Where did the pain start, and where is it now?
Some patients, particularly elderly or anxious patients, may no longer remember precisely where the pain originated, although they can easily point out where the pain is currently. In this case, the physician, together with the patient, can try to work back from the current location to its place of origin.
The location of the pain can be indicated on a diagram [Figure 1].
Figure 1: Regions of the abdomen
1 = epgastric region
2 = umbilical region
3 = pubic (hypogastric) region
4 = hypochondriac region
5 = lateral (lumbar) region
6 = inguinal region
Relationship between pain site and intra-abdominal organs:
1 = stomach, duodenum
2 = small intestine, caecum, retroperitoneal structures
3 = bladder, uterus, ovaries and transverse colon
4R = gall blader
4L = pancreas
5R & 5L = kidneys, testis
6R = appendix, caecum
6L = sigmoid
Do you have lower back pain?
In this instance, the lower back refers to the lumbar region and the dorsal portion of the lateral region [Figure 2].
Figure 2: Right lower back
Lower back pain suggests possible problems in the urinary tract.
Pain indicated by the patient with one finger is almost always parietal. The location of the pain also gives an indication of the anatomical site of the affected organ.
Visceral pain is usually diffuse and cannot be located precisely: the patient almost always indicates this form of pain with some hesitancy, through a vague wave of an open hand over a certain region of the abdomen. The location of pain is then related to the ‘embryologic origin’ of the affected organ.
Referred pain is often indicated by the patient with a vague indication of an area of skin.
Many disorders are characterised by ‘stereotypical’ pain sites. These stereotypes may be of some value in making a diagnosis, but appendicitis can also cause pain in the upper right abdomen, and pain in the lower right abdomen is not always caused by appendicitis.
Whether the pain changes position or remains in one place is also of importance.
Does the pain radiate outward?
Because many patients do not understand the term ‘radiate’ in this context, simple language is needed when discussing this topic. For example, the patient may be asked whether the pain feels as if it is moving from the painful spot in the abdomen to another place.
Pain radiating from the upper right abdomen to the tip of the homolateral scapula can suggest gallstones. If the pain radiates from the lower abdomen to the back or even one of the shoulder tips, urinary tract infection, incomplete miscarriage, salpingitis, and ectopic pregnancy should be considered as possible causes. Urinary tract stone formation can cause pain that radiates to the homolateral groin. A ruptured aneurysm of the abdominal aorta is notorius for causing pain that radiates to the back and both hips.
Did the pain develop suddenly or gradually?
Abdominal pain can be considered acute if the patient remembers the exact time at which the pain began and experienced the pain as severe from the start. In all other cases, the pain must be characterised as starting gradually.
How long does the pain last?
The duration of the pain can be expressed in hours, days or weeks. Pain-free intervals, if present, should be indicated precisely.
A patient with severe abdominal pain lasting more than one week has a much smaller chance of having appendicitis or ileus and a greater chance of having a malignancy, compared with a patient with comparable abdominal pain lasting only a few hours.
Has the pain become better or worse?
Changes in the severity of pain should be assessed in terms of periods of at least two hours.
Increasing pain severity often corresponds with worsening of the tissue damage responsible for the pain. However, decreasing pain severity does not always indicate improvements in the underlying disorder: there may be only an apparent improvement. Examples of this phenomenon include the notorius ‘quiet period’ that follows stomach perforation (a pain-free interval due to dilution of the acidic stomach content as it rapidly spreads into the abdominal cavity) and the reductions in painful cramping seen with intestinal necrosis due to ileus with circulatory impairment.
What type of pain is it?
Distinction must be made between colicky pain [Figure 3] (usually visceral pain) and continuous pain [Figure 4] (usually parietal pain). Colicky pain is intermittent and separated by partially or completely pain-free intervals: the pain increases gradually to a certain maximum level and then decreases quickly. However, this definition is not entirely sufficient, because in practice the pain often persists between the characteristic colicky exacerbations. Therefore, pain that follows a rhythmic pattern can also be considered colicky pain.
Colicky pain often suggests partial or complete obstruction of a hollow organ and occurs when the organ attempts to alleviate the obstruction through peristaltic contractions (colic).
Continuous pain may be an initial indication of inflammation (e.g. appendicitis, diverticulitis) or circulatory impairment with impending necrosis (e.g. ileus, mesenteric thrombosis).
Figure 3: Colicky pain
Figure 4: Continuous (parietal) pain
How severe is the pain?
Assessment of intensity is difficult and not very reliable. How a patient experiences and describes pain is highly individualised. There are also cultural differences with regard to the perception of pain. This further complicates the interpretation of pain. Therefore, the degree of assessment is often limited to whether the pain is bearable or unbearable.
Are there factors that make the pain worse?
Regardless of the answer, the patient is asked to cough or breathe in and out deeply. If these actions cause an obvious worsening in the pain, then the presence of one or more exacerbating factors has been confirmed with sufficient certainty. Abdominal pain that is exacerbated by movement is also referred to as ‘pain upon movement’.
If the patient reports worsening of abdominal pain upon moving, coughing, or breathing in deeply, irritation of the peritoneum (peritonitis) should be considered.
Abdominal pain can also be caused by thoracic disorders, such as infections and malignancies, via pleural irritation. In this case, respiration may be an exacerbating factor.
Pain that becomes worse at night may be referred to as nocturnal pain or hunger pains. This is consistent with a peptic ulcer.
Are there factors that make the pain better?
Minimising movement, avoiding normal activities, assuming certain positions, or an urge to move around in attempt to alleviate abdominal pain, are important diagnostic phenomena.
Minimising movement (walking and sitting carefully) or total avoidance of normal activities (lying still in bed) indicates parietal peritonitis.
Sitting in a hunched-over position can reduce pain in patients with acute pancreatitis. (The pathophysiological explanation for this phenomenon is that this position results in less intense contact between the peritoneum and the retroperitoneal inflammation).
Patients with restless tendencies feel the need to keep moving about. This often occurs with colicky pain.
Whether the pain becomes better after the patient eats or drinks (particularly milk) or takes an antacid (i.e. after dilution or buffering of the acidic stomach content) is another factor that is important in establishing the diagnosis. This phenomenon suggests a diagnosis of peptic ulcer.
Is there a raised body temperature or fever? Has the patient suffered from chills?
If the patient has measured their own temperature, record the result and method of measurement. Fever is an important symptom. It occurs in association with inflammation, but also cell death (necrosis). It is important to ascertain the temporal relationship between the occurrence of fever and other symptoms. An increase in temperature that occurs gradually after abdominal pain has already been established is consistent with acute abdomen. A high fever present immediately at the start of abdominal pain (sometimes accompanied by chills) is more consistent with acute infection, e.g. urinary tract infection.
Do you feel faint?
Fainting (syncope) is often the result of a vasovagal reaction provoked by pain and/or anxiety. (Imminent) shock, for example, which may be due to internal haemorrhage, should be ruled out in patients with an urge to faint. Pulse rate and blood pressure should be monitored regularly.
Have you experienced loss of appetite (anorexia) or weight loss?
Quantify the weight loss. These symptoms are associated with many abdominal disorders as well as malignancies and long-standing infections.