gastrointestinal malignancies may be associated with abdominal discomfort. These are
discussed in detail in specific topics. As examples:
Colorectal cancer Patients with colorectal cancer may present with abdominal pain from partial
obstruction, peritoneal dissemination, or perforation. (See "Clinical presentation, diagnosis, and
staging of colorectal cancer", section on 'Clinical presentation'.)
Gastric cancer Patients with gastric cancer may have abdominal pain that is often epigastric pain.
(See "Clinical features, diagnosis, and staging of gastric cancer", section on 'Clinical features'.)
Pancreatic cancer The most common symptoms in patients with pancreatic cancer are pain,
jaundice, and weight loss. (See "Clinical manifestations, diagnosis, and staging of exocrine pancreatic
cancer", section on 'Clinical presentation'.)
Additionally, patients may have pain as part of pain syndromes related to malignancy (table 14). (See
"Overview of cancer pain syndromes", section on 'Tumor-related visceral pain syndromes'.)
Celiac disease Patients with celiac disease may complain of abdominal pain in addition to diarrhea with
bulky, foul-smelling, floating stools due to steatorrhea and flatulence. (See "Pathogenesis, epidemiology,
and clinical manifestations of celiac disease in adults", section on 'Clinical manifestations'.)
Ketoacidosis Patients with ketoacidosis (eg, from diabetes or alcohol) may have diffuse abdominal pain
as well as nausea and vomiting. (See "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in
adults: Clinical features, evaluation, and diagnosis", section on 'Abdominal pain in DKA' and "Fasting
ketosis and alcoholic ketoacidosis", section on 'Clinical presentation'.)
Adrenal insufficiency Patients with adrenal insufficiency may have diffuse abdominal pain as well as
nausea and vomiting. Patients with adrenal crisis may present with shock and hypotension. Patients with
chronic adrenal deficiency may also complain of malaise, fatigue, anorexia, and weight loss. (See "Clinical
manifestations of adrenal insufficiency in adults", section on 'Primary adrenal insufficiency' and "Clinical
manifestations of adrenal insufficiency in adults", section on 'Gastrointestinal complaints'.)
Foodborne disease A foodborne disease will typically manifest as a mixture of nausea, vomiting, fever,
abdominal pain, and diarrhea. Toxin-mediated illnesses can occur within hours of ingestion, but bacterial
colitis generally requires 24 to 48 hours to develop. Certain foods may be linked to particular pathogens
(table 15). (See "Differential diagnosis of microbial foodborne disease", section on 'Clinical manifestations'.)
Irritable bowel syndrome (IBS) Patients with IBS can present with a wide array of symptoms which
include both gastrointestinal and extraintestinal complaints. However, the symptom complex of chronic
abdominal pain and altered bowel habits remains the nonspecific yet primary characteristic of IBS. (See
"Clinical manifestations and diagnosis of irritable bowel syndrome in adults", section on 'Clinical
manifestations'.)
Constipation Constipation may be associated with abdominal pain. Diseases associated with
constipation include neurologic and metabolic disorders, obstructing lesions of the gastrointestinal tract,

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including colorectal cancer, endocrine disorders such as diabetes mellitus, and psychiatric disorders such
as anorexia nervosa (table 16). Constipation may also be due to a side effect of drugs (table 17). (See
"Etiology and evaluation of chronic constipation in adults".)
Diverticulosis Uncomplicated diverticulosis is often asymptomatic and an incidental finding on
colonoscopy or sigmoidoscopy. However, these patients may have symptoms of abdominal pain and
constipation. (See "Colonic diverticulosis and diverticular disease: Epidemiology, risk factors, and
pathogenesis", section on 'Symptomatic uncomplicated diverticular disease'.)
Lactose intolerance Symptoms of lactose intolerance include abdominal pain, bloating, flatulence, and
diarrhea. The abdominal pain may be cramping in nature and is often localized to the periumbilical area or
lower quadrants. (See "Lactose intolerance: Clinical manifestations, diagnosis, and management", section
on 'Clinical features'.)
LESS COMMON CAUSES Less common causes of abdominal pain include (table 18):
Abdominal aortic aneurysm (AAA) Most patients with AAA have no symptoms. When patients with a
nonruptured AAA do have symptoms, abdominal, back, or flank pain is the most common clinical
manifestation. Classically, ruptured AAA is associated with severe pain, hypotension, and a pulsatile
abdominal mass, but patients may have variable presentations. (See "Clinical features and diagnosis of
abdominal aortic aneurysm", section on 'Asymptomatic AAA' and "Clinical features and diagnosis of
abdominal aortic aneurysm", section on 'Symptomatic (nonruptured) AAA'.)
Abdominal compartment syndrome Abdominal compartment syndrome generally occurs in patients
who are critically ill. Patients have a tensely distended abdomen. (See "Abdominal compartment
syndrome".)
Abdominal migraine Recurrent abdominal pain may occur in patients with abdominal migraine [9].
These patients usually also suffer from typical migraine headaches, although occasional patients present
with gastrointestinal symptoms only [10]. Abdominal migraines have also been linked to cyclic vomiting
syndrome. (See "Pathophysiology, clinical manifestations, and diagnosis of migraine in adults" and "Cyclic
vomiting syndrome", section on 'CVS and migraines'.)
Acute intermittent porphyria (AIP) AIP is a rare cause of abdominal pain. The presentation of AIP is
highly variable and patients have nonspecific symptoms. Abdominal pain is the most common and often
earliest symptom. (See "Pathogenesis, clinical manifestations, and diagnosis of acute intermittent
porphyria", section on 'Acute attacks'.)
Angioedema Angioedema with abdominal pain may be caused by hereditary angioedema (HAE) or
related to ACE inhibitor therapy. It can present with recurrent episodes of abdominal pain, accompanied by
nausea, vomiting, colicky pain, and diarrhea. (See "Hereditary angioedema: Epidemiology, clinical
manifestations, exacerbating factors, and prognosis" and "ACE inhibitor-induced angioedema", section on
'Intestine'.)
Celiac artery compression syndrome Celiac artery compression syndrome (also referred to as celiac
axis syndrome, median arcuate ligament syndrome, and Dunbar syndrome) is defined as chronic, recurrent
abdominal pain related to compression of the celiac artery by the median arcuate ligament. (See "Celiac
artery compression syndrome".)
Chronic abdominal wall pain Chronic abdominal wall pain usually refers to anterior cutaneous nerve
entrapment syndrome. Pain associated with nerve entrapment is characteristically maximal in an area <2
cm in diameter. (See "Chronic abdominal wall pain", section on 'Clinical manifestations'.)
Colonic pseudo-obstruction Pseudo-obstruction is characterized by signs and symptoms of a
mechanical obstruction of the small or large bowel in the absence of a mechanical cause. The main clinical
feature is abdominal distention, but patients may have associated abdominal pain, nausea, and vomiting.
Acute colonic pseudo-obstruction is also known as Ogilvie's syndrome. (See "Acute colonic pseudoobstruction (Ogilvie's syndrome)", section on 'Clinical manifestations' and "Chronic intestinal pseudoobstruction", section on 'Clinical manifestations'.)

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Eosinophilic gastroenteritis Eosinophilic gastroenteritis belongs to a group of diseases that includes


eosinophilic esophagitis, gastritis, enteritis, and colitis. Symptoms depend on what part of the
gastrointestinal tract is affected. (See "Eosinophilic gastroenteritis".)
Epiploic appendagitis Epiploic appendagitis (also known as appendicitis epiploica, hemorrhagic
epiploitis, epiplopericolitis, or appendagitis) is a benign and self-limited condition of the epiploic
appendages. Patients with epiploic appendagitis most commonly present with acute or subacute onset of
lower abdominal pain. The pain is on the left side in 60 to 80 percent of patients, but has also been
reported in the right lower quadrant. (See "Epiploic appendagitis".)
Familial Mediterranean fever The typical manifestations of familial Mediterranean fever are recurrent
attacks of severe pain (due to serositis at one or more sites) and fever, lasting one to three days and then
resolving spontaneously. Most patients have abdominal pain. In between attacks, patients feel entirely well.
(See "Clinical manifestations and diagnosis of familial Mediterranean fever".)
Helminthic infections Patients with helminthic infections can manifest with gastrointestinal symptoms,
including abdominal pain. The clinical manifestations for specific helminth infections are discussed in the
appropriate topics.
Herpes zoster Herpes zoster neuropathic pain may precede the development of skin lesions. Depending
on the dermatome involved, this pain can be confused with other etiologies, such cholecystitis or renal
colic. (See "Clinical manifestations of varicella-zoster virus infection: Herpes zoster", section on 'Clinical
manifestations'.)
Hypercalcemia Hypercalcemia can cause abdominal pain, either directly or as an etiology for
pancreatitis or constipation. (See "Clinical manifestations of hypercalcemia", section on 'Gastrointestinal
abnormalities'.)
Hypothyroidism Hypothyroidism can occasionally cause abdominal pain in the setting of constipation
and ileus. (See "Clinical manifestations of hypothyroidism", section on 'Gastrointestinal disorders'.)
Lead poisoning Abdominal pain is associated with acute lead poisoning. (See "Adult lead poisoning",
section on 'Clinical manifestations'.)
Meckel's diverticulum Meckel's diverticulum is usually clinically silent and can be found incidentally, or
can present with a variety of clinical manifestations including gastrointestinal bleeding or other acute
abdominal complaints. Acute abdominal pain related to Meckel's diverticulum can be the result of
diverticular inflammation, similar to acute appendicitis, related to bowel obstruction, or perforation of the
Meckel's or adjacent bowel. (See "Meckels diverticulum", section on 'Clinical presentations' and "Meckels
diverticulum", section on 'Acute abdominal pain'.)
Narcotic bowel syndrome The most common side effect of opioids is constipation, but some patients
may have associated abdominal pain. (See "Cancer pain management with opioids: Prevention and
management of side effects", section on 'Bowel issues'.)
Pseudoappendicitis Acute yersiniosis or campylobacter infection can mimic appendicitis presenting with
right lower abdominal pain, fever, vomiting, leukocytosis, and mild diarrhea. (See "Clinical manifestations
and diagnosis of Yersinia infections", section on 'Pseudoappendicitis' and "Clinical manifestations,
diagnosis, and treatment of Campylobacter infection", section on 'Pseudoappendicitis'.)
Pulmonary etiologies Lower lobe pulmonary pathologies (eg, pneumonia, pulmonary embolism) or
inflammatory pleural effusions (eg, empyema, pulmonary infarction) can present with what appears to be
upper abdominal pain because they occur at the threshold of the abdomen. Some patients with pneumonia
(eg, Legionella) may also have abdominal pain and other gastrointestinal symptoms as part of their illness.
(See "Clinical manifestations and diagnosis of Legionella infection", section on 'Symptoms'.)
Rectus sheath hematoma (RSH) RSH is a rare clinical entity that results from accumulation of blood
within the rectus sheath. RSH most often presents as acute onset of abdominal pain with a palpable
abdominal wall mass. (See "Rectus sheath hematoma", section on 'Clinical presentation'.)

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Renal infarction Renal infarction is rare. Patients with acute renal infarction typically complain of the
acute onset of flank pain or generalized abdominal pain, frequently accompanied by nausea, vomiting, and,
occasionally, fever. (See "Renal infarction", section on 'Clinical presentation'.)
Rib pain Patients may have upper abdominal pain from lower rib pain syndromes. (See "Major causes of
musculoskeletal chest pain in adults", section on 'Lower rib pain syndromes'.)
Sclerosing mesenteritis Sclerosing mesenteritis is part of a spectrum (including mesenteric
lipodystrophy and mesenteric panniculitis) of idiopathic primary inflammatory and fibrotic processes that
affect the mesentery. The clinical manifestations of sclerosing mesenteritis are varied but may include
abdominal pain and other gastrointestinal symptoms. (See "Sclerosing mesenteritis", section on 'Clinical
manifestations'.)
Somatization Patients with somatization may present with a wide array of symptoms including
gastrointestinal symptoms. (See "Somatization: Epidemiology, pathogenesis, clinical features, medical
evaluation, and diagnosis", section on 'Clinical presentation'.)
Wandering spleen The wandering (or ectopic) spleen is a rare condition where the spleen migrates from
its normal site to another location in the abdomen because of laxity or maldevelopment of the supporting
ligaments [11]. Wandering spleen may be congenital or acquired from weakened supporting splenic
ligaments. Patients may be asymptomatic or present with acute, chronic, or intermittent pain from torsion of
the wandering spleen. Adults present with nonspecific abdominal pain associated with a palpable
abdominal mass while children most often present with acute abdominal pain.
SPECIAL POPULATIONS In addition to the etiologies listed above, certain etiologies are specific to special
populations of patients.
Women Lower abdominal pain and/or pelvic pain in women is frequently caused by disorders of the internal
female reproductive organs (table 7). The etiologies and evaluation of acute and chronic pelvic pain are
discussed in detail separately. (See "Evaluation of acute pelvic pain in women" and "Causes of chronic pelvic
pain in women".)
Pregnancy/pregnancy complications Pregnancy and/or complications of pregnancy can lead to
abdominal pain. This is discussed in detail separately. (See "Approach to abdominal pain and the acute
abdomen in pregnant and postpartum women", section on 'Differential diagnosis of abdominal pain'.)
Ectopic pregnancy The most common clinical presentation of ectopic pregnancy is first trimester vaginal
bleeding and/or abdominal pain. Clinical manifestations of ectopic pregnancy typically appear six to eight
weeks after the last normal menstrual period, but can occur later, especially if the pregnancy is in an
extrauterine site other than the fallopian tube. Women with ruptured ectopic pregnancy can present with
life-threatening hemorrhage. (See "Ectopic pregnancy: Clinical manifestations and diagnosis", section on
'Abdominal pain'.)
Pelvic inflammatory disease (PID) Lower abdominal pain is the cardinal presenting symptom in women
with PID. Any sexually active female is at risk for PID. There is a wide-spectrum of clinical presentations.
Acute symptomatic PID is characterized by the acute onset of lower abdominal or pelvic pain, pelvic organ
tenderness, and evidence of inflammation of the genital tract. Women may also develop tuboovarian
abscess as a complication. (See "Pelvic inflammatory disease: Clinical manifestations and diagnosis" and
"Epidemiology, clinical manifestations, and diagnosis of tuboovarian abscess", section on 'Clinical
presentation'.)
Ovarian torsion The classic presentation of ovarian torsion is the acute onset of moderate to severe
pelvic pain, often with nausea and possibly vomiting, in a woman with an adnexal mass. (See "Ovarian and
fallopian tube torsion", section on 'Clinical presentation'.)
Ruptured ovarian cyst Rupture of an ovarian cyst may be asymptomatic or associated with a sudden
onset of unilateral lower abdominal pain. The classic presentation is sudden onset of severe focal lower
quadrant pain following sexual intercourse. (See "Evaluation and management of ruptured ovarian cyst",
section on 'Clinical presentation'.)

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Endometriosis The classic symptoms of endometriosis are dysmenorrhea, pelvic pain, dyspareunia,
and/or infertility, but other symptoms may also be present (eg, bowel or bladder symptoms). Patients may
present with one symptom or a combination of symptoms. (See "Endometriosis: Pathogenesis, clinical
features, and diagnosis", section on 'Clinical presentation'.)
Endometritis Endometritis refers to inflammation of the endometrium, the inner lining of the uterus.
Acute endometritis is most often preceded by PID. The diagnosis of acute endometritis is made clinically
based upon criteria for the diagnosis of acute PID. (See "Endometritis unrelated to pregnancy", section on
'Acute endometritis'.)
Women with symptomatic chronic endometritis usually present with abnormal uterine bleeding, which may
consist of intermenstrual bleeding, spotting, postcoital bleeding, menorrhagia, or amenorrhea. Vague,
crampy lower abdominal pain accompanies the bleeding or may occur alone. (See "Endometritis unrelated
to pregnancy", section on 'Chronic endometritis'.)
Leiomyomas (fibroids) Leiomyomas may cause pelvic pressure or pain. These symptoms may be
related to bulk or infrequently fibroids can cause acute pain from degeneration (eg, carneous or red
degeneration) or torsion of a pedunculated tumor. Pain may be associated with a low grade fever, uterine
tenderness on palpation, elevated white blood cell count, or peritoneal signs. (See "Epidemiology, clinical
manifestations, diagnosis, and natural history of uterine leiomyomas (fibroids)", section on 'Pelvic pressure
and pain'.)
Ovarian hyperstimulation Ovarian hyperstimulation syndrome can cause abdominal discomfort from
enlarged ovaries in women undergoing fertility treatment (table 19). (See "Pathogenesis, clinical
manifestations, and diagnosis of ovarian hyperstimulation syndrome", section on 'Clinical manifestations'.)
Ovarian cancer Women with ovarian cancer may present with bloating or abdominal or pelvic pain. (See
"Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Clinical features and diagnosis", section
on 'Pelvic and abdominal symptoms'.)
Postoperative patients A variety of postoperative complications can cause abdominal pain:
Postoperative ileus (see "Postoperative ileus", section on 'Clinical features')
Surgical site infections (see "Complications of abdominal surgical incisions", section on 'Surgical site
infection')
Hematoma/seroma formation and nerve injury (see "Complications of abdominal surgical incisions", section
on 'Hematoma and seroma' and "Complications of abdominal surgical incisions", section on 'Nerve injury')
Sickle cell Severe intermittent crises of abdominal pain can occur with sickle cell anemia, particularly after an
acute precipitant, such as dehydration. (See "Overview of the clinical manifestations of sickle cell disease",
section on 'Acute painful episodes'.)
Patients with sickle cell may also have right upper quadrant pain in the setting of hepatic involvement. The liver
can be affected by a number of complications due to the disease itself and its treatment. (See "Hepatic
manifestations of sickle cell disease", section on 'Disorders associated with the sickling process' and "Hepatic
manifestations of sickle cell disease", section on 'Disorders related to coexisting conditions'.)
HIV Etiologies of abdominal pain in patients with human immunodeficiency virus (HIV) can be related to
opportunistic infections (eg, cytomegalovirus, mycobacterium avium complex) in the setting of severe
immunodeficiency, or may be due to other more common etiologies seen in the general population (eg,
appendicitis, diverticulitis) (table 20). (See "Evaluation of abdominal pain in the HIV-infected patient".)
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, "The Basics" and
"Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given condition. These
articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond
the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written
at the 10th to 12th grade reading level and are best for patients who want in-depth information and are

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comfortable with some medical jargon.


Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these
topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
"patient info" and the keyword(s) of interest.)
Basics topic (see "Patient information: Acute abdomen (belly pain) (The Basics)")
Beyond the Basics topics (see "Patient information: Upset stomach (functional dyspepsia) in adults
(Beyond the Basics)" and "Patient information: Chronic pelvic pain in women (Beyond the Basics)")
SUMMARY
Pain receptors in the abdomen respond to mechanical and chemical stimuli. The type and density of
visceral afferent nerves makes the localization of visceral pain imprecise. Pain originating in the viscera
may also be perceived as originating from a site distant from the affected organ (referred pain) (figure 1).
(See 'Pathophysiology of abdominal pain' above.)
Upper abdominal pain typically has characteristic locations: right upper quadrant pain (table 1), epigastric
pain (table 2), or left upper quadrant pain (table 3). (See 'Upper abdominal pain syndromes' above.)
Lower abdominal pain syndromes (table 6) often cause pain in either or both lower quadrants. Women may
have lower abdominal pain from disorders of the internal female reproductive organs (table 7). (See 'Lower
abdominal pain syndromes' above.)
Abdominal pain syndromes may have diffuse or non-specific pain (table 9). (See 'Diffuse abdominal pain
syndromes' above.)
There are many other less common causes of abdominal pain (table 18). (See 'Less common causes'
above.)
Certain etiologies are specific to special population of patients (women (table 7), postoperative patients,
sickle cell patients, and HIV patients). (See 'Special populations' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. Ray BS, Neill CL. Abdominal Visceral Sensation in Man. Ann Surg 1947; 126:709.
2. Bentley FH. Observations on Visceral Pain : (1) Visceral Tenderness. Ann Surg 1948; 128:881.
3. CHAPMAN WP, HERRERA R, JONES CM. A comparison of pain produced experimentally in lower
esophagus, common bile duct, and upper small intestine with pain experienced by patients with diseases
of biliary tract and pancreas. Surg Gynecol Obstet 1949; 89:573.
4. Brown FR. The Problem of Abdominal Pain. Br Med J 1942; 1:543.
5. Bloomfield AL, Polland WS. EXPERIMENTAL REFERRED PAIN FROM THE GASTRO-INTESTINAL
TRACT. PART II. STOMACH, DUODENUM AND COLON. J Clin Invest 1931; 10:453.
6. DWORKEN HJ, BIEL FJ, MACHELLA TE. Supradiaphragmatic reference of pain from the colon.
Gastroenterology 1952; 22:222.
7. Ryle JA. Visceral pain and referred pain. Lancet 1926; 1:895.
8. Saik RP, Greenburg AG, Farris JM, Peskin GW. Spectrum of cholangitis. Am J Surg 1975; 130:143.
9. Roberts JE, deShazo RD. Abdominal migraine, another cause of abdominal pain in adults. Am J Med
2012; 125:1135.
10. d'Onofrio F, Cologno D, Buzzi MG, et al. Adult abdominal migraine: a new syndrome or sporadic feature of
migraine headache? A case report. Eur J Neurol 2006; 13:85.
11. Gayer G, Hertz M, Strauss S, Zissin R. Congenital anomalies of the spleen. Semin Ultrasound CT MR
2006; 27:358.

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GRAPHICS
Patterns of referred abdominal pain

Pain from abdominal viscera often (but not always) localizes according to the
structure's embryologic origin, with foregut structures (mouth to proximal half of
duodenum) presenting with upper abdominal pain, midgut structures (distal half of
duodenum to middle of the transverse colon) presenting with periumbilical pain, and
hind gut structures (remainder of colon and rectum, pelvic genitourinary organs)
presenting with lower abdominal pain. Radiation of pain may provide insight into the
diagnosis. As examples, pain from pancreatitis may radiate to the back while pain
from gallbladder disease may radiate to the right shoulder or subscapular region.
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Causes of right upper quadrant (RUQ) abdominal pain


RUQ

Clinical features

Comments

Biliary
Biliary colic

Intense, dull discomfort


located in the RUQ or

Patients are generally


well-appearing.

epigastrium. Associated with


nausea, vomiting, and
diaphoresis. Generally lasts at
least 30 minutes, plateauing
within 1 hour. Benign
abdominal examination.
Acute cholecystitis

Prolonged (>4 to 6 hours)


RUQ or epigastric pain, fever.
Patients will have abdominal
guarding and Murphy's sign.

Acute cholangitis

Fever, jaundice, RUQ pain.

May have atypical presentation


in older adults or
immunosuppressed patients.

Sphincter of Oddi
dysfunction

RUQ pain similar to other


biliary pain.

Biliary type pain without other


apparent causes.

RUQ pain with fatigue,

Variety of etiologies include

malaise, nausea, vomiting,


and anorexia. Patients may

hepatitis A, alcohol, and


drug-induced.

Hepatic
Acute hepatitis

also have jaundice, dark urine,


and light-colored stools.
Perihepatitis (FitzHugh-Curtis syndrome)

Liver abscess

RUQ pain with a pleuritic


component, pain is sometimes

Aminotransferases are usually


normal or only slightly

referred to the right shoulder.

elevated.

Fever and abdominal pain are


the most common symptoms.

Risk factors include diabetes,


underlying hepatobiliary or
pancreatic disease, or liver
transplant.

Budd-Chiari syndrome

Symptoms include fever,


abdominal pain, abdominal

Variety of causes.

distention (from ascites),


lower extremity edema,
jaundice, gastrointestinal
bleeding, and/or hepatic
encephalopathy.
Portal vein thrombosis

Symptoms include abdominal

Clinical manifestations depend

pain, dyspepsia, or
gastrointestinal bleeding.

on extent of obstruction and


speed of development. Most
commonly associated with
cirrhosis.

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Causes of epigastric abdominal pain


Epigastric
Acute myocardial infarction

Acute pancreatitis

Clinical features

Comments

May be associated with


shortness of breath and

Consider particularly in
patients with risk factors for

exertional symptoms.

coronary artery disease.

Acute-onset, persistent upper


abdominal pain radiating to
the back.

Chronic pancreatitis

Peptic ulcer disease

Epigastric pain radiating to the

Associated with pancreatic

back.

insufficiency.

Epigastric pain or discomfort is

Occasionally, discomfort

the most prominent symptom.

localizes to one side.

Gastroesophageal reflux

Associated with heartburn,

disease

regurgitation, and dysphagia.

Gastritis/gastropathy

Abdominal discomfort/pain,
heartburn, nausea, vomiting,

Variety of etiologies including


alcohol and nonsteroid

and hematemesis.

anti-inflammatory drugs
(NSAIDs).

The presence of one or more


of the following: postprandial

Patients have no evidence of


structural disease.

Functional dyspepsia

fullness, early satiation,


epigastric pain, or burning.
Gastroparesis

Nausea, vomiting, abdominal


pain, early satiety,

Most causes are idiopathic,


diabetic, or postsurgical.

postprandial fullness, and


bloating.
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Causes of left upper quadrant (LUQ) abdominal pain


LUQ
Splenomegaly

Clinical features
Pain or discomfort in LUQ, left
shoulder pain, and/or early

Comments
Multiple etiologies.

satiety.
Splenic infarct

Severe LUQ pain.

Atypical presentations
common. Associated with a
variety of underlying
conditions (eg,
hypercoagulable state, atrial
fibrillation, and splenomegaly).

Splenic abscess

Associated with fever and LUQ


tenderness.

Uncommon. May also be


associated with splenic
infarction.

Splenic rupture

May complain of LUQ, left

Most often associated with

chest wall, or left shoulder


pain that is worse with

trauma.

inspiration.
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Major causes of the Budd-Chiari syndrome


Myeloproliferative diseases
Malignancy
Hepatocellular carcinoma is most common

Infections and benign lesions of the liver


Hypercoagulable states
Oral contraceptive use
Pregnancy
Factor V Leiden mutation
Prothrombin gene mutation
Antiphospholipid antibody syndrome
Antithrombin III deficiency
Protein C deficiency
Protein S deficiency
Paroxysmal nocturnal hemoglobinuria
JAK2 mutations

Behet's disease
Membranous webs of the inferior vena cava and/or the hepatic veins
Miscellaneous conditions including celiac disease, ulcerative colitis, hypereosinophilic syndrome,
and granulomatous venulitis
Idiopathic
Many may have an underlying myeloproliferative disease

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Neuromuscular disorders impairing gastric motor


function

Several common neurologic disorders can affect gastrointestinal motility by


altering the parasympathetic or sympathetic supply to the gut.
X: vagal nuceli; CNS: central nervous system; CVA: cerebrovascular accident; SCG:
sympathetic chain ganglia.
Reproduced with permission from: Camilleri M, Prather CM. In: Sleisenger and
Fordtran's Gastrointestinal Disease, 6th ed, Feldman M, Scharschmidt BF, Sleisenger
MH (Eds), WB Saunders, Philadelphia 1998. p.572.
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Major causes of splenomegaly


Congestive
Cirrhosis
Heart failure
Thrombosis of portal, hepatic, or splenic veins

Malignancy
Lymphoma, usually indolent variants
Acute and chronic leukemias
Polycythemia vera
Multiple myeloma and its variants
Essential thrombocythemia
Primary myelofibrosis
Primary splenic tumors
Metastatic solid tumors

Infection
Viral - hepatitis, infectious mononucleosis, cytomegalovirus
Bacterial - salmonella, brucella, tuberculosis
Parasitic - malaria, schistosomiasis,toxoplasmosis, leishmaniasis
Infective endocarditis
Fungal

Inflammation
Sarcoid
Serum sickness
Systemic lupus erythematosus
Rheumatoid arthritis (Felty syndrome)

Infiltrative, nonmalignant
Gaucher's disease
Niemann-Pick disease
Amyloid
Glycogen storage disease
Langerhans cell histiocytosis
Hemophagocytic lymphohistiocytosis
Rosai-Dorfman disease

Hematologic (hypersplenic) states


Acute and chronic hemolytic anemias, all etiologies
Sickle cell disease (children)
Following use of recombinant human granulocyte colony-stimulating factor

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Causes of lower abdominal pain


Lower abdomen
Appendicitis

Localization
Generally right lower
quadrant

Clinical features

Comments

Periumbilical pain
initially that radiates

Occasional patients
present with epigastric

to the right lower


quadrant. Associated

or generalized
abdominal pain.

with anorexia, nausea,


and vomiting.
Diverticulitis

Generally left lower


quadrant; right lower

Pain usually constant


and present for

Clinical presentation
depends on severity of

quadrant more
common in Asian

several days prior to


presentation. May

underlying
inflammatory process

patients

have associated
nausea and vomiting.

and whether or not


complications are
present.

Nephrolithiasis

Either

Pain most common


symptom, varies from

Cause symptoms as
stone passes from

mild to severe.
Generally flank pain,

renal pelvis to ureter.

but may have back or


abdominal pain.
Pyelonephritis

Either

Associated with
dysuria, frequency,
urgency, hematuria,
fever, chills, flank
pain, and
costovertebral angle
tenderness.

Acute urinary

Suprapubic

retention

Present with lower


abdominal pain and
discomfort; inability to
urinate.

Cystitis

Suprapubic

Associated with
dysuria, frequency,
urgency, and
hematuria.

Infectious colitis

Either

Diarrhea as the
predominant

Patients with
Clostridium difficile

symptom, but may


also have associated

infection can present


with an acute

abdominal pain, which


may be severe.

abdomen and
peritoneal signs in the
setting of perforation
and fulminant colitis.

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Pelvic causes of abdominal pain in women


Pelvic causes
of abdominal
pain in
women
Ectopic
pregnancy

Lateralization

Clinical features

Comments

Either side or
diffuse abdominal

Vaginal bleeding with abdominal


pain, typically six to eight weeks

Patients can
present with

pain

after last menstrual period.

life-threatening
hemorrhage if
ruptured.

Pelvic

Lateralization

Characterized by the acute onset of

Wide spectrum

inflammatory
disease

uncommon

lower abdominal or pelvic pain,


pelvic organ tenderness, and

of clinical
presentations.

evidence of inflammation of the


genital tract. Often associated with
cervical discharge.
Ovarian torsion

Ruptured
ovarian cyst

Localized to one
side

Localized to one
side

Acute onset of moderate-to-severe


pelvic pain, often with nausea and

Generally not
associated with

possibly vomiting, in a woman with


an adnexal mass.

vaginal
discharge.

Sudden-onset unilateral lower


abdominal pain. The classic

Generally not
associated with

presentation is sudden onset of


severe focal lower quadrant pain

vaginal
discharge.

following sexual intercourse.


Endometriosis

Associated with dysmenorrhea,

Patients may

pelvic pain, dyspareunia, and/or


infertility, but other symptoms may

present with
one symptom

also be present (eg, bowel or bladder


symptoms).

or a
combination of
symptoms.

Acute
endometritis

Most often preceded by pelvic


inflammatory disease.

Diagnostic
criteria the
same as pelvic
inflammatory
disease.

Chronic

Present with abnormal uterine

endometritis

bleeding, which may consist of


intermenstrual bleeding, spotting,
postcoital bleeding, menorrhagia, or
amenorrhea. Vague, crampy lower
abdominal pain accompanies the
bleeding or may occur alone.

Leiomyomas
(fibroids)

Symptoms related to bulk or


infrequently acute pain from
degeneration or torsion of
pedunculate tumor. Pain may be
associated with a low-grade fever,
uterine tenderness on palpation,
elevated white blood cell count, or
peritoneal signs.

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Ovarian
hyperstimulation

http://www.uptodate.com/contents/causes-of-abdominal-pain-in-adults...

Abdominal distention/discomfort,
nausea/vomiting, and diarrhea. More

Women
undergoing

severe cases can have severe


abdominal pain, ascites, intractable

fertility
treatment.

nausea, and vomiting.


Ovarian cancer

Abdominal or pelvic pain. May have


associated symptoms of bloating,
urinary urgency or frequency, or
difficulty eating/feeling full quickly.

Pregnancy and related complications*


* Refer to the UpToDate topics on abdominal pain.
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Clinical manifestations of Clostridium difficile infection


Type of
infection

Diarrhea

Other
symptoms

Physical
examination

Diarrhea with
colitis

Multiple loose
bowel

Nausea,
anorexia, fever,

Abdominal
distention,

movements per
day

malaise,
dehydration,

tenderness

Fecal
leukocytes

leukocytosis with
left shift

Sigmoidoscopic
examination
Diffuse or patchy
nonspecific colitis

present (50
percent of
cases)
Occult
bleeding may
be seen

Hematochezia
rare
Fulminant

Diarrhea may

Lethargy, fever,

May present as

Sigmoidoscopy and

colitis

be severe OR
diminished

tachycardia,
abdominal pain;

acute abdomen;
peritoneal signs

colonoscopy
contraindicated;

(due to
paralytic ileus

dilated
colon/paralytic

suggest
perforation

flexible proctoscopy
with minimal air

and colonic
dilatation)

ileus may be
demonstrated on

Surgical
consult

plain abdominal
film

insufflation may be
diagnostic

required;
colectomy can
be life saving
Asymptomatic

Absent

Absent

Normal

Normal

carriage
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Causes of diffuse abdominal pain


Diffuse/poorly
characterized
Bowel obstruction

Clinical features
Most common symptoms are
nausea, vomiting, crampy

Comments
Multiple etiologies.

abdominal pain, and obstipation.


Distended, tympanic abdomen with
high-pitched or absent bowel
sounds.
Perforation of the

Severe abdominal pain, particularly

Can present acutely or in an indolent

gastrointestinal
tract

following procedures.

manner, particularly in
immunosuppressed patients.

Acute mesenteric

Acute and severe onset of diffuse

May occur from either arterial or

ischemia

and persistent abdominal pain,


often described as pain out of

venous disease. Patients with aortic


dissection can have abdominal pain

proportion to examination.

related to mesenteric ischemia.

Chronic mesenteric

Abdominal pain after eating

May occur from either arterial or

ischemia

("intestinal angina"), weight loss,


nausea, vomiting, and diarrhea.

venous disease.

Inflammatory bowel
disease (ulcerative

Associated with bloody diarrhea,


urgency, tenesmus, bowel

May have symptoms for years


before diagnosis. Associated

colitis/Crohn
disease)

incontinence, weight loss, and


fevers.

extraintestinal manifestations (eg,


arthritis, uveitis).

Viral gastroenteritis

Diarrhea accompanied by nausea,


vomiting, and abdominal pain.

Spontaneous

Fever, abdominal pain, and/or

Most often in cirrhotic patients with

bacterial peritonitis

altered mental status.

advanced liver disease and ascites.

Dialysis related

Abdominal pain and cloudy

Only in peritoneal dialysis patients.

peritonitis

peritoneal effluent. Other symptoms


and signs include fever, nausea,
diarrhea, abdominal tenderness,
and rebound tenderness.

Colorectal cancer

Variable presentation, including


obstruction and perforation.

Other malignancy

Vary depending on malignancy.

Celiac disease

Abdominal pain in addition to


including diarrhea with bulky,
foul-smelling, floating stools due to
steatorrhea and flatulence.

Ketoacidosis

Diffuse abdominal pain and nausea


and vomiting.

Adrenal

Diffuse abdominal pain and nausea

Patients with adrenal crisis may

insufficiency

and vomiting.

present with shock and hypotension.

Foodborne illness

Mixture of nausea, vomiting, fever,


abdominal pain and diarrhea.

Irritable bowel
syndrome

Chronic abdominal pain with altered


bowel habits.

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Constipation

Associated with a variety of


neurologic and metabolic disorders,
obstruction lesions of the
gastrointestinal tract, endocrine
disorders, psychiatric disorders, and
side effect of medications.

Diverticulosis

Lactose intolerance

May have symptoms of abdominal

Often an asymptomatic and

pain and constipation.

incidental finding on colonoscopy or


sigmoidoscopy.

Associated with abdominal pain,


bloating, flatulence, and diarrhea.
Abdominal pain may be cramping in
nature.

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Causes of bowel obstruction


Lesion
Extrinsic
lesions

Etiology
Adhesions

Risk factors
Prior surgery, diverticulitis, Crohn
disease, VP shunt, peritonitis (eg,
tuberculous peritonitis)

Hernia (congenital, acquired)

Abdominal wall hernia, inguinal


hernia, femoral hernia, diaphragmatic
hernia

Volvulus

Chronic constipation, congenital


abnormal mesenteric attachments

Intra-abdominal abscess

Diverticulitis, appendicitis, Crohn


disease

Peritoneal carcinomatosis

Ovarian cancer, colon cancer, gastric


cancer

Endometriosis
Sclerosing mesenteritis

Prior surgery, abdominal trauma,


autoimmune disorders, malignancy,
neuroendocrine tumor

Desmoid tumor/other soft tissue


sarcoma (rare)

Intrinsic
lesions

Superior mesenteric artery syndrome

Rapid weight loss

Congenital malformations, atresia,


duplication

See appropriate topic reviews

Large bowel neoplasm


Adenocarcinoma

Hereditary colorectal cancer syndromes


(HNPCC, FAP), inflammatory bowel
disease, bowel irradiation, others (see
appropriate topic reviews)

Desmoid
Carcinoid
Neuroendocrine tumor
Lymphoma

Small bowel neoplasm*


Adenocarcinoma

Hereditary cancer syndomes (HNPCC,


FAP, Peutz-Jeghers, MUTYH-associated
polyposis, attenuated FAP)

Leiomyosarcoma
Paraganglioma
Schwannoma
Metastatic disease

Melanoma, breast cancer, cervical cancer,


colon cancer (see appropriate topic
reviews)

Gastrointestinal stromal tumor


Neuroendocrine tumor
Lymphoma

Chronic inflammation

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Benign lesions

Peutz-Jeghers polyps, xanthomatosis,


leiomyoma

Intraluminal
obstruction of
normal bowel

Anastomotic stricture

Prior intestinal surgery

Inflammatory stricture

Crohn disease, diverticular disease,


NSAID enteropathy

Ischemic stricture

Peripheral artery disease, aortic


surgery, colon resection

Radiation enteritis/stricture

Prior abdominal or pelvic irradiation

Intussusception*

Small bowel tumor (see above)

Gallstones

Cholecystitis

Congenital webs
Feces or meconium

Cystic fibrosis, severe constipation

Bezoar (phytobezoar,
pharmacobezoar)

Intestinal motility disorders

Intramural hematoma
Traumatic

Blunt abdominal trauma

Spontaneous

Antithrombotic therapy

Foreign body
Ingested

Psychiatric disturbance

Medical device migration

PEG tube, jejunal tube

Parasites

Ascaris lumbricoides, Strongyloides


stercoralis

VP: ventriculoperitoneal; HNPCC: hereditary nonpolyposis colorectal cancer; FAP: familial adenomatous
polyposis; NSAID: nonsteroidal anti-inflammatory drug; PEG: percutaneous endoscopic gastrostomy.
* May be due to an intrinsic lesion serving as a lead point.
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Clinical features of acute colonic and small bowel ischemia


Acute colonic
ischemia

Acute mesenteric ischemia involving small bowel

90 percent of patients
over age 60 years

Age varies with etiology of ischemia

Acute precipitating cause


is rare

Acute precipitating cause is typical

Patients do not appear

Patients appear severely ill

severely ill
Mild abdominal pain,

Pain is usually severe, tenderness is not prominent early

tenderness present
Rectal bleeding, bloody

Bleeding uncommon until very late

diarrhea typical
Colonoscopy is
procedure of choice

MRA or MDCT angiography may be considered as the initial diagnostic


test, angiography is recommended if there is strong clinical suspicion

MDCT: multidetector row computed tomography; MRA: magnetic resonance angiography.


Data from: Reinus JF, Brandt LJ, Boley SJ, Gastroenterol Clin North Am 1990; 19:319.
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Presentations of aortic dissection based on affected structures


Clinical findings

Artery or structure involved

Aortic insufficiency or heart failure

Aortic valve

Myocardial infarction

Coronary artery (often right)

Cardiac tamponade

Pericardium

Hemothorax

Thorax

Stroke or syncope

Brachiocephalic, common carotid, or left subclavian


arteries

Upper extremity pulselessness,


hypotension pain

Subclavian artery

Paraplegia

Intercostal arteries (give off spinal and vertebral


arteries)

Lower extremity pain, pulselessness,


weakness

Common iliac artery

Abdominal pain; mesenteric ischemia

Celiac or mesenteric arteries

Back or flank pain; renal failure

Renal artery

Horner syndrome (ptosis, miosis,

Superior cervical sympathetic ganglion

anhidrosis)
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Extraintestinal manifestations of inflammatory bowel disease


Common extraintestinal manifestations
Musculoskeletal
Arthritis - Colitic type, ankylosing spondylitis, isolated joint involvement such as sacroiliitis
Hypertrophic osteoarthropathy - Clubbing, periostitis, metastatic Crohn disease
Miscellaneous - Osteoporosis, aseptic necrosis, polymyositis, osteomalacia
Skin and mouth
Reactive lesions - Erythema nodosum, pyoderma gangrenosum, aphthous ulcers,
vesiculopustular eruption, necrotizing vasculitis, Sweet syndrome, metastatic Crohn disease
Specific lesions - Fissures and fistulas, oral Crohn disease, drug rashes
Nutritional deficiency - Acrodermatitis enteropathica (zinc), purpura (vitamins C and K),
glossitis (vitamin B), hair loss and brittle nail (protein)
Associated diseases - Vitiligo, psoriasis, amyloidosis, epidermolysis bullosa acquisita
Hepatobiliary
Specific complications - Primary sclerosing cholangitis (PSC) and bile duct carcinoma, small
duct PSC, cholelithiasis
Associated inflammation - Autoimmune chronic active hepatitis, pericholangitis, portal fibrosis
and cirrhosis, granuloma in Crohn disease
Metabolic - Fatty liver, gallstones associated with ileal Crohn disease
Ocular
Uveitis iritis, episcleritis, scleromalacia, corneal ulcers, retinal vascular disease, retrobulbar
neuritis, Crohn keratopathy
Metabolic
Growth retardation in children and adolescents, delayed sexual maturation

Less common extraintestinal manifestations


Blood and vascular
Anemia due to iron, folate, or B12 deficiency or autoimmune hemolytic anemia, anemia of
chronic disease, thrombocytopenic purpura; leukocytosis and thrombocytosis; thrombophlebitis
and thromboembolism, arteritis and arterial occlusion, polyarteritis nodosa, Takayasu arteritis,
cutaneous vasculitis, anticardiolipin antibody, hyposplenism.
Renal and genitourinary tract
Urinary calculi (oxalate stones in ileal disease), local extension of Crohn disease involving
ureter or bladder, amyloidosis, drug-related nephrotoxicity.
Renal tubular damage with increased urinary excretion of various enzymes (eg, beta N-acetylD-glucosaminidase).
Neurologic
Up to 3 percent of patients may have non-iatrogenic neurologic involvement, including
peripheral neuropathy, myelopathy, vestibular dysfunction, pseudotumor cerebri, myasthenia
gravis, and cerebrovascular disorders. Incidence equal in ulcerative colitis and Crohn disease.
These disorders usually appear five to six years after the onset of inflammatory bowel disease
and are frequently associated with other extraintestinal manifestations.
Airway and parenchymal lung disease

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Pulmonary fibrosis, vasculitis, bronchitis, acute laryngotracheitis, interstitial lung disease,


sarcoidosis. Abnormal pulmonary function tests without clinical symptoms are common (up to
50% of cases).
Cardiac
Pericarditis, myocarditis, endocarditis, and heart block: more common in ulcerative colitis than
in Crohn disease; cardiomyopathy, cardiac failure due to anti-TNF therapy.
Pericarditis may also occur from sulfasalazine/5-aminosalicylates.
Pancreas
Acute pancreatitis: more common in Crohn disease than in ulcerative colitis. Risk factors
include 6-mercaptopurine and 5-aminosalicylate therapy, duodenal Crohn disease.
Autoimmune
Drug-induced lupus and autoimmune diseases secondary to anti-TNF-alpha therapy.
Positive DNA, anti-double-stranded DNA, cutaneous and systemic manifestations of lupus.
TNF: tumor necrosis factor.
Modified from: Das KM. Relationship of extraintestinal involvements in inflammatory bowel disease:
New insights into autoimmune pathogenesis. Dig Dis Sci 1999; 44:1.
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Chronic pain syndromes directly related to cancer


Nociceptive pain syndromes: Somatic
Tumor-related bone pain
Multifocal bone pain

Bone metastases
Bone marrow expansion (hematologic malignancies)
Oncogenic hypophosphatemic osteomalacia
Vertebral syndromes

Atlanto-axial destruction and odontoid fracture


C7-T1 syndrome
T12-L1 syndrome
Sacral syndrome
Back pain secondary to spinal cord compression
Pain syndromes related to pelvis and hip

Pelvic metastases
Hip joint syndrome
Malignant piriformis syndrome
Base of skull metastases

Orbital syndrome
Parasellar syndrome
Middle cranial fossa syndrome
Jugular foramen syndrome
Occipital condyle syndrome
Clivus syndrome
Sphenoid sinus syndrome
Tumor-related soft tissue pain
Headache and facial pain
Ear and eye pain syndromes
Pleural pain
Paraneoplastic pain syndromes
Muscle cramps
Hypertrophic osteoarthropathy
Tumor-related gynecomastia (eg, in testicular neoplasms that secrete human chorionic
gonadotropin)
Paraneoplastic pemphigus
Paraneoplastic Raynaud phenomenon

Nociceptive pain syndromes: Visceral


Hepatic distention syndrome
Midline retroperitoneal syndrome

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Chronic intestinal obstruction


Peritoneal carcinomatosis
Malignant perineal pain
Adrenal pain syndrome
Ureteric obstruction

Neuropathic pain syndromes


Leptomeningeal metastases
Malignant painful radiculopathy
Painful cranial neuralgias
Glossopharyngeal neuralgia
Trigeminal neuralgia
Radiculopathies
Lumbosacral radiculopathy
Cervical radiculopathy
Thoracic radiculopathy
Plexopathies
Cervical plexopathy
Malignant brachial plexopathy
Malignant lumbosacral plexopathy
Lower lumbosacral plexopathies, including sacral and coccygeal plexopathy and panplexopathy
Painful peripheral mononeuropathies
Paraneoplastic sensory neuropathy
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Differential diagnosis of foodborne disease by item consumed


Item

Commonly associated microbes*

Raw seafood

Norwalk-like virus, Vibrio spp, hepatitis A

Raw eggs

Salmonella spp

Undercooked meat or

Salmonella spp, Campylobacter spp, STEC, Clostridium perfringens

poultry
Unpasteurized milk or

Salmonella spp, Campylobacter spp, STEC, Yersinia enterocolitica

juice
Unpasteurized soft

Salmonella spp, Campylobacter spp, STEC, Y. enterocolitica, Listeria

cheeses

monocytogenes

Homemade canned goods

Clostridium botulinum

Raw hot dogs, deli meat

L. monocytogenes

STEC: shiga toxin-producing Escherichia coli.


* This association lists the commonly associated organisms and is not fully comprehensive.
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Causes of chronic constipation


Neurogenic disorders

Non-neurogenic disorders

Peripheral

Hypothyroidism

Diabetes mellitus

Hypokalemia

Autonomic neuropathy

Anorexia nervosa

Hirschsprung disease
Chagas disease

Pregnancy
Panhypopituitarism

Intestinal pseudoobstruction

Systemic sclerosis
Central
Myotonic dystrophy
Multiple sclerosis
Spinal cord injury

Idiopathic constipation

Parkinson disease

Normal colonic transit

Irritable bowel syndrome


Drugs

Slow transit constipation


Dyssynergic defecation

See separate table


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Drugs associated with constipation


Analgesics
Anticholinergics
Antihistamines
Antispasmodics
Antidepressants
Antipsychotics

Cation-containing agents
Iron supplements
Aluminum (antacids, sucralfate)
Barium

Neurally active agents


Opiates
Antihypertensives
Ganglionic blockers
Vinca alkaloids
Calcium channel blockers
5HT3 antagonists
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Less common causes of abdominal pain


Abdominal aortic aneurysm (AAA)
Abdominal compartment syndrome
Abdominal migraine
Acute intermittent porphyria
Angioedema (either hereditary or angiotensin-converting enzyme [ACE] inhibitor-related)
Celiac artery compression syndrome
Chronic abdominal wall pain
Colonic pseudo-obstruction (acute or chronic)
Eosinophilic gastroenteritis
Epiploic appendagitis
Familial Mediterranean fever
Helminthic infections
Herpes zoster
Hypercalcemia
Hypothyroidism
Lead poisoning
Meckel's diverticulum
Narcotic bowel syndrome
Pseudoappendicitis
Pulmonary etiologies
Rectus sheath hematoma
Renal infarction
Rib pain
Sclerosing mesenteritis
Somatization
Wandering spleen
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Classification of OHSS: Clinical and biochemical features [1]

Mild

Clinical features

Biochemical features

Abdominal distention/discomfort

No clinically important laboratory


findings

Mild nausea/vomiting
Diarrhea
Enlarged ovaries
Moderate

Severe

Presence of mild features plus:

Elevated Hct (>41%)

Ultrasonographic evidence of

Elevated WBC (>15,000/mL)

ascites

Hypoproteinemia

Presence of mild and moderate


features plus:

Hemoconcentration (Hct >55%)


WBC >25,000/mL

Clinical evidence of ascites


(can be tense ascites)

Serum creatinine >1.6 mg/dL

Severe abdominal pain

Hyponatremia (Na + <135 mEq/L)

Intractable nausea and

Hypokalemia (K + >5 mEq/L)

vomiting

Creatinine clearance <50 mL/min

Elevated liver enzymes

Rapid weight gain (>1 kg in 24


hours)
Pleural effusion
Severe dyspnea
Oliguria/anuria
Low blood/central venous
pressure
Syncope
Venous thrombosis
Critical

Presence of severe features plus:


Anuria/acute renal failure

Worsening of biochemical findings


seen with severe OHSS

Arrhythmia
Pericardial effusion
Massive hydrothorax
Thromboembolism
Arterial thrombosis
ARDS
Sepsis
OHSS: ovarian hyperstimulation syndrome; Hct: hematocrit; WBC: white blood cell; Na: sodium; K:
potassium; ARDS: acute respiratory distress syndrome.
Reference:
1. Navot D, Bergh PA, Laufer N. Ovarian hyperstimulation syndrome in novel reproductive
technologies: prevention and treatment. Fertil steril 1992; 58:249.
From: Fiedler K, Ezcurra D. Predicting and preventing ovarian hyperstimulation syndrome (OHSS): the
need for individualized not standardized treatment. Reprod Biol Endocrinol 2012; 10:32. Copyright
2012 Fiedler and Ezcurra. Reproduced from BioMed Central Ltd.
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Differential diagnosis of abdominal pain in AIDS


Organ

Causes

Stomach
Gastritis

CMV*, cryptosporidium, Helicobacter pylori

Focal ulcer

CMV*, acid-peptic disease

Outlet

Cryptosporidium*, CMV, lymphoma, MAC

obstruction
Mass

Lymphoma, KS, CMV

Small bowel
Enteritis

Cryptosporidium*, CMV, MAC

Obstruction

Lymphoma*, KS

Perforation

CMV*, lymphoma

Colon
Colitis

CMV*, HSV, salmonella, Histoplama

Obstruction

Lymphoma*, KS, intussusception,

Perforation

CMV*, lymphoma, HSV

Appendicitis

KS*, cryptosporidium, CMV

Anorectum
Proctitis

Herpes*, bacteria, CMV

Tumor

KS, lymphoma, condyloma

Liver, spleen
Infiltration

Lymphoma*, CMV, MAC

Biliary tract
Cholecystitis

CMV*, cryptosporidium*, KS

Papillary

CMV*, cryptosporidium*, KS, cholangitis, CMV*

stenosis
Pancreas
Inflammation

CMV*, KS, pentamidine, DDI

Tumor

Lymphoma, KS

Mesentery, peritoneum
Infiltration

MAC*, cryptococcus, KS, lymphoma, histoplasmosis, tuberculosis,


coccidiomycosis, toxoplasmosis

AIDS: acquired immunodeficiency syndrome; CMV: cytomegalovirus; DDI: didanosine; HSV: herpes
simplex virus; KS: Kaposi sarcoma; MAC: Mycobacterium avium complex.
* More frequent.
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Disclosures
Robert M Penner, BSc, MD, FRCPC, MSc Speaker's Bureau: AbbVie [Inflammatory bowel disease (Adalimumab)];
Janssen [Inflammatory bowel disease (Infliximab, ustekinumab, golimumab)]; Takeda [Inflammatory bowel disease (Vedolizumab)].
Consultant/Advisory Boards: AbbVie [Inflammatory bowel disease (Adalimumab)]; Janssen [Inflammatory bowel disease (Infliximab,
ustekinumab, golimumab)]; Takeda [Inflammatory bowel disease (Vedolizumab)] Mary B Fishman, MD Nothing to disclose. Sumit R
Majumdar, MD, MPH Nothing to disclose. Andrew D Auerbach, MD, MPH Nothing to disclose. Mark D Aronson, MD Nothing to
disclose. Lee Park, MD, MPH Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a
multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced
content is required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

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