"Gas" and abdominal pain — what it actually turns out to be

What abdominal pain actually turns out to be

Start with the numbers, because they reorder everything that follows. In 264 consecutive patients presenting to an Indian emergency department with non-traumatic acute abdominal pain, the final diagnoses were:

Two things jump out. The urinary tract accounts for almost as much abdominal pain as every surgical cause put together — and acid peptic disease, the thing nearly everyone here is treated for, accounted for one case in twelve.

A West Bengal series says something compatible. At a hospital in Durgapur, abdominal pain accounted for 1,236 of 8,688 emergency admissions (14.2%), of which roughly 42% were surgical and 58% non-surgical; within the surgical group appendicitis was 38.9%, gallbladder disease 21.0% and renal or ureteric colic 14.2%.^[2]

These are emergency-department figures, so they over-represent severe and acute presentations relative to a clinic. But the direction of the correction holds: the differential for abdominal pain is much wider than the stomach, and pantoprazole is not a diagnostic strategy.

Is it the stomach at all?

Before the list, two exclusions that change the urgency.

The heart. Upper abdominal discomfort attributed to gas is one of the commonest ways a heart attack presents in this district, and relief from an antacid proves nothing at all. If the discomfort is central, comes on with exertion, or comes with sweating or breathlessness, it is assessed as chest pain. The chest pain guide sets out why an antacid response and a normal ECG both mislead.

The airway. Less obviously, bronchospasm presents as chest and upper abdominal tightness and gets treated as reflux for months. In one series of patients whose only complaint was chest pain, the median delay before asthma was diagnosed was four months, with some carrying the symptom over ten years while being treated for reflux oesophagitis. The breathlessness guide covers this.

Gastritis, reflux and Helicobacter pylori

This remains a real and common cause — it is simply not the whole of it. H. pylori is the part worth finding, because it is a bacterial infection that responds to a two-week course and, once eradicated, does not usually return. It causes peptic ulcers and is a risk factor for gastric cancer.

Regional prevalence is less well established than it should be. The largest Indian meta-analysis puts national prevalence near 58% with a West Bengal band around 54%, but it draws on few Bengal studies and appears in a low-profile venue, so it is indicative rather than authoritative.^[3] The most solid regional figure is from Sikkim, in the eastern Himalaya bordering North Bengal: 27% of 1,539 consecutive upper GI endoscopies were positive, higher in men (31%) than women (22%).^[4]

Test-and-treat before endoscopy is reasonable in younger patients without alarm features, which is what both the international and the recent Indian consensus recommend.^[5]

When endoscopy is needed — and why the age-60 rule does not transfer

The American and Canadian guideline recommends endoscopy for dyspepsia at 60 and above, and explicitly does not recommend routine endoscopy for alarm features under 60 — while noting that a lower threshold is warranted for people born and raised in South and South-East Asia.^[5] That caveat is the important part. In 294 Indian patients aged 18 to 60 with dyspepsia and at least one alarm feature, 65.3% had organic disease and 15.6% had an upper gastrointestinal malignancy; the authors concluded the Western rule is unsafe applied here.^[6] The Indian consensus published in 2026 prioritises endoscopy above 60 with symptoms of a month or more, with test-and-treat first in younger patients.^[7] The position taken here: alarm features get endoscopy at any adult age.

The same study carries its own corrective — 34.7% of that alarm-feature group had a completely normal endoscopy.^[6] Alarm features are a reason to look, not a prediction of what will be found.

The pantoprazole problem

A great many people arrive on a proton pump inhibitor taken for years, started by someone for a reason nobody now remembers, with no test ever done. Two things are wrong with that. It is a treatment standing in place of a diagnosis — and given the aetiology table above, there is a real chance the organ being treated is not the organ causing the pain. And these drugs are not consequence-free: Indian audits found 57% of inpatient PPI use outside approved indications in one study and 46% of prescriptions inappropriate in another.^[8][9] Documented associations with long-term use include community-acquired pneumonia (OR 1.49, and OR 2.10 in the first month), hypomagnesaemia (RR 1.43) and small-intestinal bacterial overgrowth (OR 2.28).^[10] The absolute risks are small, but they are being accepted in exchange for a benefit nobody has checked.

The urinary tract — the group most often missed

Nearly a third of abdominal pain in the Indian series above was urological, and much of it did not announce itself with urinary symptoms. Urinary infection presenting as abdominal pain accounted for 12.5% of all presentations on its own.^[1] A urine test is therefore not an afterthought here; it is one of the first tests.

Stones

Ureteric colic was the single commonest individual diagnosis in that series at 16.3%.^[1] The pain is characteristic once heard: sudden, severe, coming in waves, in the loin and radiating to the groin, with the patient unable to find a comfortable position — in contrast to peritonitis, where any movement is avoided.

Around 12% of the Indian population is described as prone to urinary stones, and the "stone belt" named in the literature includes West Bengal alongside Maharashtra, Gujarat, Rajasthan, Punjab, Haryana, Delhi, Madhya Pradesh and Bihar.^[11] That belt is a narrative assertion rather than a West Bengal prevalence measurement, and no district figure for Cooch Behar exists — but working in high temperatures and low fluid intake are established risk factors,^[12] which is worth knowing for anyone doing outdoor work through a Bengal summer. Stones recur: pooled across 53 studies and 488,130 patients, about 17.4% of patients had a recurrence, with prior surgery (OR 3.18), prior stones (OR 1.40) and higher BMI (OR 1.06) among the predictors.^[13]

Infection, pyelitis and pyelonephritis

Infection confined to the bladder produces burning, frequency and lower abdominal pain. When it ascends to the kidney it produces fever, shaking chills and loin pain — and that combination needs treating promptly rather than with another course of whatever was left in the cupboard.^[14]

Which brings up the most treatment-changing fact on this page. India's national antimicrobial resistance network tested 33,882 urinary E. coli isolates in 2023, at sites including the Calcutta School of Tropical Medicine. The results:

Three in four urinary infections in India will not respond to ciprofloxacin, and more than half will not respond to co-trimoxazole. Those are the two drugs most often bought over the counter for burning urine. A separate national network reports the same direction.^[16] This is why a urine culture is worth doing rather than guessing, and why a course from a shop that "did not work" usually means the wrong drug rather than the wrong diagnosis.

Parasites

Intestinal worms and protozoa cause abdominal pain, bloating and iron loss, and they are worth taking seriously here. They are also an area where the honest answer is less certain than the confident one.

The pooled Indian paediatric figures are Ascaris 25%, Trichuris 13% and hookworm 10%, with hookworm regionally highest in eastern India at 49%.^[17] But that eastern figure rests almost entirely on Kolkata surveys from 1968 and 1978, and the only post-2000 North Bengal datapoint inside the same meta-analysis — a small Darjeeling study — found no hookworm at all.^[17] Sanitation has changed a great deal in fifty years. So the claim that half of eastern India carries hookworm should not be repeated as a current fact, and no current North Bengal prevalence has been published.

What is measured recently: Giardia duodenalis in 6.8% of diarrhoeal patients in south-eastern West Bengal.^[18] Amoebiasis carriage across India runs 3–23% asymptomatic and 0.64–11% symptomatic.^[19]

On treatment, two points are worth being clear about. India's National Deworming Day covers ages 1 to 19 only — adults are not included.^[20] The World Health Organization does recommend preventive treatment for defined adult groups: annual or biannual albendazole for women of reproductive age (15–49) where local soil-transmitted helminth prevalence is 20% or more, and it names tea-garden workers among high-risk occupations^[21][22] — directly relevant to the North Bengal tea belt. Against that, a Cochrane review of community deworming found essentially no effect on haemoglobin (mean difference 0.06 g/dL, 95% CI −0.05 to +0.17), though it studied children only.^[23] Empirical deworming is therefore reasonable in specific situations and is not a substitute for finding the cause of pain.

One consequence worth knowing: a gut infection can leave lasting bowel symptoms. Post-infectious irritable bowel syndrome follows about 11.5% of episodes of acute gastroenteritis, and the risk is highest after protozoal infection, intermediate after bacterial and lowest after viral.^[24] Which connects this section to the next.

Irritable bowel syndrome

IBS is a positive diagnosis, not a label applied when tests are normal. Community prevalence in India is about 4.0%, from a door-to-door survey of 4,767 people — in a sample where 17.3% reported abdominal pain of some kind.^[25]

Two features make Indian IBS different from the Western picture, and both matter for recognising it:

The Indian consensus — 28 statements from the Indian Neurogastroenterology and Motility Association with the Indian Society of Gastroenterology — recommends diagnosis on symptoms with baseline investigations only, reserving extensive testing for alarm features, and prefers the Rome III criteria over Rome IV for Indian patients because Rome IV under-detects here.^[26][27] Its alarm features are: onset after 45, anaemia, blood in stool, weight loss, symptoms waking you at night, fever, an abdominal mass, or a family history of bowel cancer.^[26]

Pain from the abdominal wall and the spine

This is the group most often investigated in the wrong place, sometimes for years, because everyone keeps looking inside the abdomen for a pain arising in its wall.

Abdominal cutaneous nerve entrapment syndrome — a nerve trapped where it pierces the abdominal wall muscle — accounted for 1.7% of 5,111 emergency patients with abdominal pain.^[28] Among patients with chronic abdominal pain the share is far higher: of 100 consecutive patients referred by gastroenterologists to a pain clinic, 43 had abdominal wall pain.^[29]

It can be distinguished at the bedside in under a minute. Carnett's test asks the patient to tense the abdominal wall by lifting the head and shoulders while the tender spot is pressed: pain from the wall gets worse, pain from inside gets better as the muscle shields it. In 130 outpatients this gave a positive likelihood ratio of 2.91 and a negative likelihood ratio of 0.19.^[30] The tell-tale history is pain in one small spot the patient can point to with a fingertip, unchanged by meals or bowels, worse on sitting up or turning in bed.

Pain referred from the thoracolumbar spine is real but rarer — thoracic disc herniation accounts for under 1% of all disc herniations, and presentation as abdominal pain is at case-report level.^[31] The pattern to recognise is a band of pain following one dermatome round from the back, sometimes with numbness, changing with posture rather than with food.

And shingles causes abdominal pain for several days before any rash appears, along a thoracic dermatome and not crossing the midline — a diagnosis that may be impossible to make until the rash arrives, and one that is worth waiting a few days for rather than escalating investigations.^[32]

Surgical causes

Appendicitis is the commonest, with a lifetime risk of 8.6% in men and 6.7% in women,^[33] and it was 38.9% of surgical acute abdomen in the West Bengal series.^[2] The Alvarado score is useful in one direction only: at a cut-off of 5 its sensitivity is 99%, so a low score genuinely argues against appendicitis, but at a cut-off of 7 its specificity is only 81% overall and 57% in men — a high score is not a licence to operate.^[34]

Epiploic appendagitis deserves naming because it is benign and routinely mistaken for something that is not. Small fat-filled pouches on the outside of the colon can twist or clot, producing sharp, well-localised abdominal pain in someone who is otherwise entirely well — no fever, no vomiting, normal appetite. It accounts for 2–7% of patients initially suspected of having appendicitis or diverticulitis, is diagnosed on CT by a characteristic oval fatty lesion with a hyperattenuating ring, and resolves on its own within about two weeks with anti-inflammatory tablets. It does not need surgery.^[35] Recognising it is the difference between two weeks of discomfort and an unnecessary operation.

Acute mesenteric ischaemia is the must-not-miss. It is rare — 0.09 to 0.2% of acute surgical admissions — but carries a mortality of 30 to 70%, and above the age of 75 it is a more prevalent cause of acute abdomen than appendicitis. The classic clue is pain out of proportion to the examination findings.^[36]

Enteritis, colitis and infection

Typhoid remains a genuine cause of abdominal pain with fever here: modelled Indian incidence is 360 cases per 100,000 person-years, with a striking urban-rural gap (770 urban against 150 rural).^[37] The fever guide covers how it is tested for and why the Widal test is unreliable.

Inflammatory bowel disease is less common in India than in the West but is rising while global incidence falls — 31,774 new cases and 270,719 prevalent cases in 2019, with age-standardised incidence increasing by 0.05 per 100,000 per year against a global decline of 0.18.^[38] Anaemia complicates 47.7% of Indian IBD patients against 31.1% globally.^[38] Blood in the stool, diarrhoea for weeks, weight loss or waking at night with symptoms takes the case out of the IBS category and into this one.

One diagnostic problem specific to India deserves mention: intestinal tuberculosis and Crohn's disease look almost identical, and the tests do not resolve it cleanly — interferon-gamma release assay sensitivity 74%, MTB-PCR 47%, and Xpert MTB/RIF only 23% on intestinal samples, so "no single finding can conclusively diagnose" either.^[39] Quantified misdiagnosis rates in that pair exist only from Korea, not India. In a high-TB district this is a reason for specialist referral rather than a confident label.

What is actually done at the consultation

Where the pain is, what it does, and what changes it. Then Carnett's test, which costs nothing. Urine analysis is done early rather than late, because of how much of this turns out to be urological. Blood count, ESR or CRP, liver and kidney function, blood sugar. Stool examination where the history fits. H. pylori testing in persistent dyspepsia. Ultrasound is arranged at an imaging centre in Cooch Behar — there is no scanner at the clinic — and endoscopy is referred, with a dedicated service planned for 2027. Where infection is suspected, a urine culture is worth the wait, given what the resistance figures above show about guessing.

Reports are reviewed with you at follow-up, which is not charged within 10 days.