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by James M. Stewart, MD

Abdominal pain is one of the most common complaints a gastroenterologist hears in daily practice. Evaluating abdominal pain is complicated and often involves looking for patterns. The first place to start is with some questions about the pain.

Common questions include:

• When did the pain start? Whether a patient’s pain has been present acutely (starting within the last month) or chronically (starting months to years ago) helps narrow the diagnosis.

• Where does it hurt? Some abdominal pain stays in one part of the abdomen, such as just above the right hipbone (appendicitis) or under the right ribs (gallbladder disease). Other pains may migrate around the abdomen or be very difficult to localize to one spot.

• Does it ever go away? Most pains will come and go but some pains are consistent for long periods of time.

• Is there anything that a patient can do to make the pain better or worse? Is it associated with eating or defecating? Is it worse during the morning or night? Is it exercise or position-related?

• Are there any other symptoms present at the same time as the pain, such as diarrhea or nausea? This can help a physician figure out which part of the gastrointestinal tract is involved.

A physician’s physical exam focuses on palpating places in the abdomen to feel for masses or lumps that may provide clues. The physician is also trying to see if pressure will increase the pain. At the physician’s discretion, further physical exam aids include tapping on the abdomen to listen for trapped air or listening to the bowel sounds within the abdomen.

Bloodwork may be ordered to evaluate for abdominal pain. The physician will often combine physical exam, bloodwork, and the patient’s history with other diagnostic testing to find the cause or to suggest a treatment regimen.

If the physician believes that the pain is coming from the intestinal tract they may use an endoscopy to diagnose abdominal pain. An upper endoscopy is an evaluation through the mouth that looks at the esophagus, stomach, and the first several inches of the small intestine (the duodenum). A lower endoscopy, or colonoscopy, primarily evaluates the large intestine and a little of the very end of the small intestines. Biopsies can be taken during an endoscopy, which can be analyzed under a microscope to provide guidance regarding the pain.

Additional tests include 3D imaging of the abdomen, often done with a CT scan or with an ultrasound or MRI machine. These exams look under the skin and muscles of the abdomen to the organs underneath and see if anything looks unusual about them.

Sometimes, even after all of this testing, there is no obvious source of the abdominal pain. It can be frustrating for patients to not have a definitive cause for the pain.

At this point, a physician and patient discuss the pros and cons of medication, supplement trials or dietary approaches to aid the body. Sometimes, psychotherapy can be helpful if stress or anxiety are manifesting as abdominal pain. It takes patience and sometimes trial and error to find something that helps alleviate the pain. Since opiate-based pain medications can worsen gastrointestinal symptoms and pain, gastroenterologists very rarely use these medications.

Determining the cause of your abdominal pain can be a process, but one well worth discussing with your gastroenterologist to alleviate pain, discomfort and its interruptions to living your life well.

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