Introduction
Chronic abdominal pain—lasting for weeks, months, or even years—can arise from a range of conditions, from benign bowel disorders to life-threatening diseases. This in-depth guide breaks down causes by region, key red flags, and essential diagnostic steps.
What is Chronic Abdominal Pain?
- Pain lasting >3 months, intermittent or constant
- Often associated with GI, hepatobiliary, renal, or gynecological systems
- May fluctuate or follow a post-meal, menstrual, or stress-related pattern
Key Clinical Insights
- Back pain suggests retroperitoneal origin (e.g., pancreas, kidney)
- Pelvic pain points to ovarian, uterine, or bladder issues
- Relationship to food may indicate ulcer, gallstones, or mesenteric angina
- Pain with bowel habits → IBS, colitis, obstruction
Causes of Chronic Abdominal Pain by Region
Right Upper Quadrant (RUQ)
- Hepatitis (viral, alcoholic)
- Hepatic tumour
- Hepatic abscess
- Pyelonephritis
- Empyema of gallbladder
- Appendix abscess
Epigastric Region
- Gastritis
- Peptic ulcers (gastric, duodenal)
- Oesophagitis
- Pancreatitis (chronic)
- Pancreatic cancer
- Carcinoma of the stomach
Left Upper Quadrant (LUQ)
- Pancreatitis
- Pyelonephritis
Right Iliac Fossa (RIF)
- Crohn’s disease
- Appendix abscess
- Caecal carcinoma
- Tuberculosis
- Ovarian cyst
Left Iliac Fossa (LIF)
- Diverticulitis
- Colitis
- Irritable bowel syndrome (IBS)
- Ovarian cyst
Central Abdomen
- Mesenteric ischaemia
- Adhesions
- Meckel’s diverticulum
- Crohn’s disease
- Retroperitoneal fibrosis
- Lymphoma
- Small bowel tumour
- Aortic aneurysm
Suprapubic Region
- Diverticulitis
- Uterine fibroid
- Ovarian cyst
- Cystitis
- Appendix abscess
Functional vs Organic Pain
| Feature | Functional (e.g. IBS) | Organic (e.g. malignancy, inflammation) |
|---|---|---|
| Onset | Gradual | Sudden or progressive |
| Triggers | Stress, diet | Inflammation, obstruction |
| Exam findings | Usually normal | Local tenderness, masses |
| Labs/imaging | Normal | Abnormal (e.g., anemia, imaging lesions) |
| Treatment | Lifestyle, diet, reassurance | Etiology-specific |
Red Flags in Chronic Abdominal Pain
- Blood in stool
- Weight loss
- Nocturnal pain
- Anemia
- New onset >50 years
- Palpable abdominal mass
- Positive family history of GI cancers
Irritable Bowel Syndrome
- Colicky pain, bloating, diarrhea or constipation
- No blood, weight loss, or abnormal exam
- Rule out other causes before diagnosing IBS
Adhesional Pain
- Post-surgical complication
- Causes recurrent incomplete small bowel obstruction
- Diagnosis of exclusion
- Treatment may include adhesiolysis if persistent
Chronic Incomplete Bowel Obstruction
- Recurrent colicky pain, nausea, bloating
- May be due to adhesions, tumors, Crohn’s
- Often self-limiting but needs evaluation
Mesenteric Angina
- Postprandial pain in elderly
- Weight loss, fear of eating
- Caused by atherosclerotic narrowing of mesenteric vessels
- Best test: CT angiography
Meckel’s Diverticulum
- Rare, but important cause in young adults
- Intermittent central pain
- Occult GI bleeding, anemia
- Best test: Technetium-99m pertechnetate scan
Investigations for Chronic Abdominal Pain
| Test | Purpose |
|---|---|
| FBC | Anemia, infection, malignancy |
| LFTs | Hepatitis, liver mass, gallstones |
| MSU | UTI, renal stones |
| FOBT | Occult GI bleeding |
| ECG | Ischemic heart pain |
| Abdominal X-ray | Obstruction, calcifications |
| Ultrasound | Cysts, liver, kidneys, appendiceal abscess |
| Colonoscopy | IBD, colorectal cancer, ischaemia |
| CT scan | Tumors, fibrosis, chronic pancreatitis |
| Barium enema | Strictures, colitis |
| OGD | Ulcer, gastritis, carcinoma |
| ERCP | Pancreatic cancer, chronic pancreatitis |
| IVU | Urinary tract obstruction |
| Small bowel enema | Crohn’s, strictures, Meckel’s |
| Radionuclide scan | Meckel’s diverticulum |
Management Based on Cause
1. IBS
- Fiber, probiotics, antispasmodics
- Avoid FODMAPs
- Psychological support
2. Ulcers / Gastritis
- PPI therapy
- H. pylori eradication
- Avoid NSAIDs
3. Pancreatitis
- Pain control
- Enzyme replacement
- Alcohol cessation
4. Crohn’s Disease
- Steroids, immunomodulators
- Surgery for strictures or abscess
5. Gynecological Causes
- Hormonal therapy
- Surgery for fibroids, ovarian cysts
6. Cancer
- Referral, staging, surgical or oncological treatment
FAQs About Chronic Abdominal Pain
When should chronic abdominal pain be investigated?
Any persistent or unexplained pain beyond a few weeks needs investigation, especially with red flags.
Is IBS dangerous?
No, but other dangerous causes must be ruled out first.
Can cancer present only with abdominal pain?
Yes—especially stomach, pancreatic, or colon cancers in early stages.
Are imaging scans always needed?
Not in typical IBS, but red flag symptoms always require imaging and labs.
What’s the role of food intolerance in chronic pain?
Lactose, gluten, and FODMAP intolerance can trigger symptoms; elimination diets help identify them.
Conclusion
Chronic abdominal pain is a diagnostic puzzle—one that demands careful regional evaluation, red flag screening, and appropriate testing. From IBS to cancer, identifying the correct cause is key to relief and recovery.
