Surgical Abdomen – Differential Diagnosis

by / Saturday, 12 June 2010 / Published in Internal Medicine, Surgery

This post contains the differential diagnosis for most common conditions that cause an acute abdomen.  

The following illustrates the differential diagnosis for abdominal pain in the right upper quadrant, right lower quadrant, left upper quadrant, left lower quadrant.


 Right Upper Quadrant Conditions – Differentiating



  • Presents with RUQ pain and/or tenderness
  • Jaundice is most likely present
  • Fever is present
  • Perform an ultrasound to rule out other causes of pain



  • RUQ pain and tenderness
  • (+) Murphy’s sign (inspiratory arrest during palpation)
  • Perform an ultrasound to detect gallstones, a thickened gallbladder wall, or pericholecystic fluid



  • RUQ pain that is worsened with the ingestion of fatty foods
  • Jaundice is often present
  • Perform an ultrasound to detect dilatation of the common bile duct


Biliary Cholic

  • Constant epigastric and RUQ pain
  • Perform an ultrasound to detect the presence of gallstones without any other gallbladder-related findings



  • A life-threatening condition
  • Presence of Charcot’s triad: Fever + Jaundice + RUQ pain
  • If there is also hypotension and mental status changes, this qualifies as Reynold’s pentad
  • Perform and ultrasound and a CT to detect biliary duct dilatation due to gallstone obstruction
  • Confirm diagnosis with ERCP



  • Presence of pleuritic chest pain
  • Perform a CXR, which will show pulmonary infiltrates


Fitz-Hugh-Curtis Syndrome

  • RUQ pain, fever
  • There is going to be a history of salpingitis
  • Caused by ascending Chlamydia or gonorrhea-related salpingitis
  • Perform an ultrasound which will show a normal gallbladder and biliary tree with fluid around the liver and gallbladder


Right Lower Quadrant Conditions – Differentiating


  • Diffuse abdominal pain that localizes to the RLQ at McBurney’s point (2/3 distance from umbilicus to ASIS)
  • Fever and diarrhea often present
  • Abdominal xray or CT to solidify diagnosis
  • Decision to remove is based on clinical presentation


Ectopic Pregnancy

  • Presents with constant lower abdominal pain, crampy in nature
  • Vaginal bleeding
  • Tender adnexal mass
  • Labs will show beta-hCG



  • Lower abdominal pain
  • Purulent vaginal discharge
  • Cervical motion tenderness
  • Perform an ultrasound to detect the abscess, and a CT to rule out other conditions

Meckel’s Diverticulitis

  • Follows the 1-10-100 rule
  • 1%-2% prevalence
  • 1-10cm in length
  • 50-100 cm proximal to ileocecal valve
  • Presents with GI bleed, small bowel obstruction (SBO)
  • Technetium pertechnetate scan to detect


Yersinia Enterocolitis

  • Presents similarly to appendicitis (fever, diarrhea, severe RLQ pain)
  • XRAY will be negative
  • Treat with aggressive antibiotic therapy


Ovarian Torsion

  • Patient develops an acute onset of severe, unilateral pain
  • Pain changes with movement
  • Presence of a tender adnexal mass
  • Ultrasound is done first
  • Confirm with a laparoscopy



  • Classically presents with CVA tenderness, high fever, and shaking chills
  • Best initial diagnostic test is a UA and Urine culture



  • Seen most commonly in infants between 5 and 10 months of age
  • Presence of currant jelly stool (mix of blood and mucus)
  • Vomiting, intense crying
  • Infants will often pull legs into the abdomen to relieve some pain
  • Barium enema is used for both diagnosis and treatment


Left Upper Quadrant Conditions – Differentiating

Myocardial Infarction

  • Crushing chest pain that radiates to the jaw, neck, left arm
  • Nausea, diaphoresis is present
  • Diagnosed by EKG, cardiac enzymes (CKMB, trop I)


Peptic Ulcer

  • Presents as epigastric pain that is relieved by foods and/or antacids
  • Perforations presents with acute and severe epigastric pain, may radiate to shoulders (Splenic nerve involvement)
  • Diagnose with an upper GI endoscopy


Ruptured Spleen

  • Usually a history of trauma
  • Presence of Kehr’s sign (LUQ pain that radiates to the left shoulder)
  • Diagnose with an abdominal CT


Left Lower Quadrant Conditions – Differentiating


  • Similar to the RLQ conditions are: Ovarian torsion, Ectopic pregnancy, and Salpingitis



  • Patient has LLQ pain, fever, and urinary urgency
  • Diagnose with a CT scan, which shows thickening of the large intestine wall


Sigmoid Volvulus

  • Most commonly seen in an older patient
  • Presents with constipation, distended abdomen, and abdominal pain
  • Contrast enema to diagnose, will see the classic “bird’s beak”



Classically presents with CVA tenderness, high fever, and shaking chills

Differential Diagnoses for Midline Conditions



  • Epigastric/substernal burning pain
  • Degree of pain changes with different positions (worse when patient is supine)
  • Diagnosis made with either a barium swallow, pH testing, or upper GI endoscopy


Abdominal Aortic Aneurysm

  • Asymptomatic usually until it ruptures
  • If rupture occurs, patient experiences abdominal pain + shock
  • There is usually a palpable pulsatile periumbilical mass
  • Ultrasound done first (least invasive), but can visualize with an xray or CT of the abdomen



  • Epigastric pain that radiates to the back
  • Nausea and vomiting are usually present
  • Patient often has a history of alcoholism


Pancreatic Pseudocyst

  • Is a result of pancreatitis
  • Consider this if patient had pancreatitis that recurred and/or did not resolve
  • Ultrasound will show a pseudocyst


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To your success in weight loss and in health,

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