Chronic/Recurrent Abdominal Pain in Adults

Differential Diagnosis

Common Diagnoses

Rare Diagnoses

  • Mesenteric Artery Ischaemia (Abdominal Angina)
  • Chronic Pancreatitis
  • Subacute Obstruction (Adhesions, Malignancy and Diverticulitis)
  • Functional (Psychogenic) Abdominal Pain
  • Malignancy
  • Metabolic Causes, e.g. Addison’s Disease, Porphyria, Lead Poisoning

Ready Reckoner

Key distinguishing features of the most common diagnoses

High Abdominal PainPossibleNoYesPossiblePossible
Weight LossNoPossiblePossibleNoNo
Rectal BleedingNoNoNoPossiblePossible

Possible Investigations

Likely:Urinalysis, FBC, ESR/CRP, MSU, H. pylori testing

Possible:U&E, LFT, amylase, coeliac screen, CA-125, FIT, faecal calprotectin, plain abdominal X-ray, ultrasound, renal imaging, hospital-based lower GI investigations, gastroscopy.

Small Print:Specialised investigations such as mesenteric angiography and further tests for rare medical causes.

  • Urinalysis: Blood alone with stone; blood, pus cells and nitrite in UTI.
  • MSU: To confirm urinary infection and guide treatment.
  • FBC and ESR/CRP: May suggest inflammatory bowel disease, PU or malignancy. Raised platelets associated with oesophageal or stomach cancer.
  • U&E may be deranged in hydronephrosis, renal stones or Addison’s disease.
  • LFT and amylase: LFT may be abnormal if carcinoma present. Amylase may be raised in pancreatitis and bowel ischaemia.
  • Coeliac screen: Anti-endomysial and anti-gliadin antibodies – suggest coeliac disease if positive.
  • CA-125: Especially in women aged 50 or more, may help exclude ovarian cancer.
  • H. pylori testing: Strong association with peptic ulcer disease.
  • FIT: A useful colorectal cancer ‘rule out’ test in patients at low risk. Also commonly required now when arranging a two-week referral to help secondary care stratify urgency of investigation.
  • Faecal calprotectin: To help rule out inflammatory bowel disease, especially if recurrent or persistent diarrhoea is also a feature.
  • Plain abdominal X-ray: May reveal constipation, subacute obstruction or kidney stones.
  • Renal imaging: For renal stones or recurrent UTI.
  • Ultrasound: Will show hydronephrosis and gallstones. Pelvic/abdominal ultrasound also indicated if CA-125 elevated.
  • Hospital-based lower GI investigations: For various lower bowel disorders.
  • Gastroscopy: May be required to confirm PU and exclude gastric carcinoma.
  • Further tests such as angiography (for mesenteric ischaemia) or investigations for rare medical causes may be arranged after specialist referral.

Top Tips

  • Simply establishing what provokes or relieves the problem can provide helpful pointers – pain occurring after eating suggests gallstones, PU, gastric carcinoma or mesenteric ischaemia; if relieved by defecation, the likely diagnoses are IBS or constipation.
  • In an otherwise well patient, the longer the history the less likely there is to be significant underlying disease.
  • Avoid repeated investigation if a patient has already been thoroughly assessed in the past – unless the individual becomes unwell or develops new symptoms. Be frank with the patient by explaining about the ‘law of diminishing returns’ in investigating chronic unexplained abdominal pain.
  • Be prepared to make a positive diagnosis of IBS in a fit young patient if the symptoms are classical and basic investigations are negative; explanation and education are the keys to effective management.

Red Flags

  • Weight loss in association with recurrent abdominal pain suggests significant pathology.
  • Hard enlarged left supraclavicular nodes (Troisier’s sign) are pathognomic of gastric carcinoma.
  • Beware that constipation itself is often a symptom rather than a diagnosis. Be sure to establish and treat any underlying cause if it doesn’t respond to simple treatment.
  • IBS is the commonest diagnosis – but consider other possibilities if the pain is always in the same site, wakes the patient at night or is associated with rectal bleeding or weight loss.
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