Abdominal pain differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]Amandeep Singh M.D.[3]

Overview

Diagnosing the cause of abdominal pain can be difficult, because many diseases can cause this symptom. Most frequently the cause is benign and/or self-limiting, but more serious causes may require urgent intervention. Acute abdominal pain is a severe, persistent abdominal pain of sudden onset that is likely to require surgical intervention to treat its cause. The following table summarizes differential diagnosis for abdominal pain.

Differential diagnosis of abdominal pain

Classification of acute abdomen based on etiology Presentation Clinical findings Diagnosis Comments Fever Rigors and Chills Abdominal Pain Jaundice Hypotension Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Common causes of Peritonitis Spontaneous bacterial peritonitis + Diffuse − − − − Hypoactive Ascitic fluid PMN>250 cells/mm³ Culture: Positive for single organism Ultrasound for evaluation of liver cirrhosis - Perforated gastric and duodenal ulcer + Diffuse − + + + N Ascitic fluid LDH > serum LDH Glucose < 50mg/dl Total protein > 1g/dl Air under diaphragm in upright CXR Upper GI endoscopy for diagnosis Acute suppurative cholangitis + + RUQ + + + + ± Acute cholangitis + − RUQ + − − − N Abnormal LFT Ultrasound shows biliary dilatation Biliary drainage (ERCP) + IV antibiotics Acute cholecystitis + RUQ + − − Hypoactive Hyperbilirubinemia Leukocytosis Ultrasound shows gallstone and evidence of inflammation Murphy’s sign Acute pancreatitis + Epigastric ± − − N Increased amylase / lipase Ultrasound shows evidence of inflammation Pain radiation to back Acute appendicitis + RLQ − + + Hypoactive Leukocytosis Ultrasound shows evidence of inflammation Nausea & vomiting, decreased appetite Acute diverticulitis + LLQ ± + − Hypoactive Leukocytosis CT scan and ultrasound shows evidence of inflammation Hollow Viscous Obstruction Small intestine obstruction − Diffuse − + ± Hyperactive then absent Leukocytosis Abdominal X ray Nausea & vomiting associated with constipation, abdominal distention Gall stone disease/Cholelithiasis ± − Volvulus - Diffuse - + - Hypoactive Leukocytosis CT scan and abdominal X ray Nausea & vomiting associated with constipation, abdominal distention Biliary colic - RUQ + - - N Increased bilirubin and alkaline phosphatase Ultrasound Nausea & vomiting Renal colic - Flank pain - - - N Hematuria CT scan and ultrasound Colicky abdominal pain associated with nausea & vomiting Vascular Disorders Ischemic causes Mesenteric ischemia ± Periumbilical - - - Hyperactive Leukocytosis and lactic acidosis CT scan Nausea & vomiting, normal physical examination Acute ischemic colitis ± Diffuse - + + Hyperactive then absent Leukocytosis CT scan Nausea & vomiting Hemorrhagic causes Ruptured abdominal aortic aneurysm - Diffuse - - - N Normal CT scan Unstable hemodynamics Intra-abdominal or retroperitoneal hemorrhage - Diffuse - - - N Anemia CT scan History of trauma Gynaecological Causes Fallopian tube Acute salpingitis + LLQ/ RLQ − ± ± N Leukocytosis Pelvic ultrasound Vaginal discharge Ovarian cyst complications and endometrial disease Torsion of the cyst - RLQ / LLQ - ± ± N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting Endometriosis - RLQ/LLQ - +/- +/- N Normal Laproscopy Menstrual-associated symptoms, pelvic symptoms Cyst rupture - RLQ / LLQ - +/- +/- N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting Pregnancy Ruptured ectopic pregnancy - RLQ / LLQ - - - N Positive pregnancy test Ultrasound History of missed period and vaginal bleeding Functional Irritable Bowel Syndrome - Diffuse - - - - N Clinical diagnosis ROME III/IV criteria Pharmacologic studies based criteria - High dietary fiber Osmotic laxatives Antispasmodicdrugs The following is a list of diseases that present with acute onset severe lower abdominal pain: Disease Findings Ectopic pregnancy History of missed menses, positive pregnancy test, ultrasound reveals an empty uterus and may show a mass in the fallopian tubes. Appendicitis Pain localized to the right iliac fossa, vomiting, abdominal ultrasound sensitivity for diagnosis of acute appendicitis is 75% to 90%. Rupturedovarian cyst Usually spontaneous, can follow history of trauma, mild chronic lower abdominal discomfort may suddenly intensify, ultrasound is diagnostic. Ovarian cyst torsion Presents with acute severe unilateral lower quadrant abdominal pain, nausea and vomiting, tender adnexal mass palpated in 90%, ultrasound is diagnostic. Hemorrhagic ovarian cyst Presents with localized abdominal pain, nausea and vomiting. Hypovolemic shock may be present, abdominal tenderness and guarding are physical exam findings, ultrasound is diagnostic. Endometriosis Presents with cyclic pain that is exacerbated by onset of menses, dyspareunia. laparoscopic exploration is diagnostic. Acute cystitis Presents with features of increased urinary frequency, urgency, dysuria, and suprapubic pain. References Template:WikiDoc Sources