When to Worry About Abdominal Pain

Find out when stomach pain—from upper abdominal pain to middle stomach pain—is serious and when you can ride it out.

Rob Lamberts, MD,
August 30, 2016
Episode #060

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Stomach PainIn previous articles, I’ve given mystery symptoms and shown how doctors make the diagnosis. But something needs to happen before the doctor can make a diagnosis: the patient has to come in. Deciding when to worry about symptoms is one of the hardest decisions. On the one hand, you don’t want to feel foolish coming in for something small; on the other, you don’t want sit at home with a serious problem.

According to a prior study, over a third of abdominal pain complaints in the emergency room are discharged without a known cause. How can doctors send a patient home without finding the specific cause of a patient’s abdominal pain? The truth is that we are trained to search for “red flags,” or more serious symptoms. 

So what are these red flags? When should you worry about any sort of upper abdominal pain or middle stomach pain?

When to Worry About Abdominal Pain

In my series, “When to Worry….” I try to give you guidelines as to when a symptom is worrisome, and when it is OK to wait to seek help. Let me emphasize, however, that this is general advice that doesn’t apply to all circumstances. It is far better to be seen for a problem that ends up not being serious than to sit at home with a dangerous condition.

It’s two in the morning and you wake up with pain in your abdomen, or perhaps your child wakes you up with a stomach ache. When should you seek immediate help, when should you make a doctor’s appointment, and when is it OK to wait? 

Anatomy of the Abdomen

The abdomen is divided into five sections. The location of the pain can sometimes help doctors tell whether pain is worrisome or not. Here are the main regions:

Upper right quadrant: The right upper quadrant contains the liver and gallbladder, which are protected by the lower right part of the ribcage. The large intestine, or colon, also spends a little time in this section.

Upper left quadrant: The left upper quadrant contains part of the stomach and the spleen. The colon spends time here as well.

Upper middle section: Between these two sections, in the upper middle of the abdomen, is a section known as the epigastrium. This is an important section because it contains the most of the stomach, part of the small intestine, and the pancreas—all of which can cause pain.

Right lower quadrant: This quadrant contains more colon and the last part of the small intestine, where the appendix resides. In women, one of the ovaries is in this section.

Lower left quadrant: The other ovary lives in the left lower quadrant, along with the last part of the colon.

What Causes Abdominal Pain?

There are a few common problems that are caused by certain troublemakers in the abdomen. I’ll give you the list of the “abdomen’s most wanted,” and where they tend to hang out.

The appendix: This is a small tube that can become infected and cause a dangerous problem. Appendicitis pain usually starts as a severe pain around the naval, but then settles in the right lower quadrant. This is true the majority of time, but not all the time. More on this later.

The gallbladder: This organ is a sack that collects a digestive juice called bile. It can get infected or get stones, and usually causes severe, intermittent upper abdominal pain on the right side with radiation to the shoulder or back in some patients, which is triggered by the ingestion of fatty or greasy foods. This occurs as the gallbladder squeezes and places pressure on an obstructing stone in the adjacent bile duct. Less commonly, this type of pain can also occur in the center of the abdomen above the belly button. Many patients often describe it as a 10/10 severe pain that is reminiscent of labor during childbirth. It is important to note that an obstructing stone that causes a nearby infection producing a fever and/or jaundice (yellowing of the skin or white part of the eyes) is a dire emergency.  

The stomach and first part of the small intestine: Ulcers can form in these organs, causing bleeding, pain, and less commonly a perforation, leaking stomach acid into the abdominal cavity. Ulcers usually cause burning or cramping pain of variable severity in the middle of the stomach, above the belly button. Food ingestion often either improves or worsens the pain; there is often a relationship between the pain and food intake.

The pancreas: This organ puts out strong digestive juices that break down our consumed food. These juices are so strong that they can actually digest abdominal organs if the juice gets in the wrong place.  Excessive alcohol intake or stones stuck in the nearby biliary ducts can cause “pancreatitis,” or inflammation of the pancreas. This pain also tends to be quite severe, and located in the center above the belly button. Most patients with acute pancreatitis end up hospitalized because the pain is so severe.

The colon: Pain from the colon can occur at nearly any place in the abdomen, although one common condition, called diverticulitis, an infection of the common out-pouching that can entrap and harbor food particles, hence, causing an infection in the lining of the colon that is involved. The pain is usually in the left lower quadrant. This pain is also often described as moderate to severe on the pain scale.


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