Causes of Abdominal Pain by Location: The Stomach Grid
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Introduction
Abdominal pain, or stomach pain, is a common chief complaint, and unfortunately there are many different causes.
Etiologies may include gallstones (cholelithiasis), kidney stones (nephrolithiasis), pancreatitis, appendicitis, peptic ulcer disease (stomach ulcers), gastroesophageal reflux (acid reflux), pain with pregnancy, ectopic pregnancy, colitis, etc.
With such a wide range of abdominal pathology, it can be challenging to understand the meaning or cause of the pain.
Identifying where the abdominal pain is located can help narrow down and/or prioritize the differential diagnosis.
Abdominal pain can be right sided, left sided, upper, or lower, and each location can provide clues to the etiology.
Once the location has been determined, this information can be combined with other features including the characteristics of the pain, the onset of the pain, male or female, and associated symptoms such as diarrhea, nausea or vomiting, bloating, pain after eating, pain with pregnancy, etc.
This EZmed post will use simple diagrams and charts to walk you through the different abdominal quadrants, the anatomy within each region, and the abdominal pathology that can occur at each location!
If you would like information about the upper abdomen only check out the following EZmed post! “Upper Abdominal Pain: Anatomy and Causes”
Let’s get started!
Abdominal Quadrants
As mentioned above, there are many different causes of abdominal pain which can make it challenging to determine the underlying process.
The location of the pain is important to consider as this can help distinguish potential causes.
The simplest way to determine the location is to divide the abdomen into 9 different regions using a 3 x 3 grid as demonstrated below.
Superior Row
Let’s begin with the superior/upper row of the abdomen.
The right upper section is the right upper quadrant (RUQ) - also referred to as the right hypochondriac region.
The central upper section is the epigastric region.
Lastly, the left upper section is the left upper quadrant (LUQ) - also known as the left hypochondriac region.
Middle Row
The middle row represents the mid-section of the abdomen.
The right mid-section is the right flank, also known as the right lumbar region.
The center of the abdomen is the umbilical region.
Lastly, the left mid-section is the left flank or left lumbar region.
Inferior Row
Finally, we have the inferior/lower row of the abdomen.
The right lower section is the right lower quadrant (RLQ) - also known as the right iliac region.
The central lower section is the suprapubic region - sometimes referred to as the hypogastric region.
Lastly, the left lower section is the left lower quadrant (LLQ) - or left iliac region.
Abdominal Anatomy
Now that we have divided the abdomen into different regions, let’s discuss the anatomy of each section.
The below image can be used as a reference.
**We will focus on the main organs and not every single micro-structure. Also note that portions of structures can extend into other regions as well.
Upper Abdomen
Right Upper Quadrant
The right upper quadrant primarily contains the liver, gallbladder, and biliary system.
Portions of the right kidney, small intestine, and ascending/transverse colon can also extend into the RUQ.
Epigastric
The epigastric region contains the stomach (as well as the lower part of the esophagus and first part of the duodenum/small intestine) and part of the pancreas.
The liver and biliary system can also extend into the epigastric region.
The descending aorta travels posteriorly through the epigastric region as well.
Left Upper Quadrant
In addition to the spleen being located in the left upper quadrant, part of the stomach and pancreas usually extend into this region too.
Portions of the left kidney, small intestine, and transverse/descending colon can also extend into the LUQ.
Mid-Abdomen
Right Flank or Lumbar
The main structures in the right flank/lumbar region include the right kidney, ascending colon, and parts of the small intestine.
Umbilical
The umbilical region contains the bulk of the small intestine.
It also comprises the colon, mainly the transverse portion.
Lastly, the aorta traverses inferiorly through the umbilical region posterior to the above structures.
Left Flank or Lumbar
The left flank or lumbar region consists of the left kidney, descending colon, and parts of the small intestine.
Lower Abdomen
Right Lower Quadrant
The main structures in the right lower quadrant for both males and females are the appendix and cecum.
The cecum is the junction of the small intestine and large intestine.
It is also important to note that the right ovary and part of the fallopian tube can extend into the right lower quadrant in females as well.
Suprapubic
The primary structure in the suprapubic region for both males and females is the bladder.
The uterus also resides in this location in females.
Left Lower Quadrant
The left lower quadrant is similar to the right lower quadrant with a few differences.
First, there is no appendix.
Second, the sigmoid portion of the colon is located in the left lower quadrant rather than the cecum.
Third, the left ovary and fallopian tube are located here in females rather than right.
Abdominal Pain - Upper Abdomen
Now that we have discussed the main structures in each region of the abdomen, let’s discuss potential causes of abdominal pain by location.
**Below focuses on the main pathology for each quadrant and is not an extensive list of all abdominal pathology that can occur.
Let’s start with the upper abdomen.
For a simple mnemonic to remember the main causes of upper abdominal pain check out the following EZmed post! “Approach to Upper Abdominal Pain: The UPPER STOMACH Mnemonic”
Right Upper Quadrant
The primary structures in the right upper quadrant include the liver, gallbladder, and biliary system.
Therefore, problems with any of these structures may cause right upper quadrant pain.
Liver pathology may include hepatitis (inflammation and/or infection of the liver), hepatic abscess (abscess of the liver), cirrhosis (chronic degeneration, inflammation, and scarring of the liver).
Biliary pathology may include cholangitis - inflammation and/or infection of the biliary system usually caused by an obstruction of the common bile duct such as a gallstone.
Gallbladder pathology may include gallstones, also known as cholelithiasis, which may cause biliary colic.
If a gallstone leads to obstruction of the cystic duct, then cholecystitis may develop - inflammation and/or infection of the gallbladder.
Epigastric Region
As previously mentioned, part of the liver/biliary system can extend into the epigastric region.
Therefore, the hepatobiliary pathology discussed above may also present as epigastric pain.
Since the stomach and part of the pancreas are also located in the epigastric region, problems to these structures can lead to epigastric discomfort as well.
This may include pancreatitis (inflammation of the pancreas), gastritis (inflammation of the stomach), GERD (gastroesophageal reflux), peptic ulcer disease (PUD/stomach ulcers), gastroparesis (a complication usually of diabetes), or gastric perforation (hole in the stomach).
Left Upper Quadrant
The primary structures in the left upper quadrant include the rest of the pancreas, part of the stomach, and the spleen.
Therefore, pancreatitis can cause both epigastric and left upper quadrant pain.
Similarly, the stomach pathology discussed above can cause left upper quadrant pain as well.
Lastly, given the spleen is located in the left upper quadrant, any pathology to the spleen could present as pain to this region.
Spleen pathology may include splenic rupture, splenic abscess, or splenic infarct.
Abdominal Pain - Mid Abdomen
Let’s now move on to the mid-section of the abdomen.
Right Flank/Lumbar
First, the primary structures in the right flank/lumbar region are the right kidney, ascending portion of the colon, and parts of the small intestine.
Therefore, pathology to any of these structures may cause right flank pain.
Kidney pathology may include neprholithiasis (kidney stones), pyelonephritis (inflammation and/or infection of the kidney), or perinephric abscess (abscess involving the kidney).
Colitis (inflammation and/or infection of the colon) may cause pain to this region as well, especially if involving the ascending colon.
Lastly, pathology to the portion of small intestine within this location may cause right sided pain.
This could include gastroenteritis (inflammation and/or infection of the intestines) or a small bowel obstruction involving this quadrant.
Umbilical
As mentioned above, the bulk of the small intestine is located in the umbilical region.
Therefore, pathology to the small intestine often presents as periumbilical pain.
This may include gastroenteritis, small bowel obstruction, or mesenteric ischemia (decreased arterial blood flow/oxygen to the small intestine).
We also said the transverse portion of the colon is located in this region, so any pathology to this area of the colon may cause umbilical pain as well.
Lastly, we mentioned the aorta traveled inferiorly through the umbilical region.
This is important as many abdominal aortic aneurysms (AAA) form here.
As a result, a AAA may cause umbilical pain especially if it ruptures or dissects.
Left Flank/Lumbar
Pathology to the left flank is very similar to the right flank as they contain similar structures.
First, the left kidney can present with the same pathology as the right.
Second, parts of the small intestine extend into the left flank/lumbar region, and similar pathology discussed above can present as left sided pain.
Lastly, the descending portion of the colon is located here (rather than the ascending colon we saw in the right flank/lumbar region).
Therefore, pathology to the descending colon may cause left flank pain.
Abdominal Pain - Lower Abdomen
Let’s now move to the lower/inferior abdomen.
Right Lower Quadrant
Structures located in the right lower quadrant include the appendix and cecum in both males and females, as well as the right ovary in females.
Therefore, pathology to any of these structures may cause right lower quadrant pain.
First, the common diagnosis people consider with right lower quadrant pain is appendicitis, as the appendix normally sits in this region.
The cecum is the junction between the small and large intestine, specifically the ileum and ascending colon.
It is located in this region, and therefore pathology to the cecum may cause right lower quadrant pain.
Lastly, the right ovary and potentially parts of the right fallopian tube can extend into the right lower quadrant in females.
Therefore, right ovarian pathology may cause discomfort to this region.
This may include ovarian torsion (twisting of the ovary), ovarian cyst (especially if ruptures), and tubo-ovarian abscess (TOA, abscess involving the ovary/fallopian tube).
Suprapubic
As we move to the suprapubic region, the bladder is the main structure in both males and females.
Therefore, bladder pathology such as cystitis or urinary tract infections may cause suprapubic pain.
Furthermore, sexually transmitted infections may cause lower abdominal discomfort whether male or female.
Lastly, we also said the uterus is located here in females.
Therefore, pregnancy can cause lower abdominal discomfort, especially if there is an ectopic pregnancy in which the embryo attaches to a location other than the uterus.
Pelvic inflammatory disease (PID), which is a female complication usually from sexually transmitted infections, may also cause suprapubic pain.
Left Lower Quadrant
The left lower quadrant is similar to the right lower quadrant, with a couple differences.
First, there is no appendix. However, it is important to note early appendicitis may begin as generalized abdominal pain before migrating to the right lower quadrant.
Second, the portion of the colon in the left lower quadrant is primarily the sigmoid rather than the cecum.
Diverticulitis (inflammation and/or infection of the diverticulum involving the colon) most commonly occurs in the sigmoid.
Therefore, diverticulitis often presents as left lower quadrant pain.
Lastly, it is the left ovary rather than right located in this region. However, the same ovarian pathology we discussed with the right ovary can occur in the left.
Referred Pain - From the Abdomen
While the source of abdominal pain may come from the organs and structures within that region, referred pain may also be present.
Referred pain is defined as pain that is perceived at a location different from where the stimulus is.
Pain may also radiate - pain that originates in one area and spreads to another in a fairly continual pattern.
Pain may also migrate - pain that originates in one location and then moves to a completely different location.
Here are several intra-abdominal examples in which pain can be referred or radiate elsewhere.
Upper Abdomen
Referred Pain - While hepatobiliary pathology commonly causes right upper quadrant abdominal pain as discussed above, the pain may also be referred to the right shoulder and patients might complain of right shoulder discomfort instead.
Radiating Pain - While pancreatitis usually presents as epigastric and/or left upper quadrant pain, this pain can also radiate to the back.
In fact, the patient complaint of “epigastric/LUQ pain radiating to the back” is a common buzzword phrase that shows up on medical examinations.
Mid-Abdomen
Radiating Pain - While kidney stones often cause flank pain, this pain can radiate to the groin.
In fact, the patient complaint of “flank pain radiating to the groin” is a common buzzword phrase that shows up on medical examinations.
Lower Abdomen
Migratory Pain - Early appendicitis can present as generalized abdominal pain or periumbilical pain. As the disease progresses, the pain usually migrates to the right lower quadrant.
Hepatobiliary pathology - referred pain to the right shoulder
Pancreatitis - epigastric/LUQ pain radiating to the back
Kidney Stone - flank pain radiating to the groin
Appendicitis - migratory pain from the periumbilical region to the RLQ
Referred Pain - To the Abdomen
Similar to how intra-abdominal pathology can cause referred pain outside the abdomen, pathology outside the abdomen can cause referred pain in the abdomen.
Let’s take a look at some examples.
Upper Abdomen
When pain is referred to the upper abdomen, it is usually caused by pathology in the thorax.
Therefore, problems in the chest can present as upper abdominal pain.
One important consideration is acute coronary syndrome - a range of conditions to describe reduced blood flow to the heart.
For example, a myocardial infarction (heart attack) may cause epigastric discomfort instead of/in addition to chest pain.
Therefore, it is important to consider acute coronary syndrome and obtain an EKG (electrocardiogram) in individuals who have risk factors for cardiac pathology and are presenting with epigastric discomfort.
Lung pathology can also cause upper abdominal pain.
For example, a right lower lobe pneumonia may cause right upper quadrant pain, and a left lower lobe pneumonia may cause left upper quadrant pain.
Similarly, a pulmonary embolism, pleural effusion, or pneumothorax may cause right and/or left upper quadrant pain. There is usually a component of shortness of breath present as well.
Mid-Abdomen
A number of non-abdominal etiologies can cause referred pain to the mid-section of the abdomen including endocrine, autoimmune, or psychiatric processes.
For example, diabetic ketoacidosis (DKA) may cause generalized or periumbilical abdominal pain.
Autoimmune disorders such as inflammatory bowel disease (Crohn’s or ulcerative colitis) can cause generalized pain or pain to the mid-section of the abdomen.
Lastly, anxiety and other psychiatric disorders may cause periumbilical or generalized abdominal pain.
Lower Abdomen
When pain is referred to the lower abdomen, it is usually caused by pathology in the hip or pelvis.
Therefore, problems in the hip or pelvic region can present as lower abdominal pain.
For example, hip fractures, osteoarthritis, or musculoskeletal injuries involving the hip/pelvis may cause referred pain to the lower abdomen.
We also discussed above how the ovaries can cause lower abdominal pain in females.
In males, testicular pathology may cause referred pain to the lower abdomen.
This could include testicular torsion (twisting of the testicle), orchitis (inflammation and/or infection of testicle), or epididymitis (inflammation and/or infection of the epididymis).
Therefore, it is important to consider testicular pathology in a male presenting with lower abdominal pain.
Conclusion
Hopefully this provided you with a good overview of the abdominal quadrants, anatomy within each region, pathology that can occur at each location, and referred pain.
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