Evaluation of chronic abdominal pain in adults

Summary

Chronic abdominal pain is defined as continuous or intermittent abdominal discomfort lasting for at least 3 months.[1] Pain may arise from any system, including the genitourinary, gastrointestinal, and gynecologic tracts. The etiology of chronic abdominal pain is so wide that only the more common causes can be covered here. A clear relationship with an anatomic structure or underlying process may not always be present.

Diagnosis and management of patients with chronic abdominal pain is often challenging and can be a frustrating experience for both physicians and patients. Factors that contribute to this include poor sensitivity of the history and physical exam, a broad differential diagnosis that crosses several specialties, and an often negative diagnostic workup.

Classification

Chronic abdominal pain is divided into organic and functional etiologies.[2] Organic etiologies have a clear anatomic, physiologic, or metabolic cause. Chronic abdominal pain without clear source, in spite of a thorough diagnostic evaluation, is usually termed a functional disorder.[3] Functional abdominal pain is thought to arise from multifactorial visceral hypersensitivity and dysmotility and altered function of the brain-gut axis.[4]

Chronic abdominal pain is less likely to reveal underlying organic pathology than acute abdominal pain. Acute abdominal pain often indicates a sudden physiologic change such as an obstructed or perforated hollow organ, infection, inflammation, or a sudden ischemic event.

Epidemiology

Chronic abdominal pain is a common complaint in primary care and subspecialty clinics.[3] The incidence of unspecified abdominal pain is 22.3 per 1000 person-years.[5] In an international meta-analysis, the primary care consultation prevalence for abdominal pain is 2.8%.[6] More than half of all patients presenting with the symptom of abdominal pain do not have a causative diagnosis.[6] [7] [8] One cross-sectional survey of US adults reported a prevalence of abdominal pain in 21.8% in the general population.[9] Women are more likely than men to report chronic abdominal pain.[3] In the US, abdominal pain is the most common symptom and diagnosis of gastrointestinal diseases to prompt a healthcare visit.[10] However, in a US survey of adults with a history of abdominal pain, almost 40% did not seek medical care for their symptoms.[11]

Worldwide, the prevalence of functional gastrointestinal disorders (FGID, also known as disorders of gut-brain interaction) in adults is over 40%.[12] FGID conditions are heterogenous and irritable bowel syndrome and functional dyspepsia are the most common.[12] However, the pain associated with these disorders is nonspecific and can resemble or coexist with organic disorders.[13] A subset of patients with FGID do not respond to first-line therapy and have persistent chronic abdominal pain.[14]

The prevalence of chronic abdominal pain in children varies widely (4% to 53%).[15] [16] [17] The prevalence of pediatric functional abdominal pain is 13.5%.[18]

Citations

Key Articles

Keefer L, Drossman DA, Guthrie E, et al. Centrally mediated disorders of gastrointestinal pain. Gastroenterology. 2016 May;150(6):1408-19.[Abstract]
Rubio-Tapia A, Hill ID, Semrad C, et al. American College of Gastroenterology guidelines update: diagnosis and management of celiac disease. Am J Gastroenterol. 2023 Jan 1;118(1):59-76.[Abstract][Full Text]
Camilleri M, Kuo B, Nguyen L, et al. ACG clinical guideline: gastroparesis. Am J Gastroenterol. 2022 Aug 1;117(8):1197-220.[Abstract][Full Text]
Maaser C, Sturm A, Vavricka SR, et al. ECCO-ESGAR guideline for diagnostic assessment in IBD part 1: initial diagnosis, monitoring of known IBD, detection of complications. J Crohns Colitis. 2019 Feb 1;13(2):144-64.[Abstract][Full Text]

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