View source for Spontaneous bacterial peritonitis differential diagnosis

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[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Spontaneous_bacterial_peritonitis]]
{{CMG}} ; {{AE}} {{SCh}};{{AY}}

==Overview==
[[SBP]] must be differentiated from other abdominal conditions presenting with [[fever]] and [[abdominal pain]]. It also has to be differentiated from [[secondary peritonitis]], [[Peritonitis|chemical peritonitis]], [[peritoneal dialysis]] [[peritonitis]], [[Tuberculous peritonitis|chronic tuberculous peritonitis]].

==Differentiating Spontaneous bacterial peritonitis from other Diseases==
[[Spontaneous bacterial peritonitis]] presents with [[fever]] and [[abdominal pain]]. Diseases presenting with similar features include: 

{| border="1"
|+ 
'''Differentiating secondary peritonitis from spontaneous bacterial peritonitis'''
! colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Characteristic}}
! colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Spontaneous bacterial peritonitis}}  
! colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Secondary peritonitis}}
|-
!Presentaion
|
* Main manifestations of [[peritonitis]] are acute abdominal [[Abdominal pain|pain]], [[Abdominal tenderness|tenderness]], and [[Abdominal guarding|guarding]], which are exacerbated by moving the peritoneum, e.g. coughing, flexing the hips, or elicitingthe [[Blumberg sign]] (a.k.a. [[rebound tenderness]]) 
|
* Similar presentation but insidious onset unlike rapid onset in [[SBP]]
|-
![[Microorganism]]
|
* Monomicrobial involvement is common
* No identifiable source of [[intra-abdominal infection]]
|
* Polymicrobial involvement is common
* Identifiable source of [[intra-abdominal infection]], with or without perforation (surgically treatable source)<ref name="pmid6724512">{{cite journal| author=Runyon BA, Hoefs JC| title=Ascitic fluid analysis in the differentiation of spontaneous bacterial peritonitis from gastrointestinal tract perforation into ascitic fluid. | journal=Hepatology | year= 1984 | volume= 4 | issue= 3 | pages= 447-50 | pmid=6724512 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6724512  }} </ref>
|-
![[Diagnostic criteria]]
| valign="top" |[[SBP]] is diagnosed in the presence of:<ref name="pmid3729637">{{cite journal| author=Runyon BA, Hoefs JC| title=Spontaneous vs secondary bacterial peritonitis. Differentiation by response of ascitic fluid neutrophil count to antimicrobial therapy. | journal=Arch Intern Med | year= 1986 | volume= 146 | issue= 8 | pages= 1563-5 | pmid=3729637 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3729637  }} </ref> 
* [[Ascitic|Ascitic fluid]] [[PMN]] count of  ≥250/mm3
* No evident [[Intra-abdominal infection|intra-abdominal source of infection]]
* Positive [[Bacterial cultures|ascitic fluid bacterial culture]]
|Diagnosed in the presence of 
* Positive [[Bacterial cultures|ascitic fluid bacterial culture]]
* Ascitic fluid [[PMN]] count of ≥250/mm3
* Evidence of a source of infection (demonstrated at surgery or autopsy], either intra-abdominal or contiguous with the [[peritoneal cavity]]
|-
!Follow-up paracentesis 
|
* [[Ascitic|Ascitic fluid]] usually became sterile after one dose of [[antibiotic]]
|
* Failure of the [[Ascites|ascitic fluid]] to become culture-negative despite of initial [[Antibiotic|antibiotic treatment]], appears to be typical of secondary peritonitis due to continuous spillage of [[organisms]] into [[abdominal cavity]] which requires surgery.<ref name="pmid3518442">{{cite journal| author=Runyon BA| title=Bacterial peritonitis secondary to a perinephric abscess. Case report and differentiation from spontaneous bacterial peritonitis. | journal=Am J Med | year= 1986 | volume= 80 | issue= 5 | pages= 997-8 | pmid=3518442 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3518442  }} </ref><ref name="pmid2293571">{{cite journal| author=Akriviadis EA, Runyon BA| title=Utility of an algorithm in differentiating spontaneous from secondary bacterial peritonitis. | journal=Gastroenterology | year= 1990 | volume= 98 | issue= 1 | pages= 127-33 | pmid=2293571 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2293571  }} </ref>
|}

{| style="margin: 1em 1em 1em 0; background: #f9f9f9; border: 1px #aaa solid; border-collapse: collapse;" cellspacing="0" cellpadding="4" border="2"
|+'''Differentiating SBP from other causes of peritonitis'''
! colspan="2" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF| '''Disease'''}}
! colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF| '''Prominent clinical findings'''}}
! colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF| '''Lab tests'''}}
! colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF| '''Tratment'''}}
|-
| rowspan="3" |'''Primary peritonitis'''
|'''[[Primary peritonitis|Spontaneous bacterial peritonitis]]'''
|
* Absence of GI [[perforation]], most closely associated with [[cirrhosis]] and [[Liver disease|advanced liver disease]]. 
* Presents with abrupt onset of [[fever]], [[abdominal pain]], [[distension]], and [[rebound tenderness]]. 
|
* Most have clinical and biochemical manifestations of advanced [[cirrhosis]] or [[nephrosis]] like [[leukocytosis]],[[hypoalbuminemia]], 
* Prolonged [[prothrombin]] time. SAAG >1.1 g/dL, increased serum [[lactic acid]] level, or a decreased [[Ascites|ascitic fluid]] pH (< 7.31) supports the diagnosis. [[Gram staining]] reveals bacteria in only 25% of cases.
* Diagnosed by analysis of the [[Ascitic|ascitic fluid]] which reveals [[WBC]] > 500/ML, and [[PMN]] >250cells/ml. 
* [[Culture medium|Culture]] of ascitic fluid inoculated immediately into [[blood culture]] media at the bedside usually reveals a single [[Enteric Bacilli|enteric organism]], most commonly ''[[Escherichia coli]]'', ''[[Klebsiella]]'', or [[streptococci]]. 
|
* Once diagnosed,it is treated with [[Ceftriaxone]].
|-
|'''[[Tuberculous peritonitis]]'''
|
* Seen in 0.5% of new cases of [[tuberculosis]] particularly in young women in endemic areas as a primary infection.
* Presents with [[abdominal pain]] and [[distension]], [[fever]], [[night sweats]], [[weight loss]], and altered bowel habits. 
|
* [[Ascites]] is present in about half of cases. [[Abdominal mass]] may be felt in a third of cases. The [[peritoneal fluid]] is characterized by a [[protein]] concentration > 3 g/dL with < 1.1 g/dL SAAG and [[Lymphocyte|lymphocyte predominance]] of [[WBC]]. 
* Definitive diagnosis in 80% of cases is by culture. Most patients presenting acutely are diagnosed only by [[laparotomy]].
|
* Combination [[Antituberculosis|antituberculosis chemotherapy]] is preferred in chronic cases.
|-
|'''[[Continuous ambulatory peritoneal dialysis|Continuous Ambulatory Peritoneal Dialysis]]''' [[Continuous ambulatory peritoneal dialysis|('''CAPD peritonitis)''']]
|
* [[Peritonitis]] is one of the major complications of [[peritoneal dialysis]] & 72.6% occurred within the first six months of [[peritoneal dialysis]]. 
* Historically, [[coagulase-negative staphylococci]] were the most common cause of peritonitis in [[Continuous ambulatory peritoneal dialysis|CAPD]], presumably due to touch contamination or infection via the pericatheter route. 
* Treatment for [[peritoneal dialysis]]-associated peritonitis consists of [[Antimicrobial drug|antimicrobial therapy]], in some cases catheter removal is also warranted. 
* Additional therapies for [[Peritonitis|relapsing or recurrent peritonitis]] may include [[Fibrinolytic agent|fibrinolytic agents]] and [[peritoneal lavage]]. Most episodes of peritoneal dialysis-associated peritonitis resolve with outpatient [[Antibiotic|antibiotic treatment]]. 
|
* Majority of [[peritonitis]] cases are caused by [[bacteria]] (50%-due to [[Gram-positive bacteria|gram positive]] organisms, 15% to [[gram negative]] organisms,20% were culture negative.2% of cases are caused by [[fungi]], mostly [[Candida]] species. Polymicrobial infection in 4%.Exit-site infection was present in 13% and a [[peritoneal fluid]] leak in 3 % and [[M.tuberculosis]] 0.1%.
|
* [[Antibiotic|Initial empiric antibiotic coverage]] for peritoneal dialysis-associated peritonitis consists of coverage for [[gram-positive]] organisms (by [[vancomycin]] or a [[Cephalosporins|first-generation cephalosporin]]) and [[gram-negative]] organisms (by a [[cephalosporin|third-generation cephalosporin]] or an [[aminoglycoside]]). Subsequently, the regimen should be adjusted based on [[Culture medium|culture]] and [[sensitivity]] data. Cure rates are approximately 75%.
|-
| rowspan="2" |'''[[Secondary peritonitis]]'''
|'''Acute [[bacterial]] [[secondary peritonitis]]'''
|
* Occurs after perforating, penetrating, inflammatory, infectious, or [[ischemic]] injuries of the GI or GU tracts. Most often follows disruption of a hollow viscus→chemical peritonitis→bacterial peritonitis(polymicrobial, includes [[aerobic]] [[gram negative]] {[[E coli]], [[Klebsiella]], [[Enterobacter]], [[Proteus mirabilis]]} and gram positive { [[Enterococcus]], [[Streptococcus]]} and [[anaerobes]] {[[Bacteroides]], [[clostridia]]}). 
* Presents with [[abdominal pain]], [[tenderness]], [[guarding]] or rigidity, [[distension]], free peritoneal air, and diminished [[bowel sounds]]. Signs that reflect irritation of the parietal peritoneum resulting [[ileus]]. Systemic findings include [[fever]], [[chills]] or [[rigors]], [[tachycardia]], [[sweating]], [[tachypnea]], [[restlessness]], [[dehydration]], [[oliguria]], [[disorientation]], and, ultimately, refractory [[shock]]. 
|
|
* [[Peritoneal lavage]], [[Laparoscopy]] are the treatment of choice.
|-
|'''[[Biliary]] [[Secondary peritonitis|peritonitis]]'''
|
* Most often seen in cases of rupture of pathological [[gallbladder]] or [[bile duct]] or [[Cholangitis|cholangitic abscess]] or secondary to obstruction of  the [[biliary tract]].
* Seen in alcoholic patients with [[ascites]].
|
|
|-
| colspan="2" |'''[[Peritonitis|Tertiary peritonitis]]'''
|
* Persistence or recurrence of [[Infection|intraabdominal infection]] following apparently adequate therapy of [[Peritonitis|primary or secondary peritonitis]]. 
* Associated with [[Mortality|high mortality]] due to multi organ dysfunction. It presents in a similar way as other [[peritonitis]] but is recognized as an adverse outcome with poor prognosis.
|
* [[Enterococcus]], [[Candida]], [[Staphylococcus epidermidis]], and [[Enterobacter]] being the most common organisms.
|
* Characterized by lack of response to appropriate surgical and [[antibiotic therapy]] due to disturbance in the hosts [[immune response]].
|-
| colspan="2" |'''[[Familial mediterranean fever|Familial Mediterranean fever (periodic peritonitis, familial paroxysmal polyserositis)]]'''
|
* Rare [[Genetic disorder|genetic condition]] which affects individuals of Mediterranean genetic background. 
* Etiology is unclear.
* Presents with recurrent bouts of [[abdominal pain]] and [[tenderness]] along with [[pleuritic]] or [[joint pain]]. [[Fever]] and [[leukocytosis]] are common. 
|
|
* [[Colchicine]] prevents but does not treat acute attacks.
|-
| colspan="2" |'''[[Granulomatous peritonitis]]'''
|
* A rare condition caused by disposable surgical fabrics or food particles from a [[perforated ulcer]], eliciting a vigorous [[granulomatous]] ([[Hypersensitivity|delayed hypersensitivity]]) response in some patients 2-6 weeks after [[laparotomy]]. 
* Presents with [[abdominal pain]], [[fever]], [[nausea and vomiting]], [[ileus]], and systemic complaints, mild and diffuse [[abdominal tenderness]]. 
|
* Diagnosed by the demonstration of diagnostic Maltese cross pattern of starch particles.
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* The disease is self-limiting.
* Treated with [[corticosteroids]] or [[Anti inflammatory medications|anti-inflammatory agents]].
|-
| colspan="2" |'''[[Sclerosing encapsulating peritonitis]]'''
|
* Seen in conditions associated with long term [[peritoneal dialysis]], shunts like [[Ventriculoperitoneal shunt|VP shunts]], history of [[Abdominal surgery|abdominal surgeries]], [[liver transplantation]]. 
* Symptoms include [[nausea]], [[abdominal pain]], [[diarrhea]], [[anorexia]], bloody [[ascites]].
|
|
|-
| colspan="2" |'''[[Abscess|Intraperitoneal abscesses]]'''
|
* Most common etiologies being [[Perforation|Gastrointestinal perforations]], postoperative complications, and penetrating injuries. 
* Signs and symptoms depend on the location of the [[abscess]] within the [[peritoneal cavity]] and the extent of involvement of the surrounding structures.
* Diagnosis is suspected in any patient with a predisposing condition. In a third of cases it occurs as a sequela of [[Peritonitis|generalized peritonitis]]. 
* The pathogenic organisms are similar to those responsible for [[peritonitis]], but [[anaerobic]] organisms occupy an important role.
* The [[mortality rate]] of serious [[Abscesses|intra-abdominal abscesses]] is about 30%.
|
* Diagnosed best by [[CT-scans|CT]] scan of the abdomen.
|
* Treatment consists of prompt and complete [[CT]] or [[Ultrasound|US]] guided drainage of the [[abscess]], control of the primary cause, and adjunctive use of effective [[Antibiotics|antibiotics.]] Open drainage is reserved for [[abscesses]] for which percutaneous drainage is inappropriate or unsuccessful.
|-
| colspan="2" |'''[[Peritoneal mesothelioma]]'''
|
* Arises from the [[mesothelium]] lining the [[peritoneal cavity]]. 
* Its incidence is approximately 300-500 new cases being diagnosed in the United States each year.  As with [[pleural mesothelioma]], there is an association with an [[Asbestos|asbestos exposure]].
* Most commonly affects men at the age of 50-69 years. Patients most often present with [[abdominal pain]] and later increased abdominal girth and [[ascites]] along with [[anorexia]], [[weight loss]] and [[abdominal pain]]. 
* Mean time from diagnosis to death is less than 1 year without treatment.  
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* [[Computed tomography|CT]] with [[Contrast|intravenous contrast]] typically demonstrates the thickening of the [[peritoneum]]. [[Laparoscopy]] with tissue biopsy or CT guided tissue biopsy with [[immunohistochemical staining]] for [[calretinin]], [[cytokeratin|cytokeratin 5/6]], [[mesothelin]], and [[WT1|Wilms tumor 1 antigen]] remain the [[Gold standard (test)|gold standard]] for diagnosis.
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* At [[laparotomy]] the goal is cytoreduction with [[excision]]. Debulking surgery and intraperitoneal [[chemotherapy]] improves survival in some cases.
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| colspan="2" |'''[[peritoneal carcinomatosis]]'''
|
* Associated with a history of [[ovarian]] or [[Malignancy|GI tract malignancy]].
* Symptoms include [[ascites]], [[abdominal pain]], [[nausea]], [[vomiting]].
|
|
|}

==Differentiating spontaneous bacterial peritonitis from other diseases that may cause abdominal pain==
{| align="center"
|-
|
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
! colspan="2" rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" | Classification of acute abdomen based on etiology
! colspan="1" rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Presentation
! colspan="3" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Symptoms
! colspan="3" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Signs
! colspan="2" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Diagnosis
! colspan="1" rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" | Comments
|-
! colspan="1" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Fever 
! style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal Pain
! style="background:#4479BA; color: #FFFFFF;" align="center" |Jaundice 
! colspan="1" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Guarding
! style="background:#4479BA; color: #FFFFFF;" align="center" |Rebound Tenderness
! style="background:#4479BA; color: #FFFFFF;" align="center" |Bowel sounds
! colspan="1" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Lab Findings
! style="background:#4479BA; color: #FFFFFF;" align="center" |Imaging
|-
! colspan="1" rowspan="8" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Common causes of Peritonitis
! colspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Primary Peritonitis
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Spontaneous bacterial peritonitis]] 
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Diffuse
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Ascitic fluid [[PMN]]>250 cells/mm<small>³</small>

* Culture: Positive for single organism 
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound for evaluation of liver cirrhosis
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
|-
! colspan="1" rowspan="7" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Secondary Peritonitis
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Perforated [[Gastric ulcer|gastric]] and [[duodenal ulcer]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | Diffuse
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Ascitic fluid
** [[LDH]] > serum [[LDH]]

** Glucose < 50mg/dl

** Total protein > 1g/dl 

| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Air under [[diaphragm]] in upright [[CXR]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Upper GI [[endoscopy]] for diagnosis
|-
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Acute cholangitis 
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | [[RUQ]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Abnormal [[LFT]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound shows [[biliary]] dilatation
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Biliary drainage ([[Endoscopic retrograde cholangiopancreatography|ERCP]]) + IV antibiotics
|-
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Acute cholecystitis|Acute cholecystitis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | [[RUQ]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Hyperbilirubinemia]]
* [[Leukocytosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound shows gallstone and evidence of inflammation
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Murphy's sign|Murphy’s sign]]
|-
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |  [[Acute pancreatitis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | [[Epigastric]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +/-
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Increased [[amylase]] / [[lipase]] 
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound shows evidence of [[inflammation]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Pain radiation to back
|-
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Acute appendicitis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | RLQ
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound shows evidence of [[inflammation]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Nausea and vomiting|Nausea & vomiting]], [[decreased appetite]]
|-
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Diverticulitis|Acute diverticulitis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | LLQ
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +/-
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan and ultrasound shows evidence of inflammation
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
|-
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Salpingitis|Acute salpingitis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | LLQ/ RLQ
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +/-
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +/-
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Pelvic ultrasound]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Vaginal discharge]]
|-
! colspan="2" rowspan="4" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Hollow Viscous Obstruction 
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Small intestine obstruction
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Diffuse
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +/-
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive then absent
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Abdominal X-ray|Abdominal X ray]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Nausea and vomiting|Nausea & vomiting]] associated with [[constipation]], [[Abdominal distension|abdominal distention]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Volvulus]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Diffuse
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>+</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan and [[Abdominal x-ray|abdominal X ray]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Nausea and vomiting|Nausea & vomiting]] associated with [[constipation]], [[Abdominal distension|abdominal distention]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Biliary colic]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |RUQ
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Increased [[bilirubin]] and [[alkaline phosphatase]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Nausea and vomiting|Nausea & vomiting]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Renal colic]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Flank pain]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Hematuria]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan and ultrasound
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Colicky [[abdominal pain]] associated with [[Nausea and vomiting|nausea & vomiting]]
|-
! rowspan="4" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Vascular Disorders
! rowspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Ischemic causes 
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Mesenteric ischemia]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>+/-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Periumbilical
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]] and [[lactic acidosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Nausea and vomiting|Nausea & vomiting]], normal physical examination
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Ischemic colitis|Acute ischemic colitis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>+/-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Diffuse
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>+</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>+</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive then absent
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Nausea and vomiting|Nausea & vomiting]]
|-
! rowspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Hemorrhagic causes
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Ruptured abdominal aortic aneurysm]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Diffuse
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Normal
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan 
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Unstable hemodynamics
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Intra-abdominal or [[retroperitoneal hemorrhage]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Diffuse
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Anemia]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |History of [[trauma]]
|-
! rowspan="3" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Gynaecological Causes 
! rowspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Ovarian cyst|Ovarian Cyst]] Complications
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Torsion of the cyst
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |RLQ / LLQ
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>+/-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>+/-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Increased [[ESR]] and [[CRP]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Sudden onset sever pain with [[nausea and vomiting]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Cyst rupture
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |RLQ / LLQ
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>+/-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>+/-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Increased [[ESR]] and [[CRP]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Sudden onset sever pain with [[nausea and vomiting]]
|-
! style="padding: 5px 5px; background: #DCDCDC;" align="center" |Pregnancy
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Ruptured [[ectopic pregnancy]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |RLQ / LLQ
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |<nowiki>-</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Positive [[pregnancy test]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |History of missed period and [[vaginal bleeding]]
|-
|}

==References==
{{reflist|2}}
 [[Category:Emergency mdicine]]
[[Category:Disease]]
[[Category:Primary care]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]