Stomach pain: what to do depending on where it sits

Where the pain sits, how it started and whether it moves are worth more than any remedy, because the same heating pad that settles a spasm is worthless over a gallbladder. A map first, then what to do.

Where it sits tells you what it is

• Upper middle, below the breastbone: the stomach, the duodenum, the pancreas, and sometimes the heart. Burning here with a relation to meals or to coffee and painkillers is dyspepsia or gastritis. Severe, constant, boring through to the back with vomiting is pancreatitis. An ache relieved by food that returns two to three hours later is a duodenal ulcer. Pain in this region in a diabetic or an older person, with sweating and breathlessness, is an ECG question, not an antacid one.
• Right under the ribs: gallbladder and liver. A gallbladder attack is classically steady, severe, twenty minutes to a few hours, in the right upper abdomen or the middle, often after a fatty meal, radiating to the right shoulder blade or the back, with nausea. Yellow eyes, dark urine and pale stool with pain is a blocked duct and needs same-day assessment.
• Left upper: usually trapped gas at the bend of the colon, the splenic flexure, and rarely the spleen.
• Around the navel: small bowel. Early appendicitis starts exactly here as a vague ache and then moves down and to the right over six to twelve hours, with nausea and a low fever. A periumbilical pain that does that sequence in anyone, at any age, should be examined before it becomes a perforation.
• Lower right: appendix, and in a woman the right ovary, including a torsion or a ruptured cyst, and an ectopic pregnancy until a test says otherwise. Tuberculosis of the bowel also sits here and presents as weeks of pain with fever and weight loss.
• Lower left: the sigmoid colon. Constipation and gas are the usual explanations; diverticulitis, which comes with fever and tenderness, is not.
• Low in the middle: bladder, uterus, and bowel. Burning with frequency is urinary; cyclical and midline is gynaecological.
• In the side, radiating round to the groin in waves so severe you cannot sit still: a ureteric stone. Nothing you take by mouth settles that; heat, prescribed medicine and fluids are what you can do on the way to being seen.
• Pain that moves with the skin, with burning and then blisters in a strip on one side, is shingles and needs treatment within three days.

How it started, and whether it moves

Sudden and maximal within seconds, like being kicked, is the pattern that worries a surgeon most: a perforation, a torsion, a leaking aneurysm or a stone. Comes in waves with a build and a fall, and you cannot find a comfortable position: that is a hollow organ squeezing against an obstruction, a bowel, a bile duct or a ureter, and colic is why people pace rather than lie still. Constant, dull, worse on movement or coughing, and lying still is preferred: that is inflammation touching the peritoneal lining, and it should be examined rather than treated. Burning tied to meals is acid. Cramping tied to the stress of a work day and relieved by a motion is functional. Pain that wakes you from sleep reliably, night after night, is not functional.

The everyday causes and what actually settles them

Most stomach pain in a healthy person under forty is gas, dyspepsia, constipation, or a viral or food-related spasm. For those:

• Move. Walking is the single most effective gas-pain measure, because peristalsis is what clears it. Lying still makes it last longer.
• Heat. A hot water bag or a heating pad over the abdomen for twenty minutes eases smooth-muscle spasm. It is genuinely analgesic for cramps, gas and dysmenorrhoea. Do not put strong heat on an acutely rigid, febrile abdomen or in pregnancy without asking.
• Position. Left side lying with the knees drawn up helps gas at the splenic flexure; knee-chest or child's pose is the one that moves wind fastest; semi-sitting and leaning forward is how a pancreas hurts least; a reclined position with the head raised suits reflux.
• Ajwain, hing, saunth, and ginger in warm water for the distension-and-spasm pattern; simethicone capsules for gas, which are safe and work by a purely mechanical route; a plain antacid or an alginate taken at the right time relative to food.
• Undo the constipation, because a chronically full left colon produces daily pain that is treated with nothing but fibre, water and time and is misdiagnosed as gastritis for years.
• Stop the causative medicine where there is one: painkillers taken daily for back or knee pain are the commonest cause of recurrent epigastric pain in this country, and an ulcer caused by them heals faster than the knee problem gets solved.

What not to do

Do not take a painkiller for undiagnosed abdominal pain and then keep taking it for a week; a dose of paracetamol is reasonable and does not hide a diagnosis, but masking the pain while continuing to work is how people arrive with a perforation on day eight. Do not take an anti-inflammatory for epigastric pain, ever; that is adding fuel. Do not take a purgative or an enema for severe pain with distension and no wind. Do not take an antibiotic before stool and blood cultures are sent. Do not eat a large meal if the pain is coming in gallbladder waves, and do not drink alcohol with upper abdominal pain of any kind. Do not ignore pain in pregnancy, and do not accept threadworm medicine for pain that has persisted beyond two weeks.

The red flags that end the home phase

Sudden severe pain. A hard, board-like or distended abdomen, or one that is tender and worse on the slightest movement or on releasing pressure. Fever with localised pain, particularly right lower quadrant. Repeated vomiting, green vomit, or no stool and no wind passing. Blood in the stool or black tarry stool. Yellow eyes or dark urine. Pain with chest tightness, breathlessness, sweating or pain in the jaw or arm. Fainting, or a pounding pulsating sensation in the abdomen of an older person. Unintentional weight loss, loss of appetite, or new persistent pain in anyone over fifty. Testicular or ovarian pain, which is referred abdominal pain and is time-critical. Blood in the urine. A woman of reproductive age with lower abdominal pain and a missed period. Pain that reliably wakes you at night. And pain that has not changed character but has not resolved in two weeks, because that is not self-limited whatever it is called.

How we look at it at Aksa

Location, pattern, timing, relation to food and to motions, and what makes it better, which is where the diagnosis usually is. Then the examination: auscultation, percussion, the tenderness mapped, the groin and the spine examined, and in a woman the pelvic question asked directly rather than implied. Bloods for pancreatic enzymes, liver and bile markers, sugar, haemoglobin, inflammatory markers; urine; an ultrasound of the whole abdomen as the first imaging study for most of these presentations; an endoscopy for the persistent upper abdominal picture, with a test for H. pylori done properly and off acid suppression; and a chest or abdominal X-ray when the sudden severe pain needs a decision within the hour. H. pylori in particular runs in households here, so a positive result is a family conversation rather than one prescription. Where the work-up is clean and the pain is functional, which is a real diagnosis rather than a shrug, we say so and treat it as such, and that conversation alone settles a great deal of what brought the person in.