14. Chronic Abdomen / W.G. Thompson 

Recurrent abdominal pain; recurrent abdominal pain in children. 

Ten percent of children suffer recurrent abdominal pain and approximately 20% of adults have abdominal pain at least six times per year unrelated to menstruation. The pain is chronic when it has been present for six months or more. It may be related to gastrointestinal functions such as eating and defecation. It is often a feature of dyspepsia or the irritable bowel syndrome. Occasionally, the pain has no relationship to bodily functions, and no gastrointestinal, hepatobiliary, genital or renal cause for the pain can be found. 

The mechanisms of abdominal pain are discussed above, in Section 13 ("Acute Abdomen"). Of course, chronic abdominal pain may be caused by many organic diseases. Peptic ulcer generally produces pain after meals or on an empty stomach and is relieved by food or antacid. Abdominal pain awakening the patient at night is a particularly discriminating feature. 

Biliary colic may be due to cystic or common bile duct obstruction by a stone. Characteristically this pain is significant enough to awaken the patient at night or require a visit to the emergency room for analgesia. It lasts from 1 hour to 12 hours; beyond that time consider acute cholecystitis or pancreatitis. Attacks are sporadic and at intervals, not continuous. Biliary pain is located in the epigastrium, the right upper quadrant and/or the right scapula. It leaves the patient shaken but well. Should the gallbladder become inflamed, cholecystitis results. Obstruction of the common bile duct with a stone results in pain, jaundice and sometimes fever (cholangitis). 

Pancreatitis is a devastating illness, with steady epigastric pain radiating to the back and sometimes accompanied by shock. It almost always requires admission to hospital. 

Ischemic bowel disease, subacute bowel obstruction caused by Crohn’s disease, neoplasm or volvulus may present with recurrent bouts of abdominal pain, often related to eating. These conditions are usually progressive and accompanied by physical signs. 

In a patient with diverticular disease, a peridiverticular abscess may develop, causing recurrent bouts of severe left lower quadrant abdominal pain and fever. Usually, diverticula are asymptomatic and symptoms that do occur are those of coincident irritable bowel syndrome. 

Renal colic due to a stone in the ureter is rarely chronic but may be recurrent. It consists of severe flank pain radiating to the groin and testicle, and may be accompanied by hematuria. Typically, a patient smitten with renal colic is unable to lie still. 

Gynecologic conditions ranging from mittelschmerz (ruptured ovarian cyst) to pelvic inflammatory disease may account for recurrent abdominal pain. Menstruation-related pain in a young woman suggests endometriosis. Chronic pelvic pain often relates to the irritable bowel syndrome. 

Chronic appendicitis probably does not exist. 

The chronic abdomen is seldom explained by the above mechanisms. Functional abdominal pain may originate in any part of the gastrointestinal tract or biliary tree. It is unrelated to bodily function and may be continuous. It is uncertain whether the pain is due to a normal perception of abnormal gut motility or an abnormal perception of normal motility, or indeed if it is due to the gut at all; there are frequently accompanying psychosocial difficulties. 

Pain, when related to a bodily function ^_ defecation, eating, micturition or menstruation ^_ focuses the investigation upon the involved system. Certain physical findings (such as an abdominal mass, or blood or mass upon rectal examination) point to specific organic diseases. Fever, weight loss, rectal bleeding and/or anemia indicate further tests. These features are absent in chronic functional abdominal pain. 

Management of the organic causes of the chronic abdomen can be directed at the underlying disease process. In many instances, however, there is no organic basis. Here, the physician’s responsibility is to reassure the patient that no serious disease exists, and help the patient coexist with the symptoms in the light of the patient’s social background. One might improve digestion through regular and better eating habits, and treat bowel dysfunction, particularly constipation, with increased dietary bulk. 

There are patients who have severe recurrent abdominal pain unrelated to bodily function or organic disease. Such patients see many doctors without satisfaction; the genesis of the symptom is thought to be psychogenic. This pain is often given such descriptors as "illness behavior" and "pain proneness." Some have hypochondriasis and do not improve when organic disease has been disproved. An extreme example is the Münchausen syndrome, where the patient deliberately relates a tall tale of medical duress in order to precipitate treatment, perhaps even surgery. 

Functional pain is frequent in those who have recent conflicts, have experienced a death in the family, or have become overly concerned with fatal illness. Depression and anxiety are frequent. Here, it is important not to carry out extensive investigation in a fruitless search for an elusive cause. This only reinforces the patient’s belief that something is wrong and undermines the patient’s confidence in the benign diagnosis. 

Such pain may be an emotional expression, in which case regular visits are necessary to allow the patient to vent his or her problems. Drugs, especially narcotics, should be used with restraint, and the physician should strive to develop a strong doctor-patient relationship while dealing with the patient’s depression, anxiety, frustration and often hostility. These patients test our skill in the art rather than the science of medicine.