Chronic abdominal pain is pain that is present for more than 3 months. It may be present all the time (chronic) or come and go (recurring). Chronic abdominal pain can occur in children any time after age 5 years. Some children aged 5 to 16 years, particularly those aged 8 to 12 years, have chronic or recurring abdominal pain. It is somewhat more common among girls. Chronic abdominal pain is also common among adults, affecting women more often than men.
People with chronic abdominal pain may also have other symptoms, depending on the cause.
Causes of Chronic or Recurring Abdominal Pain
Usually by the time abdominal pain has been present for 3 months or more, people have been evaluated by a doctor, and typical disorders that cause acute abdominal pain have already been identified. If people have been evaluated and the cause has not been identified by this time, only a minority of them have a specific physical disorder (see table Physical Causes and Features of Chronic Abdominal Pain). The majority has what is called centrally mediated abdominal pain syndrome (previously known as functional abdominal pain).
Centrally mediated abdominal pain syndrome causes real pain that exists for more than 6 months and occurs with no evidence of a specific physical disorder or other gastrointestinal problem (for example, peptic ulcer disease). It is also not related to a medication or a toxin and does not alter bowel habits (such as constipation or diarrhea). (When abdominal pain occurs in people who have altered bowel habits, it is called irritable bowel syndrome [IBS].) The pain can be severe and typically interferes with the person's life. Exactly what causes the pain is unknown. But the nerves of the digestive tract and brain-gut axis may become oversensitive to sensations (such as normal movements of the digestive tract), which do not bother most people. Genetic factors, life stresses, personality, social situations, and underlying mental disorders (such as depression or anxiety) may all contribute to the pain. Chronic abdominal pain in children may be related to a need for attention (as when a sibling is born or the family moves), the stress of starting school, lactose intolerance, or sometimes child abuse.
Common physical causes
Many physical disorders cause chronic abdominal pain (see table Physical Causes and Features of Chronic Abdominal Pain). The most common causes vary by age.
In children, the most common causes are
Lactose intolerance (lactose is a sugar in dairy products)
In young adults, common causes include
Indigestion (dyspepsia) due to peptic ulcer or medications such as aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs)
Stomach irritation (caused by aspirin or NSAIDs, cola beverages [acidity], and spicy foods)
Gallbladder disorders, such as cholecystitis
Parasitic infections, such as giardiasis
Inflammatory bowel disease, such as Crohn disease
In older adults, cancer (such as stomach, pancreatic, colon, or ovarian cancer) becomes more common.
Evaluation of Chronic or Recurring Abdominal Pain
Doctors first focus on whether the pain is functional pain or is caused by a disorder, medication, or toxin. Making this distinction may be difficult. However, if warning signs are present, functional pain is unlikely (but not impossible).
Warning signs
The following symptoms are cause for concern:
Fever
Loss of appetite and weight
Pain that awakens the person from sleep
Blood in vomit, stool, or urine
Severe or frequent vomiting
Jaundice (yellowing of the skin and whites of the eyes)
Swelling of the abdomen and/or legs
When to see a doctor
If people with chronic abdominal pain develop warning signs, they should see a doctor right away unless the only warning signs are loss of appetite, jaundice, and/or swelling.
People with loss of appetite, jaundice, and/or swelling or with steady, worsening pain should see a doctor within a few days.
When warning signs are present, a physical cause is very likely.
People without warning signs should see a doctor at some point, but a delay of a few days or so is not harmful.
What the doctor does
Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the pain and the tests that may need to be done (see table Physical Causes and Features of Chronic Abdominal Pain).
Doctors ask particularly about activities (such as eating, urinating, or having a bowel movement) that relieve or worsen the pain. Whether the pain or other digestive upset occurs after eating or drinking dairy products is important because lactose intolerance is common, especially among people of African, Hispanic, Asian (particularly East Asian countries), and American Indian heritage. Doctors also ask about other symptoms (such as vomiting, diarrhea, or constipation), about diet, and about any surgery involving the abdomen, medications used, and previous tests and treatments for the pain. Whether any family members have disorders that cause abdominal pain is also important.
Doctors also ask about a person's diet because ingesting large amounts of cola beverages, fruit juices (which may contain significant quantities of the sugars fructose and sorbitol), or gas-producing foods (such as beans, onions, cabbage, and cauliflower) can sometimes be the cause of otherwise puzzling abdominal pain.
The physical examination is focused particularly on the abdomen to identify any tender areas, masses, or enlarged organs. Usually, a rectal examination is done, and the doctor tests the stool for blood. A pelvic examination is also done in women.
Doctors note whether the skin looks yellow (jaundice) and whether people have a rash or swelling in the legs.
Between the initial visit and follow-up visits, people are often asked to record information about the pain, bowel movements, diet, any activities that seem to trigger pain, any remedies tried, and the effects of the remedies.
Physical Causes and Features of Chronic Abdominal Pain
Cause* | Common Features† | Tests‡ |
|---|---|---|
Disorders of the digestive tract | ||
In children, not growing as expected (failure to thrive) Abdominal bloating and often diarrhea or light-colored, bulky, and unusually foul-smelling stools that may appear oily Symptoms that worsen when people eat foods containing wheat products (which contain gluten) | Blood tests to measure levels of antibodies produced when people with celiac disease eat foods containing gluten Biopsy of the upper small intestine | |
Cholecystitis (inflammation of the gallbladder), if chronic | Recurring crampy pain in the upper right part of the abdomen | Ultrasonography to look for gallstones |
Usually no discomfort, but if the colon is partially blocked, possibly crampy discomfort Sometimes blood in stool (blood may be visible or detected during a doctor's examination) Weight loss | Imaging tests such as CT of the colon after drinking a contrast agent (CT colonography) | |
Hard, less frequent bowel movements that are difficult to pass Crampy pain in the lower abdomen that decreases after a bowel movement Sometimes pain during a bowel movement | A doctor’s examination, including thorough dietary history | |
Recurring episodes of severe pain with fever, loss of appetite, weight loss, and diarrhea | Colonoscopy Imaging of the small intestine (CT scan, MRI, or CT enterography) | |
Gastroesophageal reflux disease (sometimes related to a hiatus hernia) | Heartburn (burning pain that begins in the upper abdomen and travels up to the throat, sometimes with an acid taste in the mouth) Sometimes chest pain Sometimes a cough, hoarseness, or both Symptoms sometimes worsened by lying down Relief with antacids | Often only a doctor's examination plus trying treatment with medications to suppress acid production (if symptoms are relieved, the cause is probably gastroesophageal reflux disease) Sometimes endoscopy of the upper digestive tract (examination of the esophagus and stomach using a flexible viewing tube), x-rays of the upper digestive tract after barium is given by mouth (barium swallow), or testing for presence of acid reflux with a pH probe |
Bloating, cramps, passing of gas (flatulence), and diarrhea after consuming milk products | Sometimes a breath test to detect hydrogen, indicating undigested lactose A diet that excludes foods containing lactose (elimination diet) to determine whether those foods trigger the symptoms | |
Constant pain in the upper abdomen, often radiating to the back Weight loss Sometimes jaundice | CT MRI/MRCP | |
Pancreatitis, if chronic or accompanied by a pancreatic pseudocyst | Episodes of severe pain in the upper middle of the abdomen Sometimes diarrhea and fat in stool Usually in people known to have had acute pancreatitis | Blood tests to measure levels of an enzyme produced by the pancreas Imaging tests such as CT or MRI/MRCP Stool tests (for chronic pancreatitis) |
Parasitic infections (particularly giardiasis) | Recent travel to developing countries, ingestion of water from streams or lakes, or contact with people with the infection Cramps, flatulence, and diarrhea | Examination of stool to check for parasites or their eggs |
Stomach pain relieved by eating food and taking antacids May awaken people at night May be caused by use of NSAIDs | Endoscopy and biopsy for Helicobacter (H.) pylori (bacteria that can cause peptic ulcers) Sometimes an H. pylori breath test or a stool test | |
Scar tissue that develops around the intestines (adhesions) in people who have had abdominal surgery | Crampy discomfort accompanied by nausea and sometimes vomiting | Upper GI series (x-rays taken of the stomach and small intestine after drinking liquid barium) and other x-rays of the small intestine CT scan |
Indigestion or mild pain Often tiny amounts of blood in stool (detectable only during a doctor's examination) Typically in older adults | Endoscopy of the esophagus and stomach | |
Crampy pain with several separate episodes of bloody diarrhea Typically in young adults | Sigmoidoscopy or colonoscopy Biopsy of the rectum or colon | |
Kidney and urinary tract disorders | ||
Frequent urinary tract infections Typically in children | Intravenous urography or CT Ultrasonography | |
Pain in the side (flank) that comes and goes, often in people known to have stones Sometimes fever Dark or bloody urine | Urinalysis CT or intravenous urography | |
Reproductive system disorders (in women) | ||
Discomfort mainly before or during menstrual periods | Laparoscopy | |
Vague discomfort in the lower abdomen | Ultrasonography of the pelvis | |
Bloating Sometimes a mass in the pelvis detected during a doctor's examination | Ultrasonography of the pelvis | |
Systemic disorders | ||
Recurring attacks of severe abdominal pain and vomiting Sometimes muscle weakness, seizures, and mental disturbances (such as irritation or agitation) In some types of porphyria, blistering of the skin when exposed to sunlight | Urine and blood tests to check for substances (porphyrins) produced during the attacks | |
Cannabis (marijuana) use (cannabinoid hyperemesis syndrome) | Persistent nausea, vomiting, and indigestion Usually develops after longstanding cannabis use Relief after a hot shower or goes away after people stop using marijuana | A doctor's examination Urine drug test |
Family members who have the disorder Episodes of abdominal pain lasting 48 to 72 hours and often accompanied by fever Starting during childhood or adolescence | Genetic testing | |
Symptoms that develop only after eating certain foods such as seafood | An elimination diet | |
Immunoglobulin A–associated vasculitis (formerly Henoch-Schönlein purpura) | A reddish-purple rash of tiny dots (petechiae) or larger splotches (purpura) on the arms, legs, buttocks, and top of the feet Achy, tender, swollen joints Nausea, vomiting, and diarrhea Blood in stool detected during a doctor's examination | Biopsy of affected skin |
Crampy abdominal pain Mental changes such as a reduced attention span, confusion, and altered behavior Loss of appetite, vomiting, and constipation Achy joints Usually only in workers exposed to lead More often in young children who live in houses in which lead-based paint (banned in 1978) or lead pipes may have been used | Blood tests to measure the lead level | |
Severe episodes of abdominal pain lasting over a day Recurring pain in places other than the abdomen, such as the back, chest, arms, and/or legs In Black children who typically have family members with the disorder | Blood tests to check for sickle-shaped red blood cells and for the abnormal hemoglobin that characterizes sickle cell disease | |
* Physical causes are responsible for only about 10% of cases of chronic abdominal pain. Most cases are functional abdominal pain. This table does not include all physical causes of chronic abdominal pain. | ||
† Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present. | ||
‡ For most people with chronic abdominal pain, doctors typically do basic blood and urine tests such as a complete blood cell count, blood tests to evaluate how the liver and pancreas are functioning, and urinalysis. Other tests are done based on results of these tests and the examination. | ||
CT = computed tomography; MRCP = magnetic resonance cholangiopancreatography; MRI = magnetic resonance imaging; NSAIDs = nonsteroidal inflammatory drugs. | ||
Testing
Usually, doctors do certain tests. These tests include urinalysis, a complete blood cell count, and blood tests to evaluate how the liver, kidneys, and pancreas are functioning. Usually if people are over 45 or have risk factors for colon cancer (such as a family history of the disease), a colonoscopy is also recommended if they have not already been screened for colon cancer. Some doctors recommend computed tomography (CT) of the abdomen if people are under 45, but other doctors wait for specific symptoms to develop. Other tests are done depending on results of the history and physical examination (see table Physical Causes and Features of Chronic Abdominal Pain).
Additional tests are done if any test results are abnormal, if people develop new symptoms, or if new abnormalities are detected during the examination.
Treatment of Chronic or Recurring Abdominal Pain
Treatment of abdominal pain depends on the cause and the symptoms. For example, if people have lactose intolerance, a lactose-free diet (eliminating milk and other dairy products) can help. If people are constipated, using a laxative for a few days plus adding fiber to the diet can help.
Centrally mediated abdominal pain syndrome
Treatment of centrally mediated abdominal pain syndrome depends on the symptoms and is focused on helping people return to normal daily activities and lessening the discomfort. Usually, treatment involves a combination of strategies. Several visits to the doctor may be needed to develop the best combination. Doctors often arrange follow-up visits, depending on people's needs. Visits are continued until well after the problem has resolved.
After centrally mediated abdominal pain syndrome is diagnosed, doctors emphasize that the pain, although real, usually does not have a serious cause and that emotional factors (for example, stress, anxiety, depression) may trigger or worsen an episode of pain. Doctors try to avoid repeating tests after thorough testing has failed to show a physical cause of the symptoms.
Although there are no treatments to cure this type of chronic abdominal pain, many helpful measures are available. These measures depend on a trusting and understanding relationship between the doctor, person, and person's family members. Doctors explain how the laboratory and other test results show that the person is not in danger. Doctors encourage people to participate in work, school, and social activities. Such participation does not worsen the condition but instead encourages independence and self-reliance. People who withdraw from their daily activities risk having their symptoms control their life.
Changing the diet and consuming a high-fiber diet or fiber supplements helps some people. People may need to avoid foods that trigger their pain. For example, some people should avoid eating large amounts of foods that are difficult to digest and produce a lot of gas and avoid drinks that are high in sugar.
Many medications have been tried with varying success. They include medications that reduce or stop muscle spasms in the digestive tract (antispasmodics) and peppermint oil.
Sources of stress or anxiety are minimized as much as possible. Parents and other family members should avoid reinforcing the pain by giving it too much attention. If people continue to feel anxious or depressed and this seems to be related to the pain, doctors may prescribe antidepressants or medications to reduce anxiety. Therapies that help people modify their behavior, such as relaxation training, biofeedback, and hypnosis, may also help reduce anxiety and help people better tolerate their pain.
For children, help from parents is essential. Parents are advised to encourage the child to become independent and to fulfill the child’s normal responsibilities, particularly attending school. Allowing the child to avoid activities may actually increase the child’s anxiety. Parents can help the child manage pain during daily activities by praising and rewarding the child’s independent and responsible behaviors. For example, parents could reward the child by scheduling special time with the child or a special outing. Involving school personnel can help. Arrangements can be made to let the child rest briefly in the nurse's office during the school day, then return to class after 15 to 30 minutes. The nurse can sometimes allow the child to call a parent, who should encourage the child to stay in school.
Key Points
Usually, chronic or recurring abdominal pain is centrally mediated (that is, people have pain but no specific physical disorder and no other gastrointestinal problem).
Symptoms that require a doctor’s immediate attention include a high fever; loss of appetite or weight; pain that awakens the person; blood in vomit, stool, or urine; jaundice; severe nausea and vomiting; and swelling of the legs and/or abdomen.
Blood and urine tests are usually done to check for disorders that may cause the pain.
Additional tests are needed only if people have abnormal test results, warning signs, or symptoms of a specific disorder.
For centrally mediated pain, treatment involves learning to minimize stress or anxiety, participating in normal daily activities, trying a trial of fiber supplements and/or high-fiber foods, taking medications that reduce or stop muscle spasms in the digestive tract, sometimes taking medications or using behavioral modification therapies to relieve anxiety, and sometimes altering the diet.
