Repeated episodes of abdominal pain can arise from a variety of medical causes, including some serious conditions. Everyone who has unexplained abdominal pain requires a medical evaluation by a doctor. Please take the time today to arrange a medical evaluation, if you have not already done so.

Identifying the source of recurring abdominal pain can require multiple doctor visits and multiple tests. This interactive guide will help you identify those features about your pain that are clues to its cause and provide insight into how the medical evaluation may proceed. The guide is not designed to substitute for office-based care.

This guide addresses recurring episodes of abdominal pain over several weeks to many months. If your pain is newer than this, or if you are currently having pain that is more severe than usual, please visit our Decision Guide called Understanding New and Severe Abdominal Pain.

The guide was not designed to substitute for office-based care. The purpose of this guide is to help you get the most out of a medical evaluation that is performed by your doctor.

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A precise location of abdominal pain can be difficult to identify. The most common causes of recurring abdominal pain can be separated into two groups based upon their location.

Do you feel your most noticeable pain in the lower abdomen or is it somewhere higher, in your upper abdomen or near your navel?

My pain is in my upper abdomen or is near my navel.

My pain is in my lower abdomen.

Lower abdominal pain is occasionally a sign of serious illness. It is important to identify warning symptoms early that could be a sign of a dangerous problem within the lower abdomen. Doctors sometimes call warning symptoms "red flags."

Fever is one symptom that is a "red flag" when it is experienced with lower abdominal pain.

Have you experienced unexplained fever along with your pain?

Yes, I have unexplained episodes of fever.

No, I do not have fever.

Another "red flag" is weight loss without explanation.

If you have reduced the amount that you eat because eating causes you pain, then some weight loss is expected or "explained."

Do you have unexplained weight loss of more than ten pounds?

Yes, I have lost weight and don't have a clear explanation.

No, this does not apply to me.

If bleeding in the bowel is present along with your pain, your evaluation must identify the source of blood.

Have you noticed blood in your stools, or have you noticed black stools with a tar-like texture (caused by deteriorated blood)?

Yes, I have seen evidence of bleeding in my stools.

No, I have not seen evidence of bleeding.

Excellent. You have not reported any of the "red flags" that are suggestive for one of the most serious causes of abdominal pain. Still, your symptoms need a thorough evaluation and diagnosis.

Lower abdominal pain sometimes begins when your bowel digestion is most active, and this can be a clue to its source. Any evidence that convincingly links your pain to your digestion is important history.

Do your pain episodes follow meals, or occur in the night within four hours of your dinner?

Yes, my symptoms occur after eating.

No, the pain is not worse after meals.

Do you have frequent diarrhea?

Yes, I do have diarrhea.

No, I do not have diarrhea.

Do your cramps feel more comfortable after you pass a bowel movement, or do you frequently find mucus in the stool or experience constipation?

Yes, I have relief passing stool or inconsistent stools.

No, I do not notice these symptoms.

If you are a woman, some pelvic conditions must be considered as a possible cause of your pain.

Are you a woman or a man?

I am a woman.

I am a man.

Recurring abdominal pain is sometimes caused by scarring that occurs after surgery. It is possible for pain to occur many years after a surgery was performed.

Have you ever had surgery in your abdomen or pelvis, or have you had a serious bacterial infection in the abdomen, such as appendicitis?

Yes, I have had prior surgery or infection.

No, none of these apply to me.

It is common for women to have pain with menstruation.

Do your pain symptoms coincide or worsen with the week of your menses, or just prior to your menses?

Yes, my pain is worse around the time of my menses.

No, my pain is not worse around the time of my menses.

I no longer have periods.

Physical violence or sexual abuse in women can lead a woman to experience recurring abdominal pain. The cause of the abdominal pain is not fully understood. Some experts think it may be caused by increased nerve sensitivity in the abdomen that is triggered by the stress and trauma of abuse events.

Has another individual treated you violently in a current or previous relationship, or have you been the victim of a physical or sexual assault?

Yes.

No.

Your menstrual cycle can cause pain at times separate from your menses. If you notice that your pain recurs monthly, even if it is not present while you are bleeding, your pain may be related to your cycle.

Consider your last several episodes of lower abdominal pain as examples. Did each of your pain episodes occur two weeks prior to the start of a menstrual period?

Yes, two weeks prior to my menses sounds about right.

No, my symptoms do not cycle on a monthly schedule.

Physical violence or sexual abuse in women can lead a woman to experience recurring abdominal pain. The cause of the abdominal pain is not fully understood. Some experts think it may be caused by increased nerve sensitivity in the abdomen that is triggered by the stress and trauma of abuse events.

Has another individual treated you violently in a current or previous relationship, or have you been the victim of a physical or sexual assault?

Yes.

No.

Recurring abdominal pain is sometimes caused by scarring that occurs after surgery. It is possible for pain to occur many years after a surgery was performed.

Have you ever had surgery in your abdomen or pelvis, or have you ever had a serious abdomen or pelvic infection such as appendicitis or pelvic inflammatory disease (PID)?

Yes, I have had prior surgery or infection.

No, none of these apply to me.

Whether or not your pain is related to your experience of intimate partner violence or assault, you should discuss your personal history with your physician or counselor, if you can be comfortable sharing this information.

If you are currently in a violent or sexually controlling relationship, your health is in serious danger. You should request help from a local agency or provider who is experienced in supporting victims of intimate partner abuse.

Your physician or a social worker can identify local resources for you.

To learn about additional reasons that may be contributing to recurring abdominal pain

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Recurring abdominal pain is sometimes caused by scarring that occurs after surgery. It is possible for pain to occur many years after a surgery was performed.

Have you ever had surgery in your abdomen or pelvis, or have you ever had a serious abdomen or pelvic infection such as appendicitis or pelvic inflammatory disease (PID)?

Yes, I have had prior surgery or infection.

No, none of these apply to me.

You have not provided very much information that can help to narrow the list of possible causes for your abdominal pain. It will be helpful for your doctor to know that your pain is primarily in the lower part of your abdomen.

Some causes that might be considered to explain your lower abdominal pain include:

• abdominal adhesions

• abdominal angina and bowel infarction (a form of atherosclerosis)

• acute pancreatitis

• celiac disease (celiac sprue)

• chronic pancreatitis

• colon cancer

• constipation

• Crohn's disease

• diverticulosis

• emotional stress

• endometriosis (if you are a woman)

• gas

• hernia

• irritable bowel syndrome

• lead poisoning

• ovarian cyst

• ovarian cancer

• ulcerative colitis

• vertebral fracture.

Because the list of possible causes is large, your evaluation will begin with the basics: a physical examination and possibly some blood or urine tests. It may be helpful to have a test that can view the lining of the large intestine, such as a camera-guided inspection of the colon (a colonoscopy or flexible sigmoidoscopy examination). A computed tomography scan (CT scan) may also be considered. The specific test that is selected will be dependent upon additional details that you provide to your doctor and your past history of medical problems.

Because you have had a prior surgery, your pain might be caused by abdominal adhesions.

If you have had abdominal or pelvic surgery or if you have had an infection in the abdomen or pelvis, you may have formed scar tissue. Areas of fibrous scar tissue adherent to the bowel or other abdominal structures are called "adhesions." Adhesions can encircle the bowel or pull on the bowel or other structures in the abdomen, resulting in pain.

Other than your surgical history, you have not reported specific symptoms or history that can easily guide a doctor toward a diagnosis for your abdominal pain. Your doctor is likely to initiate your evaluation with some basic tests, such as blood tests and possibly urine tests. If your pain is significant, an x-ray test to view the bowel or a camera test that can view the bowel (such as a colonoscopy or flexible sigmoidoscopy) might be useful.

Some other causes that might be considered to explain your lower abdominal pain include

• abdominal angina and bowel infarction (a form of atherosclerosis)

• acute pancreatitis

• celiac disease (celiac sprue)

• chronic pancreatitis

• colon cancer

• constipation

• Crohn's disease

• diverticulosis

• emotional stress

• endometriosis (if you are a woman younger than menopause)

• gas

• hernia

• irritable bowel syndrome

• constipation

• ovarian cancer

• ovarian cyst

• ulcerative colitis

• vertebral fracture.

The timing of your pain may be specific enough to identify your diagnosis.

Mid-Menstrual Cycle Pain(Mittelschmerz)

Two weeks prior to the onset of bleeding each month, one of your ovaries releases a maturing egg. This normal event is "ovulation," and it can be painful. Pain caused by ovulation has a medical name, "Mittelschmerz." Mittelschmerz is not harmful, and it can be treated with over-the-counter pain medicines if symptoms linger for more than a few minutes. It is common for Mittelschmerz pain to last for several hours.

Endometriosis

Another condition that can cycle with a monthly pattern is endometriosis. For most women this condition is worst during the days immediately prior to the menses. It can cause pain that is more prolonged than is Mittelschmerz.

The type of tissue that makes up the uterus lining is "endometrial tissue." Some women have small collections of endometrial tissue that are located outside of the uterus. This condition is called "endometriosis." Endometrial tissue in any location can respond to hormone changes by releasing small amounts of blood. Blood that is outside of the uterus can be irritating, resulting in pain. Endometriosis may be responsive to treatment with non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) or naproxen (Aleve.) It can also be treated with hormonal medicines or destruction of the extra tissue during laparoscopic (camera guided) surgery.

Your doctor is likely to reassure you and recommend over-the-counter NSAID medicines if the timing of your symptoms suggests Mittelschmerz. If your pain episodes are severe or if they continue for more than a few hours, your doctor might advise that you have a camera guided inspection of your pelvic organs (laparoscopic surgery) to check for endometriosis.

Please call your doctor today to arrange an evaluation.

Abdominal or pelvic pain with menstruation is very common. There are two conditions that commonly explain menstrual pain.

Dysmenorrhea

Most women who have pain with menstruation are reacting to the substance "prostaglandin" which is a normal hormone that is produced during menstruation. Pain that comes from normal menstruation is called "dysmenorrhea." Dysmenorrhea is very responsive to treatment with non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) or naproxen (Aleve.) It may also be lessened by regular use of birth control pills.

Endometriosis

The type of tissue that makes up the uterus lining is "endometrial tissue." Some women have small collections of endometrial tissue that are located outside of the uterus. This condition is called "endometriosis." Endometrial tissue in any location can respond to hormone changes by releasing small amounts of blood. Blood that is outside of the uterus can be irritating, resulting in pain. Endometriosis can be treated with NSAID pain medicines, hormonal treatments, or destruction of the extra tissue during laparoscopic (camera guided) surgery.

Your doctor is likely to begin treatment with medicines that can relieve pain during your menses. If your pain is severe or if it continues at times that are apart from your menstruation, your doctor might recommend a camera guided inspection of your pelvic organs (laparoscopic surgery) to check for endometriosis.

Please call your doctor today to arrange an evaluation.

You have not noticed in general that meals trigger your pain, but it is important to explore the health of your digestion further because you report diarrhea. Diarrhea is a sign of disordered digestion. Although you tolerate most meals, you may have noticed that certain foods are difficult for you.

Are your symptoms most noticeable after a meal that is heavy in cream, milk, cheese, or other dairy products?

Yes, I sometimes trigger symptoms with milk or dairy products.

No, I have not noticed this.

You have identified that meals provoke your symptoms.

Are your symptoms most noticeable after a meal that is heavy in cream, milk, cheese, or other dairy products?

Yes, I sometimes trigger symptoms with milk or dairy products.

No, I have not noticed this.

So far you have not noticed extra problems from dairy products. However, since you have pain after eating, you should consider this possibility closely. Incomplete digestion of milk sugar ("lactose intolerance") leads to gas, cramps in the lower abdomen or navel area, and diarrhea because milk sugar that you have not absorbed is fermented by bacteria in your colon.

The fact that you have pain after eating should be explored further, to understand whether your digestion is what makes you uncomfortable.

Do your cramps feel more comfortable after you pass a bowel movement, or does your diarrhea alternate with episodes of constipation?

Yes, I have relief passing stool or inconsistent stools.

No, I have not noticed this.

So far you have indicated that your recurrent lower abdominal discomfort is associated with loose stools.

Does your pain feel more comfortable after you pass a bowel movement, or do you have diarrhea alternating with episodes of constipation?

Yes, I have relief passing stool or inconsistent stools.

No, I don't have these symptoms.

You seem to be sensitive to milk products, and abdominal cramps may be a consequence of the milk in your diet.

It is common for people to lose their ability to digest the milk sugar lactose during adulthood. "lactose intolerance" could be a cause of your abdominal pain even if milk digestion used to be normal for you.

About Lactose Intolerance

Undigested lactose passes into your colon where it can nourish bacteria and ferment into gas. Undigested milk products can also cause diarrhea and abdominal cramps.

Lactose intolerance can be managed with total or near-total avoidance of milk and dairy products. Some people improve symptoms by swallowing a milk digestion aid with meals called lactase (Lactaid).

One of the most practical steps in your abdominal pain evaluation might be to try a careful elimination diet that excludes milk and milk products. Depending on the severity of your symptoms, additional evaluation might or might not be postponed until your response to diet changes can be judged.

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In addition to milk sugar, dairy products contain milk fat. Milk can trigger symptoms in some people who do not have true lactose intolerance. Here is a follow up question to help explore your symptoms further:

Does your pain feel more comfortable after you pass a bowel movement, or do you have diarrhea alternating with episodes of constipation?

Yes, I have relief passing stool or inconsistent stools.

No, I don't have these symptoms.

Answering our questions, you have either reported that your pain is worse after eating or you have reported diarrhea. This means your lower abdominal pain is associated with a symptom that can arise from disordered digestion. Several common conditions are likely to be considered in your evaluation:

Irritable bowel syndrome

Some of your symptoms are suggestive for irritable bowel syndrome, but you do not have all of the characteristic symptoms of this condition. Common symptoms of irritable bowel syndrome include

• pain in the mid-abdomen or lower abdomen

• diarrhea, constipation, or episodes of each

• mucus that is passed with bowel movements

• fullness (bloating) in the abdomen

• loose or frequent stools during pain episodes

• relief of pain following a bowel movement

• a feeling that you can't empty your rectum completely.

Celiac disease (celiac sprue)

This illness is caused by an abnormal immune reaction to gluten, a protein that is contained in wheat, oats, barley, and rye grains and many food additives. Blood tests that check for a certain type of antibodies can help diagnose this syndrome.

Crohn's disease

This autoimmune condition is most common in young adults.

Chronic pancreatitis

Good pancreas function is needed for you to digest your foods easily. The pancreas is most active after meals. Diarrhea from pancreatitis is frequently greasy or oily and very strong in its odor.

Abdominal adhesions

If you have had abdominal or pelvic surgery or if you have had an infection in the abdomen or pelvis, you may have formed scar tissue. Areas of fibrous scar tissue adherent to the bowel or other abdominal structures are called "adhesions." Adhesions can encircle the bowel or pull on the bowel or other structures in the abdomen, resulting in pain.

Please call your doctor today to arrange an evaluation.

Some of the symptoms that you have reported suggest "irritable bowel syndrome." Irritable bowel syndrome, also known as "IBS," "spastic colon," or "mucus colitis," is discomfort from the lower bowel that occurs during normal digestion. It is a common problem, causing symptoms in more than ten percent of the population.

About Irritable Bowel Syndrome

All people have nerve endings in their intestinal tracts. These nerves sense stretching of the small intestine and colon and control their periodic contractions (known as peristalsis) that propel food along the digestive tract. In the case of an irritable bowel, the nerves within the bowel are unusually sensitive. They can react in a disorderly or exaggerated way to normal stretching from food residue that is passing through the intestines. Your nerves may cause your colon to be unusually active or unusually still. Normal digestion activity can therefore result in symptoms.

The most typical symptoms from an irritable bowel include

• pain in the mid-abdomen or lower abdomen

• diarrhea, constipation, or episodes of each

• mucus that is passed with bowel movements

• fullness (bloating) in the abdomen

• loose or frequent stools during pain episodes

• relief of pain following a bowel movement

• a feeling that you can't empty your rectum completely.

Irritable bowel symptoms can be managed with adjustments in your diet and can be aided with medicines that reduce nerve sensitivity or spasm in the bowel.

The diagnoses that might be considered in your evaluation are

• abdominal adhesions

• celiac disease (celiac sprue)

• Crohn's disease

• irritable bowel syndrome

• lactose intolerance

• ulcerative colitis.

Your weight loss is a worrisome symptom. Weight loss can be a sign of cancer, or it can be a sign of poor nutrition due to problems with your digestion.

If bleeding in the bowel is present along with your pain, your evaluation must identify the source of blood.

Have you noticed blood in your stools, or have you noticed black stools with a tar-like or paste-like texture (caused by deteriorated blood)?

Yes, I have seen evidence of bleeding in my stools.

No, I have not seen evidence of bleeding.

Your age will make some causes of weight loss more likely than others.

How old are you?

Age 40 or older

Under age 40

Are you a man or a woman?

I am a man.

I am a woman.

It is reassuring that you do not have visible blood in your stool. However, due to your age and weight loss, a cancer in the intestinal tract still must be considered.

Lower abdominal pain and weight loss can be a sign of colon cancer. Because you are old enough to be at increased risk for colon cancer, you must be evaluated for this problem before most other diagnoses are considered. Please call your doctor today to arrange an urgent evaluation.

Your evaluation will likely include a colonoscopy, a test that can view the inside of your colon.

If your colonoscopy does not show a reason for the pain and weight loss, other possibilities include

• abdominal angina and bowel infarction (a form of atherosclerosis)

• celiac disease (celiac sprue) or other causes of malabsorption

• chronic pancreatitis

• diverticulosis

• kidney cancer

• liver cancer

• ovarian cancer

• pancreatic cancer

• stomach cancer .

It is reassuring that you do not have visible blood in your stool. However, due to your age and weight loss, a cancer in the intestinal tract still must be considered.

Lower abdominal pain and weight loss can be a sign of colon cancer. Because you are old enough to be at increased risk for colon cancer, you must be evaluated for this problem before most other diagnoses are considered. Please call your doctor today to arrange an urgent evaluation.

Your evaluation will likely include a colonoscopy, a test that can view the inside of your colon.

If your colonoscopy does not show a reason for the pain and weight loss, other possibilities include

• abdominal angina and bowel infarction (a form of atherosclerosis)

• celiac disease (celiac sprue) or other causes of malabsorption

• chronic pancreatitis

• diverticulosis

• kidney cancer

• liver cancer

• pancreatic cancer

• stomach cancer.

Your age will make some sources of bleeding and weight loss more likely than others.

How old are you?

Under age 40

Age 40 or older.

Lower abdominal pain and bleeding into the stools can be signs of colon cancer. Because you are old enough to be at increased risk for colon cancer, you must be evaluated for this problem before most other diagnoses are considered.

These symptoms can also result from intense inflammation in the bowel.

Because of your bleeding, it is imperative that you have a medical evaluation without delay. Please call your doctor today to arrange an urgent evaluation.

Your evaluation should include a colonoscopy, a test that can view the inside of your colon.

If your colon is not found to contain a cancer, other diagnoses that are likely to be considered include

• abdominal angina and bowel infarction (a form of atherosclerosis)

• antibiotic-associated diarrhea (colitis)

• Crohn's disease

• diverticulosis

• stomach cancer

• ulcerative colitis.

Lower abdominal pain with bleeding into the stools can be caused by intense inflammation in the bowel. Pain and bleeding can also be caused by a cancer in the intestinal tract. Because you are young, you are more likely to have inflammation than cancer.

Because  you have a "red flag" symptom along with your abdominal pain, it is imperative that you have a medical evaluation without delay. Please call your doctor today to arrange an urgent evaluation.

In addition to blood tests, your evaluation might begin with a test that can view the inside of your colon or small intestine. Examples are a colonoscopy or an x-ray series with a swallowed liquid that can be seen on x-ray ("upper GI series").

The most common causes of inflammation in the bowel that cause recurrent symptoms are "inflammatory bowel" diseases, including

• Crohn's disease

• ulcerative colitis.

Other conditions that are less likely to be the cause of your symptoms include

• celiac disease (celiac sprue)

• colon cancer

• lymphoma.

Lower abdominal pain with weight loss can be caused by intense inflammation in the bowel. Because you are young, cancer is less likely.

Because you have a "red flag" symptom along with your abdominal pain, it is imperative that you have a medical evaluation without delay. Please call your doctor today to arrange an urgent evaluation.

In addition to blood tests, your evaluation might begin with a test that can view the inside of your colon or small intestine. Examples are a colonoscopy or an x-ray series with a swallowed liquid that can be seen on x-ray ("upper GI series").

The most common causes of inflammation in the bowel that cause recurrent symptoms are "inflammatory bowel" diseases, including

• Crohn's disease

• ulcerative colitis.

Other conditions that are less likely to be the cause of your symptoms include

• celiac disease (celiac sprue)

• colon cancer

• lymphoma.

A variety of problems can cause fever with recurring abdominal pain. The causes that are most likely are different depending on the age group.

How old are you?

I am under age 40.

I am 40 or older.

Fever and abdominal pain are a serious medical concern when they occur together, because they can be caused by an infection. Contact your doctor right away to arrange an urgent visit so you can have an examination!

Changes in the colon that occur with age can predispose you to infection. Many adults form "diverticuli," which are hollow tubular bulges that branch from the colon lining and "dead-end." These pockets can accumulate bacteria and can cause symptoms much like appendicitis. Between episodes of infection, diverticuli can be asymptomatic, or they may cause pain or brisk bleeding.

Your doctor is likely to diagnose an infection in your bowel. A computed tomography scan (CT scan) may be helpful in your evaluation.

Diagnoses that may be considered in your evaluation include

• appendicitis

• diverticulitis.

Fever and abdominal pain are a serious medical concern when they occur together, because they can be caused by an infection. Contact your doctor right away to arrange an urgent visit so you can have an examination!

Fever can arise from infection or from the inflammation that comes from an autoimmune illness. In someone your age, one of the most common causes of recurrent lower abdominal pain with fever would be autoimmune illness.

Based on your symptoms, one of the first tests your doctor is likely to recommend may be an x-ray series with swallowed contrast ("upper GI series") or a computed tomography scan (CT scan).

An upper GI series can identify inflammation in the small intestine.

A CT scan can be useful if infection is suspected.

Diagnoses that your doctor might consider include

• appendicitis

• Crohn's disease

• diverticulitis. (This is less common in people under age 40.)

• pelvic inflammatory disease

• ulcerative colitis.

Upper abdominal pain sometimes begins when your digestion is most active, and this can be a clue to its source.

Do your pain episodes follow meals, or occur in the night within four hours of your dinner?

Yes, my pain gets worse soon after meals.

No, the pain is not worse after meals.

You do not have worsening of your pain with eating. You still might notice a relationship of another kind with meals, however.

Does eating relieve your pain?

Yes, my pain is improved by eating.

No, my pain is not improved by eating.

Your pain is neither triggered nor relieved by food. This makes it somewhat less likely that your problem lies within your digestive tract organs. However, it is important to identify warning symptoms that could signify a dangerous problem within the gastrointestinal tract.

Have you experienced any of the following worrisome symptoms:

• vomiting with blood

• black stools with a tar-like texture (caused by deteriorated blood)

• difficulty swallowing

• fever

• unexplained weight loss?

Yes, I have experienced one or more of these symptoms.

No, I do not have any of these symptoms.

Good. You do not have any "red flags" that would suggest a complicated problem.

You have identified that your pain is in the upper abdomen or near your navel, and it is neither triggered nor relieved by food. It might be provoked by some other common triggers, so we should explore these.

Do you use one or more medicines from the following list:

• pain medicines that are non-steroidal anti-inflammatory drugs (NSAIDs, such as ibuprofen, naproxen, aspirin, and others)

• alendronate (Fosamax) or other osteoporosis medicine

• antidepressants

• laxatives?

Yes, I take one of these medicines.

No, I do not take these medicines.

You don't take one of the medicines on that list, but many others can cause abdominal pain as a side effect. If you take any medicines, you should check with your doctor or pharmacist to see if a drug might be the cause of your pain. Since you aren't on one of the medicines that we thought of, let's move on from medicines to consider other causes of your pain.

Do pain episodes happen after you drink alcohol?

Yes, my pain can be triggered with alcohol.

No, alcohol does not affect my pain.

Does your pain worsen when you lie down?

Yes, my pain is worse when I lie down.

No, my pain is not worse when I lie down.

Does your pain often begin after you cough, sneeze, strain, or lift something heavy, or is it ever accompanied by a bulge on the front of your abdomen?

Yes, I notice these triggers or I notice a bulge.

No, I do not notice these triggers.

Are your pain episodes triggered by exercise?

Yes, my pain is triggered by exercise.

No, my pain does not begin after exercise.

Your answers indicate that you have abdominal pain primarily in the upper part of your abdomen or near your navel. But you don't have any of the more common triggers that cause recurrent abdominal pain.

Some causes that might be considered to explain your upper abdominal pain include

• abdominal adhesions

• celiac disease (celiac sprue)

• chronic pancreatitis

• Crohn's disease

• gallstones

• gas

• gastritis

• gastroesophageal reflux

• Giardiasis (Giardia infection)

• indigestion (dyspepsia)

• irritable bowel syndrome

• lactose intolerance

• migraine headache

• painful menstruation (dysmenorrhea)

• peptic ulcer disease

• stress.

Because the list of possible causes is large, your evaluation will begin with the basics: a physical examination, and possibly some blood or urine tests. It is likely that your doctor will order a test to view the abdominal structures, such as an ultrasound, esophagogastroduodenoscopy ("EGD" or "endoscopy," in which you swallow a small camera on a flexible tube), a series of x-rays after you swallow barium ("barium swallow" or "upper GI series"), or a computed tomography scan (CT scan). The specific test that is selected will be dependent upon additional details that you provide to your doctor, and your past history of medical problems.

Since your pain is related to exercise, it is important to consider the possibility of heart disease:

Are you over 50 years old, or have you been diagnosed with coronary artery disease?

Yes, I am 50 or older, or my heart health is in question.

No, I am under age 50 and in good heart health.

Because of your young age, your symptoms are not likely to be coming from your heart. Pain like yours that involves the upper abdomen and is provoked by exercise can be caused by gastroesophageal reflux. This problem, caused by splashing of acid into the esophagus, can result when fluid shifts in the stomach during exercise. Your doctor might first recommend a trial of anti-acid medicine, because if you improve this can help diagnose gastroesophageal reflux. If your symptoms are mild, you may choose to begin this yourself by using an over-the-counter anti-acid medicine.

However, abdominal symptoms with exercise may also be caused by a problem unrelated to digestion.

It will be appropriate for your doctor to include an examination of your back, legs and feet in your evaluation, because several spine problems can result in pain with exercise. Your doctor may also want to view the lining of your esophagus and stomach as a part of your evaluation. Tests that can identify irritation or injury in these structures include esophagogastroduodenoscopy ("EGD" or "endoscopy," in which you swallow a small camera on a flexible tube) or a series of x-rays after you swallow barium ("barium swallow" or "upper GI series").

In addition to gastroesophageal reflux, your symptoms could be explained by

• abdominal (ventral) hernia

• umbilical hernia,  including inguinal hernia (hernia in the groin)

• muscle strain

• vertebral disk disease (bulging or ruptured disk)

• vertebral fracture.

Because of your risk for heart disease, you must consider the small chance that your abdominal pain could be a cardiac symptom.

Your pain may be angina, a symptom that is caused when your heart is not getting adequate blood flow.

You urgently need to discuss your symptoms with your doctor.

In your case, the fact that you have pain provoked by exercise makes a cardiac evaluation a high priority. Angina is sometimes felt in the abdomen.

If you have sweating or shortness of breath accompanying your pain, this too could suggest that you are experiencing angina.

Your doctor may wish to begin your evaluation with a "stress test" for coronary artery disease. Several different stress tests are available.

Less dangerous causes of your symptoms are, of course, possible. After your doctor considers heart disease as a possible source of your pain, diagnoses that fit well with your symptoms include

• gallstones

• gastritis

• gastroesophageal reflux disease

• indigestion (dyspepsia)

• peptic ulcer disease.

To examine for these conditions, tests that might be considered early in your evaluation include a treatment trial with antiacid medicines, endoscopy (a video evaluation of the esophagus and stomach), a barium swallow x-ray test, or an ultrasound of the abdomen.

If your pain is provoked by abrupt pressure in your abdominal cavity (as is caused by a cough or sneeze), it is possible that you have a hernia. A hernia is an area of bowel that can become pinched as it pushes through an accidental opening in the abdomen, such as a tear in your muscular abdominal wall.

Some hernias create a bulge in the naval area, the middle of the abdomen, or on one side of the groin, but hernias can also occur without a visible bulge.

Hernias can be difficult to diagnose, since the bowel usually appears normal on tests that are done between attacks. If a hernia is considered likely, your doctor might choose to begin your evaluation with a series of x-rays taken after you swallow a liquid named barium ("upper GI series") or with a computed tomography scan (CT scan).

Some problems in the back can cause pain in the abdomen. If you have back pain with your abdominal pain, a back problem should be considered.

Common problems that can be sensitive to cough, sneezing or straining in the abdomen and can result in abdominal pain include

• abdominal (ventral) hernia or umbilical hernia (including abdominal hernia, umbilical hernia, or inguinal (groin) hernia)

• inguinal hernia (hernia in the groin)

• muscle strain

• vertebral disk disease (bulging or ruptured disk)

• vertebral fracture.

You have reported that your pain is worse when you are lying down. Although this symptom does not predict your diagnosis perfectly, it can suggest that your pain is sensitive to shifting fluid in the upper abdomen.

Fluid in your stomach may cause symptoms when it splashes or shifts with movement or redistributes with gravity. When you lie down, fluid in the stomach can flow backwards (reflux) into your esophagus. This problem, named gastroesophageal reflux, can cause irritation in the chest from acid (heartburn). Gastroesophageal reflux can sometimes cause recurring abdominal pain.

Depending upon the severity of your symptoms, your doctor may recommend tests or may recommend that you start taking anti-acid medicine, to see if this improves your symptoms. Anti-acid treatments are available over-the-counter.

If your doctor recommends testing, he or she may want to view the lining of the esophagus, stomach and small intestine. Tests that can identify irritation or injury in these structures include esophagogastroduodenoscopy ("EGD" or "endoscopy," in which you swallow a small camera on a flexible tube) or a series of x-rays after you swallow barium ("barium swallow" or "upper GI series").

Alcohol has several direct effects on your digestive tract within hours of your drink. The fact that your pain is provoked by alcohol may be a strong clue to your diagnosis, and it might be the key to your recovery.

Alcohol loosens the sphincter that seals your stomach and stomach contents from your esophagus between swallows. For this reason, one common cause of pain that follows alcoholic beverages is gastroesophageal reflux.

Alcohol is an irritant to the stomach lining and liver. Pain from irritation of the stomach lining is named gastritis. Liver irritation results in alcoholic hepatitis.

Alcohol also stimulates activity within digestive organs that help you to digest high calorie substances. Two of these organs include the gallbladder and the pancreas. If you have problems affecting the gallbladder or pancreas, your symptoms can be provoked by alcohol. Relevant problems include

• acute pancreatitis

• chronic pancreatitis

• gallstones.

During and after your evaluation, it will be especially important for you to stop drinking alcohol.

Your initial evaluation may include lab tests to evaluate the pancreas, an ultrasound to evaluate your gallbladder, or a test to inspect the inside lining of the stomach. To evaluate the stomach, your doctor might recommend esophagogastroduodenoscopy ("EGD" or "endoscopy," in which you swallow a small camera on a flexible tube) or a series of x-rays after you swallow barium ("upper GI series").

You take a medicine that commonly causes recurrent abdominal pain. Before you undergo any testing and before other diagnoses are considered, your doctor may recommend discontinuing one of your medicines or finding an appropriate substitute.

Please do not discontinue a medication without consulting your physician.

If your symptoms are severe, your doctor may recommend that you undergo one or more tests in addition to considering a change in your medicines.

Recommended tests might include a variety of blood tests, and stool tests or a rectal exam to check for blood in the stool. Your doctor may also recommend a test to view the lining of the stomach and small intestine as one of the first tests in your evaluation. Tests that can identify irritation or injury in the stomach and intestine lining include esophagogastroduodenoscopy ("EGD" or "endoscopy," in which you swallow a small camera on a flexible tube) or a series of x-rays after you swallow a liquid named barium ("upper GI series").

Your improvement after eating strongly suggests that you have an injury or irritation of your stomach or small intestine lining. After you eat, your stomach and small intestine coat themselves with soothing mucus and can temporarily relieve pain.

For the time being, we will narrow our thinking to problems that occur in the stomach or small intestine. As we consider possible diagnoses, it is important to identify symptoms that could be a sign of a dangerous condition in one of these areas.

Have you experienced any of the following worrisome symptoms:

• vomiting with blood

• black stools with a tar-like or paste-like texture (caused by deteriorated blood)

• difficulty swallowing

• fever

• unexplained weight loss?

Yes, I have experienced one or more of these symptoms.

No, I do not have any of these symptoms.

Good, you do not have any "red flags" that would suggest a complicated problem.

Your pain is in the upper abdomen and it does appear to be eased by eating.

In addition to blood and stool tests to check for blood loss, your doctor may recommend a test to view the lining of the stomach and small intestine as one of the first tests in your evaluation. Tests that can identify irritation or injury in the stomach and intestine lining include esophagogastroduodenoscopy ("EGD" or "endoscopy," in which you swallow a small camera on a flexible tube) or a series of x-rays after you swallow barium ("upper GI series").

Two conditions that could cause your pain include

• gastritis

• peptic ulcer disease.

You need to be evaluated for bleeding, infection or cancer within your upper digestive tract. Contact your doctor for an urgent evaluation.

Pain with blood in the vomit or blackened stools could represent an ulcer in your stomach or small intestine, irritation in the stomach lining ("gastritis"), or cancer. Fever could arise from an abdominal infection such as an abscess, a cancer, or a break (perforation) in the stomach lining at the site of an ulcer.

Based on your symptoms, your doctor is likely to recommend evaluation with either an endoscopy test (esophagogastroduodenoscopy, or "EGD") or a computed tomography scan (CT scan).

With an EGD, a doctor can view the inside of your esophagus, stomach, and the first segment of your small intestine by way of a flexible tube and camera. This is a particularly helpful test if you have evidence of bleeding from the upper digestive tract.

Your doctor might choose a computed tomography scan if your symptoms involve fever or weight loss. Certain cancers or infections are visible on a CT scan.

Some specific diagnoses that your doctor may consider include

• stomach cancer

• gastritis

• peptic ulcer disease.

Certain organs within the upper abdomen or near the upper abdomen can also cause pain in the chest.

Does your pain extend up into the chest?

Yes, the pain goes up to my chest.

No, the pain does not extend to my chest.

Reviewing your symptoms, you have pain somewhere in the upper abdomen or navel area, but you do not have pain in the chest. Your pain is worse within a few hours of your meals. Because your symptoms follow meals, your problem is probably arising from a structure that is active during the first hours of your digestion: your stomach, your small intestine, your gallbladder, or your pancreas.

Have you experienced any of the following worrisome symptoms:

• vomiting with blood

• black stools with a tar-like texture (caused by deteriorated blood)

• difficulty swallowing

• fever

• unexplained weight loss?

Yes, I have experienced one or more of these symptoms.

No, I have not experienced any of these symptoms.

Good, you do not have any "red flags" that would suggest a complicated problem. So far, we have identified your stomach and duodenum, gallbladder and pancreas as structures that can generate symptoms like yours. We need to prioritize our suspicions.

Does the pain seem to be strongest on your right side?

Yes, I feel pain in my right abdomen.

No, my pain is in my center, on my left side, or felt strongly.

So far, the most helpful clue that you have provided about your pain is the fact that it occurs following meals.

Following meals, when your digestion becomes active, your circulation adjusts to deliver more blood and oxygen to digestive structures. Before we consider the health of your digestive organs, we should make sure that your problem is not likely to be caused by poor circulation.

Are you over 50 years old, or have you been diagnosed with coronary artery disease, stroke, or other artery problems?

Yes, I am age 50 or older, or my heart health is in question.

No, I am under age 50 and in good heart health.

Are your symptoms most noticeable after a meal that is heavy in cream, milk, cheese, or other dairy products?

Yes, I sometimes trigger symptoms with milk or dairy products.

No, I have not noticed this.

You urgently need to discuss your symptoms with your doctor.

In your case, your age and risk for artery disease make it important for you to have your pain evaluated promptly. If a diagnosis is not identified easily, your doctor may consider the possibility that your pain could arise from artery disease (atherosclerosis).

Angina (the symptom of inadequate blood flow to your heart muscle) is sometimes felt in the abdomen, and it is sometimes provoked by meals. It is possible to have angina after eating if your blood flow adjusts after meals to give more blood to the digestive organs and less blood to your heart muscle. This change in blood flow occurs in some people after meals.

Eating can also trigger intestinal pain if an artery that is supposed to supply blood to your small intestine is too narrow to give your intestine an adequate supply. This is sometimes called "abdominal angina," "intestinal angina," or "ischemic bowel."

If your abdominal pain is brought on by exercise, if you have sweating or shortness of breath accompanying your pain, or if you are a smoker, artery disease is a stronger possibility.

Although an evaluation of your heart and arteries will probably not be the first priority in your evaluation, you and your doctor should remember this possibility if an explanation for your pain is not quickly identified.

Let's continue to explore other reasons for your recurrent abdominal pain.

Click here to continue.

Are your symptoms most noticeable after a meal that is heavy in cream, milk, cheese, or other dairy products?

Yes, I sometimes trigger symptoms with milk or dairy products.

No, I have not noticed this.

Your problem can probably be blamed on one of the digestive structures in the upper abdomen, but it is difficult to narrow down the list of possible explanations without a physical examination and testing.

A variety of blood tests and stool testing to check for blood in the stool may be helpful. It is likely that your doctor will recommend a test to view the lining of the stomach and small intestine. Tests that can identify irritation or injury in the stomach and intestine lining include esophagogastroduodenoscopy ("EGD" or "endoscopy," in which you swallow a small camera on a flexible tube) or a series of x-rays after you swallow barium ("upper GI series").

The diagnoses that are most likely based on your symptoms include

• acute pancreatitis

• celiac disease (celiac sprue)

• chronic pancreatitis

• Crohn's disease

• gallstones

• gastritis

• gastroesophageal reflux disease

• gastroparesis (slow stomach emptying, a complication of diabetes)

• indigestion

• lactose intolerance

• peptic ulcer disease.

You seem to be sensitive to milk products, and abdominal cramps in the navel area or in the lower abdomen may be caused by the milk in your diet.

It is common for people to lose their ability to digest the milk sugar "lactose" during adulthood. "Lactose intolerance" could be a cause of your abdominal pain even if milk digestion used to be normal for you.

About Lactose Intolerance

Undigested lactose passes into your colon where it can nourish bacteria and ferment into gas. Undigested milk products can also cause diarrhea and abdominal cramps.

Lactose intolerance can be managed with total or near-total avoidance of milk and dairy products. Some people improve symptoms by swallowing a milk digestion aid with meals called lactase (Lactaid).

One of the most practical steps in your abdominal pain evaluation might be to try a careful elimination diet that excludes milk and milk products. Depending on the severity of your symptoms, additional evaluation might or might not be postponed until your response to diet changes can be judged.

Other diagnoses that may be considered in your evaluation include

• acute pancreatitis

• celiac disease (celiac sprue)

• chronic pancreatitis

• Crohn's disease

• gallstones

• gastroesophageal reflux disease

• gastroparesis (slow stomach emptying, a complication of diabetes)

• indigestion (dyspepsia)

• peptic ulcer disease.

Your pain is experienced during times of active digestion, and your pain is particularly strong on your right side. These features are very suggestive of gallstones.

Gallstones cause pain within several hours of a meal, particularly if the meal is high in fat. Sometimes symptoms are only noticeable after large, rich evening meals. After meals, the gallbladder squeezes to release bile that can aid your digestion. If the gallbladder contains a stone, its squeezing is painful.

One of the first tests in your evaluation should probably be an ultrasound of the abdomen. This test can show whether you have gallstones. If gallstones are present, it is very likely that they are the cause of your symptoms.

Blood tests to evaluate your liver and check for infection may also be obtained early in your evaluation. If your gallbladder is not found to contain stones, your doctor might also consider the following diagnoses:

• acute pancreatitis

• chronic pancreatitis

• Crohn's disease

• gastroparesis (a stomach complication from diabetes)

• indigestion (dyspepsia)

• peptic ulcer disease.

You need to be evaluated for bleeding, irritation, infection or cancer within your upper digestive tract. Contact your doctor for an urgent evaluation.

Pain with blood in the vomit or blackened stools could represent an ulcer in your stomach or small intestine, irritation in the stomach lining ("gastritis"), or cancer. Fever could arise from infection in or near the gallbladder, cancer, severe inflammation within the pancreas, or a break (perforation) in the stomach lining at the site of an ulcer.

Based on your symptoms, your doctor may recommend evaluation with either an endoscopy test (esophagogastroduodenoscopy, or "EGD"), an ultrasound, an x-ray series with swallowed contrast ("upper GI series"), or a computed tomography scan (CT scan).

• With an EGD, a doctor can view the inside of your esophagus, stomach, and the first part of your small intestine by way of a flexible tube and camera.

• An ultrasound is able to identify gallstones or an infection in the gallbladder.

• An upper GI series can identify inflammation in the small intestine.

• A CT scan can be useful if infection or pancreatitis is suspected.

Diagnoses that your doctor may consider include

• acute pancreatitis

• cholecystitis (gallbladder infection)

• chronic pancreatitis

• Crohn's disease

• stomach cancer

• gastritis

• pancreatic cancer

• peptic ulcer disease.

Reviewing your symptoms, you have pain in the upper abdomen or navel area, and you also have pain in the chest. This pain is worse within a few hours of your meals. Based upon your symptoms, it is beginning to sound likely that your pain is originating from a problem near or above the diaphragm.

Have you experienced any of the following worrisome symptoms:

• vomiting with blood

• black stools with a tar-like or paste-like texture (caused by deteriorated blood)

• difficulty swallowing

• fever

• unexplained weight loss?

Yes, I have experienced one or more of these symptoms.

No, I do not have any of those symptoms.

Good. So far there are no "red flags" that would suggest a complicated problem.

Since your pain extends to your chest, it is important to consider the possibility of heart disease.

Are you over 50 years old, or have you been diagnosed with coronary artery disease?

Yes, I am age 50 or older, or my heart health is in question.

No, I am under age 50 and in good heart health.

Because of your young age, your symptoms are not likely to be coming from your heart. Pain like yours that involves both the abdomen and chest and recurs with meals is most often caused by a problem in the esophagus or stomach.

The most common condition that can result in your symptoms is Gastroesophageal Reflux Disease (GERD, acid reflux), but several other diagnoses are possible. Depending upon the severity of your symptoms, your doctor may recommend tests or may recommend that you proceed straight to try out anti-acid medicine, to see if this brings relief. For comprehensive information and advice about GERD, you may want to visit our Acid Reflux Treatment Guide.

If your doctor recommends testing, he or she may want to view the lining of the esophagus, stomach and small intestine. Tests that can show irritation or injury in these structures include esophagogastroduodenoscopy ("EGD" or "endoscopy," in which you swallow a small camera on a flexible tube) or a series of x-rays after you swallow a liquid named barium ("upper GI series").

The diagnoses that are most likely to cause abdominal pain similar to yours include

• gallstones

• gastritis

• gastroesophageal reflux disease (GERD)

• indigestion (dyspepsia)

• peptic ulcer disease.

Because of your risk for heart disease, you must consider the small chance that your pain could be a heart symptom.

Your pain may be angina, a symptom that is caused when your heart muscle is not getting enough blood.

You urgently need to discuss your symptoms with your doctor.

The fact that you have chest symptoms makes a cardiac (heart) evaluation a high priority. Angina is sometimes felt in the abdomen, and it is sometimes provoked by meals. It is possible to have angina after eating if your blood flow adjusts after meals to give more blood to the digestive organs and less blood to your heart muscle. This change in blood flow occurs in some people after meals.

If your abdominal pain is brought on by exercise, or if you have sweating or shortness of breath accompanying your pain, this too could suggest that you are experiencing angina.

Your doctor may wish to start your evaluation with a "stress test" for coronary artery disease. Several different stress tests are available.

Less dangerous causes of your symptoms are, of course, possible. After your doctor considers heart disease as a possible source of your pain, tests that might be used to find the cause of your abdominal pain include

• treatment with antiacid medicines, to see if this helps

• endoscopy (a video evaluation of the esophagus and stomach)

• a barium swallow x-ray test

• an ultrasound of the abdomen.

Diagnoses that fit well with your symptoms include

• gallstones

• gastritis

• gastroesophageal reflux disease (GERD)

• indigestion (dyspepsia)

• peptic ulcer disease.

You need to be evaluated for bleeding, inflammation, or possibly cancer within the esophagus and stomach. Contact your doctor for an urgent evaluation.

Pain with blood in the vomit or blackened stools could be caused by

• an ulcer in the esophagus or stomach

• irritation in the esophagus or stomach lining ("esophagitis" or "gastritis")

• a tear in the esophagus

• cancer.

Swallowing difficulty could arise from

• infection

• esophagus scarring

• cancer.

Based on your symptoms, your doctor is likely to recommend evaluation with an endoscopy test (esophagogastroduodenoscopy, or "EGD"). With this test, a doctor can view the inside of your esophagus, stomach, and the first part of your small intestine using a flexible tube and camera.

Diagnoses that your doctor will strongly consider as he or she designs your evaluation include

• esophagitis

• esophagus ring or web

• gastritis

• gastroesophageal reflux

• peptic ulcer disease

• stomach cancer.