Chronic abdominal pain – when to see a surgeon

Chronic abdominal pain - when should you contact a surgeon?

Abdominal pain is one of the most common reasons for contacting the healthcare system, affecting 15-25% of adults in any given year [1]. Most cases are harmless and self-limiting, but chronic or recurrent pain should always be investigated. This article will help you understand when symptoms require urgent help, a visit to your GP - or a referral to a surgeon.

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What is considered "chronic" abdominal pain?

Abdominal pain is considered chronic when it lasts for more than 3 months or recurs for at least half of the time during this period [2]. It differs from acute pain, which typically has a more distinct starting point.

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The most common causes

Functional/Gastrointestinal:

• Irritable bowel syndrome (IBS) - approx. 5-10% of the population [3]
• Functional dyspepsia
• GERD/reflux
• Constipation

Organic gastrointestinal diseases:

• Gallstones and gallstone attacks
• Diverticular disease and diverticulitis
• Inflammatory bowel disease - Crohn's disease and ulcerative colitis
• Coeliac disease
• Stomach ulcers and Helicobacter pylori
• Hernia (inguinal, umbilical or incisional)
• Adhesions after previous surgery
• Chronic pancreatitis
• Endometriosis
• Malignancies (bowel cancer, stomach cancer, ovarian cancer)

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Alarm symptoms ("red flags")

The following should always prompt a swift medical examination - and often a referral to a surgeon or an urgent investigation [4]:

• Unintentional weight loss of >5% within 6 months
• Blood in your stool or black, tar-like stools
• Difficulty swallowing or pain when swallowing (see article)
• Persistent vomiting
• Waking at night due to pain
• Fever combined with pain
• A growing lump in your abdomen
• Family history of bowel or stomach cancer
• New symptoms appearing after the age of 50
• Iron-deficiency anaemia with no other explanation

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When is it a surgical issue?

You should consider a referral to a surgeon for:

1. Pain in the upper right quadrant with nausea after fatty food → suspicion of gallstones
2. Pain in the lower left quadrant with fever/raised CRP → diverticulitis
3. Pain in the lower right quadrant with nausea and a mild fever → appendicitis
4. Abdominal pain + a change in bowel habits after the age of 50 → colonoscopy
5. Localised pain with a visible bulge → hernia
6. Pain around the anus - see pain around the anus

Functional conditions like IBS, dyspepsia and GERD should initially be investigated in general practice and only referred on if treatment fails or if alarm symptoms are present [5].

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What happens during a surgical investigation?

At the clinic, we always begin with a thorough consultation and a physical examination. Depending on your symptoms, the investigation may include:

• Blood tests (incl. CRP, haemoglobin, liver function tests, lipase, faecal calprotectin)
• Ultrasound scan of the abdomen
• Gastroscopy or colonoscopy
• CT or MRI scan if needed
• Anorectal examination for pain or bleeding from the back passage

Early diagnosis significantly improves the prognosis - especially for cancer and inflammatory diseases [6]. For bowel cancer, patients diagnosed at an early stage have a 5-year survival rate of over 90%, whereas this falls to below 15% when the cancer has spread to other parts of the body [7].

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Treatment and follow-up

The treatment depends entirely on the cause - from lifestyle and diet for functional conditions to medical and surgical treatment for organic diseases. Many cases of chronic abdominal pain can be significantly relieved, but this requires a correct diagnosis.

At Kirurgen.dk, we see patients with a referral from their GP and offer prompt investigation and treatment under the public health insurance scheme - with no co-payment.

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References

1. Sperber AD, et al. Worldwide prevalence and burden of functional gastrointestinal disorders. Gastroenterology 2021;160(1):99-114.
2. Drossman DA. Functional gastrointestinal disorders: history, pathophysiology, clinical features, and Rome IV. Gastroenterology 2016;150(6):1262-79.
3. Lovell RM, Ford AC. Global prevalence of and risk factors for irritable bowel syndrome: a meta-analysis. Clin Gastroenterol Hepatol 2012;10(7):712-21.
4. NICE Guideline NG12. Suspected cancer: recognition and referral. National Institute for Health and Care Excellence, opdateret 2023.
5. Vasant DH, et al. British Society of Gastroenterology guidelines on the management of irritable bowel syndrome. Gut 2021;70(7):1214-40.
6. Brenner H, et al. Colorectal cancer. Lancet 2014;383(9927):1490-502.
7. SEER Cancer Statistics. Colon and Rectal Cancer - Stage Distribution and 5-Year Relative Survival. National Cancer Institute, USA, 2024.

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See also

Pancreatitis · Stomach ulcers · Chronic inflammatory bowel disease (IBD)

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See also

Bloating (meteorism)