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Chronic Upper Abdominal Pain

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Chronic Upper Abdominal Pain Gut, 1992, 33, 743-748 743 Chronic upper abdominal pain: site and radiation in various structural and functional disorders and the effect of various foods Gut: first published as 10.1136/gut.33.6.743 on 1 June 1992. Downloaded from J Y Kang, HH Tay, R Guan Abstract right or left hypochondrium, periumbilical, Pain site and radiation and the effect ofvarious right or left lumbar, or generalised following the foods were studied prospectively in a consecu- landmarks suggested by French.' The abdomen tive series of patients with chronic upper was divided into nine regions by the intersection abdominal pain. Patients followed for less than of two horizontal and two sagittal planes. The one year were excluded unless peptic ulcer or upper horizontal plane was at a level midway abdominal malignancy had been diagnosed or between the suprasternal notch and the symphy- laparotomy had been carried out. A total of632 sis pubis. The lower plane was at the upper patients .were eligible for the first study and 431 border ofthe iliac crests. The sagittal planes were for the second. Gastric ulcer pain was more vertical lines drawn through points midway likely to be left hypochondrial (17%) compared between the pubis and the anterior superior iliac with pain from duodenal ulcer (4%) or from all spines. Patients with suprapublic and right and other conditions (5%). It was less likely to be left iliac fossa pains were not included in the epigastric (54%) compared with duodenal ulcer present study unless there was concomittant pain (75%). Oesophageal pain was more likely upper abdominal pain. The site of radiation to to be both retrosternal and epigastric (25%) the back, if present, was recorded as (a) right, compared with non-oesophageal pain (2%). left, or central and (b) thoracic or lumbar using Radiation to the back was more common in the 12th ribs as landmarks. peptic ulcer (31%) and biliary pain (35%) com- pared with functional pain (20%). Pain precipi- tation by fatty foods was commoner in biliary EFFECT OF VARIOUS FOODS disease (40%) than in duodenal ulcer (11%), Consecutive patients presenting with upper peptic ulcer (9%), or non-ulcer dyspepsia abdominal pain ofat least three months' duration http://gut.bmj.com/ (19%). Orange, alcohol, and coffee precipi- as the only complaint or as one of several tated pain more frequently in duodenal ulcer complaints between April 1984 and December (41%, 50%, and 43% respectively) than in 1987 were included in the study. The time period biliary disease (17%, 0%, and 14% respect- of three months was chosen since patients with ively). Chilli precipitated pain in one quarter to shorter histories, and thus fewer pain episodes, one half of subjects regardless of diagnosis. may not be able to determine the effect of Approximately one tenth of all subjects individual food items on their pain. on September 29, 2021 by guest. Protected copyright. avoided chilli, curry, coffee, and tea because After a routine history had been obtained, of medical or other advice. each patient was shown a list of food items - chilli, fatty foods, curry, orange, other fruits, cucumber, onions, alcohol, coffee, and tea. He Upper abdominal pain can be caused by a large or she was asked whether (1) each food was taken number of structural and functional disorders. regularly (at least once weekly) without exacer- While the typical sites ofpain caused by different bation of pain, (2) each food item brought on conditions are well known, variations occur. The pain. For food items that were deliberately advent ofmodern imaging techniques has made a avoided patients were further asked to indicate if definitive diagnosis possible for most patients. the avoidance was because of dislike or because This study aimed to compare the site and of advice from physicians, friends, or other radiation of upper abdominal pain caused by sources of information, even though the patient different conditions and to investigate the did not notice any direct relationship between effect of ingestion of individual foods on upper those items and the onset of pain. abdominal pain. Division of Gastroenterology, PATIENT EVALUATION Department of Medicine, National University Methods A full history was taken and physical examina- Hospital, Singapore tion performed. In most cases investigation J Y Kang PAIN SITE included blood count, erythrocyte sedimenta- H H Tay R Guan All patients presenting to one of us (JYK) with tion rate, liver function tests, and gastroduo- upper abdominal pain between April 1984 and denoscopy, although the latter was not repeated Correspondence to: Associate Professor J Y Kang, December 1987 were included in the study if it had recently been performed at another Division of Gastroenterology, was or one institution. Other endoscopic, radiological Department of Medicine, whether the pain the only complaint National University Hospital, of several complaints. The author is a physician, (including ultrasonography, computed tomo- Lower Kent Ridge Road, and patients with acute surgical abdomens were graphy, and angiography), or other studies were Singapore 0511. indicated. Generally, Accepted for publication seldom seen and not included in the present performed if clinically 21 October 1991 study. The site ofpain was recorded as epigastric, abdominal ultrasonography was performed if 744 Kang, Tay, Guan there was severe pain consistent with biliary influenced by his memory of the initial interview colonic. Patients with recent change of bowel and yet not so long that the pain could have habits underwent sigmoidoscopy if they were genuinely changed. years. aged below 40 Older subjects underwent Gut: first published as 10.1136/gut.33.6.743 on 1 June 1992. Downloaded from barium enema examination or colonoscopy. After initial diagnosis and treatment, patients STATISTICAL ANALYSIS were followed up either at the outpatient clinic, The x2 test, with Yates's correction where appro- by telephone interview, or by a postal question- priate, was used to compare categorical data. naire. Enquiry was made as to whether any new Probability values of <0 05 were considered diseases had been detected to account for the significant. patients' original abdominal pains. Patients followed up for less than one year after comple- tion of investigations were excluded from the Results study unless peptic ulcer or abdominal malig- nancy had been diagnosed or unless laparotomy EXCLUSIONS (Table I) had been performed, thereby reducing the chances of a wrong diagnosis. Pain site and radiation Patients with gastric ulcers underwent routine Over the study period, 856 consecutive patients biopsy and were followed until healing occurred. presented with upper abdominal pain. One Oesophagitis was diagnosed by a combination of hundred and fifty one patients without peptic criteria including clinical and endoscopic find- ulcer or gastrointestinal malignancy and in ings as well as the acid infusion test. Irritable whom laparotomy had not been performed were bowel syndrome was diagnosed by exclusion of lost to follow up within one year of the comple- structural disease plus the presence of at least tion of investigations (four died of unrelated two ofthe following criteria: altered bowel habit, diseases within one year). Data collection or relief of pain by defecation, looser and/or more investigations were incomplete in 53 and 10 frequent stools with onset of pain, passage of patients respectively. Three patients had dual mucus, abdominal distension,2 and reproduction diagnoses that made the cause of pain difficult to of pain by colonic air insufflation at sigmoido- identify (duodenal ulcer and gall stones (2), scopy.3 Non-ulcer dyspepsia was defined as pain duodenal ulcer and oesophagitis (1). In seven related to food and/or relieved by antacids in the patients the initial diagnoses may have been absence of organic disease and irritable bowel wrong. Two patients with duodenal erosions and syndrome. Patients with gastric or duodenal no scarring were initially diagnosed as non-ulcer were duodenal erosions or endoscopic gastroduodenitis dyspepsia but subsequently developed http://gut.bmj.com/ considered, for the purposes of this study, to ulcer. Two other patients thought to have non- have functional disease since it has not been ulcer dyspepsia subsequently had gall stones proved that these cause symptoms. However, demonstrated. Two patients thought to have patients with duodenal pseudodiverticula or non-ulcer dyspepsia and irritable colon respect- scarring were considered to have duodenal ulcer. ively had gastric ulcer and acute pancreatitis Patients with cholelithiasis and/or choledocho- diagnosed at other institutions, four years and 19 Another who lithiasis and those with gall bladder carcinoma months later. patient initially on September 29, 2021 by guest. Protected copyright. were grouped together since these diagnoses refused endoscopy and whose barium meal was tended to occur in the same patients. normal, was found to have gastric ulcer at another institution. The proportion of patients whose original diagnoses could have been wrong REPRODUCIBILITY OF DATA COLLECTION was therefore 1*1% (7/(632+7)), or 2*2% In order to assess the reproducibility of the (7/(310+7)) if only patients with non-ulcer dys- assessment of pain site and radiation, consecu- pepsia or irritable colon were considered. tive patients were seen again by JYK one to three In seven patients new diagnoses were made months after the initial interview and were over the follow up period but the original questioned a second time about pain site and diagnoses were nonetheless felt to be correct. radiation as well as the effect of various foods, One patient with non-ulcer dyspepsia sub- without the original records being available. The sequently developed oesophagitis: another period of one to three months was chosen since developed duodenal ulcer and cholelithasis was this was not short enough for the questioner to be also diagnosed. In both cases different types of pain occurred with the later problems. One patient with duodenal ulcer and another with chronic pancreatitis subsequently developed features of irritable bowel syndrome also.
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