Causes of Gastric Pain

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Whether it is a mild stomachache, sharp pain or stomach cramps, abdominal pain has numerous. These include:

• Inflammatory – gastroenteritis, appendicitis, gastritis, esophagitis, diverticulitis, Crohn’s disease, ulcerative colitis, microscopic colitis
• Obstruction – a hernia, intussusception, volvulus, post-surgical adhesions, tumors, severe constipation, hemorrhoids
• Vascular –  embolism, thrombosis, hemorrhage, sickle cell disease, abdominal angina, blood vessel compression (such as celiac artery compression syndrome), superior mesenteric artery syndrome, postural orthostatic tachycardia syndrome
• Digestive – peptic ulcer, lactose intolerance, coeliac disease, food allergies

Glands

Bile system

• Inflammatory: cholecystitis, cholangitis
• Obstruction: cholelithiasis, tumors

Liver

• Inflammatory: hepatitis, liver abscess

Pancreatic

• Inflammatory: pancreatitis

Renal and urological

• Inflammation: pyelonephritis, bladder infection, indigestion
• Obstruction: kidney stones, urolithiasis, urinary retention, tumors
• 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)

• Physical examination
• Laboratory tests — complete blood count (CBC), liver enzymes, pancreatic enzymes (amylase and lipase), pregnancy, and urinalysis tests
• Plain X-rays of the abdomen
• Radiographic studies
• Ultrasound
• Computerized tomography (CT) of the abdomen (this includes all organs and the intestines)
• Magnetic resonance imaging (MRI)
• Barium X-rays
• Capsule endoscopy
• Endoscopic procedures, including esophagogastroduodenoscopy or EGD
• Colonoscopy or flexible sigmoidoscopy
• Endoscopic ultrasound (EUS)

Laboratory tests

Laboratory tests such as the complete blood count (CBC), liver enzymes, pancreatic enzymes (amylase and lipase), pregnancy test and urinalysis are frequently ordered.

• An elevated white count suggests inflammation or infection (as with appendicitis, pancreatitis, diverticulitis, or colitis).
• A low red blood cell count may indicate a bleed in the intestines.
• Amylase and lipase (enzymes produced by the pancreas) commonly are elevated in pancreatitis.
• Liver enzymes may be elevated with gallstone attacks or acute hepatitis.
• Blood in the urine suggests kidney stones.
• When there is diarrhea, white blood cells in the stool suggest intestinal inflammation or infection.
• A positive pregnancy test may indicate an ectopic pregnancy (a pregnancy in the fallopian tube instead of the uterus).

Plain X-rays of the abdomen

• Plain X-rays of the abdomen also are referred to as a KUB (because they include the kidney, ureter, and bladder). The KUB may show enlarged loops of intestines filled with copious amounts of fluid and air when there is an intestinal obstruction.
• Patients with a perforated ulcer may have air escape from the stomach into the abdominal cavity. The escaped air often can be seen on a KUB on the underside of the diaphragm. Sometimes a KUB may reveal a calcified kidney stone that has passed into the ureter and resulted in referred abdominal pain or calcifications in the pancreas that suggests chronic pancreatitis.

Radiographic studies

• Ultrasound – is useful in diagnosing gallstones, cholecystitis appendicitis, or ruptured ovarian cysts as the cause of the pain.
• Computerized Tomography (CT) of the abdomen – is useful in diagnosing pancreatitis, pancreatic cancer, appendicitis, and diverticulitis, as well as in diagnosing abscesses in the abdomen. Special CT scans of the abdominal blood vessels can detect diseases of the arteries that block the flow of blood to the abdominal organs.
• Magnetic Resonance Imaging (MRI) – is useful in diagnosing many of the same conditions as CT tomography.
• Barium X-rays – of the stomach and the intestines (upper gastrointestinal series or UGI with a small bowel follow-through) can be helpful in diagnosing ulcers, inflammation, and blockage in the intestines.
• Computerized Tomography (CT) of the small intestine – can be helpful in diagnosing diseases in the small bowel such as Crohn’s disease.
• Capsule Enteroscopy – uses a small camera the size of a pill swallowed by the patient, which can take pictures of the entire small bowel and transmit the pictures onto a portable receiver. The small bowel images can be downloaded from the receiver onto a computer to be inspected by a doctor later. Capsule enteroscopy can be helpful in diagnosing Crohn’s disease, small bowel tumors, and bleeding lesions not seen on x-rays or CT scans.

Endoscopic procedures

• Esophagogastroduodenoscopy or EGD is useful for detecting ulcers, gastritis (inflammation of the stomach), or stomach cancer.
• Colonoscopy or flexible sigmoidoscopy is useful for diagnosing infectious colitis, ulcerative colitis, or colon cancer.
• Endoscopic ultrasound (EUS) is useful for diagnosing pancreatic cancer or gallstones if the standard ultrasound or CT or MRI scans fail to detect them.
• Balloon enteroscopy, the newest technique allows endoscopes to be passed through the mouth or anus and into the small intestine where small intestinal causes of pain or bleeding can be diagnosed, biopsied, and treated.
• Carnett’s sign – Abdominal wall tenderness can be caused by trauma, and with increasing numbers of patients on therapeutic anticoagulation, abdominal wall hematoma. The following technique, described by Carnett in 1926, may confirm the abdominal wall as the source of the patient’s pain. The point of maximal pain is identified, and this is palpated with the abdomen wall relaxed and then tensed through the performance of a half sit-up with the arms crossed. Increased pain with the wall tensed is a positive sign of abdominal wall pathology, a decrease in pain is considered a negative test. When prospectively applied in 120 patients, the test was positive in 24, with only one having an intra-abdominal pathologic condition.[Rx]Others have found it less accurate but still useful.[Rx] This test should not be routinely applied but is considered when there is a supportive history and absence of indicators of other illness.[Rx]
• Cough test – Originally described by Rostovzev in 1909, this test seeks evidence of peritoneal irritation by having the patient cough.[Rx] Jeddy and colleagues[Rx] described a positive test as a cough causing a sharp, localized pain. They applied this prospectively to patients with right lower quadrant pain and found it to have near perfect sensitivity with a specificity of 95% for the detection of appendicitis or peritonitis (one patient with perforated diverticulitis). Bennett and colleagues[Rx] consider signs of pain on coughing such as flinching, grimacing, or moving of hands to the abdomen as a positive test and reported a sensitivity of 78% with a specificity of 79% for the detection of peritonitis in a prospective study of 150 consecutive patients with abdominal pain.
• Closed eyes sign – Based on the assumption that the patient with an acute abdominal condition will carefully watch the examiner’s hands to avoid unnecessary pain, this test is considered an indicator of the nonorganic cause of abdominal pain. The test is considered positive if the patient keeps their eyes closed when abdominal tenderness is elicited. In a prospective study of 158 patients, Gray and colleagues[Rx] found that 79% of the 28 patients who closed their eyes did not have identifiable organic pathology.
• Murphy’s sign – Murphy described the cessation of inspiration in cholecystitis when the examiner curled their fingers below the anterior right costal margin from above the patient.[Rx] Now most commonly performed from the patient’s side, inspiratory arrest while deeply palpating the right upper quadrant is the most reliable clinical indicator of cholecystitis, although it only has a sensitivity of 65%.[Rx]
• The psoas sign – The psoas sign is provoked by having the supine patient lift the thigh against hand resistance, or with the patient laying on their contralateral side and the hip joint passively extended. Increased pain suggests irritation of the psoas muscle by an inflammatory process contiguous to the muscle. When positive on the right, this is a classic sign suggestive of appendicitis. Other inflammatory conditions involving the retroperitoneum, including pyelonephritis, pancreatitis, and psoas abscess, will also elicit this sign.
• The obturator sign – The obturator sign is elicited with the patient supine and the examiner supporting the patient’s lower extremity with the hip and knee both flexed to 90 degrees. The sign is positive if passive internal and external rotation of the hip causes reproduction of pain, and suggests the presence of an inflammatory process adjacent to the muscle deep in the lateral walls of the pelvis. Potential diagnoses include pelvic appendicitis (on the right only), sigmoid diverticulitis, pelvic inflammatory disease, or ectopic pregnancy.
• The Rovsing sign – The Rovsing sign is a classic test used in the diagnosis of appendicitis. It is a form of indirect rebound testing in which the examiner applies pressure in the left lower quadrant, remote from the usual area of appendiceal pain and tenderness. The test is positive if the patient reports rebound pain in the right lower quadrant when the examiner releases pressure.[Rx] In limited studies, the psoas, obturator, and Rovsing signs demonstrate a low sensitivity (15%–35%) but a relatively high specificity (85%–95%) for appendicitis.[Rx],[Rx]

Treatments of Abdominal Pain

• Over-the-counter pain relievers
• Prescription medications for inflammation, GERD, ulcers, or general pain
• Antibiotics
• Anti ulcerant
• Low-dose antidepressants
• low doses of an anti-hormonal drug
• Enzymatic drug for constipation
• Changes in behavior, including the elimination of certain foods or beverages that may be contributing to abdominal pain
• Surgery to remove intestinal blockages, hernia, or infected organs.

Medications

There are several medications that can be used to treat GERD. They include:

• Over-the-counter acid buffers — Buffers neutralize the acid. They include Mylanta, Maalox, Tums, Rolaids, and Gaviscon. The liquid forms of these medications work faster But the tablets may be more convenient. Antacids that contain magnesium can cause diarrhea. And antacids that contain aluminum can cause constipation. Your doctor may advise you to alternate antacids to avoid these problems. These medicines work for a short time and they do not heal the inflammation of the esophagus.
• Over-the-counter proton pump inhibitors — Proton pump inhibitors shut off the stomach’s acid production. Proton pump inhibitors are very effective. They can be especially helpful in patients who do not respond to H2 blockers and antacids. These drugs are more potent acid-blockers than are H2 blockers, but they take longer to begin their effect.
• Proton pump inhibitors – should not be combined with an H2 blocker. The H2 blocker can prevent the proton pump inhibitor from working. These are prescribed at higher doses than those available in over-the-counter forms.
• Motility drugs – These medications may help to decrease esophageal reflux. But they are not usually used as the only treatment for GERD. They help the stomach empty faster, which decreases the amount of time during which reflux can occur.
• Mucosal protectors – These medications coat, soothe and protect the irritated esophageal lining. One example is sucralfate (Carafate).

Over-the-counter and prescription medicines

You can buy many GERD medicines without a prescription. However, if you have symptoms that will not go away, you should see your doctor.

• Antacids – Doctors often first recommend antacids to relieve heartburn and other mild GER and GERD symptoms. Antacids include over-the-counter medicines such as. Antacids can have side effects, including diarrhea and constipation.

H2 blockers – H2 blockers decrease acid production. They provide short-term or on-demand relief for many people with GER and GERD symptoms. They can also help heal the esophagus, although not as well as other medicines. You can buy H2 blockers over-the-counter or your doctor can prescribe one. Types of H2 blockers include

• cimetidine 
• famotidine 
• nizatidine 
• ranitidine 

Proton pump inhibitors (PPIs) – PPIs lower the amount of acid your stomach makes. PPIs are better at treating GERD symptoms than H2 blockers. They can heal the esophageal lining in most people with GERD. Doctors often prescribe PPIs for long-term GERD treatment. Such as

• Esomeprazole 
• Lansoprazole 
• Omeprazole 
• Pantoprazole 
• Rabeprazole 

Talk with your doctor about taking lower-strength omeprazole or lansoprazole, sold over the counter.

Antibiotics – Antibiotics, including erythromycin, can help your stomach empty faster. Erythromycin has fewer side effects than prokinetics; however, it can cause diarrhea.

Prokinetics – Prokinetics help your stomach empty faster. Prescription prokinetics include

• bethanechol 
• metoclopramide

Taking Care of Yourself at Home

Most abdominal pain goes away without special treatment. Be guided by your doctor, but there are some things you can do to help ease the pain, including:

• Place a hot water bottle or heated wheat bag on your abdomen.
• Soak in a warm bath. Take care not to scald yourself.
• Drink plenty of clear fluids such as water.
• Reduce your intake of coffee, te, and alcohol as these can make the pain worse.
• When you are allowed to eat again, start with clear liquids, then progress to bland foods such as crackers, rice, bananas or toast. Your doctor may advise you to avoid certain foods.
• Get plenty of rest.
• Try over-the-counter antacids, to help reduce some types of pain.
• Take mild painkillers such as paracetamol. Please check the packet for the right dose. Avoid aspirin or anti-inflammatory drugs unless advised to take them by a doctor. These drugs can make some types of abdominal pain worse.

Home Treatment