Non-specific abdominal pain--a clinical entity.SD Deodhar, RG Shirahatti, JD Mohite, MS Kirloskar, SV Pandya
A total of 48 cases of non-specific abdominal pain admitted in one year period were studied. Routine investigations of blood, urine, stool and X-ray examinations done after admission were negative. The pain was relieved in 48 hours time with analgesics and antispasmodics. During their follow-up in the out-patient department a variety of causes were discovered on investigations.
Keywords: Abdominal Pain, complications,diagnosis,therapy,Adolescent, Adult, Aged, Female, Human, India, Male, Middle Age,
In 1987 we published a paper on emergency admissions in our Unit for one year. There were 603 admissions; of these 183 patients had gastro-intestinal or genitourinary symptoms; in 50 out of whom no specific diagnosis could be arrived at and hence the condition was labelled as non-specific abdominal pain (NSAP).
In view of the commonality of NSAP, we commenced a prospective study for a period of one year and the present paper is based on our findings.
All those patients admitted with pain in abdomen to our surgical unit between 1-1-1986 and 31-12-1986 were studied. Those patients in whom no definite organic cause could be ascertained and whose symptoms were relieved within 48 hours and hence were discharged with uncertain diagnosis were taken up for study.
A detailed history was obtained and physical examination carried out; special attention being paid to past episodes of pain, hospitalisation and treatment taken. in women, menstrual and obstetrical history was obtained. Immediate investigations included CBC, ESR, urine and stool examination and plain X-rays of chest and abdomen. Symptomatic treatment was given with analgesics and antispasmodics. In patients having vomiting, intravenous fluids were administered. Antibiotics were not given unless a focus of infection was clinically evident. The patients were discharged at the end of 24-48 hours by which time they had been asymptomatic. They were then asked to follow-up in the out-patient department where (specific) investigations were carried out to detect the cause of pain. When a definite cause was found, the patient was offered definitive therapy. Where no definitive cause could be found, a psychological cause was looked for.
A total of 1437 patients were admitted to our Unit during this period. Of these 48 (24 male and female each) were found to be cases of NSAP. The age distribution is given in[Table - 1].
One-third of patients suffered from pain in the upper abdomen i.e. epigastrium and right hypochondrium. Eleven patients had pain in the lumbar regions and the right iliac fossa; three patients had periumbilical pain and two had pain in the hypogastrium. The pain was generalised all over the abdomen in five patients. Pain was described as colicky by majority of patients and it radiated either to the back, genitalia or the umbilicus in nine patients.
Fourteen patients had associated gastrointestinal symptoms like vomiting, loose motions or constipation. Vomiting continued after admission in six patients while eight patients had vomiting prior to admission. Ten patients had one or two loose motions prior to admission. Abdominal examination did not reveal any abnormality in all these patients. One patient had in addition actively bleeding piles.
There were 12 patients with associated genitourinary symptoms. Of these, ten had dysuria and increased frequency of micturition. There was no history of hematuria, fever with rigors, pyuria or lithuria. Two patients had bleeding per vaginum; one of them had a deep erosion of cervix which was non-malignant on Pap smear More Details; the other had accompanied lower abdominal pain probably due to an intrauterine contraceptive device. The routine investigations done in the ward as mentioned earlier were normal in all patients. Three patients had transient but significant elevation of serum amylase levels which on repeat examination returned to normal limits at the end of 48 hours.
A total of 24 patients came for followup in the out-patient department. Twelve patients followed-up for one week, eight for one month and four for three months. The remaining patients did not follow-up in spite of being explained the necessity for further investigations [Table - 2].
Of 14 patients having associated gastrointestinal symptoms; eight followed-up in the O.P.D. Barium meal follow through, endoscopy, abdominal ultrasonography, oral cholecystography and HIDA scans were performed in them. Barium meal revealed an ulcer in first part of duodenum in only one patient. Upper G.I. endoscopy showed duodenitis with shallow duodenal ulcers in three patients. These included the previous patients in whom it was demonstrated by barium study. Repeat stool examination showed ova of ascaris lumbricoides in two patients. In three patients having transient hyperamylasaemia repeat serum and urinary amylase, OCG, endoscopy, HIDA scan and abdominal ultrasonography were normal.
Out of ten patients having urinary symptoms; nine followed-up. Urine culture, I.V.P. and cysto-urethroscopy were done in them. In two patients, I.V.P. was suggestive of renal tuberculosis; in one of them, cystoscopy showed multiple tubercles in the urinary bladder. However, urine culture for M. tuberculosis was negative in both the patients. Two patients with normal I.V.P. on urine culture showed growth of E. coli. Patients with urinary tract infection and urinary tuberculosis were advised specific treatment. I.V.P. showed radiolucent calculi in two patients.
In one patient, there was narrowing of ureter with hydronephrosis. Patients with urinary calculi passed them spontaneously. Out of two patients with bleeding P.V., one followed-up, the bleeding and pain stopped on removal of intrauterine contraceptive device. The patient with cervical erosion did not follow-up.
There were six patients who followed up, in whom no cause of pain could be ascertained even after special investigations. Two of them were found to be suffering from anxiety neurosis on psychiatric assessment and were referred to the psychiatrist. The remaining were put on placebo and ceased to follow-up after one month.
It is the impression of most clinicians that a patient admitted to the hospital with pain in abdomen, a detailed history, physical examination and a few well chosen investigations will reveal the cause of pain. Though this is true, in a majority of patients, all attempts at making a diagnosis fail in a small proportion. These patients are admitted by the casualty medical officer with various labels attached like renal colic, intestinal colic, amoebic colitis, acute gastritis etc. History and physical examination fail to provide any clue to the diagnosis. Routine investigations, as are available, arc of no help either. These patients are then treated symptomatically and usually get well within 48 hours. It is only recently that this problem is being documented ail over the world.,
Patients with non-specific abdominal pain constitute a small, but definite proportion of admissions to the hospital. This problem is more thoroughly investigated in the West, where as many as 45% of patients admitted with acute abdominal pain had no explainable cause. In a study done in Britain, out of 6097 patients admitted with abdominal pain, 43% had no obvious cause. Most of these patients had the attack of vain for the first time. In common with our experience, nearly 50% of these patients do not return for further follow-up as they are probably relieved of pain. This was also noted in a study done in the Netherlands where 77% of patients admitted with NSAP had no recurrence of the problem when interviewed five years later.
Many justifications have been sought to explain the occurrence of this self-limiting pain. Viral and bacterial infections, worm infestations of gastro-intestinal tract, abdominal wall pain, irritable bowel syndrome, pelvic inflammatory disease in females and psychosomatic pain are some of the causes believed to give rise to NSAP. Though a large amount of data have accumulated after computer-aided diagnosis, little has been achieved by way of accurately predicting this condition. In one centre, however, computer-aided diagnosis has resulted in a 25% drop in the number of emergency admissions.
However, whether NSAP is a disease entity by itself or the presentation of a number of minor intro-abdominal disorders is a moot point.
We thank the Dean, K.E.M. Hospital and Seth G.S. Medical College, Bombay, for granting permission to study the hospital records.
[Table - 1], [Table - 2]