Find out when stomach pain—from upper abdominal pain to middle stomach pain—is serious and when you can ride it out.
In 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 to 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?
When the pain is accompanied by any of the following systems, it's a good idea to call your doctor:
- Loss of appetite
- Blood in bowel movements
Let's discuss why.
Anatomy of the abdomen
The abdomen is divided into five sections.
- Upper right quadrant
- Upper left quadrant
- Upper middle section
- Right lower section
- Lower left quadrant
The location of the pain can sometimes help doctors tell whether pain is worrisome or not. Here are descriptions of 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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When should you worry about abdominal pain?
Location is important, but the nature of the pain itself is even more so.
Location is important, but the nature of the pain itself is even more so. Here are some of the things that make stomach pain more worrisome:
Severity: Pain that wakes you up out of your sleep or stops you in your tracks is always worth worrying about.
Persistence: Pain that’s continuous or lasting more than 10 minutes is more worrisome than intermittent, brief pain.
Tenderness: Doctors use the term tenderness to describe pain you feel when the body part is pressed upon. From a patient’s perspective, tenderness is when movement makes the pain worse. If your abdominal pain gets worse when you move or push on a spot, that’s worrisome.
Loss of appetite: When a serious problem happens in the abdomen, the body shuts down digestion. Things stop moving through the digestive tract and you feel nauseated and don’t want to eat. It’s rare for someone with appendicitis, for example, to want to eat anything. Significant weight loss as a result of this appetite slump is especially worrisome.
Vomiting: Vomiting becomes a concern when it is intractable, meaning without halting enough to be able to consume liquids to replace it. When vomiting is prolonged or severe, doctors worry about dehydration, which is a common reason for hospitalization and/or ER visits when patients experience abdominal pain. If you cannot keep any fluid down to replace the fluid that is being regurgitated, then it may require a visit to the ER for IV fluid replenishment.
Blood in bowel movements: Painless bleeding is not a big concern, as it’s usually from hemorrhoids. But bleeding along with abdominal pain is a symptom that causes concern.
Melena: The word melena describes black, tar-like bowel movements. That is a sign of bleeding from the gastrointestinal tract that started in the upper gastrointestinal tract, like the stomach. The blood in the stomach turns black by the time it reaches the rectum. If something is causing enough bleeding to cause melena, it is usually something bad, like a bleeding ulcer. Melena is serious, and people with it should go directly to the emergency room. That is true even if there is no pain.
Dizziness: If you are getting dizzy or light-headed with abdominal pain, it may mean your blood pressure is dropping. Get seen right away for this.
When don’t you need to worry about abdominal pain?
The reassuring signs are the flip-side of the worrisome signs:
Pain isn’t worse with pressing or movement
Pain isn’t associated with a lack of appetite
Pain doesn’t interfere with regular activity
Furthermore, the passage of stool and gas shows that the digestive tract is working, which is also reassuring. That’s why surgeons ask people if they are passing gas after they perform abdominal surgery.
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The Quick and Dirty Tip
The bottom line, of course, is that it’s better to get checked out by a doctor for nothing than to stay at home with something more serious.
It’s also vital to point out that certain patient populations are considered higher risk when it comes to abdominal pain: those who are immune compromised or have HIV, women (due to a more complex female anatomy), and the elderly.
According to previous studies, people over age 65 have a particularly higher risk of death or complications from abdominal pain because they are more likely to have vague or non-specific symptoms. Therefore, if you are in this group, it’s best to err on the side of seeing your doctor.
Sanaz Majd, MD, also contributed to this article, which was updated on August 30, 2016.