4

Abdominal pain

Differential diagnosis

Right shoulder
Diaphragm
Tip of scapula

Gallblader
Ureter
Inguinal canal

Gallbladder pain
Diaphragmatic pain
Ureteric pain
Fig. 4.3 Characteristic radiation of pain from the gallbladder, diaphragm and ureter.

Gastroduodenal disorders
Peptic ulcer disease is a common cause of
chronic upper abdominal pain. Almost all
duodenal ulcers and 70% of gastric ulcers
are attributable to H. pylori infection. Typical
features include recurrent episodes of
burning or gnawing discomfort, relationship to food (variable), associated dyspeptic
symptoms e.g. nausea, belching, waterbrash, and relief with antacids.
Gastritis without frank ulceration may
produce similar symptoms.
Gastric cancer occurs more frequently in
patients >55 years; associated symptoms
include dysphagia, early satiety, weight
loss and vomiting. All of the above disorders are best diagnosed by upper gastrointestinal endoscopy (UGIE).

Gallstones
Most gallstones are asymptomatic.
Biliary colic occurs when a gallstone
obstructs the cystic duct, causing gallbladder distension. It tends to occur 16 hours
28

after a meal, manifesting as intense, dull,

RUQ or epigastric pain radiation to the
back or scapula (see Fig. 4.3). The pain
builds to a crescendo over minutes, and
may last several hours before subsiding.
It does not cause jaundice, deranged LFTs
or abdominal signs. USS may confirm the
presence of gallstones or demonstrate pathological gallbladder changes.
Choledocholithiasis (stone in the CBD) may
cause recurrent episodes of upper abdominal pain associated with cholestatic jaundice (see Ch. 19).

Pancreatic pain
Chronic pancreatitis causes severe upper
abdominal pain that often radiates to the
back. In some patients, it is constant and
unremitting, while in others, episodes are
provoked by eating. Associated features
include weight loss, anorexia, diabetes
mellitus (endocrine deficiency) and, in
advanced disease, steatorrhoea (exocrine
insufficiency). The majority of cases are due