Chronic abdominal pain is pain that is present for more than 3 months. It may be present all the time or come and go (recurring). Chronic abdominal pain usually occurs in children beginning after age 5 years. About 10 to 15% of children aged 5 to 16 years, particularly those aged 8 to 12 years, have chronic or recurring abdominal pain. It is somewhat more common among girls. About 2% of adults, mainly women, have chronic abdominal pain.

People with chronic abdominal pain may also have other symptoms, depending on the cause.

Causes

Usually by the time abdominal pain has been present for 3 months or more, people have been evaluated by a doctor, and typical disorders that cause abdominal pain (see Symptoms of Digestive Disorders: Acute Abdominal Pain) have already been identified. If people have been evaluated and the cause has not been identified by this time, only about 10% of them have a specific physical disorder (see Symptoms of Digestive Disorders: Physical Causes and Features of Chronic Abdominal Pain). The remaining 90% have what is called functional abdominal pain.

Functional pain is real pain that occurs with no evidence of a specific physical disorder (such as peptic ulcer disease). It is also not related to body functions (such as menstrual periods, bowel movements, or eating), a drug, or a toxin. Functional pain can be severe and typically interferes with people's life. Exactly what causes the pain is unknown. But the nerves of the digestive tract may become oversensitive to sensations (such as normal movements of the digestive tract), which do not bother most people. Genetic factors, life stresses, personality, social situation, and underlying mental disorders (such as depression or anxiety) may all contribute to functional pain. Chronic abdominal pain in children may be related to a need for attention (as when a sibling is born or the family moves), the stress of starting school, lactose intolerance (see Malabsorption: Lactose Intolerance), or sometimes child abuse.

Common physical causes: Many physical disorders cause chronic abdominal pain (see Symptoms of Digestive Disorders: Physical Causes and Features of Chronic Abdominal Pain). The most common causes vary by age.

In children, the most common causes are

• Lactose intolerance (lactose is a sugar in dairy products)
• Constipation
• Gastroesophageal reflux disease

In young adults, common causes include

• Indigestion (dyspepsia) due to peptic ulcer or another problem
• Stomach irritation (caused by aspirin or nonsteroidal anti-inflammatory drugs [NSAIDs], cola beverages [acidity], and spicy foods)
• Liver disorders, such as hepatitis
• Gallbladder disorders, such as cholecystitis
• Pancreatic disorders, such as pancreatitis
• Parasitic infections, such as giardiasis
• Inflammatory bowel disease, such as Crohn's disease
• Irritable bowel syndrome

In older adults, cancer (such as stomach, pancreatic, colon, or ovarian cancer) becomes more common.

Evaluation

Doctors first focus on whether the pain is functional pain or is caused by a disorder, drug, or toxin. Making this distinction may be difficult. However, if warning signs are present, functional pain is unlikely (but not impossible).

Warning signs: The following symptoms are cause for concern:

• Fever
• Loss of appetite and weight
• Pain that awakens the person during the night
• Blood in vomit, stool, or urine
• Severe or frequent vomiting or diarrhea
• Jaundice
• Swelling of the abdomen and/or legs
• Difficulty swallowing

When to see a doctor: If people with chronic abdominal pain develop warning signs, they should see a doctor right away unless the only warning signs are loss of appetite, jaundice, and/or swelling. People with loss of appetite, jaundice, and/or swelling or with steady, worsening pain should see a doctor within a few days to a week. When these warning signs are present, a physical cause is very likely. People without warning signs should see a doctor at some point, but a delay of a few days or so is not harmful.

What the doctor does: Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the pain and the tests that may need to be done (see Symptoms of Digestive Disorders: Physical Causes and Features of Chronic Abdominal Pain).

Doctors ask particularly about activities (such as eating, urinating, or having a bowel movement) that relieve or worsen the pain. Whether the pain or other digestive upset occurs after eating or drinking dairy products is important because lactose intolerance is common, especially among blacks. Doctors also ask about other symptoms (such as vomiting, diarrhea, or constipation), about diet, and about any surgery involving the abdomen, drugs used, and previous tests and treatments for the pain. Whether any family members have disorders that cause abdominal pain is also important.

The physical examination focuses particularly on the abdomen to identify any tender areas, masses, or enlarged organs. Usually, a rectal examination is done, and the doctor tests the stool for blood. A pelvic examination is done in women. Doctors note whether the skin looks yellow (jaundice) and whether people have a rash or swelling in the legs.

Between the initial visit and follow-up visits, people are often asked to record information about the pain, bowel movements, diet, any activities that seem to trigger pain, any remedies tried, and the effects of the remedies.

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Physical Causes and Features of Chronic Abdominal Pain Cause* Common Features† Tests‡ Disorders of the digestive tract Celiac sprue In children, not growing as expected (failure to thrive) Abdominal bloating and often diarrhea or light-colored, bulky, and unusually foul-smelling stools that may appear oily Symptoms that worsen when people eat foods containing wheat products (which contain gluten) Blood tests to measure levels of antibodies produced when people with celiac sprue eat foods containing gluten Often biopsy of the upper small intestine Cholecystitis (inflammation of the gallbladder), if chronic Recurring crampy pain in the upper right part of the abdomen Ultrasonography to look for gallstones Imaging of the gallbladder after a radioactive substance (radionuclide) is injected intravenously (cholescintigraphy) Colon cancer Usually no discomfort, but if the colon is partially blocked, possibly crampy discomfort Sometimes blood in stool (blood may be visible or detected during a doctor's examination) Colonoscopy Imaging tests such as CT or x-rays after barium is inserted in the rectum (barium enema) Constipation Hard, less frequent bowel movements that are difficult to pass Crampy pain in the lower abdomen that decreases after a bowel movement Sometimes pain during a bowel movement A doctor's examination, including thorough dietary history Crohn's disease Recurring episodes of severe pain with fever, loss of appetite, weight loss, and diarrhea CT and/or colonoscopy X-rays of the small intestine Gastroesophageal reflux disease (sometimes related to a hiatus hernia) Heartburn (burning pain that begins in the upper abdomen and travels up to the throat, sometimes with an acid taste in the mouth) Sometimes chest pain Sometimes a cough, hoarseness, or both Symptoms sometimes relieved by lying down Relief with antacids Often only a doctor's examination plus trying treatment with drugs to suppress acid production (if symptoms are relieved, the cause is probably gastroesophageal reflux disease) Sometimes endoscopy of the upper digestive tract (examination of the esophagus and stomach using a flexible viewing tube) or x-rays of the upper digestive tract after barium is given by mouth (barium swallow) Hepatitis, if chronic Discomfort in the upper right part of the abdomen A general feeling of illness (malaise) Loss of appetite Jaundice (uncommon) Sometimes in people known to have had acute hepatitis Blood tests to evaluate liver function and to check for hepatitis viruses Lactose intolerance Bloating, cramps, passing of gas (flatulence), and diarrhea after consuming milk products Sometimes a breath test to detect hydrogen, indicating undigested food A diet that excludes foods containing lactose (elimination diet) to determine whether those foods trigger the symptoms Pancreatic cancer Severe, constant pain in the upper abdomen, often radiating to the back Weight loss Sometimes jaundice CT MRI (magnetic resonance cholangiopancreatography, or MRCP) Pancreatitis, if chronic or accompanied by a pancreatic pseudocyst Episodes of severe pain in the upper middle of the abdomen Sometimes diarrhea and fat in stool Usually in people known to have had acute pancreatitis Blood tests to measure levels of an enzyme produced by the pancreas Imaging tests such as CT or MRI Parasitic infections (particularly giardiasis) Recent travel to developing countries, ingestion of water from streams or lakes, or contact with people with the infection Cramps, flatulence, and diarrhea Examination of stool to check for parasites or their eggs Peptic ulcers Stomach pain relieved by eating food and taking antacids May awaken people at night Endoscopy and biopsy for Helicobacter (H.) pylori (bacteria that can cause peptic ulcers) Sometimes an H. pylori breath test Scar tissue that develops around the intestines (adhesions) in people who have had abdominal surgery Crampy discomfort accompanied by nausea and sometimes vomiting Barium swallow Stomach cancer Indigestion or mild pain Often tiny amounts of blood in stool (detectable only during a doctor's examination) Typically in older adults Endoscopy of the esophagus and stomach Ulcerative colitis Crampy pain with several separate episodes of bloody diarrhea Typically in young adults Sigmoidoscopy or colonoscopy Biopsy of the rectum or colon Kidney and urinary tract disorders Birth defects of the urinary tract Frequent urinary tract infections Typically in children Intravenous urography Ultrasonography Kidney stones Pain in the side (flank) that comes and goes, often in people known to have stones Sometimes fever Dark or bloody urine Urinalysis CT or intravenous urography Reproductive system disorders (in women) Endometriosis Discomfort mainly before or during menstrual periods Laparoscopy Ovarian cyst Ovarian cancer Vague discomfort in the lower abdomen Bloating Sometimes a mass in the pelvis detected during a doctor's examination Ultrasonography of the pelvis Systemic disorders Familial Mediterranean fever Family members who have the disorder Episodes of abdominal pain lasting 48 to 72 hours and often accompanied by fever Starting during childhood or adolescence Genetic testing A food allergy Symptoms that develop only after eating certain foods such as seafood An elimination diet Henoch-Schönlein purpura A reddish-purple rash of tiny dots (petechiae) or larger splotches (purpura) on the arms, legs, buttocks, and top of the feet Achy, tender, swollen joints Nausea, vomiting, and diarrhea Blood in stool detected during a doctor's examination Biopsy of affected skin Lead poisoning Crampy abdominal pain Mental changes such as a reduced attention span, confusion, and altered behavior Loss of appetite, vomiting, and constipation Achy joints Usually only in workers exposed to lead Less often in young children who live in houses over 30 years old, in which lead-based paint may have been used Blood tests to measure the lead level Porphyria Recurring attacks of severe abdominal pain and vomiting Sometimes muscle weakness, seizures, and mental disturbances (such as irritation or agitation) In some types of porphyria, blistering of the skin when exposed to sunlight Urine and blood tests to check for substances (porphyrins) produced during the attacks Sickle cell disease Severe episodes of abdominal pain lasting over a day Recurring pain in places other than the abdomen, such as the back, chest, arms, and/or legs In black children who typically have family members with the disorder Blood tests to check for sickle-shaped red blood cells and for the abnormal hemoglobin that characterizes sickle cell disease *Physical causes are responsible for only about 10% of cases of chronic abdominal pain. Most cases are functional abdominal pain. †Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present. ‡For most people with chronic abdominal pain, doctors typically do basic blood and urine tests such as a complete blood cell count, blood tests to evaluate how the liver and pancreas are functioning, and urinalysis. Other tests are done based on results of these tests and the examination. CT = computed tomography; MRI = magnetic resonance imaging. Physical Causes and Features of Chronic Abdominal Pain Cause* Common Features† Tests‡ Disorders of the digestive tract Celiac sprue In children, not growing as expected (failure to thrive) Abdominal bloating and often diarrhea or light-colored, bulky, and unusually foul-smelling stools that may appear oily Symptoms that worsen when people eat foods containing wheat products (which contain gluten) Blood tests to measure levels of antibodies produced when people with celiac sprue eat foods containing gluten Often biopsy of the upper small intestine Cholecystitis (inflammation of the gallbladder), if chronic Recurring crampy pain in the upper right part of the abdomen Ultrasonography to look for gallstones Imaging of the gallbladder after a radioactive substance (radionuclide) is injected intravenously (cholescintigraphy) Colon cancer Usually no discomfort, but if the colon is partially blocked, possibly crampy discomfort Sometimes blood in stool (blood may be visible or detected during a doctor's examination) Colonoscopy Imaging tests such as CT or x-rays after barium is inserted in the rectum (barium enema) Constipation Hard, less frequent bowel movements that are difficult to pass Crampy pain in the lower abdomen that decreases after a bowel movement Sometimes pain during a bowel movement A doctor's examination, including thorough dietary history Crohn's disease Recurring episodes of severe pain with fever, loss of appetite, weight loss, and diarrhea CT and/or colonoscopy X-rays of the small intestine Gastroesophageal reflux disease (sometimes related to a hiatus hernia) Heartburn (burning pain that begins in the upper abdomen and travels up to the throat, sometimes with an acid taste in the mouth) Sometimes chest pain Sometimes a cough, hoarseness, or both Symptoms sometimes relieved by lying down Relief with antacids Often only a doctor's examination plus trying treatment with drugs to suppress acid production (if symptoms are relieved, the cause is probably gastroesophageal reflux disease) Sometimes endoscopy of the upper digestive tract (examination of the esophagus and stomach using a flexible viewing tube) or x-rays of the upper digestive tract after barium is given by mouth (barium swallow) Hepatitis, if chronic Discomfort in the upper right part of the abdomen A general feeling of illness (malaise) Loss of appetite Jaundice (uncommon) Sometimes in people known to have had acute hepatitis Blood tests to evaluate liver function and to check for hepatitis viruses Lactose intolerance Bloating, cramps, passing of gas (flatulence), and diarrhea after consuming milk products Sometimes a breath test to detect hydrogen, indicating undigested food A diet that excludes foods containing lactose (elimination diet) to determine whether those foods trigger the symptoms Pancreatic cancer Severe, constant pain in the upper abdomen, often radiating to the back Weight loss Sometimes jaundice CT MRI (magnetic resonance cholangiopancreatography, or MRCP) Pancreatitis, if chronic or accompanied by a pancreatic pseudocyst Episodes of severe pain in the upper middle of the abdomen Sometimes diarrhea and fat in stool Usually in people known to have had acute pancreatitis Blood tests to measure levels of an enzyme produced by the pancreas Imaging tests such as CT or MRI Parasitic infections (particularly giardiasis) Recent travel to developing countries, ingestion of water from streams or lakes, or contact with people with the infection Cramps, flatulence, and diarrhea Examination of stool to check for parasites or their eggs Peptic ulcers Stomach pain relieved by eating food and taking antacids May awaken people at night Endoscopy and biopsy for Helicobacter (H.) pylori (bacteria that can cause peptic ulcers) Sometimes an H. pylori breath test Scar tissue that develops around the intestines (adhesions) in people who have had abdominal surgery Crampy discomfort accompanied by nausea and sometimes vomiting Barium swallow Stomach cancer Indigestion or mild pain Often tiny amounts of blood in stool (detectable only during a doctor's examination) Typically in older adults Endoscopy of the esophagus and stomach Ulcerative colitis Crampy pain with several separate episodes of bloody diarrhea Typically in young adults Sigmoidoscopy or colonoscopy Biopsy of the rectum or colon Kidney and urinary tract disorders Birth defects of the urinary tract Frequent urinary tract infections Typically in children Intravenous urography Ultrasonography Kidney stones Pain in the side (flank) that comes and goes, often in people known to have stones Sometimes fever Dark or bloody urine Urinalysis CT or intravenous urography Reproductive system disorders (in women) Endometriosis Discomfort mainly before or during menstrual periods Laparoscopy Ovarian cyst Ovarian cancer Vague discomfort in the lower abdomen Bloating Sometimes a mass in the pelvis detected during a doctor's examination Ultrasonography of the pelvis Systemic disorders Familial Mediterranean fever Family members who have the disorder Episodes of abdominal pain lasting 48 to 72 hours and often accompanied by fever Starting during childhood or adolescence Genetic testing A food allergy Symptoms that develop only after eating certain foods such as seafood An elimination diet Henoch-Schönlein purpura A reddish-purple rash of tiny dots (petechiae) or larger splotches (purpura) on the arms, legs, buttocks, and top of the feet Achy, tender, swollen joints Nausea, vomiting, and diarrhea Blood in stool detected during a doctor's examination Biopsy of affected skin Lead poisoning Crampy abdominal pain Mental changes such as a reduced attention span, confusion, and altered behavior Loss of appetite, vomiting, and constipation Achy joints Usually only in workers exposed to lead Less often in young children who live in houses over 30 years old, in which lead-based paint may have been used Blood tests to measure the lead level Porphyria Recurring attacks of severe abdominal pain and vomiting Sometimes muscle weakness, seizures, and mental disturbances (such as irritation or agitation) In some types of porphyria, blistering of the skin when exposed to sunlight Urine and blood tests to check for substances (porphyrins) produced during the attacks Sickle cell disease Severe episodes of abdominal pain lasting over a day Recurring pain in places other than the abdomen, such as the back, chest, arms, and/or legs In black children who typically have family members with the disorder Blood tests to check for sickle-shaped red blood cells and for the abnormal hemoglobin that characterizes sickle cell disease *Physical causes are responsible for only about 10% of cases of chronic abdominal pain. Most cases are functional abdominal pain. †Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present. ‡For most people with chronic abdominal pain, doctors typically do basic blood and urine tests such as a complete blood cell count, blood tests to evaluate how the liver and pancreas are functioning, and urinalysis. Other tests are done based on results of these tests and the examination. CT = computed tomography; MRI = magnetic resonance imaging.

Testing: Usually, doctors do certain tests. These tests include urinalysis, a complete blood cell count, blood tests to evaluate how the liver and pancreas are functioning, and a blood test to measure the erythrocyte sedimentation rate (ESR). The ESR is a general test to check for inflammation somewhere in the body. Usually if people are over 50, a colonoscopy is also recommended. Some doctors recommend computed tomography (CT) of the abdomen if people are under 50, but other doctors wait for specific symptoms to develop. Other tests are done depending on results of the history and physical examination (see Symptoms of Digestive Disorders: Physical Causes and Features of Chronic Abdominal Pain).

Additional tests are done if any test results are abnormal, if people develop new symptoms, or if new abnormalities are detected during the examination.

Treatment

Treatment depends on the cause. For example, if people have lactose intolerance, a lactose-free diet (eliminating milk and other dairy products) can help. If people are constipated, using a laxative for a few days plus adding fiber to the diet can help.

Functional pain: Treatment focuses on helping people return to normal daily activities and lessening the discomfort. Usually, treatment involves a combination of strategies. Several visits to the doctor may be needed to develop the best combination. Doctors often arrange follow-up visits every week, month, or 2 months, depending on people's needs. Visits are continued until well after the problem has resolved.

After functional pain is diagnosed, doctors emphasize that the pain, although real, does not have a serious cause and that stress and other psychologic factors can affect the body. Doctors try to avoid repeating tests after thorough testing has failed to show a physical cause of the symptoms.

Although there are no treatments to cure functional chronic abdominal pain, many helpful measures are available. These measures depend on a trusting, empathic relationship between the doctor, person, and person's family members. Doctors explain how the laboratory and other test results show that the person is not in danger. The doctor also explains how functional abdominal pain develops and how people perceive it. For example, they tend to feel pain when they are under stress. Doctors encourage people to participate in work, school, and social activities. Such participation does not worsen the condition but instead encourages independence and self-reliance. People who withdraw from their daily activities risk having their symptoms control their life rather than having their life control their symptoms.

Doctors recommend acetaminophen or other mild pain relievers to relieve the pain. A high-fiber diet and fiber supplements can also help. Many drugs have been tried with varying success. They include drugs that reduce or stop muscle spasms in the digestive tract (antispasmodics), peppermint oil, cyproheptadine (an antihistamine), and drugs that suppress acid production in the stomach.

Sources of stress or anxiety are minimized as much as possible. Parents and other family members should avoid reinforcing the pain by giving it too much attention. If people continue to feel anxious, doctors may prescribe antidepressants or drugs to reduce anxiety. Therapies that help people modify their behavior, such as relaxation training, biofeedback, and hypnosis, may also help reduce anxiety and help people better tolerate their pain.

For children, help from parents is essential. Parents are advised to encourage the child to become independent and to fulfill the child's normal responsibilities, particularly attending school. Allowing the child to avoid activities may actually increase the child's anxiety. Parents can help the child manage pain during daily activities by praising and rewarding the child's independent and responsible behaviors. For example, parents could reward the child by scheduling special time with the child or a special outing. Involving school personnel can help. Arrangements can be made to let the child rest briefly in the nurse's office during the school day, then return to class after 15 to 30 minutes. The school nurse can be authorized to give the child a mild pain reliever such as acetaminophen. The nurse can sometimes allow the child to call a parent, who should encourage the child to stay in school.

Key Points

• Usually, chronic or recurring abdominal pain is functional pain, often related to stress, anxiety, or diet.
• Symptoms that require a doctor's immediate attention include a high fever, loss of appetite or weight, pain that awakens the person, blood in stool or urine, jaundice, and swelling of the legs and/or abdomen.
• Blood and urine tests are usually done to check for disorders that may cause the pain.
• Additional tests are needed only if people have abnormal test results, warning signs, or symptoms of a specific disorder.
• For functional pain, treatment involves learning to minimize stress, participating in normal daily activities, relieving pain (with mild pain relievers), sometimes taking drugs or using behavioral modification therapies to relieve anxiety, and/or altering the diet.

Last full review/revision October 2012 by Norton J. Greenberger, MD