What's to blame for that stomach pain?

Posted on Wed., November 4, 2009
By Stephen Daniels, MD

Can you guess the causes of the following cases of abdominal pain?

Patient #1: "I've had this pain in the middle of my stomach for a few weeks, Doc. It's just under my ribs, and wakes me up at night. But it also bothers me during the day sometimes."

Patient #2: "This upper abdominal pain is so bad I can't stand it, Doc. When I lay down, it also hurts in my back."

Patient #3: "This lower abdominal pain on my left side has been bothering me for months, but it's gotten much worse lately."

Patient #4: "Doctor, please do something about this pain on the right side of my stomach. It hurts every time I eat, and I can't do anything to get comfortable."

An experienced doctor will often know the probable causes of all four cases of abdominal pain, based on the location and time sequence of the pain. First, though, one must know what large organs (stomach, liver, etc.) are where in the abdomen.

It is useful to divide the abdomen into four parts, or quadrants, with the navel (belly button) being where all four quadrants meet in the middle.

The right upper quadrant (nearest the person's right shoulder) contains the liver and gall bladder, and parts of the stomach, pancreas and intestines. So pain in that quadrant is usually caused by a problem in one of those organs.

The left upper quadrant contains the spleen, and parts of the stomach, liver, pancreas and intestines.

The right lower quadrant contains the intestines, including the appendix, and part of the bladder.

The left lower quadrant contains the intestines and part of the bladder.

For the sake of simplicity, we'll exclude the female reproductive organs, which can be a common cause of lower abdominal or pelvic pain in women.

It turns out that patient #1 probably has the most common cause of abdominal pain: GERD, or Gastro-Esophageal Reflux Disease. This is often caused by an inflamed stomach, and usually improves with one of the over-the-counter medicines such as PepcidAC, Zantac, Prilosec and others. Sometimes this pain can seem to come from the chest, hence the name "heart burn."

Most people with mild, recurrent upper abdominal pain should try an antacid, or one of the GERD treatments above, to see if the pain resolves.

Patient #2 is likely to have pancreatitis, since the pancreas is near the back, and lying down on one's back often increases the pain. Pancreatitis is most commonly caused by excessive alcohol consumption or viruses.

Patient #3 is likely to have diverticulitis, which is the infection and inflammation of little pouches in the wall of the large intestine.

Patient #4 is likely to have gallstones, which cause blockage in the bile ducts when stimulated by food in the small intestines. But most people with gallstones have no symptoms. So, just because a person has gallstones and right upper quadrant pain, it does not mean the gallstones are causing the pain.

Of course, these "diagnoses" are overly simplistic, because abdominal pain in all areas can have many possible causes. So, if your abdominal pain is severe or persistent or causes fever, faintness or shortness of breath, you should contact your doctor right away.

Dr. Daniels practices family medicine at the Concord and Pittsburg Health Centers, parts of Contra Costa Health Services, the county health department.