Back pain and nausea and vomiting

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]

Abbreviations: ABG = Arterial blood gases, ANA = Antinuclear antibodies, BUN = Blood urea nitrogen, CRP = C-reactive protein, CT = Computed tomography, DRA = Dual energy radiographic absorptiometry, DRE = Digital rectal exam, ERCP = Endoscopic retrograde cholangiopancreatography, ESR = Erythrocyte sedimentation rate, HSV = Herpes simplex virus, IVP = Intravenous pyelography, KUB = Kidney, bladder, ureter, LDH = Lactate dehydrogenase, LFT = Liver function test, MRA = Magnetic resonance angiography, MRC = Magnetic resonance cholangiopancreatography, MRI = Magnetic resonance imaging, MRU = Magnetic resonance urography, NSAIDs = Non-steroidal anti-inflammatory drugs, PCR = Polymerase chain reaction, PET - FDG = Positive emission tomography - fluorodeoxyglucose, PET = Positive emission tomography, PID = Pelvic inflammatory disease, PSA = Prostatic specific antigen, PTC = Percutaneous transhepatic cholangiography, RUQ = Right upper quadrant, SPECT = Single-photon emission computed tomography, TFT = Thyroid function test, VZV = Varicella zoster virus

Classification of pain in the back based on etiology	Diease	Clinical Manifestation																	Diagnosis		Comments
		Symptoms											Signs						Lab findings	Imaging
		Onset	Duration	Quality of pain	Radiation	Stiffness	Fever	Rigors and chills	Headache	Nausea and vomiting	Syncopy	Weight loss	Motor weakness	Sensory deficit	Pulse Deficit	Heart Murmur	Bowel or bladder dysfunction	Horner's syndrome
Vascular	Retroperitoneal hematoma	Acute or subacute	Minutes to hours	Sharp and knife-like, also tearing or ripping	Back and/or flanks	-	-	-	-	+/-	-	-	-	-	-	-	-	-	Typically no specific lab findings, however, evidence of hemorrhage and organ injury may be seen in: Complete blood count; normochromic normocytic anemia seen in hemorrhage Elevated serum electrolytes Elevated liver function tests Elevated amylase or lipase	CT with IV contrast May show venous delay and indicate renal trauma Cystography Should be considered in evaluation of hematuria and pelvic injury	Mostly caused by automobile accidents
Classification of pain in the back based on etiology	Diease	Clinical Manifestation																	Diagnosis		Comments
		Symptoms											Signs						Lab findings	Imaging
		Onset	Duration	Quality of pain	Radiation	Stiffness	Fever	Rigors and chills	Headache	Nausea and vomiting	Syncopy	Weight loss	Motor weakness	Sensory deficit	Pulse Deficit	Heart Murmur	Bowel or bladder dysfunction	Horner's syndrome
Neurological	Arachnoiditis	Acute	Hours	Dull aching pain	Head, neck and back	+/-	+	+/-	+/-	+/-	+/-	+/-	+/-	+/-	-	-	+/-	+/-	CSF Elevated protein with normal or low glucose Culture and sensitivity May be due to TB or Meningitis Nucleic acid tests Helpful in tuberculous meningitis	Radiography Thickened nerve roots CT Narrowing of subarachnoid space Irregular collections of contrast material Thickened nerve roots MRI Study of choice shows indistinct cord outline	Usually caused by meningitis or TB
	Epidural abscess	Acute	Variable	Dull, throbbing pain	Locally	-	+/-	+/-	+/-	+/-	+/-	+/-	+/-	+/-	-	-	+/-	+/-	CBC May show leukocytosis, left shift, thrombocytopenia, and anemia ESR Elevated Culture and sensitivity To identify causative organism Immunohistochemical staining Includes gram stain, special stains for fungi and mycobacteria, also consider brucella	MRI Of choice and demonstrates fluid collection CT Demonstrates fluid collection Radiography Demonstrates osteomyelitis or vertebral collapse	LP carries risk of spread of infection
	Classification of pain in the back based on etiology	Diease	Clinical Manifestation																	Diagnosis		Comments
			Symptoms											Signs						Lab findings	Imaging
			Onset	Duration	Quality of pain	Radiation	Stiffness	Fever	Rigors and chills	Headache	Nausea and vomiting	Syncopy	Weight loss	Motor weakness	Sensory deficit	Pulse Deficit	Heart Murmur	Bowel or bladder dysfunction	Horner's syndrome
Bone
	Discitis	Chronic	Years	Dull aching or throbbing	Local	-	+	+/-	-	+/-	-	+/-	+/-	+/-	-	-	+/-	-	CBC May demonstrate leukocytosis ESR May be elevated CRP May be elevated Procalcitonin May be elevated Culture and sensitivity To identify causative agent	MRI Narrowing of disk space and low signalling indicates edema CT Detects lesions earlier than radiography, demonstrates hypodensity of disk and destruction of endplates and calcification of annulus Radiography Disk space narrowing with destruction of endplates and calcification of annulus Nuclear imaging Focal uptake of gallium-67 and technetium-99m in area of destruction	Most likely due to hematogenous spread of organism
	Vertebral compression fracture	Acute	Minutes to hours	Sudden, severe, sharp	Shoulders, arms, hips and legs	+/-	-	-	+/-	+/-	+/-	-	+/-	+/-	-	-	+/-	-	CBC Decreased hematocrit and anemia PSA To rule out prostate cancer Urine analysis To detect Bence - Jones protein Serum protein electrophoresis M spike is seen with multiple myeloma ESR May be elevated	Radiography Decreased vertebral body height CT Detects more subtle fractures and calcifications MRI Useful in those with motor weakness and sensory deficits May demonstrate hemorrhage, tumor, or infection DRA scanning Detects low bone density PET scanning To distinguish benign from malignant causes of compression	Presents as a midline back pain
	Vertebral osteomyelitis	Acute	Minutes to hours	Sudden, severe, sharp	Shoulders, arms, hips and legs	+/-	+	+/-	-	+/-	-	-	+/-	+/-	-	-	+/-	-	CBC Leukocytosis and left shift ESR Elevated CRP Elevated Procalcitonin Elevated Culture and sensitivity To identify causative agent	Radiography Demonstrates endosteal or medullary lesion Sequestration and cavity formation MRI Bone marrow abnormalities and lytic changes CT Articular and periarticular involvement Ultrasound Soft tissue abnormalities Nuclear imaging Loss of bone density	Often caused by hematogenous spread of organism
Classification of pain in the back based on etiology	Diease	Clinical Manifestation																	Diagnosis		Comments
		Symptoms											Signs						Lab findings	Imaging
		Onset	Duration	Quality of pain	Radiation	Stiffness	Fever	Rigors and chills	Headache	Nausea and vomiting	Syncopy	Weight loss	Motor weakness	Sensory deficit	Pulse Deficit	Heart Murmur	Bowel or bladder dysfunction	Horner's syndrome
Referred pain	Aortic aneurysm rupture - Abdominal aortic aneurysm - Thoracic aortic aneurysm	Acute	Minutes to hours	Sharp and knife-like, also tearing or ripping	Back and/ or flanks	-	-	-	-	-	+/-	-	-	-	+	+/-	-	-	Typically no specific lab findings, however, evidence of haemorrhage and organ injury may be seen in: Complete blood count; normochromic normocytic anemia seen in haemorrhage Elevated serum electrolytes Elevated liver function tests Elevated amylase or lipase	Ultrasonography Visualization of aneurysm, size and/or rupture and hematoma Chest radiography Visualizes calcifications in aneurysm but not specific CT Demonstrates aortic size, extent, and involvement of organ arteries MRI Has advantage of less radiation and no use for dye, whilst demonstrating same findings as ultrasound and CT Angiography Allows 3D construction of aorta Echocardiography (Transesophageal) Demonstrates fluid shift and need for cardiology intervention	Livedo reticularis may be seen and indicates thrombotic phenomenon
	Appendicitis	Acute	Minutes to hours	Burning	Umbilicus and lower right quadrant	-	+	+/-	-	+	-	-	-	-	-	-	-	-	CBC Demonstrates leukocytosis and neutrophilia CRP May be elevated Urine analysis May demonstrate pyuria, hematuria, and/or proteinuria Urine 5-HIAA Maybe an early marker of appendictis Sudden increase may indicate necrosis	Ultrasound Demonstrates a non-compressible tubular structure CT Demonstrates an enlarged appendix with thickened walls and can detect abnormally located appendices MRI Useful in pregnant ladies KUB Radiography May detect an appendicolith Barium enema Demonstrates absent or incomplete filling Cecal spasm may be present Radionuclide scanning Appendiceal inflammation may be present	Pain begins around the umbilicus and then shifts to RUQ
	Cholelithiasis	Acute or subacute	Minutes or hours	Sharp	Tip of right shoulder	-	+/-	+/-	-	+	-	+/-	-	-	-	-	-	-	CBC Demonstrates polymorphnuclear leukocytosis LFT Elevated alanine aminotransferase and aspartate aminotransferases Elevated conjugated bilirubin Amylase and lipase Elevated	Radiography Radio-opaque stones may be present CT May indicate presence of gallstones in the distal common bile duct MRI May indicate presence of gallstones in the distal common bile duct Ultrasound May demonstrate gallbladder wall thickening (>5 mm) and gallbladder fluid and distention Gallstones may appear as echogenic foci that cast an acoustic shadow Scintigraphy May detect cystic duct obstruction ERCP Stones are seen as a filling defect and can be removed simultaneously PTC Similar to ERCP Used when ERCP is not feasible	May be completely asymptomatic
	Chronic stable angina	Chronic	Variable	Discomfort in the chest	Left shoulder, arm and jaw	-	-	-	-	+/-	+/-	-	-	-	+/-	-	-	-	Detection of: Urinary proton nuclear magnetic resonance spectroscopy Toll-like receptors 2 and 4 (TLR-2 and TLR-4)  on platelets	Chest radiography Normal, may show calcification or complications such as pleural effusion Exercise stress testing Establishes diagnosis and extent of angina Stress Echo To evaluate wall motion, normal in stable angina Nuclear imaging To assess myocardial perfusion, reduced in stable angina CT To evaluate coronary artery calcium (cac) which may or may not be elevated CT Angiography To evaluate stenosis, <70% in stable angina EKG Normal in stable angina	Hallmark is relief by rest or sublingual nitroglycerin
	Endocarditis	Acute or subacute	Variable	Discomfort in the chest	Jaw and arms	-	+/-	+/-	-	+/-	+/-	-	-	-	+/-	+	-	-	CBC Anemia and leukocytosis may be noted Serology Decrease C3, C4, and CH50 may indicate subacute endocarditis Rheumatoid factor may be positive ESR May be elevated Urine analysis May demonstrate proteinuria and microscopic hematuria Blood culture To identify causative agent Streptococci and HACEK organisms are culture negative Organisms that grow on prosthetic valves tend to be coagulase-negative staphylococci	Echocardiography Vegetations and myocardial abscesses may be present Radiography Pyogenic emboli may be seen across the lung field Ultrasound Myocardial abscesses may be seen Valvular dysfunction may also be noted	IV drug users and those who suffer from rheumatic heart disease often present with infective endocarditis
	Nephrolithiasis	Acute	Hours	Severe, sharp	Abdomen, hips, groin, legs	-	+/-	+/-	-	+/-	-	-	-	-	-	-	-	-	CBC Mild leukocytosis may indicate infection Electrolytes Hypokalemia may indicate acute tubular necrosis Hypercalcemia or hypercalciuria may be detected Creatinine To identify potential renal injury with contrast Uric acid Uric acid stones sometimes occur with gout ABG May indicate acute tubular necrosis with hypokalemia and decreased bicarbonate	CT Visualizes calcium stones and other possible pathologies, such as hydronephrosis IVP Visualizes stones and entire urinary system KUB radiography Radio-opaque stones may be present Ultrasound For visualization of stones Plain renal tomography Can distinguish between intrarenal and extrarenal calcifications Retrograde pyelography Particularly useful for ureteric calculi visualization Nuclear renal imaging May determine a decreased renal function	Hypercalcemia may indicate primary or secondary hyperparathyroidism
	Pancreatitis	Acute or chronic	Variable	Severe, sharp or dull aching	Abdomen	-	+/-	+/-	-	+	+/-	+/-	-	-	-	-	-	-	Amylase and lipase Elevated LFT Elevated alkaline phosphatase, total bilirubin, aspartate aminotransferase, and alanine aminotransferase CBC May demonstrate leukocytosis Serum electrolytes May indicate hypo or hypercalcemia BUN and creatinine May be elevated Triglycerides Usually elevated, however, falsely lowered during acute attack	KUB radiography May demonstrate free air within abdomen, indicating a perforated viscus Ultrasound Used to visualize the pancreas and biliary tree May detect microlithiasis and periampullary lesions CT Pancreas may appear enlarged MRC May demonstrate a blockage within the biliary ducts ERCP May remove a blockage, however, can in fact cause pancreatitis	Usually caused by binge drinking or long standing gallstones that block the ampulla of Vater Vomiting is a common manifestation
	Pelvic inflammatory disease	Acute or chronic	Variable	Dullaching or throbbing	Hips, groin, legs	-	+/-	+/-	-	+/-	-	-	-	-	-	-	-	-	CBC Leukocytosis, may indicate infection with trichomoniasis Pregnancy test To rule out ectopic pregnancy STD panel To rule out gonorrhea, chlamydia, hepatitis B and C, HIV, and syphilis Urine analysis To rule out a urinary tract infection	Transvaginal ultrasound May demonstrate anechoic structures in adnexa indicating hydrosalpinx and/or pyosalpinx Laparoscopy May demonstrate adhesions (Asherman's syndrome) or gun powder lesions (Endometriosis) or an ectopic pregnancy MRI and CT May indicate hydro and/ or pyosalpinx	Inflammation may spread to perihepatic structures (Fitz-Hugh−Curtis syndrome)
	Pulmonary embolism	Acute	Minutes	Severe, sharp	Chest and back	+/-	-	-	+/-	+/-	+/-	-	-	-	+/-	+/-	-	-	Lab findings are not specfic and are done to rule out other diseases such as: Antithrombin III deficiency Protein Cor protein S deficiency Lupus Homocystinuria Malignancy Connective tissue disorders	D - dimer is positive and ventilation- perfusion scanning will show a a perfusion/ventilation mismatch CT Angiography and duplex angiography are able to visualize the embolism	PE may occur even in patients that are fully anticoagulated DVT is a common source
	Pyelonephritis	Acute or chronic	Variable	Severe, sharp or dull aching	Groin, hips and legs	-	+	+/-	-	+/-	-	-	-	-	-	-	+/-	-	CRP Elevated ESR Elevated Urinalysis Pyuria Bacteriuria May be nitrite positive (gram negative organisms) Culture positibe (Uncomplicated: E. coli, Proteus mirabialis, Klebsiella, S. saprophyticus- Complicated: E. coli, enterococci, S.epidermidis	Ultrasound Hydronephrosis Non-contrast CT Pelvicalceal dilation Cortical involvement MRI T1: affected region(s) appear hypointense compared with the normal kidney parenchyma T2: hyperintense compared to normal kidney parenchyma T1 C+: reduced enhancement	Renal stones Obstruction Pregnancy Prolonged urinary catheterization
	Pneumonia	Acute or chronic	Variable	Variable	Chest, back and abdomen	-	+	+	+/-	+/-	+/-	+/-	-	-	-	-	-	-	CBC Leukocytosis is often demonstrated however, white blood cell count may be normal Blood culture To identify causative organism or rule out other organisms such as MRSA	Radiography Plain x-ray shows multiple patches in the lung fields CT Used to distinguish pneumonia from non-pneumonias	Hospital-acquired pneumonia is common
	Waterhouse-Friderichsen syndrome	Acute	Minutes to hours	Sudden, severe, sharp	Back and/or flanks	-	+	+/-	+/-	+/-	+/-	+/-	-	-	-	-	-	-	CBC May show decreased hemotocrit, leukocytosis and rarely, eosinophilia Serum electrolytes Hyponatremia Hyperkalemia Hypercalcemia Blood urea nitrogen Elevated Creatinine Elevated Plasma glucose  Hypoglycemia Serum cortisol Decreased Plasma ACTH Elevated	CT Shows adrenal enlargement or adrenal aymmetry	Short cosyntropin (Cortrosyn) stimulation test confirms the diagnosis
	Classification of pain in the back based on etiology	Diease	Clinical Manifestation																	Diagnosis		Comments
Symptoms											Signs						Lab findings	Imaging
Onset	Duration	Quality of pain	Radiation	Stiffness	Fever	Rigors and chills	Headache	Nausea and vomiting	Syncopy	Weight loss	Motor weakness	Sensory deficit	Pulse Deficit	Heart Murmur	Bowel or bladder dysfunction	Horner's syndrome
Miscellaneous	Chronic fatigue syndrome	Chronic	Years	Dull aching	Variable	+/-	-	-	+/-	+/-	-	-	-	-	-	-	-	-	Typically no specific lab findings, however, serology may be somewhat specific and demonstrate; Elevated IgM and/or IgG in coxsackie virus B titer Elevated IgM and/or IgG human herpes virus 6 titer Elevated IgM/IgG in C pneumoniae titer Decrease in natural killer cell percentage or activity Labs used to exclude other pathologies include; CBC May demonstrate leukopenia or leukocytosis LFT May demonstrate elevated serum transaminases, alkaline phosphatase, or lactic dehydrogenase TFT To rule out hypo/hyperthyroidism ESR Usually low Serum electrolytes Hypokalemia or hypocalcemia may be noted ANA May indicate an autoimmune disease Cortisol May indicate pathology of the adrenal gland Serum protein electrophoresis To rule out myeloma or lymphoma	CT and MRI Used to exclude other pathologies PET May demonstrate hypoperfusion of the frontoparietal and/or temporal region of the brain	Usually diagnosed by exclusion
	Depression	Chronic	Months to years	Severe to mild aching	Variable	+/-	-	-	+/-	+/-	+/-	+/-	-	-	-	-	-	-	Typically no specific lab findings Lab testing is used to diagnose organic causes and include; CBC TFT Vitamin B-12 detection Rapid plasma reagin HIV testing Electrolytes, especially calcium, phosphate, and magnesium levels BUN and creatinine LFTs Blood alcohol level Blood and urine toxicology screen ABG Dexamethasone suppression test Cosyntropin stimulation test	CT and MRI To rule out organic brain syndrome or hypopituitarism PET Allows for study of ligand-receptor binding SPECT May demonstrate regional blood flow deficits in the left anterofrontal and temporal regions	Must assess suicidal ideation
	Dysmenorrhea	Acute	3 - 7 days	Burning, dull aching or severe	Groin, hips, legs	-	-	-	+/-	+/-	-	-	-	-	-	-	-	-	Typically no specific lab findings Lab tests are done to rule out organic causes, and include; CBC Infection (leukocytosis) or malignancy STD panel Gonorrhea, chlamydia, and PID Beta - Human chorionic gonadotropin Elevated in pregnancy ESR Elevated in subacute salpingitis Urine analysis To rule out urinary tract infection Stool guaiac test To rule out gastrointestinal bleeding	Ultrasound May reveal endometriosis as complex mass with specks Ectopic pregnancy Ovarian cysts Fibroids Intrauterine contraceptive device Hysterosalpingography May demonstrate endometrial polyps Leiomyomas Congenital abnormalities of the uterus IVP May demonstrate a uterine malformation CT May demonstrate ovarian torsion MRI May detect adenomyosis Submucous myomas	Laparoscopy, hysteroscopy, and dilatation and curettage are useful in diagnosis and therapy
	Herpes zoster	Acute or chronic	Variable	Severe, stabbing, electric-like	Dermatomal	-	+/-	+/-	+/-	+/-	+/-	+/-	-	+/-	-	-	-	-	Tzanck smear May demonstrate multinucleated giant cells Direct fluorescent antibody test and/or PCR Allows for differentiation between HSV and VZV	Typically no routine imaging MRI Used to exclude myelopathy or encephalopathy Lumbar puncture and cerebrospinal fluid analysis In cases of suspected meningitis, increased protein and pleocytosis will be noted
	Pregnancy	Chronic	Pregnancy term	Dull aching	Groin, hips, legs	+/-	-	-	-	-	-	-	-	-	-	-	-	-	Beta - human chorionic gonadotropin If detected usually confirms pregnancy	Typically no routine imaging is done to prevent radiation exposure, unless complication occurs an MRI may be carried out
	Syringomyelia	Chronic	Years	Dull aching	Variable	+/-	+/-	-	+/-	+/-	-	-	-	-	-	-	-	-	*Typically no specific lab findings	MRI Of choice and demonstrates a syrinx (spinal cord cyst) May also be useful in assessment of CSF flow dynamics Radiography and CT May also visualize a syrinx Gadolinium scan Useful in assessment of post-operative patients and can distinguish between a tumor, scar, and disk material Myelography Used when MRI is unfruitful, and may detect widening of spinal cord and complete subarachnoid block
	Trauma	Acute or chronic	Variable	Severe, sharp to dull aching	Variable	+/-	-	-	-	+/-	+/-	-	+/-	+/-	-	-	+/-	+/-	After establishment of first aid protocol, the following lab tests may be useful; Pregnancy test In women of child-bearing age Blood typing, screening and cross matching In case of blood transfusion Prothrombin time To assess those taking warfarin Creatine kinase To determine incidence of rhadomyolysis Blood sugar To determine hypoglycemia Cardiac enzymes To determine incidence of myocardial infarction Toxicology screen and alcohol level To determine alcoholism and drug use Serum lactate Elevated serum lactate may indicate a serious injury	To assess trauma, the following imaging may be used; Portable radiography Ultrasound CT Peritoneal tap or lavage Echocardiography
	Ureteropelvic junction obstruction (UPJ)	Acute	Hours to days	Dull aching	Groin, hips, legs	-	+/-	+/-	+/-	+/-	-	-	-	-	-	-	+/-	-	CBC To rule out anemia Coagulation profile To rule out bleeding Electrolyte levels To rule out nephrolithiasis BUN and serum creatinine To assess kidney function Urine culture To rule out urinary tract infection	Voiding cystourethrography May demonstrate vesicoureteral reflux Ostruction usually shows hydronephrosis without reflux Renal ultrasonography May determine kidney malformation and scarring Dilation of collecting system Annular stricturing IVP May demonstrate a hydronephrotic kidney Used to map out entire urinary system CT and MRU Provides detail about the urinary system such as; Renal vasculature Renal pelvis anatomy Location of crossing vessels Renal cortical scarring Ureteral fetal folds in the proximal ureter Doppler Used to detect cross vessels associated with obstruction MRA May demonstrate aberrant renal vessels	Congenital abrnormalities in both children and adults are usually the cause of UPJ obstruction