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Abdominal Pain

Anatomy – Introduction & Divisions

The abdomen, justly called as a ‘Magic Box’, has a lot of organs stuffed inside in particular positions and well-designed manner. It is in fact very difficult to identify the cause of an abdominal pain because of the multiple organs within.

As you can see in the below images, abdomen is the area between the diaphragm above and the pelvic bones below. Pelvis though learned separately, is a part of abdomen.

abdominal quadrants anatomy regions image photo picture

Image 1 – Ref: viarevision.wikia.com

The images showing the 9 regions and 4 quadrants of the abdomen.

Abdomen can be divided in two ways, i.e. into 9 regions or 4 quadrants. Understanding the terms ‘Hypo’ that means ‘below’ and ‘Epi’ that means ‘above’ makes it easier to know about the regions^[2]. ‘Chondros’ means cartilage and ‘Gastrium’ is stomach. The right and left hypochondriac regions are just below the cartilaginous parts of the rib cage.

The epigastric and hypogastric regions can be explained in relation to the stomach. Umbilical region is the area surrounding the umbilicus (Navel). The right and left lumbar regions are on the sides of umbilical region and the iliac regions lay over the right and left iliac bones.

The quadrants are much easier to understand and remember. Two imaginary planes that pass through the umbilicus (navel) divide the abdomen into 4 quadrants. The meeting point of the planes is at umbilicus (navel) ^[1]. Understanding the regions and quadrants would make it easier to diagnose any pain in the abdomen.

ICD 9 code for abdominal pain – 789.0

ICD 10 code for abdominal pain – R10.9

Contents of the Abdomen

Tubular structures- Blood vessels, lymphatics, nerves
Bones- Lumbar and sacral vertebrae
Organs- Lower part of oesophagus (food pipe), Stomach, small intestine, large intestine, appendix, liver, gall bladder, pancreas, spleen, kidneys, adrenal glands, ureters, urinary bladder, uterus, fallopian tubes, ovaries.
Membrane- Peritoneum^[3]

Content of Different Regions

abdominal contents anatomy regions quadrants pain

Image 2 – Ref: http://etc.usf.edu

Contents and Locations of Different Organs in 9 Regions of abdomen

RIGHT HYPOCHONDRIAC

Ascending Colon
Gall bladder
Liver
Right Kidney
Small Intestine
Transverse colon

EPIGASTRIC

Oesophagus
Liver
Pancreas
Part of Right & Left
Kidneys
Right and left adrenal glands
Small intestine
Stomach
Transverse colon

LEFT HYPOCHONDRIAC

Left Kidney
Liver left lobe
Stomach
Tail of Pancreas
Spleen
Part of Small intestine
Part of Transverse colon
Part of Descending colon

RIGHT LUMBAR

Ascending colon
Liver
Gall bladder
Right Kidney
Small intestine

UMBILICAL

Lower part of Right and left kidneys
Right & left ureters
Part of Stomach
Small intestine
Cisterna chyli
Head of the pancreas

LEFT LUMBAR

Part of Descending colon
Tip of Left Kidney
Part of Small intestine

RIGHT ILIAC

Ascending colon
Caecum
Appendix
Right ovary and fallopian tube (in females)
Small intestine

HYPOGASTRIC

Prostate (in males)
Rectum
Sigmoid colon
Right and left fallopian tubes (in females)
Right and left ureters
Seminal vesicle (in males)
Small intestine
Urinary bladder
Uterus (in females)
Vas deferens (in males)

LEFT ILIAC

Left ovary and fallopian tube (in females)
Part of Small intestine
Part of Descending colon
Sigmoid colon

Contents and Locations of Different Organs in Quadrants of the abdomen

RIGHT UPPER QUADRANT

Liver
Gall bladder
Duodenum
Head of pancreas
Right adrenal gland
Upper lobe of right kidney
Hepatic flexure of colon
Part of ascending colon
Part of transverse colon

LEFT UPPER QUADRANT

Left lower part of liver
Upper part of left kidney
Splenic flexure of colon
Part of transverse colon
Part of descending colon
Stomach
Spleen
Pancreas
Left adrenal gland

RIGHT LOWER QUADRANT

Lower lobe of right kidney
Part of ascending colon
Right ovary and fallopian tube (in female)
Right spermatic cord (in male)
Caecum appendix
Right ureter
Uterus (in female)
Urinary bladder
Appendix

LEFT LOWER QUADRANT

Lower lobe of left kidney
Descending colon
Left spermatic cord (male)
Uterus (in female)
Sigmoid colon
Left ureter
Left ovary and fallopian tube (in female)
Urinary bladder

Pain Abdomen

Abdominal pain can occur due to infection, inflammation, distension, loss of blood supply, muscular cramps or injury to any abdominal organs. It can sometimes be felt as a diffuse pain throughout the abdomen. Few of the times it can be pin pointed to particular location on the abdomen.

However, the diagnosis can be done only after a proper history and examination of the patient. There can be variations in onset of the pain, the character, location, triggering factors, relieving factors or associated features. ^[7]

The pain usually is related to the location of the organ. Sometimes the pain may be felt in areas non-related to the organs, which is known as referred pain.

Free air under the right diaphragm from a perforated bowel abdominal erect abdomen xray

Image 3- Ref: en.wikipedia.org

The image shows an X-ray film. Free air is seen under the right dome of diaphragm, indicating air leakage into the peritoneal space most probably due to a perforation in the gastrointestinal tract.

In the tables below, the most common causes of pain in each quadrant has been explained along with diffuse abdominal pain.

Diffuse Abdominal Pain

Condition	Clinical Feature	Cause
Intestinal Obstruction	Nausea Vomiting Constipation Inability to pass stool Distended abdomen^{[8, 12, 13, 14, 15]}	Fibrous bands or adhesions causing the obstruction colon cancer hernias diverticulitis volvulus Impacted faeces.^[9]
Gastro intestinal tract perforation	Sudden onset severe pain Nausea Vomiting Tenderness of the abdomen Rebound tenderness ^[10]	Peptic ulcer disease Malignancies Inflammatory bowel disease Medications such as non-steroidal anti-inflammatory drugs Penetrating or blunt abdominal trauma Injury during procedures like ERCP and colonoscopy. ^[11]
Acute mesenteric ischemia	Sudden onset, sever, diffuse pain in the abdomen Nausea, vomiting, anorexia Diarrhoea Abdominal distension Gastrointestinal bleeding	Mesenteric arterial embolism Mesenteric arterial thrombosis Non occlusive mesenteric ischemia Mesenteric venous thrombosis^[16]
Chronic mesenteric ischemia	Generally no symptoms ^[21] Anorexia Nausea Vomiting Diarrhoea	Atherosclerosis of mesenteric vessels ^{[17, 18]} Fibromuscular dysplasia Takayasu’s disease ^[19] Retroperitoneal fibrosis ^[20]
Ulcerative colitis	Abdominal cramps Diarrhoea Bleeding from rectum Anorexia Weight loss ^[22]	Cause unknown Thought to be because of immune system over reacting to normal bacteria in the intestinal tract.
Viral gastroenteritis	Diarrhoea Nausea Vomiting	Viral infection in the intestines
Spontaneous Bacterial peritonitis	Fever Chills Nausea Vomiting Abdominal tenderness Malaise ^[26]	Cirrhosis of liver^[23] Nephrotic syndrome ^{[24, 25]}
Colorectal cancer	Diarrhoea Constipation Blood in stool Vomiting Fatigue Unexplained weight loss ^{[27, 28]}	Predisposition may be seen in Elderly Overweight Smoking Physically inactive Family history of colorectal cancer ^{[27, 28]}
Celiac disease	Chronic diarrhoea Abdominal distension Malabsorption Anorexia	Auto immune disorder- Due to over reaction of our immunity towards our own organs.
Ketoacidosis	Nausea Vomiting Abdominal pain	Diabetes Starvation Alcohol ^[29]
Adrenal insufficiency	Hypoglycemia Dehydration Weight loss Disorientation Low blood pressure Muscle aches Nausea, vomiting Diarrhoea ^{[30, 31]}	Withdrawal of long term corticosteroid therapy Addison’s disease AIDS Amyloidosis Sarcoidosis^{[30, 31]}
Irritable bowel syndrome	Diarrhoea Constipation Bloating of abdomen Abdominal Cramps ^[32]	Cause unknown ^[32]
Diverticulosis	Diarrhoea Abdominal cramps	Low fiber intake Genetic predisposition ^[33]

Right Upper Quadrant Pain (RUQ)

**Abdomen**
Organ	Cause	Comments
Vessels & Lymphatics	Mesenteric ischemia Mesenteric adenitis	Sudden onset, sever, diffuse pain in the abdomen Nausea, vomiting, anorexia Diarrhoea Abdominal distension Gastrointestinal bleeding^{[34, 35, 36, 37]}
Liver	Acute viral hepatitis Acute alcoholic hepatitis Mass or swelling in liver Enlarged Liver (hepatomegaly) Budd-Chiari Syndrome Fitz-Hugh-Curtis Syndrome	Depending on the condition symptoms appear Jaundice Right Hypochondriac pain Pale stools Dark urine Swelling in the ankles, feet and abdomen Excessive tiredness Bruising and bleeding
Gall Bladder	Acute Cholecystitis Cholelithiasis	Gall bladder inflammation Gall bladder stones
Biliary Tract	Acute Cholangitis Choledocholithiasis	Biliary tract inflammation Biliary tract stones
Others	Duodenal ulcers Pancreatitis Colon obstruction Colitis Colonic mass Pyelonephritis Perinephric abscess Nephrolithiasis Sub-diaphragmatic abscess	Infrequent causes of RUQ pain
Abdominal Wall	Cellulitis Herpes Zoster Hematoma or strain of the abdominal muscles	Skin or muscular lesions can cause abdominal pain. The pain in skin lesions can range from moderate to severe.

**Peritoneum**
	Intra-peritoneal abscess	Sub-diaphragmatic abscess
	Peritonitis	Gall bladder perforation Duodenal ulcer perforation
	Intra- peritoneal haemorrhage	Ruptured Abdominal Aortic Aneurysm.

**Extra Abdomen**
Bones	Right sided lower rib fractures Thoracic Spine fracture	It is interesting to note that few structures situated outside the abdomen may also lead to pain in the abdomen. This ‘Referred pain’ can happen when the nerves entering the spinal cord at same level are arising from different locations.
Heart	Inferior wall myocardial infarction.	It is interesting to note that few structures situated outside the abdomen may also lead to pain in the abdomen. This ‘Referred pain’ can happen when the nerves entering the spinal cord at same level are arising from different locations.
Lungs	Lower lobe pneumonia Pulmonary Embolism Pleurisy Pneumothorax

Left Upper Quadrant Pain (LUQ)

Condition	Clinical features	Diagnostics
Splenic trauma/Infarct	Left upper quadrant pain in the abdomen Fever, chills Nausea, vomiting Left shoulder pain	Complete blood count Ultrasonography of abdomen CT scan abdomen^{[38, 39, 40, 41]}
Splenomegaly (Enlarged spleen)	Left upper quadrant pain in the abdomen Fever, chills Nausea, vomiting Left shoulder pain occasionally	Complete blood count Ultrasonography of abdomen CT scan abdomen
Mesenteric Ischemia	Constant pain/Colicky pain Abdominal distension Gastro intestinal bleeding Fever Nausea, vomiting	Complete blood count Serum amylase X-ray abdomen- Flat & erect positions Angiography CT angiography
Small Bowel Obstruction	Left upper quadrant pain in the abdomen Abdominal distension Nausea Vomiting	X- ray abdomen CT abdomen
Crohn’s disease	Abdominal pain, nausea, vomiting, fatigue Arthritis, erythema nodosum, uveitis, oral ulcers	Complete blood count Colonoscopy with tissue biopsy Barium enema Ultrasonography of abdomen
Mesenteric adenitis	Usually right lower quadrant abdominal pain Fever Diarrhoea Anorexia	Complete blood count Ultrasonography of abdomen CT scan abdomen
Acute pancreatitis	Abdominal pain with radiation to back Nausea Vomiting Fever	Serum amylase, lipase CBC Ultrasonography of abdomen CT scan abdomen
Pancreatic cyst/ malignancy	Abdominal pain Jaundice Weight loss	Ultrasonography of abdomen CT scan abdomen CBC Serum amylase, lipase CEA and CA 19-9
Pyelonephritis	Dysuria Haematuria Flank pain Urgency Frequency	CBC Urine culture Ultrasonography of abdomen CT scan abdomen
Perinephric abscess	Dysuria Flank Pain Fever	CBC Urine culture Ultrasonography of abdomen CT scan abdomen
Nephrolithiasis	Flank pain Nausea Vomiting	Urinalysis Ultrasonography of abdomen X- ray abdomen

Right Lower Quadrant Pain (RLQ)

**Abdomen**
Organ	Cause	Comments
Abdominal wall	Cellulitis Herpes Zoster Hematoma or strain of the abdominal muscles Inguinal hernias	Skin or muscular lesions can cause abdominal pain. The pain in skin lesions can range from moderate to severe. ^[42]
Peritoneum and peritoneal cavity	Peritonitis Intraperitoneal abscess/haemorrhage	Acute appendicitis/ caecal perforation Diverticular abscess
Appendix	Acute Appendicitis	Appendicits is the infection of appendix. Right lower quadrant pain with rebound tenderness, nausea and vomiting can be seen. Occasionally an infected appendix may burst, leading to peritonitis.
Ileocaecal junction	Irritable bowel syndrome Crohn’s disease	Diarrhoea Constipation Bloating of abdomen Abdominal Cramps ^[32]
Caecum	Caecal volvulus Intestinal Obstruction Caecal perforation	In intestinal obstruction, the following may occur along with inability to pass stool. Nausea Vomiting Constipation Whereas in perforation, it can lead to a localized pain which may aggravate into peritonitis.
Proximal ascending colon	Colitis Colonic perforation Colonic mass	Abdominal pain, diarrhoea, blood in stool can occur in colitis. Perforation in the intestine can lead to peritonitis.
Right Kidney and ureter	Nephrolithiasis (Ureteric colic due to stone in the ureter)	Pain maybe in the flanks, lower abdomen or back
Right ovary	Endometriosis Ovarian cyst rupture Ovarian torsion	Severe abdominal pain with nausea vomiting. Right fallopian tube
Right fallopian tube	Pelvic inflammatory disease Ruptured ectopic pregnancy	Rupture can lead to internal bleeding and peritonitis.
Retroperitoneal	Iliopsoas abscess Iliopsoas haematoma	Fever, abdominal pain with or without radiation to the thigh, nausea, vomiting, anorexia.
Blood vessels and lymphatics	Mesenteric ischemia Mesenteric adenitis Vasculitis	Sudden onset, sever, diffuse pain in the abdomen Nausea, vomiting, anorexia Diarrhoea Abdominal distension Gastrointestinal bleeding

**Extra abdomen**
Hernia	Femoral hernia (hernia occurring through the femoral canal in thigh)	It causes referred pain
Right hip pathology	Osteoarthritis Intertrochanteric fracture (Fracture of the trochanteric region of the thigh bone) Acetabular fracture (Fracture of acetabulum of the hip bone)	Causes referred pain
Fracture of hip bone	Pubis ramus fracture

Left Lower Quadrant Pain (LLQ)

**Abdomen**
Organ	Cause	Comments
Abdominal wall	Cellulitis Herpes Zoster Hematoma or strain of the abdominal muscles Inguinal hernias	Skin or muscular lesions can cause abdominal pain. The pain in skin lesions can range from moderate to severe^[43]
Peritoneum and peritoneal cavity	Peritonitis Intraperitoneal abscess/haemorrhage	Intestinal perforation or haemorrhage may lead to peritonitis. This is characterized by a rigid abdomen which is tender.
Left Kidney and ureter	Nephrolithiasis (Ureteric colic due to stone in the ureter)	Pain maybe in the flanks, lower abdomen or back
Left ovary	Endometriosis Ovarian cyst rupture Ovarian torsion	Severe abdominal pain with nausea vomiting.
Left fallopian tube	Pelvic inflammatory disease Ruptured ectopic pregnancy	Rupture can lead to internal bleeding and peritonitis.
Blood vessels and lymphatics	Mesenteric ischemia Mesenteric adenitis Vasculitis	Sudden onset, sever, diffuse pain in the abdomen Nausea, vomiting, anorexia Diarrhoea Abdominal distension Gastrointestinal bleeding

**Extra abdomen**
Hernia	Femoral hernia (hernia occurring through the femoral canal in thigh)	It causes referred pain
Left hip pathology	Osteoarthritis Intertrochanteric fracture (Fracture of the trochanteric region of the thigh bone) Acetabular fracture (Fracture of acetabulum of the hip bone)	Causes referred pain
Fracture of hip bone	Pubis ramus fracture	Pain in the abdomen or lower back Pain increases on walking Numbness in the groin or legs.

Reference:

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Published on December 2nd, 2017 by Editorial Team under Anatomy and Body, Pain Management.
Article was last reviewed on January 12th, 2022.

Abdominal Pain

Abdominal Pain

Anatomy – Introduction & Divisions

ICD 9 code for abdominal pain – 789.0

ICD 10 code for abdominal pain – R10.9

Contents of the Abdomen

Content of Different Regions

Contents and Locations of Different Organs in 9 Regions of abdomen

Contents and Locations of Different Organs in Quadrants of the abdomen

Pain Abdomen

Diffuse Abdominal Pain

Right Upper Quadrant Pain (RUQ)

Left Upper Quadrant Pain (LUQ)

Right Lower Quadrant Pain (RLQ)

Left Lower Quadrant Pain (LLQ)

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Recent Posts

Abdominal Pain

Abdominal Pain

Anatomy – Introduction & Divisions

ICD 9 code for abdominal pain – 789.0

ICD 10 code for abdominal pain – R10.9

Contents of the Abdomen

Content of Different Regions

Contents and Locations of Different Organs in 9 Regions of abdomen

Contents and Locations of Different Organs in Quadrants of the abdomen

Pain Abdomen

Diffuse Abdominal Pain

Right Upper Quadrant Pain (RUQ)

Left Upper Quadrant Pain (LUQ)

Right Lower Quadrant Pain (RLQ)

Left Lower Quadrant Pain (LLQ)

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