Lecture 10: Differential Diagnosis of Abdominal Pain

Renal or Biliary Colic

acute waves of sharp pain

Intestinal Obstruction

waves of dull pain with vomiting

Peritonitis

sharp, constant pain, worsened by movement

Dissecting Aneurysm

tearing pain

Gallbladder

pain radiates to right scapula

Ruptured spleen or pancreatitis

pain radiates to left shoulder region

Renal pain

pain radiates to pubis or vagina

Acute Cholecystitis

1

Angina

2

Pleuritis Pain

3

Renal Colic Appendicitis

4

Appendicitis

5

Splenic Infarct

6

Cholecystitis

7

Substernal

Where is the Referred pain?

Esophagus

Shoulder

Where is the Referred pain?

Diaphragm

Epigastric

Where is the Referred pain?

stomach

Epigastric

Where is the Referred pain?

duodenum

Epigastric

Where is the Referred pain?

gall bladder

Epigastric

Where is the Referred pain?

liver

Right Scapula

Where is the Referred pain?

biliary tract

Midback

Where is the Referred pain?

aorta

Midback or Epigastric

Where is the Referred pain?

Pancreas

Periumbilical

Where is the Referred pain?

small intestine

Hypogastrium

Where is the Referred pain?

Colon

Sacrum

Where is the Referred pain?

Rectum

Grey Turner's sign

Massive ecchymosis noted on the flanks from pancreatitis

Cullen's sign

Bluish discoloration of the umbilicus from hemoperitoneum

Cullen's sign

Grey Turner's sign

Sister Mary Joseph nodule

• Cutaneous metastasis localized to the umbilicus

Sister Mary Joseph nodule

Urine HCG

what test is important to do for any woman of childbearing age?

CBC

for evaluation of infection or anemia

CMP

Typically includes labs to evaluate renal function, liver function, biliary tract disease, diabetes, acidosis

PT and aPTT

Evaluate for severe liver disease and bleeding disorders

ABG

Helps evaluate for ischemia

Serum Lactate

Helpful in sepsis or unexplained anion gap acidosis

Type and crossmatch

For those who are bleeding such as ruptured AAA or GI bleed

UA

Look for signs of infection, bilirubin in the urine, blood

Plain abdominal films

Evaluate for kidney stones, bowel gas patterns, perforation

CT Scan

• Consider for diffuse abdominal pain, RLQ pain, and LLQ pain

• Can evaluate for appendicitis, diverticulitis, perforation, abdominal aortic aneurysm (AAA), abscess

Ultrasound

• Consider for RUQ pain (gallbladder pathology, liver)

• Unable to evaluate hollow organs

CT Angiography

• Helpful when looking for mesenteric ischemia

Appendicitis

-periumbilical abdominal pain

-migration of pain to RLQ

-anorexia and nausea

-pain at McBurneys

Gastric Ulcer

pain cannot be relieved by eating foods; there is blood when the patient vomits called hematemesis.

Duodenal Ulcer

pain can be relieved by eating; There is bleeding in the stool called melena. Pain occurs 3-4 hours after eating.

GERD

-heart burn

-cough, wheezing, hoarseness

-worse with certain foods

Early Bowel Obstruction

-must not miss diagnosis

-inability to pass stool or flatus

-n/v

-prior abdominal surgery

Acute MI

-must not miss diagnosis

-substernal chest pain brought on by exertion

-relieved by rest or NTG

-cardiac risk factors

AAA

-must not miss diagnosis

-abdominal pain radiating into the back

-systolic bruit

Biliary Colic

-RUQ/Epigastric abdominal pain

-episodic and crampy pain that may radiate into R upper back

Renal Colic

-hematuria

-radiation to flank/groin/genitals

IBS

-long hx (years) of intermittent pain relieved by defecation or assoc with diarrhea

Acute cholangitis

-abdominal pain, jaundice, fever

-confusion and hypotension

-dark urine, rigors

Chronic Mesenteric Ischemia

-must not miss diagnosis

-post prandial pain

-weight loss

-CAD vs PVD

Cystic Duct

transfers bile between the gallbladder and common and hepatic bile ducts.

Ischemic Colitis

-usually due to non-occlusive disease in colonic perfusion

-precipitating cause often not identified

-pts usually not severely ill

-abdominal pain mild

-hematochezia common

Acute Mesenteric Ischemia

-usually due to acute arterial occlusion of SMA or celiac artery

-precipitating cause is typical

-pts appear very ill

-abdominal pain is severe

-hematochezia uncommon

-angiography indicated

Pyelonephritis

-flank pain

-fever, chills, urinary symptoms

-CVA tenderness

Ruptured AAA

-Orthostatic hypotension

-Pain radiating from abdomen to back

-Pulsatile abdominal mass

-Decreased LE pulses

Ruptured Ectopic Pregnancy

-must not miss diagnosis

-sudden, severe pelvic pain

-vaginal bleeding

Acute Abdomen

Refers to abdominal signs and symptoms that are so severe and concerning that surgical consultation should be considered

Visceral

_______________ Pain:

-innervated by autonomic nerve

fibers

-usually vague, dull, nauseating, poorly localized

Somatic

________________ Pain:

- innervated by somatic nerves

-sharp and well localized pain