The clinical evaluation of abdominal pain in adults

Abdominal pain represents a diagnostic and therapeutic challenge for the gastroenterologist and the general physician. An accurate history and diagnostic framework are essential to ensure that serious physical illness is not missed, and that psychological causes of abdominal pain are not reinforced by excessive investigation. Understanding of the pathophysiology of abdominal pain, and its common presentations, allows the skilled physician to quickly establish the diagnosis. Visceral pain is typically poorly localized, unlike somatic pain, which is well localized and sharp in nature, typically reflecting inflammation of the pleura, peritoneum or diaphragm. Referred pain is felt distant from the affected organ due to activation of dermatomal somatic nerves. This article focuses on the diagnosis and management of acute abdominal pain, and explains common presentations, including hepatobiliary, epigastric, pancreatic and lower abdominal pain. Although in most cases this diagnostic approach will provide the physician with the likely diagnosis, there are several groups of patients, including the elderly and immunosuppressed, in whom this approach is inadequate. By being alert to the atypical presentations described, these challenging patients can be successfully managed.