What's the Cause of Chronic Abdominal Pain?

I see patients with abdominal pain every day.  Over my career, I’ve sat across the desk facing thousands of folks with every variety of stomach ache imaginable.   I’ve listened to them, palpated them, scanned them, scoped them and at times referred them elsewhere for another opinion.  With this level of experience, one would suspect that I have become a virtual sleuth at determining the obvious and stealth causes of abdominal distress.  

I wish it were the case.

Some Cases Defy Sleuthing

The majority of cases of chronic abdominal pain that I – and every gastroenterologist – see will not be explained by a concrete diagnosis.   Sure, I’ve seen my share of sick gall bladders, stomach ulcers, diverticulitis, bowel obstructions, appendicitis and abdominal infections, but these represent a minority of my afflicted patients. 

Patients with acute abdominal pain are more likely to receive a specific diagnosis, such as those listed above.  However, patients who have abdominal distress for years, which constitute most of my stomach pain patients, usually will not have a specific, explanatory diagnosis even though these patients often feel otherwise.

Many of these patients come to the office advising me that “their diverticulitis is acting up” or that “their ulcer is back again”.  Usually, this is not the case and they may never have had diverticulitis or an ulcer in the first place.

Physicians often assign these patients a diagnosis of irritable bowel disease or functional bowel disease, which is a rather amorphous entity that cannot be detected on available diagnostic testing.  The labs and scans and scopes are all normal in these folks.  I believe that the condition is real, but it is a frustrating condition that is difficult to define.   It often coexists with other chronic painful conditions, such as fibromyalgia, chronic pelvic pain and migraine headaches. 

This is tough for patients and a medical profession that strive to label every symptom numerically and quantitatively.  The body does not work this way. 

Of course, I may be missing true diagnoses in some of my chronic pain patients.  Medical science isn’t perfect and neither am I.   How many celiac disease patients have I overlooked?  Should I test every individual who has a cramp now and then for celiac disease so I don’t miss a single case?  If every physician adopted this approach for celiac disease – and a hundred other conditions – we would elevate our current practice of overdiagnosis and overtreatment beyond the stratosphere. 

So, how much testing should a patient with chronic nausea or abdominal pain receive?   Patients and physicians don’t always agree here.   How much cost and care are patients, physicians and society willing to expend to approach 100% chance of not missing a diagnosis?   Is your answer the same if you or a loved one is the patient?