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12 Jun

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

 

Hepatitis

  • 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

 

Cholecystitis

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

 

Choledocholithiasis

  • 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

 

Cholangitis

  • 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

 

Pneumonia

  • 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


Appendicitis

  • 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

 

Salpingitis

  • 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

 

Pyelonephritis

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

 

Intussusception

  • 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

 

Diverticulitis

  • 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”

 

Pyelonephritis

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


Differential Diagnoses for Midline Conditions

 

GERD

  • 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

 

Pancreatitis

  • 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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