It usually starts with a face.
You know the one, that grimace patients make when you ask, “Where does it hurt?” It’s a universal expression, halfway between discomfort and confusion. Because abdominal pain, my friends, is rarely straightforward. The abdomen is a cunning storyteller; it whispers, misdirects, sometimes screams, and occasionally lies outright.
I’ve seen patients clutch the right lower quadrant with textbook precision (appendicitis, easy), and others swear it’s “just indigestion” when their perforated ulcer is already staging a coup.
So, how do you make sense of it all? Let’s take a walk through the labyrinth.
First, a confession
When I was a student, abdominal pain terrified me. Everything in there hurts the same way, or so I thought. Turns out, the trick lies in learning the language of pain. The abdomen doesn’t just ache; it communicates.
The Three Acts of Abdominal Pain
1. Visceral pain, the vague prelude.
This is the “deep ache,” the “I can’t quite point to it” kind of pain. It comes from the organs themselves, distension, ischaemia, or chemical irritation. Patients wave vaguely around the midline when describing it. Why? Because visceral afferents are sneaky, they travel with autonomic fibres, converging in the spinal cord, making localisation a nightmare.
Think of it as the body’s opening act, ominous music before the plot thickens.
2. Parietal pain, sharp, localised, and unmistakable.
Once the parietal peritoneum gets involved, things get specific. Patients can pinpoint it with a single finger. Suddenly, that dull “tummy ache” becomes “it’s right here, doctor.” The inflammatory story has reached the wall, the nerves here are somatic, precise, unforgiving.
That’s when you start seeing guarding, rigidity, and the patient giving you that don’t touch me look.
3. Referred pain, the plot twist.
Pain that turns up where it doesn’t belong. The diaphragm is irritated by a subphrenic abscess, causing shoulder pain? Classic. Or ureteric colic radiating to the groin, because embryology never really lets us off the hook.
The Geography of Pain
You remember that 3×3 grid from our last chat? (If not, go look at that illustration again, the one with the tic-tac-toe board on a belly.)
That grid now becomes your diagnostic map.
| Region | Common Culprits |
| Right hypochondriac | Gallstones, hepatitis, liver abscess, or pneumonia! |
| Epigastric | Peptic ulcer, pancreatitis, MI (yes, the heart likes to meddle here) |
| Left hypochondriac | Splenic infarct, gastritis, pneumonia or that elusive tail of pancreas |
| Right lumbar | Pyelonephritis, ureteric stone, ascending colon colic |
| Umbilical | Early appendicitis, small bowel obstruction, aortic aneurysm (the quiet killer) |
| Left lumbar | Descending colon issues, renal colic |
| Right iliac | Appendicitis (the classic), Crohn’s disease, mesenteric adenitis |
| Hypogastric | Bladder infection, uterine pain, sigmoid volvulus |
| Left iliac | Diverticulitis, sigmoid tumours, or just plain constipation |
But real life, of course, laughs at grids. Pain migrates, overlaps, teases you. The appendix, for instance, loves to begin in the umbilical region (visceral pain) before settling in the right iliac fossa (parietal pain). A move worthy of a Shakespearean entrance.
Patterns, Clues, and the Subtle Art of Listening
Timing matters.
Sudden pain that wakes someone at night? Think perforation, torsion, or rupture. Slow crescendo over hours? Inflammation. Waves of agony that make patients pace and sweat? Colicky pain, something hollow (like a ureter or bowel) is in distress.
Character matters too.
Dull and diffuse, visceral. Sharp and stabbing, parietal. Burning in the epigastrium, gastric acid’s signature move.
And here’s a pro tip: watch their face before you even touch them. You’ll learn more from their wince than from ten minutes of palpation.
Red Flags You Never Ignore
There are a few things that make surgeons’ stomachs clench tighter than the patients’:
- Rigid abdomen (“board-like”, you’ll know it when you feel it)
- Guarding (DO NOT DO REBOUND TENDERNESS, it is CRUEL! Ask them to cough, if they won’t because it hurts too much, then take that as a surrogate!)
- Persistent vomiting with distension
- Haemodynamic instability (sweaty, pale, hypotensive, bad combination)
- Pain out of proportion to exam (always think mesenteric ischaemia)
These are not “let’s get an ultrasound and see” situations. These are “call the registrar and clear theatre” moments.
The Mind Behind the Pain
Here’s where I’ll throw a curveball: not every abdominal pain is organic. The gut and brain share a language, the vagus nerve, the enteric system, all whispering to each other. Stress, anxiety, and emotional upheaval can all manifest as visceral discomfort. “Functional pain” is not imaginary; it’s neurochemical poetry gone slightly wrong.
The Human Side of It
Patients with abdominal pain aren’t just cases; they’re scared. They’ve googled appendicitis, bowel cancer, and pancreatitis before you even walk in. So, talk to them like a human. Listen, even if their story meanders. The abdomen may lie, but the patient’s pattern of worry often reveals the truth.
Final Thoughts (if you can call them that)
Abdominal pain is both an art and a science. You’ll learn the patterns, memorise the causes, and still, one day, a patient will defy everything you know. That’s when instinct steps in.
And trust me, that instinct is carved from a thousand gentle examinations, a few sleepless nights, and the occasional mistake you’ll never repeat.
So next time a patient says, “It’s just tummy pain,” don’t roll your eyes. Pull up a chair. The belly’s about to tell you a story.
