What is the diagnosis and treatment for a patient experiencing rib pain, abdominal pain, and back pain?

Acute Thoracic Aortic Dissection Must Be Ruled Out First

When a patient presents with the triad of rib pain, abdominal pain, and back pain—especially if sudden and severe—acute thoracic aortic dissection is the life-threatening diagnosis that must be immediately considered and excluded before pursuing other causes. 1

Immediate Risk Stratification for Aortic Dissection

High-Risk Pain Features Requiring Urgent Evaluation

• Abrupt or instantaneous onset of pain 1
• Severe intensity at onset 1
• Ripping, tearing, stabbing, or sharp quality 1
• Pain migrating from chest to back to abdomen suggests dissection propagation 1

Critical Historical Red Flags

• Connective tissue disorders: Marfan syndrome, Loeys-Dietz syndrome, vascular Ehlers-Danlos syndrome, Turner syndrome 1
• Family history of aortic dissection or thoracic aortic aneurysm 1
• Known aortic valve disease or thoracic aortic aneurysm 1
• Recent aortic manipulation (surgical or catheter-based) 1
• Hypertension, particularly if uncontrolled 1
• Cocaine or stimulant use 1

Physical Examination Findings Mandating Imaging

• Pulse deficit between extremities 1
• Blood pressure differential >20 mmHg between arms 1
• New murmur of aortic regurgitation 1
• Focal neurologic deficits 1

Pain Pattern Recognition

Type A dissections (ascending aorta) present with chest pain (80%) but also cause back pain (47%) and abdominal pain (21%) as dissection extends distally 1. Type B dissections (descending aorta) most commonly present with back pain (64%), followed by chest pain (63%) and abdominal pain (43%) 1. Critically, some patients present with abdominal pain alone or only lower extremity symptoms from end-organ ischemia 1.

If Aortic Dissection Is Excluded: Systematic Diagnostic Approach

For Acute Presentations (<4 weeks)

Imaging Strategy Based on Clinical Context

CT abdomen/pelvis with contrast is the first-line imaging for acute nonlocalized abdominal pain with rib and back involvement, as it identifies pathology across multiple organ systems 1. Common acute causes include: pneumonia, hepatobiliary disease, pancreatitis, nephrolithiasis, GI perforation, bowel obstruction or infarction, and abscesses 1.

Red Flags Requiring Immediate Imaging

• Cauda equina syndrome: urinary retention (90% sensitivity), fecal incontinence, saddle anesthesia, motor deficits at multiple levels 2, 3
• Malignancy indicators: history of cancer (increases probability from 0.7% to 9%), unexplained weight loss, failure to improve after 1 month, age >50 years 2
• Spinal infection: fever, recent infection, IV drug use, immunocompromised status 2
• Vertebral compression fracture: older age, osteoporosis history, steroid use 2

For Subacute/Chronic Presentations (>4 weeks)

Musculoskeletal Causes

Slipping rib syndrome is an underdiagnosed cause of lower chest/upper abdominal pain with rib involvement 4, 5. The hooking maneuver (pulling anteriorly on the lower costal margin) reproduces pain and confirms diagnosis 4, 5. This affects ribs 8-12, which are not connected to the sternum 4. The painful rib syndrome presents with: pain in lower chest or upper abdomen, tender spot on costal margin, and reproduction of pain on pressing the tender spot 5. This is a clinical diagnosis requiring no investigation 5.

Nonspecific low back pain is the most common diagnosis when red flags are absent 2. Assessment should include:

• Pain location, frequency, duration, and previous treatment response 2
• For leg pain: assess for sciatica symptoms (pain below knee in dermatomal distribution) 2, 3
• Neurologic examination: knee strength/reflexes (L4), great toe/foot dorsiflexion (L5), foot plantarflexion/ankle reflexes (S1) 2, 3

Psychosocial Factors Are Critical Prognostic Indicators

Psychosocial factors and emotional distress are stronger predictors of low back pain outcomes than physical examination findings or pain severity 2. Screen for: depression, passive coping strategies, job dissatisfaction, higher disability levels, disputed compensation claims, or somatization 2.

Obscure Causes Requiring High Clinical Suspicion

Skeletal tuberculosis should be considered in patients with travel to endemic areas who have persistent rib and back pain despite treatment 6. Bone scan reveals osteolytic lesions, and bone biopsy confirms diagnosis 6.

Constipation/fecal impaction can cause low back pain through distension of the rectosigmoid colon creating pressure on lumbosacral structures 7. However, exclude serious pathology first before attributing pain to constipation 7.

Treatment Algorithm

If Aortic Dissection Confirmed

Urgent operative management for Type A dissection with graft replacement of ascending aorta and intraoperative aortic valve assessment 1.

If Musculoskeletal Pain Confirmed

First-line medication: Acetaminophen or NSAIDs 1. Acetaminophen is safer but slightly weaker analgesic (<10 points on 100-point scale) 1. NSAIDs are more effective but carry GI, renovascular, and cardiovascular risks—use lowest effective dose for shortest duration 1.

Activity modification: Advise staying active rather than bed rest 1. Self-care education books based on evidence-based guidelines (e.g., The Back Book) are recommended 1. Application of heat provides short-term relief 1.

For slipping rib syndrome: Reassurance and avoiding postures that worsen pain are usually sufficient 4. Refractory cases may require nerve block or surgical intervention 4.

Common Pitfalls to Avoid

• Do not delay imaging when red flags are present—immediate MRI is indicated rather than waiting 4-6 weeks 2
• Do not routinely image nonspecific low back pain without red flags, as it does not improve outcomes and may lead to unnecessary interventions 2, 7
• Do not assume constipation is the cause without proper evaluation, as most low back pain is musculoskeletal 7
• Do not miss aortic dissection in patients presenting with abdominal pain alone—6.4% of dissections present without pain, and some present with only abdominal symptoms 1
• Do not overlook skeletal tuberculosis in patients with travel history and persistent pain despite treatment 6