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]Iqra Qamar M.D.[3]Amandeep Singh M.D.[4]

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

To review the differential diagnosis of Abdominal pain, click here.

To review the differential diagnosis of Abdominal pain and fever, click here.

To review the differential diagnosis of Abdominal pain, nausea and vomiting, click here.

To review the differential diagnosis of Abdominal pain and jaundice, click here.

To review the differential diagnosis of Abdominal pain and weight loss, click here.

To review the differential diagnosis of Abdominal pain and constipation, click here.

To review the differential diagnosis of Abdominal pain and diarrhea, click here.

To review the differential diagnosis of Abdominal pain and GI bleeding, click here.

To review the differential diagnosis of Abdominal pain, fever and jaundice, click here.

To review the differential diagnosis of Abdominal pain, fever, nausea and vomiting, click here.

To review the differential diagnosis of Abdominal pain, fever, and diarrhea, click here.

To review the differential diagnosis of Abdominal pain, fever and constipation, click here.

To review the differential diagnosis of Abdominal pain, fever and weight loss, click here.

To review the differential diagnosis of Abdominal pain, fever and GI bleeding, click here.

To review the differential diagnosis of Abdominal pain, nausea,vomiting and jaundice, click here.

To review the differential diagnosis of Abdominal pain, nausea,vomiting and weight loss, click here.

To review the differential diagnosis of Abdominal pain, nausea,vomiting and constipation, click here.

To review the differential diagnosis of Abdominal pain, nausea,vomiting and diarrhea, click here.

To review the differential diagnosis of Abdominal pain, nausea, vomiting and GI bleeding, click here.

To review the differential diagnosis of Abdominal pain, jaundice and weight loss, click here.

To review the differential diagnosis of Abdominal pain, jaundice and diarrhea, click here.

To review the differential diagnosis of Abdominal pain, jaundice and GI bleeding, click here.

To review the differential diagnosis of Abdominal pain,weight loss and constipation, click here.

To review the differential diagnosis of Abdominal pain,weight loss and diarrhea, click here.

To review the differential diagnosis of Abdominal pain, weight loss and GI bleeding, click here.

To review the differential diagnosis of Abdominal pain, constipation and diarrhea, click here.

To review the differential diagnosis of Abdominal pain, constipation and GI bleeding, click here.

To review the differential diagnosis of Abdominal pain, diarrhea and GI bleeding, click here.

Abdominal Pain

The following table outlines the major differential diagnoses of abdominal pain.

Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram, US = Ultrasound

Classification of pain in the abdomen based on etiology Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Abdominal causes Inflammatory causes Pancreato-biliary disorders Acute suppurative cholangitis RUQ + + + + + + + N
  • Abnormal LFT
  • WBC >10,000
  • Ultrasound shows biliary dilatation/stents/tumor
  • Septic shock occurs with features of SIRS
Acute cholangitis RUQ + + N
  • Ultrasound shows biliary dilatation/stents/tumor
  • Biliary drainage (ERCP) + IV antibiotics
Acute cholecystitis RUQ + + + Hypoactive Ultrasound shows:
  • Gallstone
  • Inflammation
Acute pancreatitis Epigastric + + ± + ± N
  • Ultrasound shows evidence of inflammation
  • CT scan shows severity of pancreatitis
  • Pain radiation to back
Chronic pancreatitis Epigastric ± ± + + N
  • Increased amylase / lipase
  • Increased stool fat content
  • Pancreatic function test
CT scan
  • Calcification
  • Pseudocyst
  • Dilation of main pancreatic duct
  • Predisposes to pancreatic cancer
Pancreatic carcinoma Epigastric + + + + N

Skin manifestations may include:

Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Primary biliary cirrhosis RUQ/Epigastric + N
  • Increased AMA level, abnormal LFTs
  • ERCP
  • Pruritis
Primary sclerosing cholangitis RUQ + + N ERCP and MRCP shows
  • Multiple segmental strictures
  • Mural irregularities
  • Biliary dilatation and diverticula
  • Distortion of biliary tree
  • The risk of cholangiocarcinoma in patients with primary sclerosing cholangitis is 400 times higher than the risk in the general population.
Cholelithiasis RUQ/Epigastric ± ± ± Normal to hyperactive for dislodged stone
  • Fatty food intolerance
Gastric causes Peptic ulcer disease Diffuse ± + + Positive if perforated Positive if perforated Positive if perforated N
  • Ascitic fluid
    • LDH > serum LDH
    • Glucose < 50mg/dl
    • Total protein > 1g/dl
Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Gastritis Epigastric ± + Positive in chronic gastritis + N
Gastroesophageal reflux disease Epigastric ± N N
  • Gastric emptying studies
Gastric outlet obstruction Epigastric ± + Hyperactive
  • Succussion splash
Gastroparesis Epigastric + + ± Hyperactive/hypoactive
  • Scintigraphic gastric emptying
  • Succussion splash
  • Single photon emission computed tomography (SPECT)
  • Full thickness gastric and small intestinal biopsy
Gastrointestinal perforation Diffuse + ± - ± + + + ± Hyperactive/hypoactive
  • WBC> 10,000
Dumping syndrome Lower and then diffuse + + + + Hyperactive
  • Postgastrectomy
Intestinal causes Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Acute appendicitis Starts in epigastrium, migrates to RLQ + Positive in pyogenic appendicitis + ± Positive in perforated appendicitis + + Hypoactive
  • Ct scan
  • Ultrasound
  • Positive Rovsing sign
  • Positive Obturator sign
  • Positive Iliopsoas sign
Acute diverticulitis LLQ + ± + + ± + Positive in perforated diverticulitis + + Hypoactive
  • CT scan
  • Ultrasound
Inflammatory bowel disease Diffuse ± ± + + + Normal or hyperactive

Extra intestinal findings:

Irritable bowel syndrome Diffuse ± ± + N Normal Normal Symptomatic treatment
Whipple's disease Diffuse ± ± + + ± N Endoscopy is used to confirm diagnosis.

Images used to find complications

Extra intestinal findings:
Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Toxic megacolon Diffuse + + + ± + Hypoactive CT and Ultrasound shows:
  • Loss of colonic haustration
  • Hypoechoic and thickened bowel walls with irregular internal margins in the sigmoid and descending colon
  • Prominent dilation of the transverse colon (>6 cm)
  • Insignificant dilation of ileal bowel loops (diameter >18 mm) with increased intraluminal gas and fluid
Tropical sprue Diffuse + + + N Barium studies:
  • Dilation and edema of mucosal folds
Celiac disease Diffuse + + Hyperactive US:
  • Bull’s eye or target pattern
  • Pseudokidney sign
  • Gluten allergy
Infective colitis Diffuse + ± + + Positive in fulminant colitis ± ± Hyperactive CT scan
  • Bowel wall thickening
  • Edema
Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Colon carcinoma Diffuse/ RLQ/LLQ ± ± + + ±
  • Normal or hyperactive if obstruction present
  • CBC
  • Carcinoembryonic antigen (CEA)
  • Colonoscopy
  • Flexible sigmoidoscopy
  • Barium enema
  • CT colonography 
  • PILLCAM 2: A colon capsule for CRC screening may be used in patients with an incomplete colonoscopy who lacks obstruction
Hepatic causes Viral hepatitis RUQ + + + Positive in Hep A and E + Positive in fulminant hepatitis Positive in acute + N
  • Abnormal LFTs
  • Viral serology
  • US
  • Hep A and E have fecal-oral route of transmission
  • Hep B and C transmits via blood transfusion and sexual contact.
Liver abscess RUQ + + + + ± + + + ± Normal or hypoactive
  • US
  • CT
Hepatocellular carcinoma/Metastasis RUQ + + +
  • Normal
  • Hyperactive if obstruction present
  • US
  • CT
  • Liver biopsy

Other symptoms:

Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Budd-Chiari syndrome RUQ ± ± Positive in liver failure leading to varices N
Findings on CT scan suggestive of Budd-Chiari syndrome include:
Ascitic fluid examination shows:
Hemochromatosis RUQ Positive in cirrhotic patients N
  • >60% TS
  • >240 μg/L SF
  • Raised LFT
    Hyperglycemia
  • Ultrasound shows evidence of cirrhosis
Extra intestinal findings:
  • Hyperpigmentation
  • Diabetes mellitus
  • Arthralgia
  • Impotence in males
  • Cardiomyopathy
  • Atherosclerosis
  • Hypopituitarism
  • Hypothyroidism
  • Extrahepatic cancer
  • Prone to specific infections
Cirrhosis RUQ + + + + N US
  • Stigmata of liver disease
  • Cruveilhier- Baumgarten murmur
Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Peritoneal causes Spontaneous bacterial peritonitis Diffuse + Positive in cirrhotic patients + ± + + Hypoactive
  • Ascitic fluid PMN>250 cells/mm³
  • Culture: Positive for single organism
  • Ultrasound for evaluation of liver cirrhosis
Renal causes Pyelonephritis Unilateral + ± + + Hypoactive
  • Urinalysis
  • Urine culture
  • Blood culture
  • CT
  • MRI
  • CVA tenderness
Renal colic Flank pain + N
  • Ultrasound
  • CT scan
Hollow Viscous Obstruction Small bowel obstruction Diffuse + + + + + + ± Hyperactive then absent Abdominal X ray
  • Dilated loops of bowel with air fluid levels
  • Gasless abdomen
  • "Target sign"– , indicative of intussusception
  • Venous cut-off sign" – suggests thrombosis
Volvulus Diffuse - + + Positive in perforated cases + + Hyperactive then absent CT scan and abdominal X ray
  • U shaped sigmoid colon
  • "Whirl sign"
Biliary colic RUQ + + N
  • Ultrasound
Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Vascular Disorders Ischemic causes Mesenteric ischemia Periumbilical Positive if bowel becomes gangrenous + + + + Positive if bowel becomes gangrenous Positive if bowel becomes gangrenous Hyperactive to absent CT angiography
  • SMA or SMV thrombosis
  • Also known as abdominal angina that worsens with eating
Acute ischemic colitis Diffuse + ± + + + + + + + Hyperactive then absent Abdominal x-ray
  • Distension and pneumatosis

CT scan

  • Double halo appearance, thumbprinting
  • Thickening of bowel
  • May lead to shock
Hemorrhagic causes Ruptured abdominal aortic aneurysm Diffuse ± + + + + N
  • Focused Assessment with Sonography in Trauma (FAST) 
  • Unstable hemodynamics
Intra-abdominal or retroperitoneal hemorrhage Diffuse ± ± + + N
  • ↓ Hb
  • ↓ Hct
  • CT scan
Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Gynaecological Causes Tubal causes Torsion of the cyst/ovary RLQ / LLQ + ± ± N
  • Ultrasound
  • Sudden onset & severe pain
Acute salpingitis RLQ / LLQ + ± ± ± N
Cyst rupture RLQ / LLQ + + ± ± N
  • Ultrasound
Pregnancy Ruptured ectopic pregnancy RLQ / LLQ + + + + N
  • Ultrasound
History of
  • Missed period
  • Vaginal bleeding
Extra-abdominal causes Pulmonary disorders Pleural empyema RUQ/Epigastric + ± + N Chest X-ray
  • Pleural opacity
  • Localization of effusion
Physical examination
Pulmonary embolism RUQ/LUQ ± ± N
  • ABGs
  • D-dimer
  • Dyspnea
  • Tachycardia
  • Pleuretic chest pain
Pneumonia RUQ/LUQ + + + ± + Normal or hypoactive
  • ABGs
  • Leukocytosis
  • Pancytopenia
  • CXR
  • CT chest
  • Bronchoscopy
  • Shortness of breath
  • Cough
Cardiovascular disorders Myocardial Infarction Epigastric ± + Positive in cardiogenic shock N ECG

Echocardiogram

  • Wall motion abnormality
  • Wall rupture
  • Septal rupture
  • Chest pain, tightness, diaphoresis

Complications:

Right upper quadrant.PNG Epigastric quadrant pain.PNG Left upper quadrant.PNG
Right flank quadrant.PNG Umbilical pain.PNG Left flank quadrant.PNG
Right lower quadrant.PNG Hypogastric.PNG Left lower quadrant.PNG

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.[1]
Appendicitis Pain localized to the right iliac fossa, vomiting, abdominal ultrasound sensitivity for diagnosis of acute appendicitis is 75% to 90%.[2]
Rupturedovarian cyst Usually spontaneous, can follow history of trauma, mild chronic lower abdominal discomfort may suddenly intensify, ultrasound is diagnostic.[3]
Ovarian cyst torsion Presents with acute severe unilateral lower quadrant abdominal pain, nausea and vomiting, tender adnexal mass palpated in 90%, ultrasound is diagnostic.[4]
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.[4]
Endometriosis Presents with cyclic pain that is exacerbated by onset of menses, dyspareunia. laparoscopic exploration is diagnostic.[4]
Acute cystitis Presents with features of increased urinary frequency, urgency, dysuria, and suprapubic pain.[5][6]

References

  1. Morin L, Cargill YM, Glanc P (2016). "Ultrasound Evaluation of First Trimester Complications of Pregnancy". J Obstet Gynaecol Can. 38 (10): 982–988. PMID 27720100. doi:10.1016/j.jogc.2016.06.001. 
  2. Balthazar EJ, Birnbaum BA, Yee J, Megibow AJ, Roshkow J, Gray C (1994). "Acute appendicitis: CT and US correlation in 100 patients". Radiology. 190 (1): 31–5. PMID 8259423. doi:10.1148/radiology.190.1.8259423. 
  3. Bottomley C, Bourne T (2009). "Diagnosis and management of ovarian cyst accidents". Best Pract Res Clin Obstet Gynaecol. 23 (5): 711–24. PMID 19299205. doi:10.1016/j.bpobgyn.2009.02.001. 
  4. 4.0 4.1 4.2 Bhavsar AK, Gelner EJ, Shorma T (2016). "Common Questions About the Evaluation of Acute Pelvic Pain". Am Fam Physician. 93 (1): 41–8. PMID 26760839. 
  5. {{Cite journal | author = W. E. Stamm | title = Etiology and management of the acute urethral syndrome | journal = Sexually transmitted diseases | volume = 8 | issue = 3 | pages = 235–238 | year = 1981 | month = July-September | pmid = 7292216
  6. {{Cite journal | author = W. E. Stamm, K. F. Wagner, R. Amsel, E. R. Alexander, M. Turck, G. W. Counts & K. K. Holmes | title = Causes of the acute urethral syndrome in women | journal = The New England journal of medicine | volume = 303 | issue = 8 | pages = 409–415 | year = 1980 | month = August | doi = 10.1056/NEJM198008213030801 | pmid = 6993946




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