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Official reprint from UpToDate®

www.uptodate.com © 2022 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Causes of abdominal pain in adults

Authors: Robert M Penner, BSc, MD, FRCPC, MSc, Mary B Fishman, MD
Section Editors: Andrew D Auerbach, MD, MPH, Mark D Aronson, MD
Deputy Editor: Lisa Kunins, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: May 2022. | This topic last updated: May 10, 2021.

INTRODUCTION

The evaluation of abdominal pain requires an understanding of the possible mechanisms

responsible for pain, a broad differential of common causes, and recognition of typical patterns
and clinical presentations. This topic reviews the etiologies of abdominal pain in adults. The
emergency and non-urgent evaluation of abdominal pain of adults discussed elsewhere. (See
"Evaluation of the adult with abdominal pain in the emergency department" and "Evaluation of
the adult with abdominal pain".)

Abdominal pain in pregnant and postpartum individuals and patients with HIV is discussed
elsewhere. (See "Approach to acute abdominal/pelvic pain in pregnant and postpartum
patients".)

PATHOPHYSIOLOGY OF ABDOMINAL PAIN

● Neurologic basis for abdominal pain – Pain receptors in the abdomen respond to
mechanical and chemical stimuli. Stretch is the principal mechanical stimulus involved in
visceral nociception, although distention, contraction, traction, compression, and torsion
are also perceived [1]. Visceral receptors responsible for these sensations are located on
serosal surfaces, within the mesentery, and within the walls of hollow viscera. Visceral
mucosal receptors respond primarily to chemical stimuli, while other visceral nociceptors
respond to chemical or mechanical stimuli.

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The events responsible for the perception of abdominal pain are not completely
understood, but depend upon the type of stimulus and the interpretation of visceral
nociceptive inputs in the central nervous system. As an example, the gastric mucosa is
insensitive to pressure or chemical stimuli. However, in the presence of inflammation,
these same stimuli can cause pain [2]. The threshold for perceiving pain may vary among
individuals and in certain diseases. (See "Evaluation of chronic non-cancer pain in adults",
section on 'Definition of pain'.)

● Localization – The type and density of visceral afferent nerves makes the localization of
visceral pain imprecise. However, a few general rules are useful:

• Most digestive tract pain is perceived in the midline because of bilaterally symmetric
innervation [1,3]. Pain that is clearly lateralized most likely arises from the ipsilateral
kidney, ureter, ovary, or somatically innervated structures, which have predominantly
unilateral innervation. Exceptions to this rule include the gallbladder and ascending
and descending colons which, although bilaterally innervated, have predominant
innervation located on their ipsilateral sides.

• Visceral pain is perceived in the spinal segment at which the visceral afferent nerves
enter the spinal cord [4]. As an example, afferent nerves mediating pain arising from
the small intestine enter the spinal cord between T8 to L1. Thus, distension of the small
intestine is usually perceived in the periumbilical region.

● Referred pain – Pain originating in the viscera may sometimes be perceived as originating
from a site distant from the affected organ ( figure 1) [5-7]. Referred pain is usually
located in the cutaneous dermatomes sharing the same spinal cord level as the visceral
inputs. As an example, nociceptive inputs from the gallbladder enter the spinal cord at T5
to T10. Thus, pain from an inflamed gallbladder may be perceived in the scapula (
figure 1).

The quality of referred pain is aching and perceived to be near the surface of the body. In
addition to pain, two other correlates of referred pain can be detected: skin hyperalgesia
and increased muscle tone of the abdominal wall (which accounts for the abdominal wall
rigidity sometimes observed in patients with an acute abdomen).

UPPER ABDOMINAL PAIN SYNDROMES

Upper abdominal pain syndromes typically have characteristic locations: right upper quadrant
pain ( table 1), epigastric pain ( table 2), or left upper quadrant pain ( table 3).
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Right upper quadrant pain — Biliary and hepatic etiologies cause right upper quadrant pain
syndromes.

Biliary etiologies include ( table 1):

● Gallstones – Symptoms of biliary colic classically include an intense, dull discomfort

located in the right upper quadrant, epigastrium, or (less often) substernal area that may
radiate to the back (particularly the right shoulder blade). Patients may have associated
nausea, vomiting, and diaphoresis. The pain generally lasts at least 30 minutes, plateauing
within an hour. Patients have an unremarkable abdominal examination. (See "Overview of
gallstone disease in adults", section on 'Biliary colic'.)

● Acute cholecystitis – The clinical manifestations of acute cholecystitis include prolonged

(more than four to six hours), steady, severe right upper quadrant or epigastric pain, fever,
abdominal guarding, a positive Murphy's sign, and leukocytosis. (See "Acute calculous
cholecystitis: Clinical features and diagnosis", section on 'Clinical manifestations'.)

● Acute cholangitis – Acute cholangitis occurs when a stone becomes impacted in the
biliary or hepatic ducts, causing dilation of the obstructed duct and bacterial
superinfection. It is characterized by fever, jaundice, and abdominal pain, although this
classic triad (known as Charcot's triad) occurs in only 50 to 75 percent of cases [8]. The
abdominal pain is typically vague and located in the right upper quadrant. (See "Acute
cholangitis: Clinical manifestations, diagnosis, and management", section on 'Clinical
manifestations'.)

● Sphincter of Oddi dysfunction – Sphincter of Oddi dysfunction can be a cause of biliary

pain in the absence of gallstones or biliary inflammation. Typically the pain is located in
the right upper quadrant or epigastrium and lasts from 30 minutes to several hours. (See
"Clinical manifestations and diagnosis of sphincter of Oddi dysfunction".)

Hepatic etiologies include ( table 1):

● Hepatitis – Patients with acute hepatitis (eg, from hepatitis A, alcohol, or medications)
may have fatigue, malaise, nausea, vomiting, and anorexia in addition to right upper
quadrant pain. Other symptoms include jaundice, dark urine, and light colored stools. (See
"Hepatitis A virus infection in adults: Epidemiology, clinical manifestations, and diagnosis",
section on 'Clinical manifestations' and "Alcoholic hepatitis: Clinical manifestations and
diagnosis", section on 'Signs and symptoms' and "Drug-induced liver injury", section on
'Clinical manifestations'.)

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● Perihepatitis – The Fitz-Hugh-Curtis syndrome, or perihepatitis, is a cause of right upper

quadrant pain in young females with pelvic inflammatory disease (PID). It occurs in
approximately 10 percent of patients with acute PID. It is characterized by right upper
quadrant pain with a distinct pleuritic component, sometimes referred to the right
shoulder. (See "Pelvic inflammatory disease: Clinical manifestations and diagnosis",
section on 'Perihepatitis'.)

● Liver abscess – Liver abscess is the most common type of visceral abscess. Patients
generally present with fever and abdominal pain. Risk factors include diabetes, underlying
hepatobiliary or pancreatic disease, or liver transplant. (See "Pyogenic liver abscess",
section on 'Epidemiology' and "Pyogenic liver abscess", section on 'Clinical
manifestations'.)

● Budd-Chiari syndrome – Budd-Chiari syndrome is technically defined as hepatic venous

outflow tract obstruction, independent of the level or mechanism of obstruction, provided
the obstruction is not due to cardiac disease, pericardial disease, or sinusoidal obstruction
syndrome (veno-occlusive disease). As commonly used, the Budd-Chiari syndrome implies
thrombosis of the hepatic veins and/or the intrahepatic or suprahepatic inferior vena cava.
Symptoms include fever, abdominal pain, abdominal distention (from ascites), lower
extremity edema, jaundice, gastrointestinal bleeding, and/or hepatic encephalopathy.
There are a variety of causes, many of which are related to an underlying prothrombotic
or hypercoagulable state ( table 4). (See "Budd-Chiari syndrome: Epidemiology, clinical
manifestations, and diagnosis", section on 'Clinical manifestations' and "Etiology of the
Budd-Chiari syndrome", section on 'Etiology'.)

● Portal vein thrombosis – Clinical manifestations of portal vein thrombosis vary

depending on the extent of obstruction as well as the speed of development (acute or
chronic). It is common in patients with cirrhosis and is associated with the severity of liver
disease. Patients may be asymptomatic or have abdominal pain, dyspepsia, or
gastrointestinal bleeding. (See "Acute portal vein thrombosis in adults: Clinical
manifestations, diagnosis, and management", section on 'Clinical manifestations' and
"Chronic portal vein thrombosis in adults: Clinical manifestations, diagnosis, and
management", section on 'Clinical manifestations'.)

Epigastric pain — Pancreatic and gastric etiologies often cause epigastric pain ( table 2).

● Acute myocardial infarction – Epigastric pain can be the presenting symptom of an

acute myocardial infarction. Patients may have associated shortness of breath or

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exertional symptoms. (See "Angina pectoris: Chest pain caused by fixed epicardial
coronary artery obstruction", section on 'History'.)

● Pancreatitis – Both acute and chronic pancreatitis are associated with abdominal pain
that often radiates to the back. Most patients with acute pancreatitis have acute onset of
persistent, severe epigastric pain. The pain is steady and may be in the mid-epigastrium,
right upper quadrant, diffuse, or, infrequently, confined to the left side. (See "Clinical
manifestations and diagnosis of acute pancreatitis", section on 'Clinical features'.)

The two primary clinical manifestations of chronic pancreatitis are epigastric pain and
pancreatic insufficiency. The pain is typically epigastric, is occasionally associated with
nausea and vomiting, and may be partially relieved by sitting upright or leaning forward.
(See "Chronic pancreatitis: Clinical manifestations and diagnosis in adults", section on
'Abdominal pain'.)

● Peptic ulcer disease – Upper abdominal pain or discomfort is the most prominent
symptom in patients with peptic ulcers. Patients most often have epigastric pain, but
occasionally the discomfort localizes to one side. (See "Peptic ulcer disease: Clinical
manifestations and diagnosis", section on 'Clinical manifestations'.)

● Gastroesophageal reflux disease – Most patients with gastroesophageal reflux disease

(GERD) complain of heartburn, regurgitation, and dysphagia. However, some patients may
also complain of epigastric and/or chest pain. (See "Clinical manifestations and diagnosis
of gastroesophageal reflux in adults", section on 'Clinical features'.)

● Gastritis/gastropathy – Gastritis refers to inflammation in the lining of the stomach.

Gastritis is predominantly an inflammatory process, while the term gastropathy denotes a
gastric mucosal disorder with minimal to no inflammation. Acute gastropathy often
presents with abdominal discomfort/pain, heartburn, nausea, vomiting, and
hematemesis. Gastropathy may be caused by a variety of etiologies including alcohol and
nonsteroidal antiinflammatory drugs (NSAIDs). (See "Acute hemorrhagic erosive
gastropathy and reactive gastropathy", section on 'Acute hemorrhagic erosive
gastropathy' and "NSAIDs (including aspirin): Pathogenesis of gastroduodenal toxicity".)

● Functional dyspepsia – Functional dyspepsia is defined as the presence of one or more of

the following symptoms: postprandial fullness, early satiation, and epigastric pain or
burning, with no evidence of structural disease (including at upper endoscopy) to explain
the symptoms. (See "Functional dyspepsia in adults".)

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● Gastroparesis – Patients with gastroparesis can present with nausea, vomiting,

abdominal pain, early satiety, postprandial fullness, bloating, and, in severe cases, weight
loss. The most common causes are idiopathic, diabetic, or postsurgical ( figure 2). (See
"Gastroparesis: Etiology, clinical manifestations, and diagnosis", section on 'Clinical
manifestations'.)

Left upper quadrant pain — Left upper quadrant pain is often related to the spleen ( table 3
).

● Splenomegaly – Splenomegaly can cause left upper quadrant pain or discomfort, referred
pain to the left shoulder, and/or early satiety. Splenomegaly has multiple causes (
table 5). (See "Evaluation of splenomegaly and other splenic disorders in adults",
section on 'Splenomegaly'.)

● Splenic infarction – Patients with splenic infarction classically present with severe left
upper quadrant pain, though atypical presentations are common. Splenic infarction is
associated with a variety of underlying conditions (eg, hypercoagulable state, embolic
disease from atrial fibrillation, conditions associated with splenomegaly). (See "Evaluation
of splenomegaly and other splenic disorders in adults", section on 'Abscess and
infarction'.)

● Splenic abscess – Splenic abscesses are uncommon and typically are associated with fever
and tenderness in the left upper quadrant. They may also be associated with splenic
infarction. (See "Evaluation of splenomegaly and other splenic disorders in adults", section
on 'Abscess and infarction'.)

● Splenic rupture – Splenic rupture is most often associated with trauma. The patient may
complain of left upper abdominal, left chest wall, or left shoulder pain (ie, Kehr's sign).
Kehr's sign is pain referred to the left shoulder that worsens with inspiration and is due to
irritation of the phrenic nerve from blood adjacent to the left hemidiaphragm. (See
"Management of splenic injury in the adult trauma patient", section on 'History and
physical examination' and "Evaluation of splenomegaly and other splenic disorders in
adults", section on 'Trauma/rupture'.)

LOWER ABDOMINAL PAIN SYNDROMES

Lower abdominal pain syndromes ( table 6) often cause pain in either or both lower
quadrants. Females may have lower abdominal pain from disorders of the internal female
reproductive organs ( table 7). (See 'Females' below.)
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Lower abdominal pain syndromes that are generally localized to one side include ( table 6):

● Acute appendicitis – Acute appendicitis typically presents with periumbilical pain initially
that radiates to the right lower quadrant. It is associated with anorexia, nausea, and
vomiting. However, occasionally patients present with epigastric or generalized abdominal
pain. The pain localizes to the right lower quadrant when the appendiceal inflammation
begins to involve the peritoneal surface. (See "Acute appendicitis in adults: Clinical
manifestations and differential diagnosis", section on 'Clinical manifestations'.)

● Diverticulitis – The clinical presentation of diverticulitis depends upon the severity of the
underlying inflammatory process and whether or not complications are present. Left
lower quadrant pain is the most common complaint in Western countries, occurring in 70
percent of patients. Right-sided diverticulitis is more common in Asian populations. The
pain is usually constant and is often present for several days prior to presentation.
Patients may also have nausea and vomiting. (See "Clinical manifestations and diagnosis
of acute diverticulitis in adults", section on 'Clinical manifestations'.)

Abdominal pain from some genitourinary etiologies may be localized to either side ( table 6):

● Kidney stones – Kidney stones usually cause symptoms when the stone passes from the
renal pelvis into the ureter. Pain is the most common symptom and varies from a mild to
severe. Patients may have flank pain, back pain, or abdominal pain. (See "Kidney stones in
adults: Diagnosis and acute management of suspected nephrolithiasis", section on
'Clinical manifestations'.)

● Pyelonephritis – Patients with pyelonephritis may or may not have symptoms of cystitis
(dysuria, frequency, urgency, and/or hematuria). These patients also have fever, chills,
flank pain, and costovertebral angle tenderness. (See "Acute simple cystitis in women",
section on 'Clinical manifestations' and "Acute simple cystitis in men", section on 'Clinical
manifestations'.)

Other etiologies of lower abdominal pain may not always be localized to one side ( table 6):

● Cystitis – Patients with cystitis may complain of suprapubic pain as well as dysuria,
frequency, urgency, and/or hematuria. (See "Acute simple cystitis in women", section on
'Clinical manifestations' and "Acute simple cystitis in men", section on 'Clinical
manifestations'.)

● Acute urinary retention – Patients with bladder outlet obstruction leading to acute
urinary retention present with the inability to pass urine. They may have associated lower

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abdominal and/or suprapubic pain or discomfort. (See "Acute urinary retention", section
on 'Clinical presentation'.)

● Infectious colitis – Patients with infectious colitis generally have diarrhea as the
predominant symptom but may also have associated abdominal pain, which may be
severe. Patients with Clostridioides difficile infection can present with an acute abdomen
and peritoneal signs in the setting of perforation and fulminant colitis ( table 8). (See
"Clostridioides difficile infection in adults: Clinical manifestations and diagnosis", section
on 'Clinical manifestations' and "Approach to the adult with acute diarrhea in resource-rich
settings", section on 'Stool tests for bacterial pathogens'.)

DIFFUSE ABDOMINAL PAIN SYNDROMES

Abdominal pain syndromes may have diffuse, nonspecific, or variable patterns of pain (
table 9).

● Obstruction – Severe, acute diffuse abdominal pain can be caused by either partial or
complete obstruction of the intestines. Intestinal obstruction should be considered when
the patient complains of pain, vomiting, and obstipation. Physical findings include
abdominal distention, tenderness to palpation, high-pitched or absent bowel sounds, and
a tympanic abdomen. There are many etiologies of obstruction ( table 10), with the
most common etiologies in adults being postoperative adhesions, malignancy related (eg,
from colorectal cancer), and complicated hernias. Other less common etiologies include
Crohn disease, gallstones, volvulus, and intussusception. (See "Etiologies, clinical
manifestations, and diagnosis of mechanical small bowel obstruction in adults" and
"Clinical presentation, diagnosis, and staging of colorectal cancer", section on 'Clinical
presentation' and "Intestinal malrotation in children" and "Gastric volvulus in adults" and
"Cecal volvulus" and "Sigmoid volvulus".)

● Perforation of gastrointestinal tract – Perforation of the gastrointestinal tract can

present acutely or in an indolent manner. Patients complain of chest or abdominal pain to
some degree. Sudden, severe chest or abdominal pain following instrumentation or
surgery is very concerning for perforation. Patients on immunosuppressive or
antiinflammatory agents may have an impaired inflammatory response, and some may
have little or no pain and tenderness. Many patients will seek medical attention with the
onset or worsening of significant chest or abdominal pain, but a subset of patients will
present in a delayed fashion. (See "Overview of gastrointestinal tract perforation", section
on 'Clinical features'.)

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● Mesenteric ischemia – Acute mesenteric ischemia presents with the acute and severe
onset of diffuse and persistent abdominal pain, often described as pain out of proportion
to examination. Several features of the pain and its presentation may provide clues to the
etiology of the ischemia and help distinguish small intestinal from colonic ischemia (
table 11). Chronic mesenteric ischemia may be manifested by a variety of symptoms
including abdominal pain after eating ("intestinal angina"), weight loss, nausea, vomiting,
and diarrhea. Ischemia that involves the celiac territory causes epigastric or right upper
quadrant pain. Ischemia may be from either arterial or venous disease. (See "Overview of
intestinal ischemia in adults" and "Chronic mesenteric ischemia" and "Mesenteric venous
thrombosis in adults", section on 'Clinical presentations' and "Colonic ischemia", section
on 'Clinical features'.)

Patients with aortic dissection may have abdominal pain from mesenteric ischemia (
table 12). (See "Clinical features and diagnosis of acute aortic dissection", section on
'Clinical features'.)

● Inflammatory bowel disease– Inflammatory bowel disease (IBD) is comprised of two

major disorders: ulcerative colitis and Crohn disease. IBD is also associated with a number
of extraintestinal manifestations ( table 13). (See "Definitions, epidemiology, and risk
factors for inflammatory bowel disease".)

• Ulcerative colitis – Patients with ulcerative colitis usually present with diarrhea which
may be associated with blood. Bowel movements are frequent and small in volume as
a result of rectal inflammation. Associated symptoms include colicky abdominal pain,
urgency, tenesmus, and incontinence. (See "Clinical manifestations, diagnosis, and
prognosis of ulcerative colitis in adults", section on 'Clinical manifestations'.)

• Crohn disease – The clinical manifestations of Crohn disease are more variable than
those of ulcerative colitis. Patients can have symptoms for many years prior to
diagnosis. Fatigue, prolonged diarrhea with abdominal pain, weight loss, and fever,
with or without gross bleeding, are the hallmarks of Crohn disease. (See "Clinical
manifestations, diagnosis, and prognosis of Crohn disease in adults", section on
'Clinical features'.)

● Viral gastroenteritis – Patients with viral gastroenteritis often have diarrhea

accompanied by nausea, vomiting, and abdominal pain. (See "Acute viral gastroenteritis in
adults", section on 'Clinical manifestations'.)

● Spontaneous bacterial peritonitis – Spontaneous bacterial peritonitis most often occurs

in cirrhotics with advanced liver disease with ascites. Patients present with fever,
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abdominal pain, and/or altered mental status. (See "Spontaneous bacterial peritonitis in
adults: Clinical manifestations", section on 'Clinical manifestations'.)

● Peritonitis in peritoneal dialysis patients – Peritonitis may develop in patients on

peritoneal dialysis either from contamination during dialysis or catheter related infection.
The most common symptoms and signs are abdominal pain and cloudy peritoneal
effluent. Other symptoms and signs include fever, nausea, diarrhea, abdominal
tenderness, rebound tenderness, and occasionally systemic signs (eg, hypotension). (See
"Clinical manifestations and diagnosis of peritonitis in peritoneal dialysis", section on
'Clinical presentation'.)

● Malignancy – Gastrointestinal malignancies may be associated with abdominal

discomfort. These are discussed in detail in specific topics. As examples:

• Colorectal cancer – Patients with colorectal cancer may present with abdominal pain
from partial obstruction, peritoneal dissemination, or perforation. (See "Clinical
presentation, diagnosis, and staging of colorectal cancer", section on 'Clinical
presentation'.)

• Gastric cancer – Patients with gastric cancer may have abdominal pain that is often
epigastric pain. (See "Clinical features, diagnosis, and staging of gastric cancer",
section on 'Clinical features'.)

• Pancreatic cancer – The most common symptoms in patients with pancreatic cancer
are pain, jaundice, and weight loss. (See "Clinical manifestations, diagnosis, and
staging of exocrine pancreatic cancer", section on 'Clinical presentation'.)

Additionally, patients may have pain as part of pain syndromes related to malignancy (
table 14). (See "Overview of cancer pain syndromes", section on 'Tumor-related visceral
pain syndromes'.)

● Celiac disease – Patients with celiac disease may complain of abdominal pain in addition
to diarrhea with bulky, foul-smelling, floating stools due to steatorrhea and flatulence.
(See "Epidemiology, pathogenesis, and clinical manifestations of celiac disease in adults",
section on 'Clinical manifestations'.)

● Ketoacidosis – Patients with ketoacidosis (eg, from diabetes or alcohol) may have diffuse
abdominal pain as well as nausea and vomiting. (See "Diabetic ketoacidosis and
hyperosmolar hyperglycemic state in adults: Clinical features, evaluation, and diagnosis",

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section on 'Abdominal pain in DKA' and "Fasting ketosis and alcoholic ketoacidosis",
section on 'Clinical presentation'.)

● Adrenal insufficiency – Patients with adrenal insufficiency may have diffuse abdominal
pain as well as nausea and vomiting. Patients with adrenal crisis may present with shock
and hypotension. Patients with chronic adrenal deficiency may also complain of malaise,
fatigue, anorexia, and weight loss. (See "Clinical manifestations of adrenal insufficiency in
adults", section on 'Autoimmune primary adrenal insufficiency' and "Clinical
manifestations of adrenal insufficiency in adults".)

● Foodborne disease – A foodborne disease will typically manifest as a mixture of nausea,

vomiting, fever, abdominal pain, and diarrhea. Toxin-mediated illnesses can occur within
hours of ingestion, but bacterial colitis generally requires 24 to 48 hours to develop.
Certain foods may be linked to particular pathogens ( table 15). (See "Causes of acute
infectious diarrhea and other foodborne illnesses in resource-rich settings", section on
'Clinical clues to the microbial cause'.)

● Irritable bowel syndrome – Patients with irritable bowel syndrome (IBS) can present with
a wide array of symptoms which include both gastrointestinal and extraintestinal
complaints. However, the symptom complex of chronic abdominal pain and altered bowel
habits remains the nonspecific yet primary characteristic of IBS. (See "Clinical
manifestations and diagnosis of irritable bowel syndrome in adults", section on 'Clinical
manifestations'.)

● Constipation – Constipation may be associated with abdominal pain. Diseases associated

with constipation include neurologic and metabolic disorders; obstructing lesions of the
gastrointestinal tract, including colorectal cancer; endocrine disorders such as diabetes
mellitus; and psychiatric disorders such as anorexia nervosa ( table 16). Constipation
may also be due to a side effect of drugs ( table 17). (See "Etiology and evaluation of
chronic constipation in adults".)

● Diverticulosis – Uncomplicated diverticulosis is often asymptomatic and an incidental

finding on colonoscopy or sigmoidoscopy. Abdominal pain and constipation seen in
patients with uncomplicated diverticulosis may be related to abnormal motility and
visceral hypersensitivity rather than to the diverticula themselves. (See "Colonic
diverticulosis and diverticular disease: Epidemiology, risk factors, and pathogenesis",
section on 'Symptomatic uncomplicated diverticular disease'.)

● Lactose intolerance – Symptoms of lactose intolerance include abdominal pain, bloating,

flatulence, and diarrhea. The abdominal pain may be cramping in nature and is often
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localized to the periumbilical area or lower quadrants. (See "Lactose intolerance and
malabsorption: Clinical manifestations, diagnosis, and management", section on 'Clinical
features'.)

LESS COMMON CAUSES

Less common causes of abdominal pain include ( table 18):

● Abdominal aortic aneurysm – Most patients with abdominal aortic aneurysm (AAA) have
no symptoms. When patients with a nonruptured AAA do have symptoms, abdominal,
back, or flank pain is the most common clinical manifestation. Classically, ruptured AAA is
associated with severe pain, hypotension, and a pulsatile abdominal mass, but patients
may have variable presentations. (See "Clinical features and diagnosis of abdominal aortic
aneurysm", section on 'Asymptomatic AAA' and "Clinical features and diagnosis of
abdominal aortic aneurysm", section on 'Symptomatic (nonruptured) AAA'.)

● Abdominal compartment syndrome – Abdominal compartment syndrome generally

occurs in patients who are critically ill. Patients have a tensely distended abdomen. (See
"Abdominal compartment syndrome in adults".)

● Abdominal migraine – Recurrent abdominal pain may occur in patients with abdominal
migraine [9]. These patients usually also suffer from typical migraine headaches, although
occasional patients present with gastrointestinal symptoms only [10]. Abdominal
migraines have also been linked to cyclic vomiting syndrome. (See "Pathophysiology,
clinical manifestations, and diagnosis of migraine in adults" and "Cyclic vomiting
syndrome", section on 'Association with migraines'.)

● Acute hepatic porphyrias – The acute hepatic porphyrias, of which acute intermittent
porphyria (AIP) is the most common, are a rare cause of abdominal pain. The presentation
of AIP is highly variable and patients have nonspecific symptoms. Abdominal pain is the
most common and often earliest symptom. (See "Porphyrias: An overview", section on
'Acute hepatic porphyrias (AHP)' and "Acute intermittent porphyria: Pathogenesis, clinical
features, and diagnosis", section on 'Acute attacks'.)

● Angioedema – Angioedema with abdominal pain may be caused by hereditary

angioedema or related to angiotensin-converting enzyme (ACE) inhibitor therapy. It can
present with recurrent episodes of abdominal pain, accompanied by nausea, vomiting,
colicky pain, and diarrhea. (See "Hereditary angioedema: Epidemiology, clinical

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manifestations, exacerbating factors, and prognosis" and "ACE inhibitor-induced

angioedema", section on 'Intestine'.)

● Celiac artery compression syndrome – Celiac artery compression syndrome (also

referred to as celiac axis syndrome, median arcuate ligament syndrome, and Dunbar
syndrome) is defined as chronic, recurrent abdominal pain related to compression of the
celiac artery by the median arcuate ligament. (See "Celiac artery compression syndrome".)

● Chronic abdominal wall pain – Chronic abdominal wall pain usually refers to anterior
cutaneous nerve entrapment syndrome. Pain associated with nerve entrapment is
characteristically maximal in an area <2 cm in diameter. (See "Anterior cutaneous nerve
entrapment syndrome", section on 'Clinical features'.)

● Colonic pseudo-obstruction – Pseudo-obstruction is characterized by signs and

symptoms of a mechanical obstruction of the small or large bowel in the absence of a
mechanical cause. The main clinical feature is abdominal distention, but patients may
have associated abdominal pain, nausea, and vomiting. Acute colonic pseudo-obstruction
is also known as Ogilvie's syndrome. (See "Acute colonic pseudo-obstruction (Ogilvie's
syndrome)", section on 'Clinical manifestations' and "Chronic intestinal pseudo-
obstruction: Etiology, clinical manifestations, and diagnosis", section on 'Clinical
manifestations'.)

● Eosinophilic gastroenteritis – Eosinophilic gastroenteritis belongs to a group of diseases

that includes eosinophilic esophagitis, gastritis, enteritis, and colitis. Symptoms depend on
what part of the gastrointestinal tract is affected. (See "Eosinophilic gastrointestinal
diseases".)

● Epiploic appendagitis – Epiploic appendagitis (also known as appendicitis epiploica,

hemorrhagic epiploitis, epiplopericolitis, or appendagitis) is a benign and self-limited
condition of the epiploic appendages. Patients with epiploic appendagitis most commonly
present with acute or subacute onset of lower abdominal pain. The pain is on the left side
in 60 to 80 percent of patients but has also been reported in the right lower quadrant. (See
"Epiploic appendagitis".)

● Familial Mediterranean fever – The typical manifestations of familial Mediterranean

fever are recurrent attacks of severe pain (due to serositis at one or more sites) and fever,
lasting one to three days and then resolving spontaneously. Most patients have
abdominal pain. In between attacks, patients feel entirely well. (See "Clinical
manifestations and diagnosis of familial Mediterranean fever".)

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● Helminthic infections – Patients with helminthic infections can manifest with

gastrointestinal symptoms, including abdominal pain. The clinical manifestations for
specific helminth infections are discussed in the appropriate topics.

● Herpes zoster – Herpes zoster neuropathic pain may precede the development of skin
lesions. Depending on the dermatome involved, this pain can be confused with other
etiologies such as cholecystitis or renal colic. (See "Epidemiology, clinical manifestations,
and diagnosis of herpes zoster", section on 'Clinical manifestations'.)

● Hypercalcemia – Hypercalcemia can cause abdominal pain, either directly or as an

etiology for pancreatitis or constipation. (See "Clinical manifestations of hypercalcemia",
section on 'Gastrointestinal abnormalities'.)

● Hypothyroidism – Hypothyroidism can occasionally cause abdominal pain in the setting

of constipation and ileus. (See "Clinical manifestations of hypothyroidism", section on
'Gastrointestinal disorders'.)

● Lead poisoning – Abdominal pain is associated with acute lead poisoning. (See "Lead
exposure and poisoning in adults", section on 'Clinical manifestations'.)

● Meckel's diverticulum – Meckel's diverticulum is usually clinically silent and can be found
incidentally or can present with a variety of clinical manifestations including
gastrointestinal bleeding or other acute abdominal complaints. Acute abdominal pain
related to Meckel's diverticulum can be the result of diverticular inflammation, similar to
acute appendicitis, related to bowel obstruction or perforation of the Meckel's or adjacent
bowel. (See "Meckel's diverticulum", section on 'Clinical presentations' and "Meckel's
diverticulum", section on 'Acute abdominal pain'.)

● Narcotic bowel syndrome – The most common side effect of opioids is constipation, but
some patients may have associated abdominal pain. (See "Prevention and management of
side effects in patients receiving opioids for chronic pain", section on 'Opioid bowel
dysfunction'.)

● Paroxysmal nocturnal hemoglobinuria – Paroxysmal nocturnal hemoglobinuria is a rare

acquired hematopoietic stem cell disorder. Up to 40 percent of patients with paroxysmal
nocturnal hemoglobinuria may ultimately develop venous thrombosis, often involving
intraabdominal (mesenteric, portal, splenic, hepatic) vessels. Additionally, during acute
hemolytic episodes, many patients experience symptoms related to esophageal spasm
and also complain of generalized cramping abdominal pain. (See "Clinical manifestations
and diagnosis of paroxysmal nocturnal hemoglobinuria", section on 'Abdominal
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pain/dysphagia' and "Clinical manifestations and diagnosis of paroxysmal nocturnal

hemoglobinuria", section on 'Thrombosis'.)

● Pseudoappendicitis – Acute yersiniosis or campylobacter infection can mimic appendicitis

presenting with right lower abdominal pain, fever, vomiting, leukocytosis, and mild
diarrhea. (See "Clinical manifestations and diagnosis of Yersinia infections", section on
'Pseudoappendicitis' and "Clinical manifestations, diagnosis, and treatment of
Campylobacter infection", section on 'Pseudoappendicitis'.)

● Pulmonary etiologies – Lower lobe pulmonary pathologies (eg, pneumonia, pulmonary

embolism) or inflammatory pleural effusions (eg, empyema, pulmonary infarction) can
present with what appears to be upper abdominal pain because they occur at the
threshold of the abdomen. Some patients with pneumonia (eg, Legionella) may also have
abdominal pain and other gastrointestinal symptoms as part of their illness. (See "Clinical
manifestations and diagnosis of Legionella infection", section on 'Clinical features'.)

● Rectus sheath hematoma – Rectus sheath hematoma is a rare clinical entity that results
from accumulation of blood within the rectus sheath. Rectus sheath hematoma most
often presents as acute onset of abdominal pain with a palpable abdominal wall mass.
(See "Spontaneous retroperitoneal hematoma and rectus sheath hematoma", section on
'Clinical presentations'.)

● Renal infarction – Renal infarction is rare. Patients with acute renal infarction typically
complain of the acute onset of flank pain or generalized abdominal pain, frequently
accompanied by nausea, vomiting, and, occasionally, fever. (See "Renal infarction", section
on 'Clinical presentation'.)

● Rib pain – Patients may have upper abdominal pain from lower rib pain syndromes. (See
"Major causes of musculoskeletal chest pain in adults", section on 'Lower rib pain
syndromes'.)

● Sclerosing mesenteritis – Sclerosing mesenteritis is part of a spectrum (including

mesenteric lipodystrophy and mesenteric panniculitis) of idiopathic primary inflammatory
and fibrotic processes that affect the mesentery. The clinical manifestations of sclerosing
mesenteritis are varied but may include abdominal pain and other gastrointestinal
symptoms. (See "Sclerosing mesenteritis", section on 'Clinical presentation'.)

● Somatization – Patients with somatization may present with a wide array of symptoms
including gastrointestinal symptoms. (See "Somatic symptom disorder: Epidemiology and
clinical presentation", section on 'Clinical presentation'.)
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● Wandering spleen – The wandering (or ectopic) spleen is a rare condition where the
spleen migrates from its normal site to another location in the abdomen because of laxity
or maldevelopment of the supporting ligaments [11]. Wandering spleen may be
congenital or acquired from weakened supporting splenic ligaments. Patients may be
asymptomatic or present with acute, chronic, or intermittent pain from torsion of the
wandering spleen. Adults present with nonspecific abdominal pain associated with a
palpable abdominal mass while children most often present with acute abdominal pain.

SPECIAL POPULATIONS

In addition to the etiologies listed above, certain etiologies are specific to special populations of
patients.

Females — Lower abdominal pain and/or pelvic pain in females is frequently caused by
disorders of the internal female reproductive organs ( table 7). The etiologies and evaluation
of acute and chronic pelvic pain are discussed in detail separately. (See "Evaluation of acute
pelvic pain in nonpregnant adult women" and "Chronic pelvic pain in nonpregnant adult
females: Causes".)

● Pregnancy/pregnancy complications – Pregnancy and/or complications of pregnancy

can lead to abdominal pain. This is discussed in detail separately. (See "Approach to acute
abdominal/pelvic pain in pregnant and postpartum patients", section on 'General
approach'.)

● Ectopic pregnancy – The most common clinical presentation of ectopic pregnancy is first
trimester vaginal bleeding and/or abdominal pain. Clinical manifestations of ectopic
pregnancy typically appear six to eight weeks after the last normal menstrual period but
can occur later, especially if the pregnancy is in an extrauterine site other than the
fallopian tube. Individuals with ruptured ectopic pregnancy can present with life-
threatening hemorrhage. (See "Ectopic pregnancy: Clinical manifestations and diagnosis",
section on 'Abdominal pain'.)

● Pelvic inflammatory disease – Lower abdominal pain is the cardinal presenting symptom
in females with pelvic inflammatory disease (PID). Any sexually active female is at risk for
PID. There is a wide-spectrum of clinical presentations. Acute symptomatic PID is
characterized by the acute onset of lower abdominal or pelvic pain, pelvic organ
tenderness, and evidence of inflammation of the genital tract. Individuals may also
develop tuboovarian abscess as a complication. (See "Pelvic inflammatory disease: Clinical

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manifestations and diagnosis" and "Epidemiology, clinical manifestations, and diagnosis

of tubo-ovarian abscess", section on 'Clinical presentation'.)

● Ovarian torsion – The classic presentation of ovarian torsion is the acute onset of
moderate to severe pelvic pain, often with nausea and possibly vomiting, in a woman with
an adnexal mass. (See "Ovarian and fallopian tube torsion", section on 'Clinical
presentation'.)

● Ruptured ovarian cyst – Rupture of an ovarian cyst may be asymptomatic or associated

with a sudden onset of unilateral lower abdominal pain. The classic presentation is sudden
onset of severe focal lower quadrant pain following sexual intercourse. (See "Evaluation
and management of ruptured ovarian cyst", section on 'Clinical presentation'.)

● Endometriosis – The classic symptoms of endometriosis are dysmenorrhea, pelvic pain,

dyspareunia, and/or infertility, but other symptoms may also be present (eg, bowel or
bladder symptoms). Patients may present with one symptom or a combination of
symptoms.

● Endometritis – Endometritis refers to inflammation of the endometrium, the inner lining

of the uterus. Acute endometritis is most often preceded by PID. The diagnosis of acute
endometritis is made clinically based upon criteria for the diagnosis of acute PID. (See
"Endometritis unrelated to pregnancy", section on 'Acute endometritis'.)

People with symptomatic chronic endometritis usually present with abnormal uterine
bleeding, which may consist of intermenstrual bleeding, spotting, postcoital bleeding,
menorrhagia, or amenorrhea. Vague, crampy lower abdominal pain accompanies the
bleeding or may occur alone. (See "Endometritis unrelated to pregnancy", section on
'Chronic endometritis'.)

● Leiomyomas (fibroids) – Leiomyomas may cause pelvic pressure or pain. These

symptoms may be related to bulk or infrequently fibroids can cause acute pain from
degeneration (eg, carneous or red degeneration) or torsion of a pedunculated tumor. Pain
may be associated with a low grade fever, uterine tenderness on palpation, elevated white
blood cell count, or peritoneal signs.

● Ovarian hyperstimulation – Ovarian hyperstimulation syndrome can cause abdominal

discomfort from enlarged ovaries in individuals undergoing fertility treatment ( table 19
). (See "Pathogenesis, clinical manifestations, and diagnosis of ovarian hyperstimulation
syndrome", section on 'Clinical manifestations'.)

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● Ovarian cancer – Patients with ovarian cancer may present with bloating or abdominal or
pelvic pain. (See "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Clinical
features and diagnosis", section on 'Pelvic and abdominal symptoms'.)

Postoperative patients — A variety of postoperative complications can cause abdominal pain:

● Postoperative ileus (see "Postoperative ileus", section on 'Clinical features')

● Surgical site infections (see "Complications of abdominal surgical incisions", section on

'Hematoma and seroma' and "Overview of the evaluation and management of surgical
site infection")

● Hematoma/seroma formation and nerve injury (see "Complications of abdominal surgical

incisions", section on 'Hematoma and seroma' and "Complications of abdominal surgical
incisions", section on 'Nerve injury')

Patients with sickle cell disease — Severe intermittent episodes of abdominal pain can occur
with sickle cell disease, particularly after an acute precipitant such as dehydration. (See
"Evaluation of acute pain in sickle cell disease".)

Patients with sickle cell may also have right upper quadrant pain in the setting of hepatic
involvement. The liver can be affected by a number of complications due to the disease itself
and its treatment. (See "Hepatic manifestations of sickle cell disease", section on 'Disorders
associated with the sickling process' and "Hepatic manifestations of sickle cell disease", section
on 'Disorders related to coexisting conditions'.)

HIV-infected patients — Causes of abdominal pain in the HIV-infected patient include

common etiologies seen in the general population (eg, appendicitis, diverticulitis) but also
opportunistic infections (eg, cytomegalovirus [CMV], Mycobacterium avium complex [MAC],
cryptosporidium) and neoplasms (eg, Kaposi sarcoma, lymphoma) if there is evidence of
advanced immunodeficiency (CD4 cell count <100 cells/microL). (See "AIDS-related
cytomegalovirus gastrointestinal disease" and "Mycobacterium avium complex (MAC) infections
in persons with HIV" and "Cryptosporidiosis: Epidemiology, clinical manifestations, and
diagnosis" and "AIDS-related Kaposi sarcoma: Clinical manifestations and diagnosis" and "HIV-
related lymphomas: Clinical manifestations and diagnosis".)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Nontraumatic
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abdominal pain in adults".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topic (see "Patient education: Abdominal pain (The Basics)")

● Beyond the Basics topics (see "Patient education: Upset stomach (functional dyspepsia) in
adults (Beyond the Basics)" and "Patient education: Chronic pelvic pain in women (Beyond
the Basics)")

SUMMARY

● Pain receptors in the abdomen respond to mechanical and chemical stimuli. The type and
density of visceral afferent nerves makes the localization of visceral pain imprecise. Pain
originating in the viscera may also be perceived as originating from a site distant from the
affected organ (referred pain) ( figure 1). (See 'Pathophysiology of abdominal pain'
above.)

● Upper abdominal pain typically has characteristic locations: right upper quadrant pain (
table 1), epigastric pain ( table 2), or left upper quadrant pain ( table 3). (See 'Upper
abdominal pain syndromes' above.)

● Lower abdominal pain syndromes ( table 6) often cause pain in either or both lower
quadrants. Females may have lower abdominal pain from disorders of the internal female

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reproductive organs ( table 7). (See 'Lower abdominal pain syndromes' above and
'Females' above.)

● Abdominal pain syndromes may have diffuse or nonspecific pain ( table 9). (See 'Diffuse
abdominal pain syndromes' above.)

● There are many other less common causes of abdominal pain ( table 18). (See 'Less
common causes' above.)

● Certain etiologies are specific to special population of patients (females ( table 7),
postoperative patients, sickle cell patients, and HIV patients). (See 'Special populations'
above.)

Use of UpToDate is subject to the Terms of Use.

REFERENCES

1. Ray BS, Neill CL. Abdominal Visceral Sensation in Man. Ann Surg 1947; 126:709.
2. Bentley FH. Observations on Visceral Pain : (1) Visceral Tenderness. Ann Surg 1948; 128:881.

3. CHAPMAN WP, HERRERA R, JONES CM. A comparison of pain produced experimentally in

lower esophagus, common bile duct, and upper small intestine with pain experienced by
patients with diseases of biliary tract and pancreas. Surg Gynecol Obstet 1949; 89:573.

4. Brown FR. The Problem of Abdominal Pain. Br Med J 1942; 1:543.

5. Bloomfield AL, Polland WS. EXPERIMENTAL REFERRED PAIN FROM THE GASTRO-INTESTINAL
TRACT. PART II. STOMACH, DUODENUM AND COLON. J Clin Invest 1931; 10:453.
6. DWORKEN HJ, BIEL FJ, MACHELLA TE. Supradiaphragmatic reference of pain from the colon.
Gastroenterology 1952; 22:222.
7. Ryle JA. Visceral pain and referred pain. Lancet 1926; 1:895.
8. Saik RP, Greenburg AG, Farris JM, Peskin GW. Spectrum of cholangitis. Am J Surg 1975;
130:143.
9. Roberts JE, deShazo RD. Abdominal migraine, another cause of abdominal pain in adults.
Am J Med 2012; 125:1135.

10. Angus-Leppan H, Saatci D, Sutcliffe A, Guiloff RJ. Abdominal migraine. BMJ 2018; 360:k179.
11. Gayer G, Hertz M, Strauss S, Zissin R. Congenital anomalies of the spleen. Semin
Ultrasound CT MR 2006; 27:358.
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GRAPHICS

Patterns of referred abdominal pain

Pain from abdominal viscera often (but not always) localizes according to the
structure's embryologic origin, with foregut structures (mouth to proximal half of
duodenum) presenting with upper abdominal pain, midgut structures (distal half
of duodenum to middle of the transverse colon) presenting with periumbilical
pain, and hind gut structures (remainder of colon and rectum, pelvic
genitourinary organs) presenting with lower abdominal pain. Radiation of pain
may provide insight into the diagnosis. As examples, pain from pancreatitis may
radiate to the back while pain from gallbladder disease may radiate to the right
shoulder or subscapular region.

Graphic 61375 Version 7.0

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Causes of right upper quadrant (RUQ) abdominal pain

RUQ Clinical features Comments

Biliary

Biliary colic Intense, dull discomfort located Patients are generally well-
in the RUQ or epigastrium. appearing.
Associated with nausea,
vomiting, and diaphoresis.
Generally lasts at least 30
minutes, plateauing within one
hour. Benign abdominal
examination.

Acute cholecystitis Prolonged (>4 to 6 hours) RUQ

or epigastric pain, fever.
Patients will have abdominal
guarding and Murphy's sign.

Acute cholangitis Fever, jaundice, RUQ pain. May have atypical presentation
in older adults or
immunosuppressed patients.

Sphincter of Oddi RUQ pain similar to other biliary Biliary type pain without other
dysfunction pain. apparent causes.

Hepatic

Acute hepatitis RUQ pain with fatigue, malaise, Variety of etiologies include
nausea, vomiting, and anorexia. hepatitis A, alcohol, and drug-
Patients may also have induced.
jaundice, dark urine, and light-
colored stools.

Perihepatitis (Fitz-Hugh- RUQ pain with a pleuritic Aminotransferases are usually

Curtis syndrome) component, pain is sometimes normal or only slightly elevated.
referred to the right shoulder.

Liver abscess Fever and abdominal pain are Risk factors include diabetes,
the most common symptoms. underlying hepatobiliary or
pancreatic disease, or liver
transplant.

Budd-Chiari syndrome Symptoms include fever, Variety of causes.

abdominal pain, abdominal
distention (from ascites), lower
extremity edema, jaundice,
gastrointestinal bleeding,
and/or hepatic encephalopathy.

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Portal vein thrombosis Symptoms include abdominal Clinical manifestations depend

pain, dyspepsia, or on extent of obstruction and
gastrointestinal bleeding. speed of development. Most
commonly associated with
cirrhosis.

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Causes of epigastric abdominal pain

Epigastric Clinical features Comments

Acute myocardial infarction May be associated with Consider particularly in patients

shortness of breath and with risk factors for coronary
exertional symptoms. artery disease.

Acute pancreatitis Acute-onset, persistent upper

abdominal pain radiating to the
back.

Chronic pancreatitis Epigastric pain radiating to the Associated with pancreatic

back. insufficiency.

Peptic ulcer disease Epigastric pain or discomfort is Occasionally, discomfort

the most prominent symptom. localizes to one side.

Gastroesophageal reflux Associated with heartburn,

disease regurgitation, and dysphagia.

Gastritis/gastropathy Abdominal discomfort/pain, Variety of etiologies including

heartburn, nausea, vomiting, alcohol and nonsteroidal
and hematemesis. antiinflammatory drugs
(NSAIDs).

Functional dyspepsia The presence of one or more of Patients have no evidence of

the following: postprandial structural disease.
fullness, early satiation,
epigastric pain, or burning.

Gastroparesis Nausea, vomiting, abdominal Most causes are idiopathic,

pain, early satiety, postprandial diabetic, or postsurgical.
fullness, and bloating.

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Causes of left upper quadrant (LUQ) abdominal pain

LUQ Clinical features Comments

Splenomegaly Pain or discomfort in LUQ, left Multiple etiologies.

shoulder pain, and/or early
satiety.

Splenic infarct Severe LUQ pain. Atypical presentations

common. Associated with a
variety of underlying conditions
(eg, hypercoagulable state,
atrial fibrillation, and
splenomegaly).

Splenic abscess Associated with fever and LUQ Uncommon. May also be
tenderness. associated with splenic
infarction.

Splenic rupture May complain of LUQ, left chest Most often associated with
wall, or left shoulder pain that trauma.
is worse with inspiration.

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Prothrombotic risk factors for BCS

A. Acquired thrombophilia

Myeloproliferative disease

Polycythemia vera

Essential thrombocytosis

Idiopathic myelofibrosis

JAK2 V617F mutation

Paroxysmal nocturnal hemoglobinuria

Behçet disease

Hyperhomocysteinemia

Antiphospholipid syndrome

B. Inherited thrombophilia

Factor V Leiden

Prothrombin gene G20210A mutation

MTHFR C677T mutation

Thalassemia

PC deficiency

Protein S deficiency

Antithrombin deficiency

C. Systemic factors

Sarcoidosis

Vasculitis

Behçet disease

Connective tissue disease

Inflammatory bowel disease

D. Hormonal factors

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Recent oral contraceptive use

Pregnancy

BCS: Budd-Chiari syndrome; JAK2: janus kinase 2; MTHFR: methyltetrahydrofolate; PC: protein C.

From: Simonetto DA, Singal AK, Garcia-Tsao G, et et al. ACG Clinical guideline: Disorders of the hepatic and mesenteric
circulation. Am J Gastroenterol 2020; 115:18. DOI: 10.14309/ajg.0000000000000486. Copyright © 2020 The American
College of Gastroenterology. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this
material is prohibited.

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Neuromuscular disorders impairing gastric motor

function

Several common neurologic disorders can affect gastrointestinal motility by

altering the parasympathetic or sympathetic supply to the gut.

X: vagal nuceli; CNS: central nervous system; CVA: cerebrovascular accident;

SCG: sympathetic chain ganglia.

Reproduced with permission from: Camilleri M, Prather CM. In: Sleisenger and Fordtran's
Gastrointestinal Disease, 6th ed, Feldman M, Scharschmidt BF, Sleisenger MH (Eds), WB
Saunders, Philadelphia 1998. p.572.

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Major causes of splenomegaly

Congestive
Cirrhosis

Heart failure

Thrombosis of portal, hepatic, or splenic veins

Malignancy
Lymphoma, usually indolent variants

Acute and chronic leukemias

Polycythemia vera

Multiple myeloma and its variants

Essential thrombocythemia

Primary myelofibrosis

Primary splenic tumors

Metastatic solid tumors

Infection
Viral – Hepatitis, infectious mononucleosis, cytomegalovirus

Bacterial – Salmonella, Brucella, tuberculosis

Parasitic – Malaria, schistosomiasis, toxoplasmosis, leishmaniasis

Infective endocarditis

Fungal

Inflammation
Sarcoid

Serum sickness

Systemic lupus erythematosus

Rheumatoid arthritis (Felty syndrome)

Infiltrative, nonmalignant
Gaucher disease

Niemann-Pick disease

Amyloid

Other lysosomal storage diseases (eg, mucopolysaccharidoses)

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Langerhans cell histiocytosis

Hemophagocytic lymphohistiocytosis

Rosai-Dorfman disease

Hematologic (hypersplenic) states

Acute and chronic hemolytic anemias, all etiologies

Sickle cell disease (children)

Following use of recombinant human granulocyte colony-stimulating factor

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Causes of lower abdominal pain

Lower abdomen Localization Clinical features Comments

Appendicitis Generally right lower Periumbilical pain Occasional patients

quadrant initially that radiates to present with epigastric
the right lower or generalized
quadrant. Associated abdominal pain.
with anorexia, nausea,
and vomiting.

Diverticulitis Generally left lower Pain usually constant Clinical presentation

quadrant; right lower and present for several depends on severity of
quadrant more days prior to underlying
common in Asian presentation. May have inflammatory process
patients associated nausea and and whether or not
vomiting. complications are
present.

Nephrolithiasis Either Pain most common Cause symptoms as

symptom, varies from stone passes from
mild to severe. renal pelvis to ureter.
Generally flank pain,
but may have back or
abdominal pain.

Pyelonephritis Either Associated with

dysuria, frequency,
urgency, hematuria,
fever, chills, flank pain,
and costovertebral
angle tenderness.

Acute urinary retention Suprapubic Present with lower

abdominal pain and
discomfort; inability to
urinate.

Cystitis Suprapubic Associated with

dysuria, frequency,
urgency, and
hematuria.

Infectious colitis Either Diarrhea as the Patients with

predominant Clostridioides
symptom, but may also difficile infection can
have associated present with an acute
abdominal pain, which abdomen and
may be severe. peritoneal signs in the
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setting of perforation
and fulminant colitis.

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Pelvic causes of abdominal pain in women

Pelvic causes of
abdominal pain Lateralization Clinical features Comments
in women

Ectopic Either side or Vaginal bleeding with abdominal pain, Patients can
pregnancy diffuse typically six to eight weeks after last present with
abdominal pain menstrual period. life-
threatening
hemorrhage if
ruptured.

Pelvic Lateralization Characterized by the acute onset of lower Wide

inflammatory uncommon abdominal or pelvic pain, pelvic organ spectrum of
disease tenderness, and evidence of clinical
inflammation of the genital tract. Often presentations.
associated with cervical discharge.

Ovarian torsion Localized to one Acute onset of moderate-to-severe pelvic Generally not
side pain, often with nausea and possibly associated
vomiting, in a woman with an adnexal with vaginal
mass. discharge.

Ruptured Localized to one Sudden-onset unilateral lower abdominal Generally not

ovarian cyst side pain. The classic presentation is sudden associated
onset of severe focal lower quadrant pain with vaginal
following sexual intercourse. discharge.

Endometriosis Associated with dysmenorrhea, pelvic Patients may

pain, dyspareunia, and/or infertility, but present with
other symptoms may also be present (eg, one symptom
bowel or bladder symptoms). or a
combination
of symptoms.

Acute Most often preceded by pelvic Diagnostic

endometritis inflammatory disease. criteria the
same as pelvic
inflammatory
disease.

Chronic Present with abnormal uterine bleeding,

endometritis which may consist of intermenstrual
bleeding, spotting, postcoital bleeding,
menorrhagia, or amenorrhea. Vague,
crampy lower abdominal pain
accompanies the bleeding or may occur
alone.
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Leiomyomas Symptoms related to bulk or infrequently

(fibroids) acute pain from degeneration or torsion
of pedunculate tumor. Pain may be
associated with a low-grade fever, uterine
tenderness on palpation, elevated white
blood cell count, or peritoneal signs.

Ovarian Abdominal distention/discomfort, Women

hyperstimulation nausea/vomiting, and diarrhea. More undergoing
severe cases can have severe abdominal fertility
pain, ascites, intractable nausea, and treatment.
vomiting.

Ovarian cancer Abdominal or pelvic pain. May have

associated symptoms of bloating, urinary
urgency or frequency, or difficulty
eating/feeling full quickly.

Ovulatory pain Occurs mid-cycle, coinciding with timing May be right-

(Mittelsmerz) of ovulation. or left-sided,
depending on
site of
ovulation
during that
cycle.

Pregnancy and related complications*

* Refer to the UpToDate topics on abdominal pain.

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Clinical manifestations of Clostridium difficile infection

Type of Physical Sigmoidoscopic

Diarrhea Other symptoms
infection examination examination

Diarrhea with • Multiple loose Nausea, anorexia, Abdominal Diffuse or patchy

colitis bowel fever, malaise, distention, nonspecific colitis
movements per dehydration, tenderness
day leukocytosis with left
shift
• Occult
bleeding may
be seen

• Hematochezia
rare

Fulminant • Diarrhea may Lethargy, fever, May present as Sigmoidoscopy and

colitis be severe OR tachycardia, abdominal acute colonoscopy
diminished (due pain; dilated abdomen; contraindicated;
to paralytic ileus colon/paralytic ileus peritoneal flexible proctoscopy
and colonic may be demonstrated signs suggest with minimal air
dilatation) on plain abdominal film perforation insufflation may be
diagnostic
• Surgical
consult
required;
colectomy can
be life saving

Asymptomatic Absent Absent Normal Normal

carriage

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Causes of diffuse abdominal pain

Diffuse/poorly
Clinical features Comments
characterized

Bowel obstruction Most common symptoms are nausea, Multiple etiologies.

vomiting, crampy abdominal pain, and
obstipation.

Distended, tympanic abdomen with

high-pitched or absent bowel sounds.

Perforation of the Severe abdominal pain, particularly Can present acutely or in an indolent
gastrointestinal following procedures. manner, particularly in
tract immunosuppressed patients.

Acute mesenteric Acute and severe onset of diffuse and May occur from either arterial or
ischemia persistent abdominal pain, often venous disease. Patients with aortic
described as pain out of proportion to dissection can have abdominal pain
examination. related to mesenteric ischemia.

Chronic Abdominal pain after eating May occur from either arterial or
mesenteric ("intestinal angina"), weight loss, venous disease.
ischemia nausea, vomiting, and diarrhea.

Inflammatory Associated with bloody diarrhea, May have symptoms for years before
bowel disease urgency, tenesmus, bowel diagnosis. Associated extraintestinal
(ulcerative incontinence, weight loss, and fevers. manifestations (eg, arthritis, uveitis).
colitis/Crohn
disease)

Viral Diarrhea accompanied by nausea,

gastroenteritis vomiting, and abdominal pain.

Spontaneous Fever, abdominal pain, and/or altered Most often in cirrhotic patients with
bacterial mental status. advanced liver disease and ascites.
peritonitis

Dialysis-related Abdominal pain and cloudy peritoneal Only in peritoneal dialysis patients.
peritonitis effluent. Other symptoms and signs
include fever, nausea, diarrhea,
abdominal tenderness, and rebound
tenderness.

Colorectal cancer Variable presentation, including

obstruction and perforation.

Other malignancy Vary depending on malignancy.

Celiac disease Abdominal pain in addition to

including diarrhea with bulky, foul-

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smelling, floating stools due to

steatorrhea and flatulence.

Ketoacidosis Diffuse abdominal pain and nausea

and vomiting.

Adrenal Diffuse abdominal pain and nausea Patients with adrenal crisis may
insufficiency and vomiting. present with shock and hypotension.

Foodborne illness Mixture of nausea, vomiting, fever,

abdominal pain and diarrhea.

Irritable bowel Chronic abdominal pain with altered

syndrome bowel habits.

Constipation Associated with a variety of neurologic

and metabolic disorders, obstruction
lesions of the gastrointestinal tract,
endocrine disorders, psychiatric
disorders, and side effect of
medications.

Diverticulosis May have symptoms of abdominal Often an asymptomatic and incidental

pain and constipation. finding on colonoscopy or
sigmoidoscopy.

Lactose Associated with abdominal pain,

intolerance bloating, flatulence, and diarrhea.
Abdominal pain may be cramping in
nature.

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Causes of bowel obstruction

Lesion Etiology Risk factors

Extrinsic lesions Adhesions Prior surgery, diverticulitis, Crohn

disease, VP shunt, peritonitis (eg,
tuberculous peritonitis)

Hernia (congenital, acquired) Abdominal wall hernia, inguinal

hernia, femoral hernia, diaphragmatic
hernia

Volvulus Chronic constipation, congenital

abnormal mesenteric attachments

Intra-abdominal abscess Diverticulitis, appendicitis, Crohn

disease

Peritoneal carcinomatosis Ovarian cancer, colon cancer, gastric

cancer

Endometriosis

Sclerosing mesenteritis Prior surgery, abdominal trauma,

autoimmune disorders, malignancy,
neuroendocrine tumor

Desmoid tumor/other soft tissue

sarcoma (rare)

Superior mesenteric artery syndrome Rapid weight loss

Intrinsic lesions Congenital malformations, atresia, Refer to appropriate topic reviews

duplication

Large bowel neoplasm

Adenocarcinoma Hereditary colorectal cancer

syndromes (HNPCC, FAP),
inflammatory bowel disease, bowel
irradiation, others (refer to
appropriate topic reviews)

Desmoid

Carcinoid

Neuroendocrine tumor

Lymphoma

Small bowel neoplasm*

Adenocarcinoma Hereditary cancer syndromes (HNPCC,

FAP, Peutz-Jeghers, MUTYH-associated

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polyposis, attenuated FAP)

Leiomyosarcoma

Paraganglioma

Schwannoma

Metastatic disease Melanoma, breast cancer, cervical

cancer, colon cancer (refer to
appropriate topic reviews)

Gastrointestinal stromal tumor

Neuroendocrine tumor

Lymphoma Chronic inflammation

Benign lesions Peutz-Jeghers polyps, xanthomatosis,

leiomyoma

Anastomotic stricture Prior intestinal surgery

Inflammatory stricture Crohn disease, diverticular disease,

NSAID enteropathy

Ischemic stricture Peripheral artery disease, aortic

surgery, colon resection

Radiation enteritis/stricture Prior abdominal or pelvic irradiation

Intraluminal Intussusception* Small bowel tumor*

obstruction of
Gallstones Cholecystitis
normal bowel
Congenital webs

Feces or meconium Cystic fibrosis, severe constipation

Bezoar (phytobezoar, Intestinal motility disorders

pharmacobezoar)

Intramural hematoma

Traumatic Blunt abdominal trauma

Spontaneous Antithrombotic therapy

Foreign body

Ingested Psychiatric disturbance

Medical device migration PEG tube, jejunal tube

Parasites Ascaris lumbricoides, Strongyloides

stercoralis

VP: ventriculoperitoneal; HNPCC: hereditary nonpolyposis colorectal cancer; FAP: familial

adenomatous polyposis; NSAID: nonsteroidal anti-inflammatory drug; PEG: percutaneous
endoscopic gastrostomy.
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* May be due to an intrinsic lesion serving as a lead point.

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Features of acute small bowel versus acute colonic ischemia

Acute small bowel ischemia Acute colonic ischemia

Age varies with etiology of ischemia 90 percent of patients over age 60 years

Acute precipitating cause is typical Acute precipitating cause is rare

Patients appear severely ill Patients do not appear severely ill

Pain is usually severe, tenderness is not Mild abdominal pain, tenderness present
prominent early

Bleeding uncommon until very late Rectal bleeding, bloody diarrhea typical

MRA or MDCT angiography may be considered as Colonoscopy is procedure of choice

the initial diagnostic test; angiography is
recommended if there is strong clinical suspicion

MRA: magnetic resonance angiography; MDCT: multidetector row computed tomography.

Data from: Reinus JF, Brandt LJ, Boley SJ. Ischemic diseases of the bowel. Gastroenterol Clin North Am 1990; 19:319.

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Presentations of aortic dissection based on affected structures

Clinical findings Artery or structure involved

Aortic insufficiency or heart failure Aortic valve

Myocardial infarction Coronary artery (often right)

Cardiac tamponade Pericardium

Hemothorax Thorax

Horner syndrome (ptosis, miosis, anhidrosis) Superior cervical sympathetic ganglion

Stroke or syncope Brachiocephalic, common carotid, or left subclavian

arteries

Upper extremity pulselessness, hypotension Subclavian artery

pain

Paraplegia Intercostal arteries (give off spinal and vertebral

arteries)

Back or flank pain; renal failure Renal artery

Abdominal pain; mesenteric ischemia Celiac or mesenteric arteries

Lower extremity pain, pulselessness, Common iliac artery

weakness

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Extraintestinal manifestations of inflammatory bowel disease

Common extraintestinal manifestations

Musculoskeletal

Arthritis – Colitic type, ankylosing spondylitis, isolated joint involvement such as sacroiliitis.

Hypertrophic osteoarthropathy – Clubbing, periostitis, metastatic Crohn disease.

Miscellaneous – Osteoporosis, aseptic necrosis, polymyositis, osteomalacia.

Skin and mouth

Reactive lesions – Erythema nodosum, pyoderma gangrenosum, aphthous ulcers,

vesiculopustular eruption, cutaneous vasculitis, neutrophilic dermatosis, metastatic Crohn
disease, epidermolysis bullosa acquisita.

Specific lesions – Fissures and fistulas, oral Crohn disease, drug rashes.

Nutritional deficiency – Acrodermatitis enteropathica (zinc), purpura (vitamins C and K), glossitis
(vitamin B), hair loss and brittle nail (protein).

Associated diseases – Vitiligo, psoriasis, amyloidosis, epidermolysis bullosa acquisita.

Hepatobiliary

Specific complications – Sclerosing cholangitis (large-duct or small-duct), bile duct carcinoma,

cholelithiasis.

Associated inflammation – Autoimmune chronic active hepatitis, pericholangitis, portal fibrosis

and cirrhosis, granuloma in Crohn disease.

Metabolic – Fatty liver, gallstones associated with ileal Crohn disease.

Ocular

Uveitis iritis, episcleritis, scleromalacia, corneal ulcers, retinal vascular disease, retrobulbar
neuritis, Crohn keratopathy.

Metabolic

Growth retardation in children and adolescents, delayed sexual maturation.

Less common extraintestinal manifestations

Blood and vascular

Anemia due to iron, folate, or vitamin B12 deficiency or autoimmune hemolytic anemia, anemia
of chronic disease, thrombocytopenic purpura; leukocytosis and thrombocytosis;
thrombophlebitis and thromboembolism, arteritis and arterial occlusion, polyarteritis nodosa,
Takayasu arteritis, cutaneous vasculitis, anticardiolipin antibody, hyposplenism.

Renal and genitourinary tract

Urinary calculi (oxalate stones in ileal disease), local extension of Crohn disease involving ureter

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or bladder, amyloidosis, drug-related nephrotoxicity.

Renal tubular damage with increased urinary excretion of various enzymes (eg, beta N-acetyl-D-
glucosaminidase).

Neurologic

Up to 3% of patients may have non-iatrogenic neurologic involvement, including peripheral

neuropathy, myelopathy, vestibular dysfunction, pseudotumor cerebri, myasthenia gravis, and
cerebrovascular disorders. Incidence equal in ulcerative colitis and Crohn disease. These
disorders usually appear 5 to 6 years after the onset of inflammatory bowel disease and are
frequently associated with other extraintestinal manifestations.

Airway and parenchymal lung disease

Pulmonary fibrosis, vasculitis, bronchitis, necrobiotic nodules, acute laryngotracheitis,

interstitial lung disease, sarcoidosis. Abnormal pulmonary function tests without clinical
symptoms are common (up to 50% of cases).

Cardiac

Pericarditis, myocarditis, endocarditis, and heart block – More common in ulcerative colitis than
in Crohn disease; cardiomyopathy, cardiac failure due to anti-TNF therapy.

Pericarditis may also occur from sulfasalazine/5-aminosalicylates.

Pancreas

Acute pancreatitis – More common in Crohn disease than in ulcerative colitis. Risk factors
include 6-mercaptopurine and 5-aminosalicylate therapy, duodenal Crohn disease.

Autoimmune

Drug-induced lupus and autoimmune diseases secondary to anti-TNF-alpha therapy.

Positive ANA, anti-double-stranded DNA, cutaneous and systemic manifestations of lupus.

TNF: tumor necrosis factor; ANA: antinuclear antibody; DNA: deoxyribonucleic acid.

Modified from: Das KM. Relationship of extraintestinal involvements in inflammatory bowel disease: New insights into
autoimmune pathogenesis. Dig Dis Sci 1999; 44:1.

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Chronic pain syndromes directly related to cancer

Nociceptive pain syndromes: Somatic

Tumor-related bone pain

Multifocal bone pain

Bone metastases

Bone marrow expansion (hematologic malignancies)

Oncogenic hypophosphatemic osteomalacia

Vertebral syndromes

Atlanto-axial destruction and odontoid fracture

C7-T1 syndrome

T12-L1 syndrome

Sacral syndrome

Back pain secondary to spinal cord compression

Pain syndromes related to pelvis and hip

Pelvic metastases

Hip joint syndrome

Malignant piriformis syndrome

Base of skull metastases

Orbital syndrome

Parasellar syndrome

Middle cranial fossa syndrome

Jugular foramen syndrome

Occipital condyle syndrome

Clivus syndrome

Sphenoid sinus syndrome

Tumor-related soft tissue pain

Headache and facial pain

Ear and eye pain syndromes

Pleural pain

Paraneoplastic pain syndromes

Muscle cramps
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Hypertrophic osteoarthropathy

Tumor-related gynecomastia (eg, in testicular neoplasms that secrete human chorionic

gonadotropin)

Paraneoplastic pemphigus

Paraneoplastic Raynaud phenomenon

Nociceptive pain syndromes: Visceral

Hepatic distention syndrome

Midline retroperitoneal syndrome

Chronic intestinal obstruction

Peritoneal carcinomatosis

Malignant perineal pain

Adrenal pain syndrome

Ureteric obstruction

Neuropathic pain syndromes

Leptomeningeal metastases

Malignant painful radiculopathy

Painful cranial neuralgias

Glossopharyngeal neuralgia

Trigeminal neuralgia

Radiculopathies

Lumbosacral radiculopathy

Cervical radiculopathy

Thoracic radiculopathy

Plexopathies

Cervical plexopathy

Malignant brachial plexopathy

Malignant lumbosacral plexopathy

Lower lumbosacral plexopathies, including sacral and coccygeal plexopathy and panplexopathy

Painful peripheral mononeuropathies

Paraneoplastic sensory neuropathy

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Differential diagnosis of foodborne disease by item consumed

Item Commonly associated microbes*

Raw seafood Norwalk-like virus, Vibrio spp, hepatitis A

Raw eggs Salmonella spp

Undercooked meat or Salmonella spp, Campylobacter spp, STEC, Clostridium perfringens

poultry

Unpasteurized milk or Salmonella spp, Campylobacter spp, STEC, Yersinia enterocolitica

juice

Unpasteurized soft Salmonella spp, Campylobacter spp, STEC, Y. enterocolitica, Listeria

cheeses monocytogenes

Homemade canned goods Clostridium botulinum

Raw hot dogs, deli meat L. monocytogenes

STEC: shiga toxin-producing Escherichia coli.

* This association lists the commonly associated organisms and is not fully comprehensive.

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Causes of chronic constipation

Neurogenic disorders Non-neurogenic disorders

Peripheral Hypothyroidism

Diabetes mellitus Hypokalemia

Autonomic neuropathy Anorexia nervosa

Hirschsprung disease Pregnancy

Chagas disease Panhypopituitarism

Intestinal pseudoobstruction Systemic sclerosis

Central Myotonic dystrophy

Multiple sclerosis Idiopathic constipation

Spinal cord injury Normal colonic transit
Parkinson disease Slow transit constipation

Irritable bowel syndrome Dyssynergic defecation

Drugs
See separate table

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Drugs associated with constipation

Analgesics

Anticholinergics

Antihistamines

Antispasmodics

Antidepressants

Antipsychotics

Cation-containing agents
Iron supplements

Aluminum (antacids, sucralfate)

Barium

Neurally active agents

Opiates

Antihypertensives

Ganglionic blockers

Vinca alkaloids

Calcium channel blockers

5HT3 antagonists

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Less common causes of abdominal pain

Abdominal aortic aneurysm

Abdominal compartment syndrome

Abdominal migraine

Acute hepatic porphyrias (eg, acute intermittent porphyria)

Angioedema (either hereditary or angiotensin-converting enzyme [ACE] inhibitor-related)

Celiac artery compression syndrome

Chronic abdominal wall pain

Colonic pseudo-obstruction (acute or chronic)

Eosinophilic gastroenteritis

Epiploic appendagitis

Familial Mediterranean fever

Helminthic infections

Herpes zoster

Hypercalcemia

Hypothyroidism

Lead poisoning

Meckel's diverticulum

Narcotic bowel syndrome

Paroxysmal nocturnal hemoglobinuria

Pseudoappendicitis

Pulmonary etiologies

Rectus sheath hematoma

Renal infarction

Rib pain

Sclerosing mesenteritis

Somatization

Wandering spleen

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Classification of OHSS: Clinical and biochemical features[1]

Clinical features Biochemical features

Mild Abdominal distention/discomfort No clinically important laboratory

Mild nausea/vomiting findings
Diarrhea
Enlarged ovaries

Moderate Presence of mild features plus: Elevated Hct (>41%)

Ultrasonographic evidence of Elevated WBC (>15,000/microL)
ascites Hypoproteinemia

Severe Presence of mild and moderate Hemoconcentration (Hct >55%)

features plus: WBC >25,000/microL
Clinical evidence of ascites (can Serum creatinine >1.6 mg/dL
be tense ascites) Creatinine clearance <50 mL/min
Severe abdominal pain Hyponatremia (Na+ <135 mEq/L)
Intractable nausea and Hyperkalemia (K+ >5 mEq/L)
vomiting
Elevated liver enzymes
Rapid weight gain (>1 kg in 24
hours)
Pleural effusion
Severe dyspnea
Oliguria/anuria
Low blood/central venous
pressure
Syncope
Venous thrombosis

Critical Presence of severe features plus: Worsening of biochemical findings

Anuria/acute renal failure seen with severe OHSS
Arrhythmia
Pericardial effusion
Massive hydrothorax
Thromboembolism
Arterial thrombosis
ARDS
Sepsis

OHSS: ovarian hyperstimulation syndrome; Hct: hematocrit; WBC: white blood cell; Na: sodium; K:
potassium; ARDS: acute respiratory distress syndrome.

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Reference:
1. Navot D, Bergh PA, Laufer N. Ovarian hyperstimulation syndrome in novel reproductive technologies: prevention and
treatment. Fertil steril 1992; 58:249.
From: Fiedler K, Ezcurra D. Predicting and preventing ovarian hyperstimulation syndrome (OHSS): the need for
individualized not standardized treatment. Reprod Biol Endocrinol 2012; 10:32. Copyright © 2012 Fiedler and Ezcurra.
Reproduced from BioMed Central Ltd.

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Contributor Disclosures
Robert M Penner, BSc, MD, FRCPC, MSc Consultant/Advisory Boards: AbbVie [Inflammatory bowel
disease]; Janssen [Inflammatory bowel disease]; Takeda [Inflammatory bowel disease]. Speaker's Bureau:
AbbVie [Inflammatory bowel disease]; Janssen [Inflammatory bowel disease]; Takeda [Inflammatory bowel
disease]. All of the relevant financial relationships listed have been mitigated. Mary B Fishman, MD No
relevant financial relationship(s) with ineligible companies to disclose. Andrew D Auerbach, MD, MPH No
relevant financial relationship(s) with ineligible companies to disclose. Mark D Aronson, MD No relevant
financial relationship(s) with ineligible companies to disclose. Lisa Kunins, MD No relevant financial
relationship(s) with ineligible companies to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.

Conflict of interest policy

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