Acute Upper Abdominal Pain — Full Text

Acute Abdominal Pain refers to pain going on 1-2 weeks, oftentimes just a few days.  The term “Acute” can also mean very serious and needing surgery, like appendicitis, but that’s not how we’re using the word here.

Also, various conditions may cause some pain, but primarily cause other more prominent symptoms like vomiting or diarrhea that lead a patient to seek care.  Those aren’t addressed here; we’re now dealing with the patient whose main concern is new-onset pain in the upper part of their belly. See also our Summary Approach to this topic, and definition of “Upper” in introductory post to abdominal pain.

Causes of Acute Upper Abdominal Pain

Right Upper Quadrant (RUQ)
 
Hepatitis (Acute)
Gallbladder Disease
Pneumonia
Stomach Ulcer ?
Muscle Strain
Herpes Zoster (Shingles)







? = sometimes here too
xxxxxxxEpigastric

Stomach Diseases:
Ulcer / Gastritis / Dyspepsia
xxxEsophageal Reflux (GERD)
Gastric Cancer
Pancreatitis
Heart Attack
Hepatitis
?
Gallbladder Disease ?
Muscle Strain
Early Appendicitis
NOT “Gastroenteritis”


? = sometimes here too
Left Upper Quadrant (LUQ)
 
Pancreatitis
Stomach Ulcer / Gastritis ?
Dyspepsia ?
Heart Attack ?
Muscle Strain
Herpes Zoster (Shingles)






? = sometimes here too

See also Diagrams — Gastrointestinal System

Before anything else, we make sure the person isn’t having a HEART ATTACK.  In some people, the pain is in the mid- or left Upper abdomen (Epigastric/LUQ in diagram), not felt in the chest.  We think about it in patients at risk:

  • Men >35, post-menopausal women;
  • Smokers;
  • People with Diabetes or Hypertension and/or High Cholesterol;
  • Same-day cocaine / amphetamine use;
  • Strong Family History of heart attack at an early age. 

Heart Attack pain feels “heavy,” gets worse with exertion, is often accompanied by shortness of breath, nausea, lightheadedness, &/or cold sweats.  If symptoms last a few minutes & disappear, then recur, we suspect Angina (obstruction of coronary arteries that may eventually cause a heart attack).  See Diagnosing Coronary Artery Disease

STOMACH  —  Assuming we’re not suspecting heart disease, most Epigastric Pain will come from the stomach.  It might be an Ulcer, Gastritis, Esophageal Reflux (GERD), or even better, “Dyspepsia“, which is Greek for “indigestion”.

Before discussing these “stomach” diseases, let’s address the other entities in the mid-upper column of our table.  Note that diseases usually occurring in the Left- or Right-Upper Quadrants may occasionally be felt in the middle (Epigastric Area).  They include:

Pancreatitis —  With inflammation of the pancreas, pain is moderate-to-severe, and usually focused in the LUQ, but sometimes not.  There’s virtually always prominent nausea / vomiting.  Often the pain radiates to the back, and is relieved a bit by leaning forward.

Most (though not all) patients with Pancreatitis have a risk factor:

  • Recent heavy drinking (alcohol)
  • Very high Triglycerides, at least >500, usually >1,000.  This is a genetic condition, not from diet.
  • Gallstones

Diagnosis is made by blood test for the pancreatic enzyme Lipase, which should be at least moderately elevated (not just a little).  Not the “amylase,” which we used to order, because we realize that one had false-positives & negatives.  Patients with acute Pancreatitis should get a CT scan to check for complications, and they benefit from IV hydration.  So if we think someone has Pancreatitis, we often send them to an ER, and they are often hospitalized.

Acute Hepatitis  —   Infection or inflammation of the Liver. Symptoms can be subtle:

  • Mild upper abdominal pain (Usually RUQ, but Epigastric too)
  • Loss of appetite
  • Malaise (feeling lousy)
  • Nausea (with/without vomiting).
  • Jaundice (eyes & skin turn yellow) may not occur for a few days, or even not at all.

On examination, punching very gently at the liver (at the lower right rib cage) causes significant discomfort, while the same maneuver on the left side is painless.

Diagnosis is made by a blood test for liver Transaminases, also called “Liver Function Tests” (“LFT’s”).  This refers specifically to the liver enzymes ALT and AST.  A normal ALT is under 45-60; elevations range from around 200 in Alcoholic Hepatitis, to >1,000 in acute Hepatitis A.  If LFTs are normal, there’s no hepatitis.

A very high ALT means nothing in terms of severity; to determine if there’s life-threatening Liver Failure, we have to order a “Prothrombin Time” for the “INR” (INR >1.5 is bad).  If you ever hear that you have “hepatitis,” or your “LFTs are high,” be sure they obtain a Prothrombin Time.

Of course, once we diagnose Hepatitis, we have to determine the cause (recent heavy Alcohol, or a virus like Hepatitis A, B, or C, etc. etc.)  See Hepatitis Blood Tests (if you’re really interested, since it’s a long discussion).

Gallbladder  Disease  —  The most common condition here is called “Biliary Colic;” when a gallstone sitting harmlessly in the gallbladder trickles into the bile duct (see 2nd diagram in Gastrointestinal System Anatomy).  Symptoms begin abruptly, and may be accompanied by nausea or vomiting.  The pain is felt mainly in the RUQ, occasionally the Epigastrium, and sometimes it radiates to the Right Shoulder or Right side of the Upper Back.  Everything resolves within 4-6 hours, and may recur frequently, occasionally, rarely, or never again.

Diagnosis is made by finding gallstones on an ultrasound exam.  However, lots of people have asymptomatic gallstones that never bother them, so the presence of stones doesn’t prove that they caused the episode of pain.  The only treatment for Biliary Colic is surgery, which would only be undertaken if symptoms recurred frequently.

Some gallbladder attacks may lead to complications like gallbladder inflammation or infection (cholecystitis), obstruction or infection of the bile duct (cholangitis), or pancreatitis.  Infections are occasionally fatal.  Patients with gallbladder pain and any of the following get sent to an ER:

  • Fever
  • Jaundice (eyes / skin turn yellow)
  • Symptoms persisting more than 6 hours

Pneumonia  —  Pneumonia in the lower lobe of the right lung can sometimes begin abruptly with right-sided upper abdominal pain that hurts with every breath, & a fever.  The cough may not occur for hours.  Diagnosis is easy — get a chest x-ray; but you have to think of it.  Pity the poor surgeons who mistakenly took out the gallbladders of such patients [pity the patients].

Muscle Strain  —  This is a commonly-missed cause of abdominal pain; it tricks us because we’re worrying about brewing catastrophes inside the abdomen, whereas our muscles are on the outside.  Sometimes we elicit a history of new physical activity (“just joined a gym,” etc.), but oftentimes not.  Since the pain of a muscle strain can begin 1-2 days after the injury, a person may not recall what provoked it.

We diagnose Abdominal Wall Muscle Strain by noting tenderness at a specific point while palpating as the patient lies relaxed on the exam table.  Then we ask the patient to begin a sit-up (flexing the abs), & we palpate again.  If the latter causes more tenderness than the former, we’re sure that it’s due to a muscle (diseases inside the abdomen would be less tender then).

The maneuver is called “Carnett’s Sign.”  Few if any clinicians will have heard of it; I’d been performing it for years before I found out there was a name.  But still, it’s there to Google if you want.

Hernias  —  These can occur in any prior surgical incision (or wound); we’d suspect the possibility in the right situation.  There’s also a midline hernia, a bulge occurring in due center of the upper- or mid-abdomen.  However, many people (usually the obese, or pregnant) may have a normal laxity in midline (called “diastasis recti”), which doesn’t hurt.  Hernia means protrusion of intestines, and is thus more painful & tender.

To find a hernia, often we have to examine the patient standing, and ask them to strain or cough while we palpate.

Herpes Zoster (Shingles)  — This is the recurrence of Varicella virus; initial Varicella is called “chickenpox”.  Chickenpox lasts a week & goes away, but latent virus remains hidden in a nerve, and often reactivates many years later.  When it reactivates, it causes pain along the nerve pathway, & clusters of blisters which merge into crusts.

Zoster can occur on either side of the abdomen (upper, lower, or flank area).  Diagnosis may be tricky at first, if not impossible, since pain may precede skin lesions by 1-2 days.  Search the skin for even the tiniest splotches of redness or blisters, anywhere from spine to mid-abdomen.  Don’t freak out about the name; Zoster is just in the same family as the STD virus Herpes simplex (there’s no STD of the belly).

If we diagnose Zoster for sure in a patient younger than 50, we suggest an HIV test.  It’ll probably be negative, but almost everyone with HIV gets Zoster at some point, due to even very subtle immune deficiency.  Not that you can’t get HIV over 50, but age by itself is enough to cause Zoster reactivation.  When it comes to Zoster, 50 is “elderly” (that’s when I began to get AARP mailings.  Hemlock & Neptune Societies too!!!).

Early Appendicitis  —  The initial pain of appendicitis (first day, rarely 2 days) might be felt as vague discomfort in the upper- or mid-abdomen.  The main symptom that might accompany it at such an early stage would be loss of appetite (nausea, vomiting, & fever usually develop later).

I’m always suspicious if in that time frame I find tenderness when palpating the Right Lower Quadrant (even if that’s not where they’d been feeling pain).  If the patient seems hardly ill, I don’t send them to an ER or order tests.  But I always warn them, “If you get worse, come back or go to the hospital.”

If you think you have Appendicitis, or any condition requiring immediate surgery, DON’T EAT OR DRINK ANYTHING.  I once sent a patient to the ER, but he stopped off at home first for a bite to eat.  The surgeon was “unappreciative” (for want of a better expression).

NOT “Gastroenteritis”  —  Why is this in the Table?  Acute gastroenteritis literally means “infection” [the “-itis”] of stomach (“gastro-”) &/or bowel (“entero-”).  Germs in the stomach cause nausea & vomiting, in the bowel diarrhea.  Of course, repetitive vomiting can wind up painful, & some diarrheal germs cause painful cramps of gas accumulation.  But “pain” isn’t the main thing.

Diagnostic Pearl:   If vomiting begins, anyone can wind up with pain later.  But if Abdominal Pain begins before the nausea & vomiting, strongly suspect a specific organ is the cause (gallbladder, pancreas, appendix, etc.) & BEWARE THE DIAGNOSIS of “Gastroenteritis.”

See Gastroenteritis and Staphylococcal Food Poisoning

STOMACH DISEASES  —  Finally!  Let’s say we’ve  decided against everything described above, and are convinced the stomach is the source of pain.  The possible conditions are:

Unfortunately, it’s very hard to distinguish among the above diseases.  Studies show that symptoms don’t match up or correlate well with results of endoscopy (looking directly into the stomach with an endoscope).

In one sense, it almost doesn’t matter, because common Antacid Medications work for all these conditions, except of course cancer.  We’d advise “no alcohol, no NSAID drugs,” no matter what.  And we prescribe a medication “trial.”  If that doesn’t help, we increase the dose, maybe change the med.  If maximum doesn’t work, that’s when to refer to a Gastroenterologist for endoscopy.

For persons >45 years-old, I’m cautious with the class of stomach medication Proton Pump Inhibitors (PPI’s), because they can relieve the pain of Stomach Cancer (other “Antacid Medications” won’t).  Stomach cancer is rare in the U.S. (as opposed to Asia), but for an older patient, after pain has improved with several weeks of a PPI, I change to another medicine.  If pain recurs, requiring ongoing PPIs, I refer for endoscopy.

Another option in the patient who doesn’t improve on high-dose stomach medications is to perform a blood test for antibodies to the bacteria Helicobacter pylori (H. pylori).  If it’s positive, 10-14 days’ of treatment might “cure” symptoms.  Disclosure: Lots of clinicians order this test on lots of patients with upper abdominal pain; I don’t.

I certainly test and treat for H. pylori if I think a patient had had a peptic ulcer or gastritis (one which isn’t due to NSAID medications), because the bacteria is a main cause.  This would be a patient with any of:

  • Vomiting blood or coffee-ground-like material, or having black tarry stools (the “black” and “coffee-ground-like” may be clotted blood)  [note that iron tablets, vitamins with iron, and medications like Pepto-Bismol® also turn stools black]
  • Iron-Deficiency Anemia by blood test
  • Significant nausea, vomiting, or weight loss that got better on stomach medicines
  • Past History of stomach bleeding (vomiting blood)
  • Daily upper abdominal pain lasting most of the day, for at least 3 weeks.

I also test and treat for H. pylori if patients have a close family history of gastric cancer.

But curing H. pylori has little effect on plain Dyspepsia.  For GERD, the bacteria may even protect against heartburn [!!!!].  In the U.S., rates of positive blood tests range from 10% among young adults to 50% among those over 60, higher among the poor and among immigrants.  But you don’t find 10% of young adults getting ulcers (nor 50% of seniors)!  Interestingly, a colleague’s patient got H. pylori treatment elsewhere, and almost died from severe muscle breakdown due to the antibiotic clarithromycin interacting with a cholesterol medication (a statin) that nobody there knew he was taking.

I got disgusted with H. pylori in the 1990s, when countless free “educational” dinners were promoted by manufacturers of brand-name PPIs and/or antibiotic before they’d gone generic (and perhaps lab test merchants too).  Various professional societies do recommend “test-for-and-treat” H. pylori, because studies show it reduces the need for endoscopies, which isn’t wrong.  But still, I’m sorry, but I remain a skeptic of the eradication crusade.  I address H. pylori for patients I truly think have ulcers or gastritis, rarely dyspepsia, and never for GERD.

See also Acute Upper Abdominal Pain for the clinician’s condensed thought-process when face-to-face with a patient.

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