La Plata Medical Society
  From time to time everyone will have abdominal pains, and everyone, even a physician, begins to worry if the pains last more than a few minutes. Encircled by skin and muscles, the abdomen is a mysterious area containing many organs that are capable of having numerous problems.

I would like to explain how a doctor categorizes his thinking in trying to determine the origin of the pain. There may be other signs or symptoms, such as fever, jaundice or bleeding, but I am going to discuss only the symptom of pain in making a diagnosis.

For the last century, physicians have divided the abdomen into an upper area and lower area, and then subdivided each of these into three areas. Therefore, the patient has a right upper area (the right upper quadrant), the middle area (epigastrium) and the left upper area (quadrant). The lower half is divided into the right lower quadrant, the suprapubic area and the left lower quadrant. Granted, a quadrant is one-fourth of a circle and we now have six parts, but physicians are usually poor mathematicians.

On the back, physicians refer to the right flank, the mid-back and the left flank. Pain occurring in a particular area directs the physician's thinking along certain tracks toward making the diagnosis.

The severity of the pain determines the rejection or acceptance of a particular diagnosis. I classify pain as moderate, severe or catastrophic. Catastrophic pain is rarely localized but is usually felt throughout the abdomen. The causes of such pain would include a perforated (ruptured) ulcer, a ruptured aortic aneurysm (a blowout of the big artery in the abdomen), a ruptured diverticulitis or appendicitis with peritonitis (generalized infection), a ruptured ectopic (tubal) pregnancy in a woman and abdominal trauma with injury to many organs.

In the right upper quadrant of the abdomen, moderate pain can be the result of a gallbladder attack, constipation, pneumonia, muscle strain, pyelonephritis (an infection of the kidney) or an enlarging liver (for one of many reasons). Severe pain in this area could be an infected gallbladder, diverticulitis of the colon in that area and, rarely, appendicitis. Severe pain in the right flank is usually due to either a kidney stone or kidney infection, but a gallbladder attack can begin with pain in this area.

Moderate pain in the epigastrium (the mid-upper abdomen) is present with ulcer disease of the stomach or duodenum, early appendicitis, hiatal hernia and gallbladder disease. Severe pain in this area is felt when an ulcer begins to penetrate (ready to perforate), in pancreatitis (severe inflammation of the pancreas gland) and occasionally during a heart attack.

The left upper quadrant seems to have fewer problems. Pains in this area are usually due to the colon (as with constipation or diverticulitis) or the spleen (when it enlarges as with infectious mononucleosis).

Pain in the right lower quadrant of the abdomen is a real challenge for physicians, especially surgeons and gynecologists, as many problems can exist there. The first diagnosis that comes to mind is that of appendicitis, yet it is not the most common cause of right lower quadrant pain. Constipation probably leads the list. In children, mesenteric adenitis (swollen lymph glands) can mimic appendicitis. Kidney stones, tumors, diverticulitis of the colon and inguinal hernias can cause pain in this area. In women, endometriosis, ovarian cysts and tumors, twisted fibroids, ectopic pregnancies and infections in the fallopian tubes add to the challenge of a diagnosis. (Now you can appreciate your physician's dilemma in making the correct diagnosis.)

The suprapubic area (mid-lower abdomen) is the area where the pain of cystitis (an infection in the urinary bladder) is noted. However, all of the female problems can be felt here.

Finally, the left lower quadrant is the most frequent site for diverticulitis and its resulting pain. Again, ovarian cysts, ectopic pregnancies and infected fallopian tubes can cause pains in women in this area. In children, pain in the left lower quadrant usually occurs from constipation.

The pain from intestinal obstruction is not usually localized to one area, but is felt throughout the abdomen.

Books have been written on this subject, and I apologize to my colleagues for omitting diagnoses such as internal hernias, herniated discs, ischemic bowel and prostatitis.

The correct diagnosis of abdominal pain may be difficult for even the expert, so please don't try to "diagnose yourself" to save a doctor's fee. See your personal physician as soon as possible and you might prevent a worsening of your condition.

Dr. John N. Withers is a practicing general surgeon in Durango

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