General information
The upper abdomen connects directly to the two costal arches towards the bottom and merges blurred into the middle abdomen. This division of the abdomen is important with regard to the organs located in that area, which can cause corresponding pain. Pain that starts at the costal arches and goes down to the level of the navel is called upper abdominal pain. There are numerous organs in this area that can cause pain. It is possible to subdivide the pain localization in the upper abdomen according to its direct location, i.e. left-sided upper abdomen, central upper abdomen or right-sided upper abdomen.
Localization of upper abdominal pain
If pain in the upper abdomen is indicated, it is in many cases in the upper abdomen on the right. If pain is indicated there, the gallbladder is highly suspect as the organ causing the pain. In particular, a sudden and stabbing pain, which may remain the same or increase in intensity, is most likely to indicate a disease of the gallbladder in the area of the right upper abdomen.
It can also cause pulling in the abdomen. Especially if the pain is reported after meals, the gallbladder is on the shortlist of diagnoses as the cause. In many cases it is gallstones that are located in the gallbladder and are initially completely free of symptoms.
After a meal, the gallbladder contracts to release the bile acids it contains. This leads to stone movements and to contact between the stones and the gallbladder wall. This leads to the described stabbing pain in the area of the right upper abdomen.
If the pain occurs independently of meals and is indicated at the site of the gall bladder, it is possible that the gall bladder has become inflamed. In most cases this happens in connection with gallstones. An inflamed gallbladder without gallstones is rather rare.
It is often the stones that have been lying in the gallbladder for many years that finally cause the gallbladder to become inflamed and lead to the described pain. If one speaks of an inflammation of the gallbladder, one usually refers to the inflamed gallbladder wall. Furthermore, it can happen that a gall stone that has matured in the gallbladder leaves the gallbladder due to contraction and travels through the bile ducts.
If this stone then remains stuck in a narrowed section of the bile duct, it usually causes very severe pain, which is also known and feared as biliary colic. The diagnosis is made by means of an ultrasound of the upper abdomen. By looking at the bile, one can see gallstones in it.
An inflammation of the gallbladder becomes visible in the ultrasound image by an even or uneven wall thickening. Stones in the bile ducts can often not be seen by the ultrasound. This is where a so-called ERCP must be used, in which a gastroscopy is performed and a contrast medium is injected into the bile duct.
An X-ray is then taken and the bile duct can be checked to ensure that it is clear. A blood test can also be used to see whether an inflammation is progressing in the body or whether a bile-specific parameter in the blood is elevated. The therapy of choice in most cases is surgical removal of the gallbladder if stones cause the symptoms or if the gallbladder is inflamed.
If a gallstone is lodged in the bile duct, it can either be recovered endoscopically or removed surgically by opening the bile duct. Furthermore, there is another organ in the area of the right upper abdomen – the liver. If right upper abdominal pain is indicated, the liver must always be examined as well.
As a rule, diseases of the liver, such as hepatitis, cirrhosis or liver carcinomas are not symptomatic due to pain. However, it is always possible that these diseases lead to swelling of the liver. The liver is surrounded by a coarse capsule, which does not leave enough space to give way to a corresponding enlargement of the liver.
This leads to increased pressure and thus to a strong pull on the liver capsule. This leads to sometimes very severe pain. If the extent of the liver appears suspicious, the edges of the liver must always be measured during the ultrasound examination.
and Enlarged LiverCore upper abdominal pain is less frequent but just as urgent to clarify.These can come from the stomach, which lies in this area, or from the pancreas. The most frequent cause of middle upper abdominal pain is diseases of the stomach. Often it is acute inflammation of the stomach lining that leads to the specified middle upper abdominal pain.
An acute inflammation of the stomach lining or acute gastritis is already the result of eating particularly fatty foods or drinking a lot of alcohol the day before. In most cases, the symptoms become more severe when pressure is applied to the middle upper abdomen or when the patient bends forward. However, severe acute gastritis can also lead to severe pulling and burning pains at rest.
In most cases, the symptoms disappear after one to three days. If they do not, it is called chronic gastritis, the cause of which must be clarified. Often it is too much acid produced by the stomach, which leads to pain in the stomach wall.
In some cases, the cause of the pain is a stomach ulcer, which initially grows unnoticed in the area of the stomach and eventually leads to pain. If the stomach pain is strongest in the middle, this may be an indication of gastritis. Central upper abdominal pain can also be caused by the pancreas.
This is usually inflammation of the pancreas (pancreatitis). Characteristically, the pain is reported to be central and radiating into the back and is described as burning, cutting or pulling. The main cause of pancreatitis is chronic alcohol consumption.
In most cases it is also the case that the area in the central upper abdomen is sensitive to pressure, similar to the inflammation of the mucous membrane of the stomach. The occurrence of pancreatitis is a serious clinical picture and must be diagnosed and treated quickly. It is usually accompanied by severe general reactions of the body, such as fever and severe deterioration of the general condition.
Patients with severe pancreatitis are often unable to walk upright and often show elevated levels of bilirubin in the blood, which stains the skin and conjunctiva. Sometimes, for various biochemical reasons, a darker coloration of the urine and a lighter coloration of the bowel movements occur. In this case the pancreas should be examined.
This is also done by means of ultrasound and a blood test. In unclear cases it may be necessary to perform a CT. In most cases, the image examinations will reveal restless condensed structures or structures without a real border.
Pancreatitis is treated with antibiotics in hospital. An inflammation of the gastric mucosa can only be proven by a gastroscopy. In this procedure, a real image of the stomach from the inside can be taken and analyzed.
Reddish changes in the stomach lining indicate an acute or chronic course of an inflammation of the gastric mucosa. Treatment is carried out with high doses of acid inhibitors and a gentle diet. Upper abdominal pain, whether central, left or right, can always be an indirect radiation of the heart.
If the organ findings are unclear, an ECG must always be written and the troponin value in the blood determined in order to rule out a heart attack. Symptoms of a myocardial infarctionThe spleen is located in the area of the left upper abdomen as a potentially pain-causing organ. However, splenic inflammation is virtually non-existent.
There are, however, some blood diseases (leukemias) and infections (Pfeiffer’s glandular fever) in which the spleen swells considerably and leads to a pull on the capsule of the spleen. This can then lead to severe pain in the area of the left upper abdomen. Untrained athletes or those who have eaten something before a training session can also complain of left-sided upper abdominal pain.
In this case, it is mostly simple, uncomplicated side stitches. In the lower part of the left (and also right) lower abdomen, the ureters lead from the kidneys to the bladder. If there is a kidney stone that has left the kidney and is stuck in the ureter, very severe left upper abdominal pain can occur, also known as colic.
Also, ascending urinary tract infections ascending from the bladder can sometimes cause left (and right) side pain. The pain is also clarified with ultrasound. The shape and size of the spleen is measured and assessed.In case of a spleen enlargement, it is essential to search for the cause.
In most cases, this is done by means of a detailed physical examination and an examination of the blood. In many cases, urinary stones stuck in a ureter cannot be seen by ultrasound. If the cause of left lower abdominal pain is unclear, a contrast medium must be applied.
In this way, appropriate patency of the ureters can be checked. If pain occurs in the right, middle or left upper abdomen after a trauma, a CT scan may have to be performed in addition to an ultrasound examination, since a traumatic injury with corresponding bleeding would be possible. One organ that is located in the left, middle and right upper abdomen is the intestine.
This can cause discomfort at any point. Both the large intestine (colon), which lies along the upper abdomen in the form of a picture frame, and the small intestine, which fills this frame, can cause complaints. The most common and uncomplicated cause of this is flatulence after eating the appropriate food.
There can also always be changes in the large intestine, which in the form of bulges and their inflammation can lead to complaints in any area of the large intestine. Although the lower left abdomen is the more frequent location of these so-called diverticulitis, in some cases this can also lead to complaints in the area of the upper left abdomen. Here, too, the cause should first be investigated by means of ultrasound or a colonoscopy.
The heart is located in the chest area, so pain originating from the heart can radiate into the upper abdomen. It is therefore advisable to write an ECG in patients with severe upper abdominal pain in order to exclude a possible heart attack as the cause. If the pain in the upper abdomen is caused by a heart attack, the pain characteristic is pressing to stabbing and extends from the back of the sternum to the upper abdomen.
The pain is very strong and patients often speak of “pain of destruction”. Especially the posterior wall infarction causes such pain. In addition to ECG diagnostics, laboratory parameters should be collected.
The heart-specific enzyme troponin, whose values are strongly elevated in the case of a heart attack and thus confirm the suspicion with relative certainty, is particularly significant. Further indicative enzymes are myoglobin, creatine kinase (CK-MB), aspartate aminotransferase (AST) and alanine aminotransferase (ALT). In addition, a cardiac echocardiography, a cardiac catheterization or even an MRI of the heart can be performed.
It is also possible that angina pectoris (“chest tightness”) is present, which causes similar symptoms but is less intense. This is not the loss of myocardial tissue as in myocardial infarction, but merely a partial temporary reduced perfusion of the heart muscle. Pain in the upper abdomen as a leading symptom is a typical feature of the so-called ulcer disease.
It involves damage to the mucous membranes in the stomach and duodenum, which are at least half a centimeter in size and affect the muscle layer (see: peptic ulcer). The development is based on factors that influence the balance of the mucous membrane. These primarily include infection with the bacterium Helicobacter pylori and altered acid production.
Further risk factors are: In many cases, acute gastritis, an inflammation of the stomach mucosa, occurs asymptomatically. However, painful complaints in the upper abdomen can also occur. Regardless of the actual cause, it is an imbalance between the factors protecting the mucous membrane and the aggressive stomach acid.
Certain drugs, such as acetylsalicylic acid, non-steroidal anti-inflammatory drugs, cytostatic drugs and corticosteroids can cause such an imbalance. Gastric cancer remains asymptomatic for a long time until it becomes symptomatic with pain in the upper abdomen, among other things. The most important risk factor for its development is infection with Helicobacter pylori.
Other triggers are: Too much fat in the blood, as well as too high calcium levels, can also promote acute pancreatitis. In every tenth case, the cause is unknown. The premature activation of pancreatic enzymes leads to “self-digestion” of the pancreas.
Chronic pancreatitis is also associated with recurrent upper abdominal pain in the early stages. In almost 80% of cases, chronic alcohol abuse precedes it.Sudden, swelling and decongesting pain in the right upper abdomen occurs in symptomatic gallstone disease. The stones may be located in the bladder itself or in the bile ducts.
They consist of components of the bile fluid. Pure and mixed cholesterol stones are the most common, while so-called pigment stones from breakdown products of the red blood cells occur less frequently. Risk factors are age over forty, overweight, the female sex, many pregnancies, high-calorie and low-fiber diet, chronic disease, type 2 diabetes mellitus and certain genetic factors.
Women are affected by gallstones more than twice as often as men. Acute cholecystitis, an inflammation of the gall bladder, can be a complication of gallstone disease. A trapped stone causes an inflammatory reaction. Typically, swelling and decongestion pain in the right upper abdomen also occurs here.
- A genetic predisposition
- Eating habits
- Nicotine abuse
- Alcohol consumption
- Stress (see: Abdominal pain and stress) and
- Especially taking non-steroidal anti-inflammatory drugs
- Accidents
- Medicines like glucocorticoids
- Antibiotics and estrogens
- Infections
- Tumors and
- Autoimmune diseases such as Crohn’s disease
