More pearls for diagnosing abdominal pain

I wished to respond to the recent Pearls from I.M. Peers article by Joel Diamant, MD, MACP, on the physical examination of patients with abdominal pain (“3 Physical Exam Pearls for Patients with Pain,” ACP Internist, January 2023).

Many years ago, I was struck by the number of patients with chronic abdominal pain that had evaded diagnosis and whom I had eventually diagnosed with abdominal wall pain. This led me to write an article about the prevalence and evaluation of patients with abdominal pain of abdominal wall origin, which was published in BMJ Case Reports in 2009.

To my surprise, a literature search disclosed a plethora of articles dealing with the same topic, and over time, I was surprised by the number of physicians who were completely unaware of the possibility and frequency of the abdominal wall as the source of their patients' abdominal pain. Edgar Ferdinand Cyriax was the first to describe abdominal pain originating from the abdominal wall, in 1919, and in 1926 John B. Carnett recognized that abdominal pain could be caused by neuralgia affecting one or more of the lower six intercostal nerves. As a result, he developed a simple test to help elucidate the origin of a patient's abdominal pain.

I would like to add a couple of points to Dr. Diamant's interesting article. First, every patient with abdominal pain should be asked if they can point to the area of pain with the tip of their index finger. Abdominal wall pain is of somatic origin, and therefore patients can easily point to its location with the tip of one finger. Visceral pain cannot be so localized. Second, asking the patient to tense the abdominal musculature by raising their heads and shoulders off the bed is more achievable for many patients who do not have the strength or coordination to raise both extended legs for any length of time. Dr. Carnett himself, in his May 1926 article in Surgery, Gynecology and Obstetrics, had recommended that a patient should tense his abdominal musculature by “contracting his diaphragm or by raising and holding his head from the pillow.” Finally, he also described a “pinch test” that, when positive, localized the pain to the abdominal wall.

I am very pleased and encouraged that ACP Internist is sharing the useful and effective “pearls” of seasoned clinicians with its readership. Despite our mesmerizing technologies, there are still diagnoses that can only be elucidated by a competent, well-performed physical examination.

Yehia Y. Mishriki, MD, FACP
Allentown, Pa.