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 Acute myocardial infarction

 Acute intermittent porphyria

 Black widow envenomation

 Diabetic ketoacidosis

 Familial Mediterranean fever

 Glaucoma

 Heavy metal poisoning

 Hereditary angioedema

 Hyperthyroidism

 Poisoning/overdose (iron, others)

 Pneumonia

 Streptococcal pharyngitis

 Sickle cell vaso‐occlusive crisis

 Shingles (Zoster herpticus)

 Uremia

 Vasculitis

Pathologic states may cause different types of pain: visceral, somatic, or referred pain. Luminal or capsular distention will typically produce visceral pain by stimulation of nerves surrounding a hollow or solid organ. Because the innervation of organs is sparse and multisegmented, this pain is usually dull and poorly localized. When caused by an obstructive process, the pain is typically intermittent or colicky. Distention of a solid organ tends to produce more constant pain (e.g., hydronephrosis, hepatitis). Visceral pain is typically associated with other autonomic phenomena such as anorexia, nausea, and vomiting.

Somatic abdominal pain typically results from irritation of the parietal peritoneum from infection or inflammation. The pathologic process stimulates peripheral nerves, and the pain tends to be more intense and distinct than visceral pain. The evolution of acute appendicitis involves both visceral and somatic pain. Early obstruction and distention of the appendix generates dull, poorly localized pain around the umbilicus. As inflammation progresses, the parietal peritoneum becomes involved and the pain becomes localized to the right lower quadrant.

Referred pain is at a site not directly involved with the disease process. Visceral and somatic nerves from different areas converge at the spinal cord allowing for misinterpretation of location by the brain. An example is irritation of the diaphragm by blood in the peritoneal cavity as might be seen following a ruptured ectopic pregnancy. This is perceived as shoulder pain because both the diaphragm and the skin near the shoulder share the C4 sensory level. Other common sites of referred pain are indicated in Table 19.1.