Abdominal Pain History

Differentials

Acute Abdominal Pain

Chronic Abdominal Pain

Checklist

Explanation

Preparation

Wash, name, explain:

• Wash your hands
• Introduce yourself by name and role
• Check the patient’s name and date of birth
• Explain the task and get consent

“I have been asked to speak to you about your abdominal pain today. I will ask you some questions to try to work out what could be causing it. Is that all right?”

Presenting Complaint

Begin with an open question to establish the patient’s reason for presentation, for example “Could you tell me about what’s been going on?”

Try to let the patient speak for 30-60 seconds without interrupting them. This is referred to as the ‘golden minute’ and can offer valuable information about why the patient has sought medical attention as well as cues surrounding their ideas, concerns, and expectations (ICE) to pick up on later in the consultation.

History of Presenting Complaint

Next you need to gather more specific information about the patient’s presenting complaint in order to establish the differential diagnosis. You can use a mixture of open and closed questions. 

An example of an open question here would be: “How would you describe this pain?” or “Have you noticed any other symptoms alongside the abdominal pain?”. Examples of closed questions include: “Is the pain a sharp, stabbing pain?” or  “Have you had any diarrhoea?”

When taking a pain history, it is useful to use the SOCRATES mnemonic to structure your questioning:

• Site – where in the abdomen is the pain? E.g., Epigastric, right upper quadrant, left iliac fossa etc.
• Onset – when did the pain start and what happened? How long has it been going on for?
• Character – what type of pain is the patient experiencing? E.g., Stabbing, cramping, burning etc.
• Radiation – does the pain travel anywhere else from the main site? E.g., Through to the back.
• Associated symptoms – does the patient experience any other symptoms alongside the pain? E.g., Vomiting.
• Timing – what is the time-course of the pain? How long does it last? Is it worse at night? Is it constant or intermittent?
• Exacerbating & relieving factors – what makes the pain better? Does anything make the pain worse?
• Severity – on a scale of 0-10, with 0 being no pain and 10 being the worst pain imaginable, how would the patient rate the severity of their pain?

System-specific History

After establishing further history of the abdominal pain, you need to gather any relevant system specific information; in the case of abdominal pain the system in question is the gastrointestinal (GI) system. Try to think of GI symptoms which may present alongside abdominal pain and ask about these. 

It is important to not only ask about these symptoms, but to think about why their presence or absence is important in narrowing down the differential diagnosis. 

For example, the presence of vomiting and diarrhoea alongside abdominal pain may make you wish to consider gastroenteritis in the differential, but the absence of either of these symptoms would make a diagnosis of gastroenteritis much less likely.

GI system symptoms to ask about include but are not limited to:

• Nausea & vomiting – how frequently? What is being vomited up? E.g., Stomach contents, bile, blood etc. Conditions including gastroenteritis, gallstones, cholecystitis, appendicitis, bowel obstruction can present with abdominal pain associated with nausea and vomiting.
• Bowel movements – constipation or diarrhoea? Have they changed frequency, consistency or colour? Is there any blood in the stool? Conditions including bowel cancer, Inflammatory Bowel Disease, Irritable Bowel Syndrome, Coeliac Disease, gastroenteritis, diverticulitis, ischaemic colitis can present with abdominal pain associated with a change in bowel habit.
• Appetite – has the patient lost their appetite? Is there early satiety? Conditions including oesophageal or gastric malignancy, appendicitis, Inflammatory Bowel Disease, gastroenteritis and many more may affect a patient’s appetite. 
• Jaundice – has the patient (or anyone else) noticed any yellow discolouration to the patient’s skin or eyes? Have they been feeling itchy? Conditions including acute cholangitis, pancreatic cancer, cholangiocarcinoma, hepatitis, liver cirrhosis can cause abdominal pain associated with jaundice. 
• Fever – whilst not a GI system specific symptom, fever can help identify infective/inflammatory causes of abdominal pain e.g., Gastroenteritis, IBD. 

Red Flags

It is important to ask about symptoms which may cause you to consider more sinister causes of abdominal pain in the differential, which may require more urgent investigation and management e.g., Malignancy.

You may need to use closed questions to rule out these symptoms. Patients may not always volunteer this information because they might find these symptoms concerning or may not have the same insight into their significance as you do. 

Red flags to screen for when taking a history of abdominal pain include:

• Weight loss – could indicate malignancy, inflammatory bowel disease, malabsorption, Coeliac disease, chronic pancreatic insufficiency.
• Change in bowel habit – could indicate bowel cancer, inflammatory bowel disease, coeliac disease.
• Bleeding per rectum – could indicate bowel cancer, inflammatory bowel disease.
• Dysphagia – could indicate oesophageal cancer.
• Early satiety – could indicate oesophageal or gastric cancer.
• Abdominal mass – could indicate GI malignancy.

Relevant Systems Review

A systems review is a useful tool to ensure no important information from the history has been missed out, however it is key to think about which systems are relevant to review so that your questions remain relevant to the presenting complaint.

Relevant systems to review when taking a history of abdominal pain include:

• Urological – does the patient have any urinary symptoms e.g., Dysuria, frequency, urgency, haematuria etc. Urological conditions e.g., UTI, pyelonephritis can present with abdominal pain. 
• Gynaecological – could the patient be pregnant? Is there any vaginal bleeding? Are they menstruating, do they have a regular menstrual cycle? Gynaecological conditions e.g., Ectopic pregnancy or ovarian torsion can present with abdominal pain
• Sexual – does the patient have vaginal/urethral discharge? Do they have a regular sexual partner? Do they use any contraception? Are they at risk of an STI? Genitourinary conditions e.g., Pelvic Inflammatory Disease can present with abdominal pain. 

Ideas, Concerns & Expectations (ICE)

Using the ICE mnemonic you can gather information about how the patient feels about their symptoms, whether they have a specific worry or concern and how they hope to move forwards after seeking medical attention. Try to find your own style of asking about ICE that works for you, some examples are included below:

• Ideas – “Do you have any thoughts about what might be going on?”, “What do you think might be causing this pain?”.
• Concerns – “Is there anything that is worrying you about this abdominal pain?”, ‘Have you read or Googled anything about your symptoms that has worried you?”
• Expectations – “Was there anything specifically you were hoping we’d do today?”, “Do you have any ideas of what might happen next?”.

Past Medical History

Gather information about previous or existing health conditions that the patient may have. Try to note when an existing condition may be of significance in the context of the presenting complaint of abdominal pain, e.g., The patient has previously been told they have gallstones, or they have recurrent urinary tract infections. Don’t forget to ask about prior similar episodes of this presenting complaint.

Ask about previous surgery the patient may have undergone, especially if it will help to rule in/out a differential diagnosis e.g., The patient has presented with RIF pain but they had their appendix removed 20 years ago.

Drug History

Ask the patient about any regular medication they take, not forgetting to ask specifically about medications that the patient may not think to volunteer e.g., over the counter medications, herbal or alternative medication, contraception, HRT, injections such as B12. Check whether the patient is compliant with their medication and taking it as prescribed.

Try to think about whether the information you are given could be relevant to the differential diagnosis e.g., The patient has presented with epigastric pain and they have been taking an NSAID for 6 weeks due to a knee injury.

Remember to ask about drug allergies and clarify any reported symptoms to differentiate a true allergy from an intolerance.

Social History

This is the chance to learn a bit more about the patient, other than their presenting complaint.

• Who do they live with? Does anyone else at home have the same symptoms e.g., Infective gastroenteritis? Do they have a social support network e.g., Debilitating or terminal diagnosis 
• Do they work? Do they need time off work for infection control e.g., Viral gastroenteritis, do they need to inform their employer e.g., Certain communicable diseases in certain professions.
• Do they drive? Does their condition affect their ability to drive or to attend appointments?
• Have they had contact with someone with similar symptoms? E.g., Infective gastroenteritis, viral hepatitis
• Have they recently returned from travelling abroad? E.g., Traveller’s diarrhoea, hepatitis
• Do they smoke? Smoking is associated with some GI conditions e.g., Crohn’s, GORD, Peptic Ulcer disease and protective against others e.g., Ulcerative Colitis
• Do they drink alcohol? Alcohol can worsen symptoms of GORD and cause liver damage leading to Alcohol-Related Liver Disease. 
• Do they use recreational drugs?

Try to think about the relevance of the information you are given, e.g., The patient has presented with severe epigastric pain radiating through to the back and they have a history of significant alcohol intake. 

Family History

Does anyone in the family have any GI–specific conditions e.g., Gallstones, inflammatory bowel disease, coeliac disease?

Do any health conditions run in the family e.g., Diabetes?

Finishing

Thank the patient and wash your hands. Consider your differential diagnosis and how you might narrow this down further by way of examination, bedside tests or further investigation/imaging.

Last updated Dec 2024

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