Cláudio Wolff, MD, Gastroenterology Specialist by the Brazilian Federation of Gastroenterology.
Fábio Segal, MD., Ph. D. in Clinical Medicine by the State University Rio Grande do Sul.
Fernando Wolff, MD.
What is it?
Pain is a response and an alert from the body in an attempt at demonstrating that something wrong is occurring. Pain is, therefore, a form of protection of the organism so that we can avoid doing things that may aggravate it and try to reduce it, for instance, by taking a rest, fasting, using pain killers and other types of treatment.
Pain can occur in any part of the abdomen, which is the body region limited by the chest (area where the lungs and the heart are found), in its upper portion, and the pelvic cavity (area bounded by the bones of the pelvis), in its lower portion. The abdomen contains a great number of organs and structures that can house pain. These are: stomach, small intestine, large intestine (colon), liver, pancreas, gallbladder, spleen and kidneys. In addition to these, the pain felt in the belly may originate from the urinary bladder, genital organs and circulatory system (mainly arteries). Some pains, as seen below, are peculiar to certain organs, while others, however, don’t allow us to accurately identify their origin.
What does one feel?
The best explanation for what one feels is provided by the one who is experiencing it. The references to the types of pain – burning, stabbing, colic, pressure, as well as their location, irradiation, intensity, duration, onset form, aggravation and relief, vary from person to person, according to their particular sensitivity (threshold) and tolerance.
Quite often, pains originated by diverse causes and different organs start in the middle of the belly, around the navel, or above it, in the pit of stomach. When the condition is aggravated over time, the pain may be located at the site where its cause lies.
No painful condition is totally peculiar to a specific illness. Nevertheless, we’ll describe some pain types, trying to relate them to their cause.
Burning pain and that resembling the feeling of starvation located at the pit of stomach, with or without heartburn, are highly associated with disorders in the esophagus, stomach or duodenum, such as reflux esophagitis, acute gastritis and peptic ulcer, among others. The association with a decrease in hunger, appetite and weight makes it necessary to differentiate it from cancer. The diagnosis is usually supported by supplementary exams. It must be remembered that heart conditions – angina and myocardial infarction- may often present as a pain in the upper and central areas of the abdomen (see topic related to each disease).
Pains located in the right upper quadrant and just below the last ribs on the same side are, many times, related to the liver or the gallbladder. Colic-like pains, whose intensity rapidly increases, followed by progressive relief until another episode takes place, may be related to calculus in the gallbladder or in the bile ducts, causing inflammation (cholecystitis and cholangitis). A significant, yet dull, pain in the same area, associated to appetite absence, nausea, jaundice (yellowish color in the mucosae and skin), highly dark urine and whitening of feces, is often caused by hepatitis (liver inflammation caused by viral infections and toxic substances ,e.g.). Pneumonias that affect the lower part of the right lung may be responsible for pain in this region (see topic related to each disease).
Colic pain, in the middle of the belly, associated to diarrhea, with or without vomit, is often caused by gastroenteritis, either of alimentary (intoxication ) or infectious (see acute diarrhea) type. Episodes of intense abdominal pain not well located, at a period following or near meals, particularly in the elder or in circulatory disease patients, may be caused by a deficient intestinal blood irrigation (ischemia), needing immediate medical evaluation.
Pain located in the right lower portion of the abdomen that is aggravated over time, often becoming intense and associated to fever, is characteristic of acute appendicitis. In women, it’s necessary to differentiate between this pain and that caused by gynecological disorders, such as ectopic pregnancy or twisting of the right ovary.
Diverticulitis typically causes pain in the left lower part of the abdomen, as this is traversed by the sigmoid colon (portion of the large intestine before the rectum), a site with greater occurrence of diverticula. In the same region, some people suffering from constipation (ileus) complain about pain. Diseases of the left-side gynecological organs can cause pain in this region as well.
Pain in a strip of the upper portion of the abdomen, with irradiation to the back, may be related to an acute pancreatitis or a chronic pancreatitis becoming severe. A history of frequent or excess alcoholic drinking, gallbladder calculus, or similar painful episodes, makes these diagnostic hypotheses highly likely.
In the middle and posterior portions of the abdomen are found the kidneys. Pain in the lumbar region, in general on only one side, that irradiates forward, associated to burning on urination, suggests a diagnosis of calculus in the urinary tract associated or not with urinary infection, which may reach the kidney.
There are several types of pain, induced by a countless number of causes for abdominal pain, and only by evaluating one case at a time, most often with the aid of exams, it is possible to arrive at a conclusion about the condition.
How is it diagnosed by the doctor?
As pain is a sensation, it can’t be directly measured by other individuals, not even by physicians. Thus, the evaluation and understanding of pain very much rely on the patient’s report.
The clinical exam helps in the search for the pain cause and in determining how severe the condition is. Supplementary exams will be required according to the physician’s suspicions. Usually, blood tests are asked in order to verify the presence of infection, or changes in the liver, pancreas or bile ducts. Urine tests are useful when the pain is suspected to be related with infection or calculus in the urinary tract.
Imaging exams, although not always necessary, are important for diagnostic documentation. Usually, echography (ultrasonography) is the method of choice. It allows optimal views from the belly organs, except for the stomach and intestines, identifying biliary or urinary obstructions, abscesses, tumors, gynecological disorders and some pancreatic alterations. Abdominal X-ray without contrast is usually used for diagnosis or for ruling out severe acute conditions, such as intestinal occlusion or perforations. Following the evaluation, we can ask for: computerized tomography, magnetic resonance, or other specific exams.
How is it treated?
Just like the diagnosis, the treatment is broad and variable, depending on the pain cause, its intensity and duration. In cases in which the physician doesn’t detect any risk, pain killers can be taken isolately. In other cases, in addition to handling the pain with medications, it’s necessary to conduct an investigation into the cause. In spite of all diagnostic resources, and even after surgery, there are cases in which the pain cause is not found out. In these cases, once more life-threatening causes are ruled out, a solely analgesic treatment can be started, keeping the patient under observation. At times, surgery is necessary for pain relief.
How is it prevented?
There isn’t only one method to prevent pain, and, in general, new episodes of pain are prevented by treating the underlying cause, when identified.