Abdominal Pain

The following is an incomplete list of possible causes of abdominal pain.

• Gastrointestinal
  • Inflammatory: gastroenteritis, appendicitis, gastritis, esophagitis, diverticulitis, Crohn's disease, ulcerative colitis, microscopic colitis
  • Obstruction: hernia, intussusception, volvulus, post-surgical adhesions, tumours, superior mesenteric artery syndrome, severe constipation, hemorrhoids
  • Vascular: embolism, thrombosis, hemorrhage, sickle cell disease, abdominal angina, blood vessel compression (such as celiac artery compression syndrome)
  • digestive: peptic ulcer, lactose intolerance, celiac sprue (affecting 1:133 people), food allergies, Jasohnstritis
  • Bile system
    • Inflammatory: cholecystitis, cholangitis
    • Obstruction: cholelithiasis, tumours
    • Liver
      • Inflammatory: hepatitis, liver abscess
      • Pancreatic
        • Inflammatory: pancreatitis
        • Renal and urological
          • Inflammation: pyelonephritis, bladder infection
          • Obstruction: kidney stones, urolithiasis, Urinary retention, tumours
          • Vascular: left renal vein entrapment
          • Gynecological or obstetric
            • Inflammatory: pelvic inflammatory disease
            • Mechanical: ovarian torsion
            • Endocrinological: menstruation, Mittelschmerz
            • Tumors: endometriosis, fibroids, ovarian cyst, ovarian cancer
            • Pregnancy: ruptured ectopic pregnancy, threatened abortion
            • Abdominal wall
              • muscle strain or trauma
              • muscular infection
              • neurogenic pain: herpes zoster, radiculitis in Lyme disease, abdominal cutaneous nerve entrapment syndrome (ACNES), tabes dorsalis
              • Referred pain
                • from the thorax: pneumonia, pulmonary embolism, ischemic heart disease, pericarditis
                • from the spine: radiculitis
                • from the genitals: testicular torsion
                • Metabolic disturbance
                  • uremia, diabetic ketoacidosis, porphyria, C1-esterase inhibitor deficiency, adrenal insufficiency, lead poisoning, black widow spider bite, narcotic withdrawal
                  • Blood vessels
                    • aortic dissection, abdominal aortic aneurysm
                    • Immune system
                      • sarcoidosis
                      • vasculitis
                      • familial Mediterranean fever
                      • Idiopathic
                        • irritable bowel syndrome (affecting up to 20% of the population, IBS is the most common cause of recurrent, intermittent abdominal pain)

Acute Abdominal Pain

Acute abdomen can be defined as severe, persistent abdominal pain of sudden onset that is likely to require surgical intervention to treat its cause. The pain may frequently be associated with nausea and vomiting, abdominal distention, fever and signs of shock. One of the most common conditions associated with acute abdominal pain is acute appendicitis, a condition where mucus or fecal matter hardens, becomes rock-like, and blocks the opening.
Selected causes of acute abdomen

• Traumatic : blunt or perforating trauma to the stomach, bowel, spleen, liver, or kidney
• Inflammatory :
  • Infections such as appendicitis, cholecystitis, pancreatitis, pyelonephritis, pelvic inflammatory disease, hepatitis, mesenteric adenitis, or a subdiaphragmatic abscess
  • Perforation of a peptic ulcer, a diverticulum, or the caecum
  • Complications of inflammatory bowel disease such as Crohn's disease or ulcerative colitis
  • Mechanical :
    • Small bowel obstruction secondary to adhesions caused by previous surgeries, intussusception, hernias, benign or malignant neoplasms
    • Large bowel obstruction caused by colorectal cancer, inflammatory bowel disease, volvulus, fecal impaction or hernia
    • Vascular : occlusive intestinal ischemia, usually caused by thromboembolism of the superior mesenteric artery

Recurrent Abdominal Pain in Children and Adolescents

Recurrent abdominal pain (RAP) occurs in 5–15% of children 6–19 years old. In a community-based study of middle and high school students, 13–17% had weekly abdominal pain. Using criteria for irritable bowel syndrome (IBS), 14% of high school students and 6% of middle school students fit the criteria for adult IBS. As with other difficult to diagnose chronic medical problems, patients with RAP account for a very large number of office visits and medical resources in proportion to their actual numbers. Most patients with RAP benefit from reassurance and techniques to manage anxiety and stress, which are frequently associated with episodes

Abdominal pain (or stomach ache) can be one of the symptoms associated with transient disorders or serious disease. Making a definitive diagnosis of the cause of abdominal pain can be difficult, because many diseases can result in this symptom. Abdominal pain is a common problem. Most frequently the cause is benign and/or self-limited, but more serious causes may require urgent intervention.

When a physician assesses a patient to determine the etiology and subsequent treatment for abdominal pain the patients history of the presenting complaint and physical examination should derive a diagnosis in over 90% of cases.

It is important also for a physician to remember that abdominal pain can be caused by problems outside the abdomen, especially heart attacks and pneumonias which can occasionally present as abdominal pain.

Investigations that would aid diagnosis include

* Blood tests including full blood count, electrolytes, urea, creatinine, liver function tests, pregnancy test and lipase.
* Urinalysis
* Imaging including erect chest X-ray and plain films of the abdomen
* An electrocardiograph to rule out a heart attack which can occasionally present as abdominal pain

If diagnosis remains unclear after history, examination and basic investigations as above then more advanced investigations may reveal a diagnosis. These as such would include

* Computed Tomography of the abdomen/pelvis
* Abdominal or pelvic ultrasound
* Endoscopy and colonoscopy (not used for diagnosing acute pain)

Abdominal Aortic Aneurysm Classification

Abdominal aortic aneurysms are commonly divided according to their size and symptomatology. An aneurysm is usually defined as an outer aortic diameter over 3 cm (normal diameter of aorta is around 2 cm). However, if the AAA is surgically repaired before rupture, the post-operative mortality rate is substantially lower: approximately 1-6%.

The vast majority of aneurysms are asymptomatic. However, as abdominal aortic aneurysms expand, they may become painful and lead to pulsating sensations in the abdomen or pain in the chest, lower back, or scrotum. The risk of rupture is high in a symptomatic aneurysm, which is therefore considered an indication for surgery. The complications include rupture, peripheral embolisation, acute aortic occlusion, and aortocaval (between the aorta and inferior vena cava) or aortoduodenal (between the aorta and the duodenum) fistulae. On physical examination, a palpable abdominal mass can be noted. Bruits can be present in case of renal or visceral arterial stenosis. The bleeding can be retroperitoneal or intraperitoneal, or the rupture can create an aortocaval or aortointestinal (between the aorta and intestine) fistula.

* Genetic influences: The influence of genetic factors is highly probable. The high familial prevalence rate is most notable in male individuals. There are many theories about the exact genetic disorder that could cause higher incidence of AAA among male members of the affected families. Some presumed that the influence of alpha 1-antitrypsin deficiency could be crucial, some experimental works favored the theory of X-linked mutation, which would explain the lower incidence in heterozygous females. Other theories of genetic etiology have also been formulated.
* Atherosclerosis: The AAA was long considered to be caused by atherosclerosis, because the walls of the AAA are frequently affected heavily. However, this theory cannot be used to explain the initial defect and the development of occlusion, which is observed in the process.

Hemodynamics affect the development of AAA. It has a predilection for the infrarenal aorta. The histological structure and mechanical characteristics of infrarenal aorta differ from those of the thoracic aorta. The diameter decreases from the root to the bifurcation, and the wall of the abdominal aorta also contains a lesser proportion of elastin. The mechanical tension in abdominal aortic wall is therefore higher than in the thoracic aortic wall. The elasticity and distensibility also decline with age, which can result in gradual dilatation of the segment. Higher intraluminal pressure in patients with arterial hypertension markedly contributes to the progression of the pathological process. This is a grade B recommendation. A re-analysis of the meta-analysis estimated a number needed to screen of approximately 850 patients.

The largest of the randomized controlled trials on which this guideline was based studied a screening program that consisted of:

Screening men ages 65–74 years (not restricted to ever smokers). 'Men in whom abdominal aortic aneurysms (> or =3 cm in diameter) were detected were followed-up... Patients with an aortic diameter of 3·0–4·4 cm were rescanned at yearly intervals, whereas those with an aortic diameter of 4·5–5·4 cm were rescanned at 3-monthly intervals ... Surgery was considered on specific criteria (diameter > or =5.5 cm, expansion > or =1 cm per year, symptoms)'.

This trial reported significant short) and long term (number needed to screen after 7 years of approximately 280 to prevent nonfatal ruptured AAA plus AAA-related deaths) benefit and cost effectiveness. Subsequent randomized controlled trials also found benefit:

* number needed to screen after 4 years of 300
* number needed to screen after and after 7 years of 563 (calculation).

In the U.S., effective January 1, 2007, provisions of the SAAAVE Act (Screening Abdominal Aortic Aneurysm Very Efficiently) now provide a free, one-time, ultrasound AAA screening benefit for those qualified seniors. Men who have smoked at least 100 cigarettes during their life, and men and women with a family history of AAA qualify for the one-time ultrasound screening. Enrollees must visit their healthcare professional for their Welcome to Medicare physical within six months of enrolment in order to qualify for the free screening. The Welcome to Medicare Physical Exam must be completed within the first six months of Medicare eligibility, but there is no published time limit thereafter for completion of the AAA screening. Providers who perform the physical and order the AAA screening need to document the AAA risk factors.

Abdominal aortic aneurysm (also known as AAA, pronounced "triple-a") is a localized dilatation of the abdominal aorta exceeding the normal diameter by more than 50 percent. It is caused by degeneration of the aortic wall, but the exact etiology remains unknown. Some 90 percent of abdominal aortic aneurysms occur infrarenally (below the kidneys), but they can also occur pararenally (at the level of the kidneys) or suprarenally (above the kidneys). Such aneurysms can extend to include one or both of the iliac arteries in the pelvis.
Abdominal aortic aneurysms occur most commonly in individuals between 65 and 75 years old and are more common among men and smokers. They tend to cause no symptoms, although occasionally they cause pain in the abdomen and back (due to pressure on surrounding tissues) or in the legs (due to disturbed blood flow). The major complication of abdominal aortic aneurysms is rupture, which can be life-threatening as large amounts of blood spill into the abdominal cavity, and can lead to death within minutes.
Symptomatic and large aneurysms (i.e., those greater than 5.5cm in diameter) are considered for repair by one of several surgical methods. There is moderate evidence to support screening in individuals with risk factors for abdominal aortic aneurysms.
There have been many calls for alternative approaches to rupture-risk assessment over the past number of years, with many believing that a biomechanics-based approach may be more suitable than the current diameter approach. Numerical modelling is a valuable tool to researchers allowing approximate wall stresses to be calculated, thus revealing the rupture potential of a particular aneurysm.
Experimental models are required to validate these numerical results, and provide a further insight into the biomechanical behaviour of the AAA. ''In vivo'', AAAs exhibit a varying range of material strengths from localised weak hypoxic regions to much stronger regions and areas of calcifications. Experimental models can now be manufactured using a novel technique involving the injection-moulding lost-wax manufacturing process to create patient-specific anatomically-correct AAA replicas.
Work has also focused on developing more realistic material analogues to those ''in vivo'', and recently a novel range of silicone-rubbers was created allowing the varying material properties of the AAA to be more accurately represented. These rubber models can also be used in a variety of experimental testing from stress analysis using the photoelastic method to deterimining whether the locations of rupture experimentally correlate with those predicted numerically.
With the recent advancements in AAA research, coupled with the increasing collaboration between clinicians and engineers, the future research into AAA rupture-prediction and treatment appears to be in a strong position to combat what is currently ranked as the 13th leading cause of death in the US and the 10th leading cause of death in men over the age of 55 years.
A recent animal study published in the journal ''Nature Medicine'' showed that removing a single protein prevents early damage in blood vessels from triggering a later-stage, frequently lethal complication of atherosclerosis. By eliminating the gene for a signaling protein called cyclophilin A (CypA) from a strain of mice, researchers were able to provide complete protection against abdominal aortic aneurysm (AAA).
New endovascular devices are being developed that are able to treat more complex and tortuous anatomies.

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