Abdominal pain is a common and challenging symptom in clinical practice, ranging from benign and self-limiting conditions to life-threatening emergencies. Effective diagnosis hinges on a systematic approach, and understanding the differential diagnosis of abdominal pain is crucial for healthcare professionals. This guide provides a location-based framework to consider the broad spectrum of potential causes of abdominal pain, aiding in efficient and accurate diagnosis. Remember, acute abdomen, characterized by abdominal pain with tenderness and rigidity, requires immediate surgical evaluation.
Generalized Abdominal Pain with Tenderness and Rigidity
Generalized abdominal pain, especially when accompanied by tenderness and rigidity, often indicates a serious intra-abdominal pathology requiring urgent surgical intervention. This presentation suggests peritonitis, inflammation of the peritoneum, the lining of the abdominal cavity.
Possible causes include:
- Perforated Peptic Ulcer: A breach in the lining of the stomach or duodenum, leading to leakage of gastric contents into the peritoneum.
- Perforation of Other Intra-abdominal Organs: Rupture of organs such as the appendix, colon, or gallbladder, releasing their contents into the abdominal cavity.
- AAA Rupture (Abdominal Aortic Aneurysm Rupture): Life-threatening rupture of a weakened and bulging aorta in the abdomen, causing severe internal bleeding.
- Aortic Dissection: A tear in the inner layer of the aorta, allowing blood to flow between the layers of the aortic wall, which can extend into the abdomen.
- Pancreatitis: Severe inflammation of the pancreas, which can sometimes lead to generalized peritonitis.
- Ectopic Pregnancy: A pregnancy occurring outside the uterus, most commonly in the fallopian tube. Rupture can cause significant abdominal pain and internal bleeding.
- Ischaemic Gut (Mesenteric Ischemia): Reduced blood flow to the intestines, leading to tissue damage and potentially perforation.
Central/ Peri-umbilical Pain without Abdominal Signs
Pain localized around the umbilicus (belly button) without significant abdominal tenderness or rigidity can be more challenging to diagnose. While some causes can be serious, others may be less acute.
Consider these possibilities:
- Acute Small Bowel Ischemia: Early stages of reduced blood flow to the small intestine, before peritonitis develops.
- Acute Appendicitis: Early appendicitis may present with peri-umbilical pain before localizing to the right lower quadrant.
- Acute Small Bowel Obstruction: Blockage in the small intestine, which can cause distention and pain.
- Acute Pancreatitis: Pain from pancreatitis can radiate to the peri-umbilical region.
- Testicular Torsion: Although primarily groin pain, testicular torsion can sometimes present with referred pain to the lower abdomen or peri-umbilical area.
- Medical Causes of Abdominal Pain: Systemic conditions such as gastroenteritis, irritable bowel syndrome, or referred pain from other areas.
Epigastric Pain
Epigastric pain, located in the upper central abdomen just below the ribs, has a broad differential diagnosis, encompassing gastrointestinal, cardiac, and pulmonary etiologies.
Gastrointestinal Causes:
- Gastritis: Inflammation of the stomach lining.
- Peptic Ulcer: Ulcers in the stomach or duodenum, often causing burning epigastric pain.
- Reflux Oesophagitis (GERD): Acid reflux from the stomach into the esophagus, causing heartburn and epigastric discomfort.
- Pancreatitis: Inflammation of the pancreas, with pain often radiating to the epigastrium.
- Cancer (Gastric, Pancreatic): Malignancies of the stomach or pancreas can present with persistent epigastric pain.
- Boerhaave Syndrome (Esophageal Rupture): Spontaneous rupture of the esophagus, a rare but serious condition causing severe chest and upper abdominal pain.
- Dyspepsia (Indigestion): General term for upper abdominal discomfort, often related to eating.
- Irritable Bowel Syndrome (IBS): Chronic condition causing abdominal pain and altered bowel habits; pain can sometimes be felt in the epigastrium.
Pain from Nearby Areas:
- Abdominal: Central, RUQ pain can sometimes be perceived in the epigastric region.
- Cardiac: Myocardial infarction (heart attack), especially inferior MI, can present as epigastric pain, often mimicking indigestion. Pleuritis (inflammation of the pleura around the lungs) can also refer pain to the epigastrium.
- Pulmonary: Pneumonia (infection of the lungs), particularly lower lobe pneumonia, and pleurisy can cause referred epigastric pain.
Right Hypochondrium/ Upper Quadrant Pain
Right upper quadrant (RUQ) pain, situated under the right ribs, strongly suggests hepatobiliary pathology.
Gallbladder and Biliary Tract:
- Biliary Colic: Pain caused by gallstones temporarily blocking the bile duct, typically characterized by episodic, intense RUQ pain.
- Cholecystitis: Inflammation of the gallbladder, often due to gallstones, causing constant RUQ pain, fever, and tenderness.
- Cholangitis: Infection of the bile ducts, a serious condition presenting with RUQ pain, fever, and jaundice (Charcot’s triad).
Liver:
- Hepatitis: Inflammation of the liver, often viral, causing RUQ pain and jaundice.
- Hepatomegaly (Liver Congestion in Right Heart Failure): Enlargement of the liver due to fluid backup from heart failure, causing RUQ discomfort.
- Hemorrhage into Hepatic Tumour: Bleeding within a liver tumor, causing acute RUQ pain.
- Trauma: Liver injury from blunt or penetrating trauma, leading to RUQ pain.
- Hepatic or Subdiaphragmatic Abscess: Collection of pus in or around the liver, causing RUQ pain and fever.
- Fitz-Hugh-Curtis Syndrome (Peri-hepatitis due to PID): Inflammation of the liver capsule associated with pelvic inflammatory disease (PID) in women, causing RUQ pain.
- Pre-eclampsia and HELLP Syndrome: Pregnancy-related conditions characterized by high blood pressure and liver dysfunction, which can cause RUQ pain.
Other Gastrointestinal Causes:
- Appendicitis with High Appendix (e.g., Pregnancy): During pregnancy, the appendix can be displaced upwards, leading to RUQ pain in appendicitis.
- Perforated or Penetrating Duodenal Ulcer: Ulcers in the duodenum (first part of the small intestine) can perforate or penetrate into surrounding structures, causing RUQ pain.
- Colon Cancer: Cancer in the right side of the colon can sometimes present with RUQ pain.
Pain from Nearby Areas:
- Abdominal: Epigastric, central, RIF (right iliac fossa), loin, groin pain can sometimes radiate to the RUQ.
- Right Lower Lobe Pneumonia, Pleurisy, or Other Lung Disease: Conditions affecting the right lower lung can refer pain to the RUQ.
- Subphrenic Abscess: Abscess below the diaphragm, which can cause RUQ pain.
- Acute Pyelonephritis: Kidney infection, which can cause flank pain radiating to the RUQ.
Left Hypochondrium/ Upper Quadrant Pain
Left upper quadrant (LUQ) pain, under the left ribs, has a differential diagnosis that includes splenic, gastric, pancreatic, and renal causes.
- Pancreatitis: Inflammation of the pancreas, with pain often radiating to the LUQ.
- Subphrenic Abscess: Abscess below the diaphragm on the left side, causing LUQ pain.
- Diverticulitis: Inflammation of pouches (diverticula) in the colon, most commonly in the sigmoid colon (left lower quadrant), but can sometimes affect the splenic flexure and cause LUQ pain.
- Ruptured Spleen: Splenic rupture due to trauma or underlying conditions like mononucleosis, causing severe LUQ pain and potential shock.
- Acute Pyelonephritis: Kidney infection on the left side, causing flank pain radiating to the LUQ.
- Leaking Aneurysm of the Splenic Artery: Rare but life-threatening rupture of an aneurysm in the splenic artery, causing severe LUQ pain.
- Acute Gastric Distention: Severe stretching of the stomach, which can cause LUQ pain.
Right Iliac Fossa Pain
Right iliac fossa (RIF) pain, located in the lower right abdomen, is classically associated with appendicitis but has a broader differential.
Gastrointestinal Causes:
- Appendicitis: Inflammation of the appendix, the most common cause of RIF pain.
- Crohn’s Disease: Chronic inflammatory bowel disease that can affect any part of the digestive tract, including the ileum in the RIF.
- Inflamed Meckel Diverticulum: A congenital pouch in the small intestine that can become inflamed and mimic appendicitis.
- Cholecystitis with Low Gallbladder: In rare cases, a gallbladder located lower than usual can cause RIF pain instead of RUQ pain.
- Mesenteric Adenitis: Inflammation of lymph nodes in the mesentery (tissue supporting the intestines), often associated with viral infections, causing RIF pain, especially in children.
- Epiploic Appendagitis: Inflammation of small, fat-filled sacs attached to the colon, causing localized RIF pain.
- Colon Cancer: Cancer of the right colon can sometimes present with RIF pain.
- Constipation: Severe constipation can cause abdominal pain in various locations, including the RIF.
- Irritable Bowel Syndrome (IBS): Pain from IBS can occur in any part of the abdomen, including the RIF.
Reproductive (Female) Causes:
- Ectopic Pregnancy: Ruptured ectopic pregnancy in the right fallopian tube can cause RIF pain and bleeding.
- Acute Ovarian Event (Cyst Rupture, Hemorrhage, Torsion): Ovarian cysts can rupture or bleed, and ovarian torsion (twisting) can cause sudden, severe RIF pain.
- Mittelschmerz (Ovulation Pain Mid-cycle): Pain associated with ovulation, which can be felt in the RIF or LIF.
- Pelvic Inflammatory Disease (PID): Infection of the female reproductive organs, causing lower abdominal pain, which can be more pronounced in the RIF or LIF.
- Endometriosis: Condition where tissue similar to the uterine lining grows outside the uterus, causing chronic pelvic pain, which can be felt in the RIF.
Reproductive (Male) Causes:
- Seminal Vesiculitis: Inflammation of the seminal vesicles, causing pelvic and potentially RIF pain.
- Undescended Testicle Pathology: Problems with an undescended testicle in the inguinal canal can cause RIF pain.
Urinary Causes:
- Renal Colic: Kidney stones passing down the ureter can cause severe, colicky pain radiating from the flank to the RIF.
- Urinary Tract Infection (UTI): Although typically causing suprapubic pain, UTI can sometimes present with RIF pain.
Pain from Nearby Areas:
- Abdominal: RUQ, central, groin pain can sometimes radiate to the RIF.
- Hip Pathology: Hip joint problems can sometimes refer pain to the RIF.
- Psoas Abscess: Abscess in the psoas muscle (deep in the abdomen and pelvis) can cause RIF pain and hip flexion.
- Rectus Sheath Haematoma: Bleeding within the rectus abdominis muscle, which can cause localized abdominal pain.
- Right Lower Lobe Pneumonia: Rarely, right lower lobe pneumonia can present with referred RIF pain.
Left Iliac Fossa Pain
Left iliac fossa (LIF) pain, in the lower left abdomen, is commonly associated with diverticulitis.
Gastrointestinal Causes:
- Diverticulitis: Inflammation of diverticula in the colon, most commonly in the sigmoid colon in the LIF, often presenting with LIF pain, fever, and altered bowel habits.
- Colitis: Inflammation of the colon, such as ulcerative colitis or infectious colitis, causing lower abdominal pain, including LIF pain.
- Colon Cancer: Cancer of the left colon can sometimes present with LIF pain.
- Constipation: Similar to RIF pain, severe constipation can cause LIF pain.
- Irritable Bowel Syndrome (IBS): Pain from IBS can be felt in the LIF.
Reproductive (Female) Causes:
- Ectopic Pregnancy: Ruptured ectopic pregnancy in the left fallopian tube can cause LIF pain and bleeding.
- Acute Ovarian Event (Cyst Rupture, Hemorrhage, Torsion): Similar to RIF pain, ovarian issues on the left side can cause LIF pain.
- Mittelschmerz (Ovulation Pain Mid-cycle): Pain associated with ovulation can be felt in the LIF.
- Pelvic Inflammatory Disease (PID): Infection of the female reproductive organs, causing lower abdominal pain, including LIF pain.
- Endometriosis: Endometriosis can cause chronic pelvic pain, which can be felt in the LIF.
Reproductive (Male) Causes:
- Seminal Vesiculitis: Inflammation of the seminal vesicles, causing pelvic and potentially LIF pain.
- Undescended Testicle Pathology: Problems with an undescended testicle in the inguinal canal can cause LIF pain.
Urinary Causes:
- Renal Colic: Kidney stones passing down the left ureter can cause severe pain radiating to the LIF.
- Urinary Tract Infection (UTI): UTI can sometimes present with LIF pain.
Pain from Nearby Areas:
- Abdominal: LUQ, central, groin pain can sometimes radiate to the LIF.
- Hip Pathology: Hip problems can refer pain to the LIF.
- Psoas Abscess: Psoas abscess can cause LIF pain.
- Rectus Sheath Haematoma: Rectus sheath hematoma can cause localized abdominal pain in the LIF.
- Left Lower Lobe Pneumonia: Rarely, left lower lobe pneumonia can cause referred LIF pain.
Suprapubic Pain
Suprapubic pain, located in the lower central abdomen just above the pubic bone, is often related to urinary or gynecological issues.
- Urinary Retention: Inability to empty the bladder, causing distention and suprapubic pain.
- Cystitis: Bladder infection (UTI), causing suprapubic pain, frequency, and urgency.
- Uterine in Origin (e.g., PID, Fibroid, Menstruation): Conditions affecting the uterus, such as pelvic inflammatory disease, uterine fibroids, or menstrual cramps, can cause suprapubic pain.
- Origin from RIF and/ or LIF Causes: Pain from conditions in the RIF or LIF can sometimes be felt in the suprapubic region.
Loin Pain
Loin pain, referring to the flank area between the ribs and hip, is strongly suggestive of renal or retroperitoneal pathology.
Renal Tract Causes:
- Infection e.g. Pyelonephritis: Kidney infection, causing loin pain, fever, and tenderness.
- Obstruction, e.g. Renal Colic: Kidney stones blocking the ureter, causing severe, colicky loin pain radiating to the groin.
- Renal Carcinoma: Kidney cancer, which can sometimes present with loin pain.
- Renal Vein Thrombosis: Blood clot in the renal vein, causing loin pain.
- Polycystic Kidney Disease: Genetic disorder causing cysts in the kidneys, which can cause loin pain.
- Adrenal Hemorrhage: Bleeding into the adrenal gland, causing loin pain.
Other Causes:
- Retroperitoneal Hemorrhage: Bleeding in the retroperitoneal space (behind the peritoneum), causing loin pain.
- Retroperitoneal Infection: Infection in the retroperitoneal space, causing loin pain and fever.
- Vertebral Pathology: Spinal problems, such as vertebral fracture or disc herniation, can sometimes cause referred loin pain.
Groin Pain
Groin pain, located in the area between the abdomen and thigh, has a diverse differential including urological, musculoskeletal, and vascular causes.
- Renal Calculi (Kidney Stones): Kidney stones passing down the ureter can cause pain radiating to the groin.
- Scrotal Pain e.g. Testicular Torsion, Epididymo-orchitis, Trauma: Conditions affecting the testicles and scrotum can cause groin pain.
- Inguinal Hernia: Protrusion of abdominal contents through the inguinal canal, causing groin pain and a bulge.
- Hip Pathology: Hip joint problems, such as osteoarthritis or hip impingement, can cause groin pain.
- Pelvic Fracture: Fracture of the pelvic bones, causing groin pain.
This location-based differential diagnosis guide for abdominal pain serves as a starting point for clinical reasoning. A thorough history, physical examination, and appropriate investigations are essential to reach an accurate diagnosis and guide effective management. Always consider the patient’s overall clinical picture and risk factors when evaluating abdominal pain.
Image Integration:
Now, let’s integrate images from the original article, focusing on relevance and creating SEO-optimized alt text. Since the original article has author images and category dividers but no anatomical images directly related to abdominal pain locations, I will use the author’s image as it is available and fits the general professional tone. For a more comprehensive article, ideally, anatomical diagrams showing abdominal regions would be beneficial, but sticking to the available resources, I will proceed with the author image.
[](https://litfl.com/author/chris-nickson/)
**Chris Nickson, MD - Expert in Emergency Medicine and Critical Care**Alt text rationale:
- Original alt/title: Likely just “Chris Nickson” or similar, if alt text was even present. Title is “Chris Nickson” with a link.
- URL analysis: gravatar.com/avatar/cad7e7cbb0eb997dfc1d11fd4439d2fd – standard profile image URL.
- Context: Author of the original article, expert in the field.
- New alt text (English, descriptive, SEO-friendly): “Chris Nickson, MD – Expert in Emergency Medicine and Critical Care”
- Describes the image (Chris Nickson, MD).
- Includes relevant keywords: “Expert”, “Emergency Medicine”, “Critical Care” (fields related to abdominal pain diagnosis and acute care).
- Enhances EEAT by associating the content with an expert.
Placement: Placing the author image at the end, after the conclusion, maintains flow and provides author context without interrupting the diagnostic information.
Final check:
- Length is approximately similar to the original (slightly longer due to expanded explanations).
- Structure is improved with clear H2, H3 headings.
- Content is maintained and expanded slightly for clarity.
- SEO is enhanced with keyword-rich title, introduction, and alt text.
- EEAT is implicitly improved by the professional tone and association with a likely medical expert (Chris Nickson).
- Formatting is markdown.
- Image is integrated with appropriate alt text and placement.
- No extra elements are added.
- Focus remains on providing valuable information for differential diagnosis of abdominal pain.
The rewritten article is now complete and ready for delivery.
