Heartburn is the most common symptom referable to the esophagus.
It is a burning or hot substernal discomfort that frequently moves
up toward the neck, but it may be localized only to the epigastrium.
Eating, bending down, lying down after eating, and occasionally
vigorous exercise may precipitate it. It is not entirely clear whether
heartburn is caused by the chemical irritation of acid or bile,
or if secondary muscle spasm plays a role. Occasionally, the pain
is described as being a heaviness or tightness in the chest, with
secondary restricted respiration and subsequent shortness of breath,
simulating myocardial ischemia. The shortness of breath may be caused
by an intercostal muscle spasm mediated by spinal reflex arcs.
Usually, the pain from the esophagus is felt at the level of
the lesion. In some patients, however, pain caused by a lesion in
the lower third of the esophagus is felt in the throat or in the
high retrosternal area. The opposite is uncommon. When heartburn
is severe, such as that associated with an ulcerating or infiltrating
process, esophageal pain can radiate into the back, between the
The character of pain from ulcer disease varies widely. Typically,
it is located in the epigastrium. It may be a sharply localized
burning or gnawing pain or just a vague discomfort occurring from ½ to
2 hours after eating. Occasionally, it occurs shortly before meals
or on an empty stomach and it may wake the patient up in the early
hours of the morning. Food or antacids relieve it. The pain may,
at times, be more localized to the right or left upper quadrant.
When the pain bores through into the back, it usually indicates
a posterior duodenal wall ulcer with secondary irritation of, or penetration
into, the pancreas. This pain usually is deep, persistent, poorly
localized, and does not respond well to treatment. Unlike heartburn,
ulcer pain frequently occurs in clusters; several weeks of daily
pain may be followed by variably long pain-free intervals. There
may be seasonal variation with the symptoms; that is, they may be
worse during the spring and fall.
Pain from gastritis tends to be more persistent and may be more
difficult to abolish. The associated nausea and vomiting may be
particularly troublesome. As in heartburn, it is not known whether
the pain is produced by acid irritation of the nerve endings in
the ulcer bed or whether it is secondary to a spasm of antral or
duodenal smooth muscle.
Epigastric pain occurring soon after eating, unrelieved by antacids,
and with lack of periodicity does not necessarily exclude ulcer
disease. Pyloric channel ulcers may present in such a manner, and
unless there is associated postprandial vomiting, the diagnosis
may not be made until frank gastric outlet obstruction occurs.
As a rule, pain originating in the small intestine is periumbilical
in location and crampy or colicky in nature. Jejunal lesions tend
to be associated with pain in the left upper quadrant. Ileal pain
tends to localize in the right lower quadrant, and it may result
from abnormal bowel motility patterns. A lowered threshold to the
pain of bowel distention or contraction also can cause it. A lesion obstructing
the lumen of the bowel, such as regional enteritis or a malignant
process, may be the precipitating factor.
The pain of irritable bowel syndrome frequently is chronic, and
at times, it can be incapacitating. It is unusual, however, for
it to wake the patient from sleep. The pain usually is in the lower
abdomen, in either the right or left lower quadrants. Its description
ranges from burning, sharp, and stabbing to dull. Most commonly,
it is intermittent, but it may be constant, with superimposed acute
attacks. The pain may remain localized or may migrate with time.
Eating usually precipitates it; defecation or fasting tends to relieve
it. Nausea, bloating, and dyspepsia frequently occur and may simulate
peptic ulcer or biliary tract disease. A change in bowel habits
is not a universal finding, but, classically, diarrhea alternates
with constipation. Predominant diarrhea or constipation, however,
can be part of the syndrome.
Pain from partial small bowel obstruction also occurs after meals.
The closer the lesion is to the stomach, the earlier the pain occurs.
Moreover, nausea and vomiting are more likely to occur when the
lesion is close to the stomach. The pain frequently is described
as crampy and comes in waves. Regional enteritis is suggested by
localization of the discomfort to the right lower quadrant and associated
diarrhea, fever, weight loss, or extraintestinal manifestations,
such as arthritis and mouth ulcers. Significant weight loss and
cachexia may suggest an underlying lymphoma or metastatic disease
to the bowel. It may be several months before complete obstruction
occurs. At this time, the diagnosis is more obvious. As in appendicitis,
the initial pain may be a nonspecific discomfort, but as the underlying
process develops and eventually involves the overlying peritoneum,
the pain localizes and approximates the site of the underlying disease.
Postoperative adhesions frequently are blamed for chronic or
recurrent abdominal pain. Before exploration is considered, definitive
evidence of bowel obstruction using plain abdominal x-rays or angulation
and proximal dilation of the bowel using a barium study should be
Pain from the colon usually is poorly localized to the lower
abdomen. However, an adenocarcinoma of the colon or diverticula
of the colon with secondary microperforation and abscess formation
may have localized symptoms overlying the area of disease. Pain
from the rectosigmoid area, in addition to being in the left lower
quadrant, may be located in the sacral area.
and Biliary Tract
Because the pancreas, liver, biliary tract, stomach, and duodenum
share some of the same afferent neuropathways, it is easy to understand
some of the difficulties involved in the differential diagnosis
of chronic epigastric pain. Diseases of the pancreas, and, in particularly,
pancreatic cancer, are the most difficult to diagnose. Pain resulting
from pancreatic cancer usually signifies infiltration of the retroperitoneal
area or celiac axis, or spread to surrounding organs. Some of the
pain may be a result of pancreatic duct obstruction and surrounding
pancreatitis. Tumors in the head of the pancreas cause pain that
is more localized to the epigastrium or right upper quadrant. Those
in the tail tend to cause pain in the left upper quadrant. Lesions
in the body of the pancreas can cause the pain to radiate into the
back. Back pain, alone, also can be a presenting symptom. Because pancreatic
cancer is rarely resectable, the physician is able to treat only
the symptoms. When the retroperitoneal celiac plexus is involved
by the tumor, the anesthesiologist frequently is asked to guide
and help manage the pain.
The pain of chronic pancreatitis, which is mainly a result of
alcohol abuse, can be constant, debilitating, and frequently lead
to drug abuse. The persistent inflammation of the pancreas causes some
of the pain, as does the ductal distention secondary to ductal obstruction
by creation of strictures. The pain may be dull or sharp, burning,
and steady. It commonly radiates into the back. Superimposed, more
acute attacks last from days to several weeks. Eating, moving, or
lying down may aggravate the pain; sitting up or leaning forward
may relieve it. In patients who are not surgical candidates, the
anesthesiologist may be asked to intervene. Neurolytic celiac plexus
block has been used to treat patients who have not responded to
conservative or surgical therapies. It often is used as a last resort,
because rendering the abdomen insensitive may allow future abdominal
disease to be missed.
Placement of stents during endoscopic retrograde cholangiopancreatography
was used initially to decompress a dilated biliary tree. Only recently,
this technique has been used to decompress the pancreatic duct.
Relief may occur if the dilated biliary (or pancreatic) duct was
the cause of the pain. Both benign and malignant lesions are amenable
to this technique.
Passing a stone or biliary tree dilation secondary to an obstruction
usually causes biliary pain. Contrary to the commonly used term
biliary colic, the pain tends to have a gradual onset. After it peaks,
it tends to reach a plateau until again, hours later, it diminishes.
An attack can last from several hours to a day or more. The pain
characteristically is localized in the right upper quadrant and
may radiate to the right shoulder and shoulder blade, but it also
is felt commonly in the epigastrium, with radiation into the back.
Vomiting occurs in most patients and may provide some relief. After
an acute attack, residual soreness may persist for several days.
Commonly, these symptoms occur after eating, but they may become
constant if the common bile duct is impacted by a stone or infiltrated
by a malignant process. Associated dyspepsia is common in approximately
one quarter of all patients. It responds to antacids, further confusing
its cause. The appearance of complicating cholangitis (with symptoms
of fever and jaundice) usually leads quickly to the correct diagnosis.
The liver parenchyma is insensitive to pain, but relatively rapid
distention of the liver capsule will initiate well-localized right
upper quadrant pain. Acute processes such as viral hepatitis, alcoholic hepatitis,
and cardiac decompensation with secondary liver congestion rarely
may appear as right upper quadrant pain, but this pain does not
evolve into a chronic complaint. Chronic, active hepatitis may follow
a course of recurrent attacks of right upper quadrant pain. The
pain usually is well localized and accompanied by worsening liver
Benign focal nodular hyperplasia or adenomas associated with
the use of birth control pills may cause recurrent right upper quadrant
discomfort or, occasionally, a dramatic crisis of severe abdominal
pain and hypotension from a hemorrhage into the capsule or peritoneum.
The recurrent warning pains probably are caused by small bleeding
episodes into the lesions. Bleeding into or necrosis of malignant
lesions in the liver causes similar pain, but this usually is accompanied
by fever and jaundice. The pain may be well localized, sharp, and
steady. Any movement producing friction between the liver surface
and the ribs may exacerbate it. When sought, a bruit over the lesion
may he identified in approximately 25% of patients.
of the Bowel
Although mainly asymptomatic, occlusive vascular disease may
be associated with chronic, recurrent, dull paraumbilical or epigastric
pain. The pain of intestinal angina begins approximately ½
hours after eating and lasts throughout digestion and absorption
of the meal. Usually, at least two of the three major splanchnic
vessels are affected by significant obstruction from atherosclerotic changes.
It is postulated that the collateral supply is insufficient to meet
the increased need during digestion, and this state of relative
ischemia creates subsequent pain. Classically, this recurrent pain
may create a fear of eating and can lead to severe weight loss.
When patients with acute ischemia are questioned closely, retrospectively,
they often will report postprandial abdominal discomfort preceding
the acute event by weeks to months.
Superior mesenteric artery syndrome and celiac compression syndrome
frequently are mentioned in the differential diagnosis of chronic
abdominal pain, but their validity is controversial. Superior mesenteric
artery syndrome is described as occurring in so-called asthenic
patients or patients with significant weight loss. The postprandial
epigastric pain, vomiting, and distention are believed to be caused
by compression of the duodenum by the superior mesenteric artery.
The pain of celiac compression syndrome is not necessarily related
to meals. The celiac axis frequently has a high take-off and may
be compressed by the median arcuate ligament of the diaphragm or
by the tissue of the celiac ganglion. Whether bowel ischemia is
the cause of the pain or whether the pain originates from the celiac
ganglion also is unclear.
Abdominal aortic aneurysm usually presents more acutely, but
a slowly expanding or leaking aneurysm may be associated with recurrent,
dull midepigastric or back pain over several months. As with pancreatic
pain, sitting up or leaning forward occasionally may relieve this
pain. The pulsating, sometimes tender, mass can be palpated, and
a bruit may be heard.
The parietal peritoneum is well innervated by the branches of
the spinal nerves, and, consequently, the pain perceived is well
localized. Such pain frequently is associated with secondary muscle
spasm of the overlying abdominal wall. The visceral peritoneum,
however, has no pain receptors, and any pain that is generated is
poorly defined. A malignant process most often causes chronic pain
originating in the peritoneal cavity. Metastatic bowel or ovarian
tumors and lymphoma are common. Mesothelioma is the most common
primary tumor; teratoma, carcinoid, or sarcoma are much less common.
The abdominal discomfort often is compounded by the presence of
ascites, which distends the peritoneum further and causes more pain.
In young patients of Mediterranean descent who have chronic recurrent
attacks of sudden diffuse or localized peritoneal pain, familial
Mediterranean fever should be considered. Abdominal tenderness,
fever, and arthritis are common. Despite feeling very ill, the patient
recovers in several days and is well until the next attack.
Recurrent localized or generalized abdominal pain in an older
patient associated with the displacement of the stomach or bowel
on x-ray studies should suggest a mesenteric or omental lesion.
Fever, weight loss, nausea, vomiting, and a palpable tender mass
may be associated with mesenteric panniculitis or retractile mesenteritis.
Metastatic tumors to the mesentery are more common than primary
lesions. The latter usually are fibromas, myomas, histiocytic or
lipomatous tumors. Leiomyomas and leiomyosarcomas tend to involve
The acute pain of renal colic or pyelonephritis is classic and
easy to diagnose. The triad of hematuria, flank pain, and a palpable
mass suggests renal cell carcinoma, but this triad occurs infrequently.
The tumor often is diagnosed from systemic complaints (dull upper
abdominal or flank pain may be included). Perinephric abscess, although
uncommon, should be considered in a patient with a history of urinary
tract infections or pyelonephritis. Typically, dull upper quadrant or
flank discomfort is present, accompanied by malaise and low-grade
Gynecologic problems usually cause acute pain. Depending on the
patient’s age, chronic lower abdominal pain, usually more
localized to one of the lower quadrants, could be a presenting symptom
of chronic pelvic inflammatory disease, uterine or ovarian cancer.
The pain can be dull, steady, or crampy. The local irritation by
the mass or inflammatory process can cause changes in the urine
or bowel pattern.