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, and a large share of adults experience abdominal pain over the course of a year. Reported proportions vary widely between studies because definitions and methods differ [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?

In clinical practice abdominal pain is often called chronic when it has lasted or kept coming back for at least 3 months. There is no single international definition, and the cut-off varies between guidelines and studies [2]. It differs from acute pain, which typically has a more distinct starting point. If you are unsure what to do next, EndoCap has a symptom checker with an overview of possible next steps.

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The most common causes

Functional/Gastrointestinal:

• Irritable bowel syndrome (IBS) - common, but reported prevalence varies markedly with the Rome criteria used, country and survey method [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. The list is a clinical summary from our practice. The British guideline NICE NG12 points to dysphagia, and to weight loss combined with upper abdominal pain, reflux or dyspepsia in people aged 55 and over, as reasons for a suspected cancer pathway referral (recommendation 1.2.1) [4]. Danish pathways follow the Danish Health Authority cancer packages:

• Unintentional weight loss you cannot account for
• 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

Under the British BSG guideline, irritable bowel syndrome (IBS) should initially be managed in general practice, with specialist referral reserved for treatment failure or alarm symptoms [5]. The same stepwise approach is used in Danish practice for functional dyspepsia and GERD, but the BSG guideline covers IBS only.

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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

In colorectal cancer the stage at diagnosis is closely linked to prognosis, and screening reduces both incidence and mortality [6]. Survival is markedly better when the disease is found while it is still localised than when it has spread to other organs. Exact survival figures depend on the registry, the country and the period, and they cannot be transferred to an individual patient. Your doctor or the treating department can give you the figures that apply to your situation.

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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.

Questions about referral, cover and price are clarified with the clinic or your GP before treatment; see contact.

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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. PMID: 27144617 (background on functional GI disorders; it does not give a general time-based definition of chronic abdominal pain)
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, Kloor M, Pox CP. Colorectal cancer. Lancet 2014;383(9927):1490-1502. DOI: 10.1016/S0140-6736(13)61649-9. PMID: 24225001
7. SEER Cancer Stat Facts. Colorectal Cancer - relative 5-year survival by SEER stage, 2016-2022 data. National Cancer Institute, USA.

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See also

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

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See also

Bloating (meteorism)