慢性腹痛是指持续 3 个月及以上的连续性或间歇性腹部不适。[1]Treede RD, Rief W, Barke A, et al. Chronic pain as a symptom or a disease: the IASP classification of chronic pain for the International Classification of Diseases (ICD-11). Pain. 2019 Jan;160(1):19-27.
http://www.ncbi.nlm.nih.gov/pubmed/30586067?tool=bestpractice.com
疼痛可来自任何系统，包括泌尿生殖系统、胃肠道或妇科生殖道。慢性腹痛的病因非常多，此处只介绍一些较常见的病因。并非所有腹痛都存在与解剖结构或基础病变的明确关联。
由于慢性腹痛的诊治经常很困难，医患双方时常无法得到满意的结果。导致这一情况的因素很多，包括病史不清、查体结果的灵敏度低、鉴别诊断涉及几个专科，以及诊断性病情检查结果经常呈阴性。
分类
慢性腹痛从病因学上可以分为器质性和功能性两种。[2]Yarger E, Sandberg K. Updates in diagnosis and management of chronic abdominal pain. Curr Probl Pediatr Adolesc Health Care. 2020 Aug;50(8):100840.
https://www.sciencedirect.com/science/article/abs/pii/S1538544220301061?via%3Dihub
http://www.ncbi.nlm.nih.gov/pubmed/32859509?tool=bestpractice.com
前者有明确的解剖、生理或代谢方面原因。尽管进行了彻底的诊断评估但仍不明原因的慢性腹痛，通常称为功能性障碍。[3]Sabo CM, Grad S, Dumitrascu DL. Chronic abdominal pain in general practice. Dig Dis. 2021;39(6):606-14.
https://karger.com/ddi/article/39/6/606/822861/Chronic-Abdominal-Pain-in-General-Practice
http://www.ncbi.nlm.nih.gov/pubmed/33631744?tool=bestpractice.com
功能性腹痛被认为源于多因素内脏高敏感性和动力障碍以及脑肠轴功能改变。[4]Korterink J, Devanarayana NM, Rajindrajith S, et al. Childhood functional abdominal pain: mechanisms and management. Nat Rev Gastroenterol Hepatol. 2015 Mar;12(3):159-71.
http://www.ncbi.nlm.nih.gov/pubmed/25666642?tool=bestpractice.com
相较于急性腹痛而言，慢性腹痛更难找到明确的病变器官。 急性腹痛一般都有突然出现的生理学的改变，例如空腔脏器的梗阻或穿孔、感染、膨胀或缺血等。
流行病学
慢性腹痛是初级卫生保健和亚专科门诊中的常见主诉。[3]Sabo CM, Grad S, Dumitrascu DL. Chronic abdominal pain in general practice. Dig Dis. 2021;39(6):606-14.
https://karger.com/ddi/article/39/6/606/822861/Chronic-Abdominal-Pain-in-General-Practice
http://www.ncbi.nlm.nih.gov/pubmed/33631744?tool=bestpractice.com
非特异性腹痛的发病率为 22.3 例/1000 人年。[5]Wallander MA, Johansson S, Ruigomez A, et al. Unspecified abdominal pain in primary care: the role of gastrointestinal morbidity. Int J Clin Pract. 2007 Oct;61(10):1663-70.
http://www.ncbi.nlm.nih.gov/pubmed/17681003?tool=bestpractice.com
一项国际荟萃分析显示，在就诊于初级卫生保健机构的患者中，腹痛的患病率为 2.8%。[6]Viniol A, Keunecke C, Biroga T, et al. Studies of the symptom abdominal pain--a systematic review and meta-analysis. Fam Pract. 2014 Oct;31(5):517-29.
https://academic.oup.com/fampra/article/31/5/517/537129?login=false
http://www.ncbi.nlm.nih.gov/pubmed/24987023?tool=bestpractice.com
在所有因腹痛症状就诊的患者中，未能诊断出病因的占一半以上。[6]Viniol A, Keunecke C, Biroga T, et al. Studies of the symptom abdominal pain--a systematic review and meta-analysis. Fam Pract. 2014 Oct;31(5):517-29.
https://academic.oup.com/fampra/article/31/5/517/537129?login=false
http://www.ncbi.nlm.nih.gov/pubmed/24987023?tool=bestpractice.com
[7]Freeman TR, Stewart M, Léger D, et al. Natural history of abdominal pain in family practice: longitudinal study of electronic medical record data in southwestern Ontario. Can Fam Physician. 2023 May;69(5):341-51.
https://www.cfp.ca/content/69/5/341.long
http://www.ncbi.nlm.nih.gov/pubmed/37172994?tool=bestpractice.com
[8]Price SJ, Gibson N, Hamilton WT, et al. Diagnoses after newly recorded abdominal pain in primary care: observational cohort study. Br J Gen Pract. 2022 Aug;72(721):e564-70.
https://pubmed.ncbi.nlm.nih.gov/35760565
http://www.ncbi.nlm.nih.gov/pubmed/35760565?tool=bestpractice.com
一项针对美国成人的横断面调查显示，一般人群的腹痛患病率为 21.8%。[9]Sandler RS, Stewart WF, Liberman JN, et al. Abdominal pain, bloating, and diarrhea in the United States: prevalence and impact. Dig Dis Sci. 2000 Jun;45(6):1166-71.
http://www.ncbi.nlm.nih.gov/pubmed/10877233?tool=bestpractice.com
女性比男性更可能报告慢性腹痛。[3]Sabo CM, Grad S, Dumitrascu DL. Chronic abdominal pain in general practice. Dig Dis. 2021;39(6):606-14.
https://karger.com/ddi/article/39/6/606/822861/Chronic-Abdominal-Pain-in-General-Practice
http://www.ncbi.nlm.nih.gov/pubmed/33631744?tool=bestpractice.com
在美国，腹痛是胃肠道疾病最常见的症状和诊断依据，发生时应就诊。[10]Peery AF, Crockett SD, Murphy CC, et al. Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: update 2021. Gastroenterology. 2022 Feb;162(2):621-44.
https://www.gastrojournal.org/article/S0016-5085(21)03655-6/fulltext?referrer=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F
http://www.ncbi.nlm.nih.gov/pubmed/34678215?tool=bestpractice.com
然而，美国一项调查显示，在有腹痛史的成人中，接近 40% 并未因该症状而就诊。[11]Lakhoo K, Almario CV, Khalil C, et al. Prevalence and characteristics of abdominal pain in the United States. Clin Gastroenterol Hepatol. 2021 Sep;19(9):1864-72.e5.
https://www.cghjournal.org/article/S1542-3565(20)30929-0/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/32629129?tool=bestpractice.com
在全球范围内，成人的功能性胃肠病（functional gastrointestinal disorder, FGID）（也称为肠-脑互动障碍）患病率超过 40%。[12]Sperber AD, Bangdiwala SI, Drossman DA, et al. Worldwide prevalence and burden of functional gastrointestinal disorders, results of Rome Foundation Global Study. Gastroenterology. 2021 Jan;160(1):99-114.e3.
https://www.gastrojournal.org/article/S0016-5085(20)30487-X/fulltext?referrer=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F
http://www.ncbi.nlm.nih.gov/pubmed/32294476?tool=bestpractice.com
FGID 为异质性疾病，以肠易激综合征和功能性消化不良最为常见。[12]Sperber AD, Bangdiwala SI, Drossman DA, et al. Worldwide prevalence and burden of functional gastrointestinal disorders, results of Rome Foundation Global Study. Gastroenterology. 2021 Jan;160(1):99-114.e3.
https://www.gastrojournal.org/article/S0016-5085(20)30487-X/fulltext?referrer=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F
http://www.ncbi.nlm.nih.gov/pubmed/32294476?tool=bestpractice.com
然而，和这些障碍相关的疼痛往往都是非特异性，可能类似于器质性疾病，有时还会和器质性疾病共存。[13]Colombel JF, Shin A, Gibson PR. AGA clinical practice update on functional gastrointestinal symptoms in patients with inflammatory bowel disease: expert review. Clin Gastroenterol Hepatol. 2019 Feb;17(3):380-90.e1.
https://www.cghjournal.org/article/S1542-3565(18)30810-3/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/30099108?tool=bestpractice.com
一小部分 FGID 患者对一线治疗无反应，并有持续的慢性腹痛。[14]Keefer L, Ko CW, Ford AC. AGA clinical practice update on management of chronic gastrointestinal pain in disorders of gut-brain interaction: expert review. Clin Gastroenterol Hepatol. 2021 Dec;19(12):2481-8.e1.
https://www.cghjournal.org/article/S1542-3565(21)00717-5/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/34229040?tool=bestpractice.com
儿童的慢性腹痛患病率差异很大（4%-53%）。[15]King S, Chambers CT, Huguet A, et al. The epidemiology of chronic pain in children and adolescents revisited: a systematic review. Pain. 2011 Dec;152(12):2729-38.
http://www.ncbi.nlm.nih.gov/pubmed/22078064?tool=bestpractice.com
[16]Tutelman PR, Langley CL, Chambers CT, et al. Epidemiology of chronic pain in children and adolescents: a protocol for a systematic review update. BMJ Open. 2021 Feb 16;11(2):e043675.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7888311
http://www.ncbi.nlm.nih.gov/pubmed/33593785?tool=bestpractice.com
[17]World Health Organization. Guidelines on the management of chronic pain in children. Dec 2020 [internet publication].
https://www.who.int/publications/i/item/9789240017870
儿童功能性腹痛的患病率为 13.5%。[18]Korterink JJ, Diederen K, Benninga MA, et al. Epidemiology of pediatric functional abdominal pain disorders: a meta-analysis. PLoS One. 2015 May 20;10(5):e0126982.
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0126982
http://www.ncbi.nlm.nih.gov/pubmed/25992621?tool=bestpractice.com
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