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Hello: everyone, it’s eric from stanford university and strong medicine. Today, I’m discussing an approach to chronic abdominal pain. Now the threshold of how long the pain needs to have been present for in order to be considered chronic is arbitrary. But for this discussion I’m considering it to be at least two months, including recurrent episodic pain in which the episodes have been occurring over that duration. This video will be longer than most in this particular series, because, despite chronic abdominal pain being a common and frustrating problem, it is rarely discussed as a symptom in coursework for healthcare professionals and even most of the individual diseases that can cause the symptom are neglected in formal education. While some etiologies are easy to identify from a combination of history, labs, endoscopy and routine imaging the majority of etiologies are not. Some diagnoses require specialized testing with which many clinicians are unfamiliar. Others are so-called clinical diagnoses, which means a diagnosis that’s made on the basis of history and exam alone, plus the elimination of alternative possibilities, because clinical diagnoses have no confirmatory tests. A clinician must have sufficient relevant expertise to have the confidence to make such a diagnosis. So, in short, the underlying cause of chronic abdominal pain is often misdiagnosed in this video I’ll be discussing the causes of chronic abdominal pain and how I approach making the diagnosis in the companion video on an approach to acute abdominal pain. I talked about how the location of the pain was an essential piece of data that helps to narrow down the list of diagnostic possibilities. We consider what organs are in that region of the abdomen or pelvis, and that gives us a starting point for a differential diagnosis so for pain in the right upper quadrant. We first consider diseases of the liver and gallbladder while for pain in the left upper quadrant. We first consider diseases of the spleen. Using this approach, we can construct a diagnostic framework for acute abdominal pain based on anatomic location. However, when it comes to chronic abdominal pain, this approach doesn’t work as well, because most etiologies cause pain that is diffuse, poorly localized or is in the midline. So when we construct a diagnostic framework in this case, that is an organized and categorized list of potential causes of the symptom, we need to do it by conventional organ system, though, with a very large miscellaneous category, I’m going to go through the framework now saying just a few words about each potential diagnosis as consistent with the other videos in this series on an approach to symptoms. This framework is not intended to include every possible disease that can cause chronic abdominal pain, because it would be ridiculously long and tedious, so instead I’ll be focusing on those diseases that are either particularly common, particularly dangerous or most often misdiagnosed. The first category is gi, which can be divided into luminal versus other, which luminal refers to the stomach and small and large intestines, while other refers to the liver, biliary system and pancreas among luminal causes is gastritis, which is inflammation of the stomach, most often caused by alcohol medications or infection. With the h pylori bacteria peptic ulcer disease refers to an ulcer, either in the stomach or duoden, which shares some of the same symptom characteristics and risk factors as gastritis, though they are distinct. Pathologies, celiac disease, also known as gluten sensitive enteropathy, is an immune-mediated disease triggered by exposure to dietary wheat gluten in genetically susceptible individuals that results in malabsorption and subsequent diarrhea and secondary nutritional deficiencies. Inflammatory bowel disease is another immune, mediated disease of of the bowels, but while celiac disease is limited to the small intestine and results in malabsorption, ibd is predominantly seen in the colon where it causes inflammation. As its name implies. There are two clinically and pathologically distinct subtypes of ibd crohn’s disease and ulcerative colitis constipation, including fecal impaction. A variety of gi infections can lead to chronic pain, including those of helmets or worms and protozoa. Small intestinal bacterial overgrowth is exactly what it sounds like too much bacteria in the small intestines. I’m listing this separate from other infections, because it doesn’t, it doesn’t consist of a one-time infection with a pathogen that can be treated and then the patient’s cured, but rather it’s due to normal gut bacteria being too numerous in an abnormal location and because for many patients, it’s an ongoing problem, an ongoing condition that is not completely resolved after a single course of antibiotics. So it’s more than just a gi infection risk factors for small intestinal bacterial overgrowth include various forms of bowel surgery, an abnormally high gastric, ph immunodeficiency and disorders of gi, motility. Speaking of motility disorders, there is gastroparesis, which is a lack of normal peristalsis within the stomach which presents with postprandial pain and nausea and vomiting it’s commonly associated with diabetes, but can also be idiopathic. There is also chronic intestinal pseudo-obstruction, a different motility disorder, which mimics mechanical bowel obstruction. Last in this category are the functional disorders. A functional disorder, functional gi disorder is one in which chronic pain and or nausea and vomiting and or alterations in bowel habits occurs without any discernible objective. Findings on routine investigations such as routine labs, imaging and endoscopy. These are all therefore so-called clinical diagnoses. There are literally dozens of separate, distinct described entities in this category, but by far the most commonly recognized is irritable, bowel syndrome or ibs. This presents with a combination of chronic pain, often characterized as bloating or cramping in nature and altered, bowel habits, diary and some patients, constipation and others, and occasionally a mix of both other entities under functional gi disorders include functional dyspepsia and something called centrally mediated abdominal pain syndrome. The clearest distinction between these two is that in the former, symptoms are associated with meals, whereas in the latter they are not. Narcotic bowel syndrome is also considered a functional diagnosis, one that refers to the situation in which patients on chronic narcotics for pain control develop paradoxical worsening of their abdominal pain due to constipation and dysmotility. Moving to the other gi category, we have chronic pancreatitis and something called a pancreatic pseudocyst, which is a long-term consequence of an episode of acute pancreatitis, there’s a condition called primary sclerosing cholangitis, which is characterized by inflammation and fibrosis of the medi and large biliary ducts. It has a strong association with inflammatory bowel disease and last is sphincter of od dysfunction. The sphincter of od controls the exit point from the common bile duct and pancreatic duct, as they empty into the duoden anatomic or functional problems with the sphincter can result in recurrent acute pancreatitis or chronic biliary type pain. Now this sphincter of odd dysfunction is frequently considered a type of functional, abdominal pain. I personally don’t think this categorization makes sense, since it’s often associated with laboratory and radiographic abnormalities which are not typical of other functional diseases. The next category is gynecological. The most notable condition here is endometriosis, which is caused by ectopic endometrial tissue, that is uterine tissue present outside of the uterus, most often in the pelvis, but which can happen virtually anywhere in the torso. Its presentation depends on the location of the ectopic tissue, but it most commonly causes chronic pain, painful or heavy menstruation, painful sexual intercourse and infertility. Another potentially painful condition in the female rep roductive system is an an ovarian cyst cysts can present with acute pain if they rupture or hemorrhage, or they can be entirely asymptomatic, but they can also cause chronic and or recurrent pain. Cramps occurring during menstruation and recurrent pain at the time of ovulation are both relatively common, and there is also pelvic inflammatory disease. A severe complication of some sexually transmitted infections and a benign uterine tumor called a fibroid. While there are certainly conditions of the male reproductive system that cause chronic pain, they typically cause scrotal or penile pain, rather than abdominal pain. A few primary vascular diseases can lead to chronic abdominal pain, for example, chronic mesenteric ischemia, in which atherosclerosis of the arteries supplying the gut limit their blood flow. It essentially causes intestinal angina, in which patients experience, postprandial pain and classically. Developing a literal fear of eating median arcuate ligament syndrome, also known as celiac artery compression syndrome, is a condition in which the celiac artery is compressed by the median arcuate ligament, the celiac artery supplies blood to the stomach, proximal, duoden, pancreas, spleen and biliary system. Its symptoms can be very similar to those from mesenteric ischemia, since the downstream consequence of external compression and internal obstruction is the same, but these patients are typically younger and lack the cardiovascular risk factors of those with chronic mesenteric ischemia aortic aneurysms can lead to abdominal pain as well as back and flank pain and coronary artery disease can occasionally result in referred pain to the epigastric region during ischemic episodes. Finally, we have the last category. Miscellaneous diseases, which are quite numerous and unusually diverse. There are various forms of hernias hypercalcemia and splenomegaly. Interstitial cystitis, also known as painful bladder syndrome, is characterized by pelvic pressure with bladder filling and improvement upon. Voiding retroperitoneal fibrosis is a rare condition, which is exactly what it sounds like it can either be idiopathic or secondary to cancer. Drugs infection or retroperitoneal hemorrhage acute intermittent porphyria is a genetic disease of porphyrin synthesis, which is the metabolic precursor of heme in hemoglobin. One would expect that a defect in heme’s synthetic pathway would lead to anemia, but instead the symptoms seen are neurologic, specifically acute attacks of normally mediated non-inflammatory, abdominal pain, autonomic dysfunction and peripheral neuropathy. There are various forms of chronic abdominal wall pain, most notably anterior, cutaneous nerve, entrapment syndrome. Familial mediterranean fever is a genetic disorder that causes a specific dysregulation of the immune system, which presents as sudden discrete episodes of fever, abdominal pain caused by non-infectious peritonitis. Chest pain, caused by non-infectious, pericarditis or pleuritis, and joint pain, mast cell disorders, including systemic mastocytosis and mast cell activation syndrome, typically present, with abdominal pain associated with nausea, vomiting, diarrhea, flushing and rhinorrhea, which are caused by the inappropriate release of vasoactive mediators from mast cells, including histamine and tryptase. Hereditary angioedema is a genetic disease of the complement cascade that presents with recurrent angioedema of the mucous membranes, as well as crampy abdominal pain, nausea, vomiting and diarrhea, all of which are due to gut wall edema. There is an uncommon variant of migraine, headaches in which affected patients present predominantly with abdominal pain rather than headache, and finally, is a phenomenon called semantization in which either a psychiatric disorder, such as anxiety or situational and emotional stress, can manifest as physical symptoms such as abdominal pain, accurately identifying and distinguishing semantization is challenging, because a psychological state that a patient is experiencing can magnify the severity of pain caused by an entirely different pathology and chronic undiagnosed. Abdominal pain, certainly accentuates such psychological symptoms of anxiety and depression. In short, there is a risk here of patients having their chronic pain misattributed to anxiety, rather than anxiety, correctly attributed to the actual physical cause of their pain, but nevertheless, psychological states can on occasion lead to abdominal pain in the absence of disease within the abdomen. Overall, the relatively common etiologies of chronic abdominal pain include gastritis, peptic, ulcer disease, constipation, irritable, bowel syndrome, endometriosis, ovarian cysts, menstrual, cramps and ovulation pain. You may have noticed an entire category of diseases absent from the framework cancer. In addition to all the aforementioned etiologies, any intra-abdominal malignancy can lead to chronic abdominal pain, including lymphoma, though most intra-abdominal cancers are painless in their earlier stages. The list of etiologies contains a spectr of diseases that range from ones that are frustrating, but not dangerous or life-limiting to those which are actively life-threatening. Are there any clues or red flags that a patient might have a potentially life-threatening ideology of their pain, something that would increase the speed with which you wanted to work it up weight loss, jaundice blood in the stool fever, shortness of breath and or chest pain and age of symptom onset after 50 years, as that increases the risk of vascular and oncologic diagnoses at this point now that we have an idea of how many diverse causes of chronic abdominal pain, there are. How do we approach a patient in front of us with this symptom, even more so than with most symptoms? The history is extremely important. Ask about the chronology of the pain, including the acuity of onset, how long it’s been present for whether it’s episodic or continuous and if episodic, how frequent and how long are the episodes? Are there any specific triggers or exacerbating factors such as food or activity? Although I mentioned earlier that location of the pain is not as helpful in chronic pain as it is an acute it’s not completely irrelevant, including whether the pain radiates or travels to anywhere else are there associated symptoms, weight loss most ominously suggests malignancy, but it can also be seen in celiac disease, mesenteric, ischemia and median arcuate ligament syndrome, nausea and vomiting are common features of gastritis gastroparesis, chronic, pancreatitis and abdominal migraines. Changes in bowel habits can be seen in any of the luminal gi ideologies. Menstrual irregularities is most suggestive of endometriosis. Fever is suggestive of an inflammatory disorder. Jaundice points towards biliary pathology, including pancreatic cancer, and both chest pain and dyspnea, occurring with episodic abdominal pain, suggest coronary artery disease, particularly if the symptoms are exertional. In addition to the history of present illness, ask about past medical surgical and for women. Gynecologic history ask about medication, use particularly opiates and other substances. Sexual history, among other things, could reveal risk factors for public inflammatory disease, but also painful intercourse is a manifestation of endometriosis family. History is important, as some diseases of chronic abdominal pain are caused by single gene mutations such as familial mediterranean fever and hereditary angioedema, but other diseases have a more complex relationship with genetics. Last are psychosocial factors, for example, abuse or intimate partner, violence which may result in somatization presenting as abdominal pain, and while I would be very hesitant to label psychiatric disease as the underlying principal cause of chronic abdominal pain. It can certainly modulate a patient’s experience of pain, potentially changing how different historical features should be weighed when developing a differential diagnosis moving to the physical exam. Unfortunately, it’s not particularly helpful for the evaluation of chronic abdomi nal pain, with a few notable exceptions. So if a patient’s history is specifically suggesting a disease that is associated with a specific physical finding, of course, look for them, but for the patient, whose history is non-specific, the focused exam that I would advocate for includes just the vitals, an abdominal exam plus or minus a rectal exam, depending on the presence of weight, loss or hematokesia, or the suggestion of fecal impaction, a lymph node exam which may be abnormal due to malignancy, including lymphoma, a pelvic exam in some, but not necessarily all women. If the history is entirely inconsistent with a gynecologic cause and a cardiac exam, if cardiovascular risk factors are present, key labs include a cbc looking for anemia due to blood loss or nutritional deficiencies or leukocytosis due to systemic inflammation, abnormal liver function. Tests might point towards a hepatobiliary or pancreatic etiology, a calci level to quickly rule out hypercalcemia, though hypocalcemia from vitamin d deficiency can also be seen in malabsorption. A hemoglobin a1c to screen for diabetes as diabetes is the most common cause of gastroparesis and a vascular risk factor in the event that the patient is a woman of child-bearing age and the pain has only been present for a few months. A pregnancy test is also a good idea, notably while I think most clinicians, including myself, would order a basic metabolic panel here to evaluate the other electrolytes as well as kidney function. It’s kind of hard to say what specific etiology of chronic pain, chronic, abdominal pain. A basic metabolic panel would help to rule in or rule out. In my experience, these so-called key labs are usually not diagnostic, which brings us to the other common tests, of which there are two categories usually done in the following order: imaging meaning either ct or ultrasound, which can help diagnose, non-luminal gi disease as well as gynecologic disease, and a few miscellaneous causes like hernias and retroperitoneal fibrosis and endoscopy, meaning an egd from above or colonoscopy from below, which can help diagnose many causes of luminal gi disease. Now, which imaging study which endoscopic procedure a patient has depends on the nature of their symptoms, presence of risk factors for certain diseases and in the case of imaging a little bit on their age, since we generally try to spare younger patients avoidable radiation. That would come with like a ct scan, speaking of which an important and often overlooked point if imaging and endoscopy are initially negative or unremarkable. Repeating them at an arbitrary point in the future is usually not helpful unless the patient’s symptoms have significantly changed, which would include progressive weight loss, I’m going to return to the diagnostic framework just for a moment to point out which of these many diagnoses can usually be made from history exam, and the tests already mentioned it’s a little less than half, though this does include most of the most common etiologies. However, it still leaves a lot left over. How do we diagnose the diagnoses that remain? We need to use clues from the history to suggest specific diagnoses, each of which has a relatively unique confirmatory diagnostic test of the diagnoses left on the screen, I’m going to go through the dozen or so that I find to be the most commonly discussed. The combination of diarrhea statoria, which means greasy unusually foul-smelling stools and nutritional deficiencies suggest celiac disease, which is diagnosed via a blood test for iga anti-tissue transglutaminase, sometimes also with a small bowel biopsy taken during endoscopy. Prominent postprandial, nausea and vomiting is suggestive of gastroparesis, which is diagnosed with a gastric emptying scan in which patients literally eat radioactive food and then detectors time how long it takes the radioactivity to pass from the stomach into the small intestine. Any combination of dysmenorrhea, dysparenia or painful intercourse, infertility, bowel and or bladder dysfunction and fatigue suggest endometriosis, which is diagnosed via a combination of pelvic exam, pelvic, ultrasound and sometimes laparoscopy with biopsy. If on exam, the patient has maximal abdominal tenderness confined to a very small area along the edge of the rectus sheath. Importantly, without any other potential gi symptoms, it suggests anterior, cutaneous nerve, entrapment syndrome. This is diagnosed with a physical exam. Maneuver called the carnet test, along with a diagnostic trigger point injection. If the pain and tenderness markedly improves after application of a local anesthetic, it is highly consistent with a source of pain within the abdominal wall. Postprandial epigastric pain, lasting for one to two hours, accompanied by weight loss, can suggest either chronic mesenteric, ischemia or median arcuate ligament syndrome. The major historical distinction between the two is that patients with the former tend to be older and have cardiovascular risk factors both of these can be diagnosed with either a ct, angiogram or duplex ultrasound of the abdomen, though, be sure to specify the suspected disease at the time. The study is ordered in order to ensure that the radiologist focuses their interpretation on the celiac artery. The combination of bloating, flatulence and chronic watery diarrhea, while also consistent with celiac disease and ibs, is also classic for small intestinal bacterial overgrowth diagnosable via a carbohydrate breath test or jejunal aspirate culture. If the pain is located in either the epigastr and or the right upper quadrant, and consists of discrete episodes lasting 30 minutes to several hours. That’s consistent with sphincter of od dysfunction, which is diagnosed with a specialized form of mri called mrcp and sphincter of od manometry, which the pressure within the sphincter is directly measured during an endoscopic procedure called an ercp if episodes last days to weeks. There is no abdominal tenderness, but there are concurrent neurologic findings that suggests acute intermittent porphyria, the diagnosis of which can be confirmed with measuring urine porphyrins if the episodes last one to three days and are accompanied by fever, peritoneal science on exam and erysipelas like erythema, that’s classic for a familial mediterranean fever, which is primarily a clinical diagnosis, supported by genetic testing. If episodes last one to three days and are accompanied by cutaneous angioedema, that’s consistent with hereditary angioedema, confirmed with complement testing and last if episodes of pain are accompanied by a constellation of flushing, diarrhea, rhinorrhea, bronchoconstriction, presyncope and hypotension. That’s highly suggestive of a mast cell disorder, which can be diagnosed by comparing a baseline, ser tryptase with one drawn shortly after onset of an episode. So that’s an overview of the etiologies and evaluation of chronic abdominal pain. It’s not going to explain every single patient presentation, but it hopefully gives you a place to start. One final point: to make many cases of chronic abdominal pain start with a presentation of acute abdominal pain, in other words, the first one or two or more episodes of an eventually chronic disease are already severe enough to bring a patient in to seek medical attention. Unfortunately, because there is so little overlap between the etiologies of chronic abdominal pain and the classically taught etiologies of acute abdominal pain. Most of these will be misdiagnosed. Sometimes it’s because clinicians make a legitimate preventable mistake. Sometimes it’s because the clinician wasn’t taught the actual etiology during training, because, as I mentioned before, many causes of chronic pain are underemphasized in school, but I think that most often these diagnoses are just hard to make until there has been a sufficient amount of time to have elapsed before a pattern to the pain becomes evident or for additional symptoms to have developed. This is a large part of the frustration with chronic abdominal pain that both clinicians and patients have like, but I think the take-home message is t hat for any patients watching this, if the cause of your pain hasn’t been figured out, yet don’t despair or give up. Just because you haven’t gotten a diagnosis yet doesn’t mean that the correct diagnosis is not forthcoming. The key takeaway points of the video common etiologies of chronic abdominal pain that are in the gi system include gastritis peptic, ulcer disease, constipation and ibs, and those in the female reproductive system include endometriosis, ovarian, cysts, menstrual, cramps and ovulation pain. The history is the most important part of the evaluation, but most patients will also receive ct and or ultrasound, plus, egd and or colonoscopy among patients lacking a diagnosis after routine labs, imaging and endoscopy the history, and rarely the exam will provide clues for additional specialized testing and last most patients with chronic abdominal pain, will start with one or more presentations to the healthcare system for acute abdominal pain, which will often be misdiagnosed until the chronicity pattern of episodes and associated symptoms are more clearly established. That’s it for this video on an approach to chronic abdominal pain, consider checking out the accompanying video on an approach to acute abdominal pain and consider subscribing for more videos on a variety of medical topics.
What users commented:
Excellent presentation. Thank you .
Wow i was watching Acute abdominal pain on your channel B4 20minutes ago
What about stool tests for H. Pylori antigen? Faecal elastase test? Or faecal calprotectin for IBD? Urea breath test? Useful tests prior to imaging.
thank you so much
This is a great video. Thank you
Thank you Eric.