Managing Nonmalignant Chronic Abdominal Pain and Malignant Bowel Obstruction Lesley K. Bicanovsky, DO, Ruth L. Lagman, MD, MPH * , Mellar P. Davis, MD, Declan Walsh, MSc, FRCP (Edin) The Harry R. Horvitz Center for Palliative Medicine, Taussig Cancer Center, Cleveland Clinic, 9500 Euclid Avenue, M76, Cleveland, OH 44195, USA A bdominal pain is challenging for any physician. It is present at some time in 50% of all adults [1]. Prevalence is high across geographical re- gions, regardless of age and ethnicity [1–3]. The most frequent cause of abdominal pain is irritable bowel syndrome (IBS) [1–3]. Difficulty exists in sep- arating IBS from abdominal pain associated with cancer or mechanical bowel obstruction. The differential diagnosis is often difficult because of the nonspe- cific nature and overlapping characteristics of abdominal pain, irrespective of the underlying cause. Abdominal pain clusters with other symptoms (back pain, bloating, nausea, vomiting), complicating the diagnosis [4]. A thorough history should include pain location, radiation, duration, severity, and associ- ated symptoms (eg, chills, constipation, diarrhea, fevers nausea, vomiting, weight loss), and family history of bowel disorders, alcohol consumption, cur- rent medications, and menstrual history [5]. Physical findings vary depending upon chronicity and etiology. Rebound tenderness occurs with acute abdominal pain caused by perforation or disten- tion. A distended but nontender abdomen and no bowel sounds occur with il- eus or pseudo-obstruction. Obstruction and opioid bowel syndrome may be inseparable based upon history and physical examination. Multiple illnesses may have similar nonspecific abdominal complaints. Pain worsened by rectus abdominus contraction is usually somatic and nonvisceral [6]. Initial laboratory tests include complete blood count with differential, complete metabolic panel, amylase, lipase, ferritin, thyroid-stimulating hormone, and urine analysis. Additional invasive testing should be directed at ruling out specific diseases and not as a general screening tool. This article reviews common causes of A World Health Organization Demonstration Project. Supported in part by a grant from the Project on Death in America of the Open Society Institute. *Corresponding author. E-mail addresses: lagmanr@ccf.org; www.clevelandclinic.org/ palliative (R.L. Lagman). 0889-8553/06/$ – see front matter ª 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.gtc.2006.01.002 gastro.theclinics.com Gastroenterol Clin N Am 35 (2006) 131–142 GASTROENTEROLOGY CLINICS OF NORTH AMERICA