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
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
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