DDx: Abdominal Pain Flashcards Preview

03 GI AND HEPATOLOGY > DDx: Abdominal Pain > Flashcards

Flashcards in DDx: Abdominal Pain Deck (26):
1

Differential Diagnosis of Acute Abdominal Pain: RUQ

Acute cholangitis

Pneumonia

Acute viral hepatitis

Acute alcoholic hepatitis

Gonococcal perihepatitis (Fitz-Hugh–Curtis syndrome)

Cholecystitis 

Others: PUD, perforated
ulcer, pancreatitis, liver tumors, gastritis,
hepatic abscess, choledocholithiasis,
pyelonephritis, nephrolithiasis,
appendicitis (especially during
pregnancy); thoracic causes (e.g.,
pleurisy/pneumonia), PE, pericarditis,
MI (especially inferior MI)

2

Acute cholangitis

RUQ pain, fever, jaundice; bilirubin generally >4 mg/dL (68.4 mmol/L), AST and ALT may be >1000 U/L; ALT usually > AST

3

Pneumonia

Cough, shortness of breath, chest or upper abdominal pain, fever

4

Acute viral hepatitis

Jaundice; AST and ALT generally >1000 U/L; ALT usually > AST

5

Acute alcoholic hepatitis

Recent alcohol intake, fever; leukocytosis, bilirubin generally >4 mg/dL (68.4 mmol/L); AST usually 2–3 times >ALT

6

Gonococcal perihepatitis (Fitz-Hugh–Curtis syndrome)

Pelvic adnexal tenderness, leukocytosis; cervical smear shows gonococci

7

Cholecystitis 

Epigastric and RUQ pain that radiates to right shoulder; mildly elevated bilirubin, AST, and ALT; ultrasonography shows thickened gallbladder and pericholecystic fluid

8

Differential Diagnosis: Midepigastric or Periumbilical:

Acute pancreatitis

Inferior myocardial infarction 

Perforating peptic ulcer

Mesenteric ischemia

Small bowel obstruction

Aortic dissection or rupture

Diabetic ketoacidosis

Celiac disease

Others (LUQ): PUD, perforated ulcer, gastritis, splenic
injury, abscess, reflux, dissecting aortic
aneurysm, thoracic causes, pyelonephritis,
nephrolithiasis, hiatal hernia (strangulated
paraesophageal hernia), Boerhaave’s
syndrome, Mallory-Weiss tear, splenic
artery aneurysm, colon disease

9

Acute pancreatitis

Midepigastric pain radiating to the back, nausea, vomiting; elevated amylase and lipase; usually secondary to gallstones or alcohol; pain from penetrating peptic ulcer may present similarly.

Dx: The best predictors of higher morbidity and mortality in patients with acute pancreatitis are those associated with hemoconcentration because it serves as a marker of capillary leak.  Patients with severe disease tend to have elevated levels of blood urea nitrogen, serum creatinine, and occasionally hematocrit (all markers of hemoconcentration).  Of these factors, the blood urea nitrogen level appears to be the most accurate for predicting severity. Other factors that predispose patients to a poor prognosis are multiple medical comorbidities, age greater than 70 years, and body mass index greater than 30.

10

Inferior myocardial infarction 

Chest or midepigastric pain, diaphoresis, shortness of breath; elevated cardiac enzymes; acutely abnormal electrocardiogram

11

Perforating peptic ulcer

Postprandial abdominal pain, weight loss, abdominal bruit (chronic presentation); pain out of proportion to tenderness on palpation

12

Mesenteric ischemia

Possible anion gap metabolic acidosis; abdominal plain films may show classic thumbprinting sign (acute presentation)

13

Small bowel obstruction

Colicky pain; obstructive pattern seen on CT or abdominal series

14

Aortic dissection or rupture

Elderly patient with vascular disease and sudden-onset severe pain that radiates to the back and lower extremity

15

Diabetic ketoacidosis

Blood glucose always elevated; anion gap always present

16

Celiac disease

Bloating, diarrhea, weight loss; may see osteopenia and anemia

17

AAA

 

Most AAAs are discovered incidentally or on screening examination.

Patients may present with symptoms related to aneurysm expansion or leakage, including back or abdominal pain. Occasionally, patients may have symptoms related to aneurysm-related thrombosis, especially in the lower extremities. Patients with a ruptured AAA are often hypotensive, and a pulsatile mass may be palpated in some patients. The lack of a pulsatile mass, however, is not reliable in excluding the diagnosis, especially in obese patients.

AAAs can be adequately evaluated either by ultrasound or by CT angiography. CT angiography is generally indicated for hemodynamically stable patients with suspected rupture, as the CT can provide additional information about aortic anatomy that will assist in intervention.

All patients with AAAs should have aggressive treatment of hypertension, hyperlipidemia, and especially tobacco dependence, as associated cardiovascular disease is very common in patients with AAAs.

Surgical treatment of asymptomatic patients who have a life expectancy of >2 years is performed when the AAA has reached a diameter of 5.5 cm or is expanding at a rate of >0.5 cm in 6 months. 

18

Differential Diagnosis: Right Lower Quadrant (RLQ):

Acute appendicitis!

Ectopic pregnancy, ovarian cyst or torsion

Pelvic inflammatory disease

Nephrolithiasis

Pyelonephritis

Others: And same as LLQ;
also mesenteric lymphadenitis, cecal
diverticulitis, Meckel’s diverticulum,
intussusception

19

Acute appendicitis

Midepigastric pain radiating to RLQ; ultrasonography and CT may confirm diagnosis; anorexia and nausea frequently present. 

Classic chronologic order:
1. Periumbilical pain (intermittent and
crampy)
2. Nausea/vomiting
3. Anorexia
4. Pain migrates to RLQ (constant and
intense pain), usually in 24 hours

20

Ectopic pregnancy, ovarian cyst or torsion

RLQ or LLQ abdominal pain, nausea, fever; leukocytosis; suspect in women with unilateral pain

21

Pelvic inflammatory disease

May be RLQ or LLQ; fever; abdominal tenderness, uterine or adnexal tenderness, cervical motion tenderness; cervical discharge

22

Nephrolithiasis

Right or left flank pain that may radiate to groin; hematuria

23

Pyelonephritis

Fever, dysuria, and pain in right or left flank that may radiate to lower quadrant; urinalysis shows leukocytes and leukocyte casts

24

Differential Diagnosis: Left Lower Quadrant (LLQ):

Acute Diverticulitis

Toxic megacolon

 

Others: sigmoid volvulus,
perforated colon, colon cancer,
urinary tract infection, small bowel
obstruction, inflammatory bowel
disease, nephrolithiasis, pyelonephritis,
fluid accumulation from aneurysm or
perforation, referred hip pain, gynecologic
causes, appendicitis (rare)

25

Acute diverticulitis

Diverticulitis results from obstruction at a diverticulum neck by fecal matter, leading to mucus production and bacterial overgrowth.

Hx: Pain usually in LLQ but can be RLQ if ascending colon is involved; Other symptoms may include nausea, vomiting, and anorexia.

Dx: CT can diagnose complicated diverticular disease with abscess formation.  More than 50% of patients with diverticulitis have leukocytosis.  Colonoscopy should be avoided in the acute setting because air insufflation may increase the risk for perforation.

Tx: Oral antibiotic therapy with agents that are effective against anaerobes and gram-negative rods (metronidazole and ciprofloxacin) is a reasonable option for initial therapy in immunocompetent patients with isolated, uncomplicated acute diverticulitis who are able to tolerate oral intake.

 

26

Toxic megacolon

Nonobstructive dilatation of transverse and descending colon; systemic toxicity; associated with inflammatory bowel disease and Clostridium difficile infection