Acute abdominal pain DDx

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Classification of acute abdomen based on etiology		Presentation	Clinical findings								Diagnosis		Comments
Classification of acute abdomen based on etiology		Presentation	Fever	Rigors and Chills	Abdominal Pain	Jaundice	Hypotension	Guarding	Rebound Tenderness	Bowel sounds	Lab Findings	Imaging	Comments
Common causes of Peritonitis		Spontaneous bacterial peritonitis	+		Diffuse	−	−	−	−	Hypoactive	Ascitic fluid PMN>250 cells/mm³ Culture: Positive for single organism	Ultrasound for evaluation of liver cirrhosis	-
		Perforated gastric and duodenal ulcer	+		Diffuse	−	+	+	+	N	Ascitic fluid LDH > serum LDH Glucose < 50mg/dl Total protein > 1g/dl	Air under diaphragm in upright CXR	Upper GI endoscopy for diagnosis
		Acute suppurative cholangitis	+	+	RUQ	+	+	+	+	±
		Acute cholangitis	+	−	RUQ	+	−	−	−	N	Abnormal LFT	Ultrasound shows biliary dilatation	Biliary drainage (ERCP) + IV antibiotics
		Acute cholecystitis	+		RUQ	+		−	−	Hypoactive	Hyperbilirubinemia Leukocytosis	Ultrasound shows gallstone and evidence of inflammation	Murphy’s sign
		Acute pancreatitis	+		Epigastric	±		−	−	N	Increased amylase / lipase	Ultrasound shows evidence of inflammation	Pain radiation to back
		Acute appendicitis	+		RLQ	−		+	+	Hypoactive	Leukocytosis	Ultrasound shows evidence of inflammation	Nausea & vomiting, decreased appetite
		Acute diverticulitis	+		LLQ	±		+	−	Hypoactive	Leukocytosis	CT scan and ultrasound shows evidence of inflammation
Hollow Viscous Obstruction		Small intestine obstruction	−		Diffuse	−		+	±	Hyperactive then absent	Leukocytosis	Abdominal X ray	Nausea & vomiting associated with constipation, abdominal distention
		Gall stone disease/Cholelithiasis	±	−
		Volvulus	-		Diffuse	-		+	-	Hypoactive	Leukocytosis	CT scan and abdominal X ray	Nausea & vomiting associated with constipation, abdominal distention
		Biliary colic	-		RUQ	+		-	-	N	Increased bilirubin and alkaline phosphatase	Ultrasound	Nausea & vomiting
		Renal colic	-		Flank pain	-		-	-	N	Hematuria	CT scan and ultrasound	Colicky abdominal pain associated with nausea & vomiting
Vascular Disorders	Ischemic causes	Mesenteric ischemia	±		Periumbilical	-		-	-	Hyperactive	Leukocytosis and lactic acidosis	CT scan	Nausea & vomiting, normal physical examination
	Ischemic causes	Acute ischemic colitis	±		Diffuse	-		+	+	Hyperactive then absent	Leukocytosis	CT scan	Nausea & vomiting
	Hemorrhagic causes	Ruptured abdominal aortic aneurysm	-		Diffuse	-		-	-	N	Normal	CT scan	Unstable hemodynamics
	Hemorrhagic causes	Intra-abdominal or retroperitoneal hemorrhage	-		Diffuse	-		-	-	N	Anemia	CT scan	History of trauma
Gynaecological Causes	Fallopian tube	Acute salpingitis	+		LLQ/ RLQ	−		±	±	N	Leukocytosis	Pelvic ultrasound	Vaginal discharge
	Ovarian cyst complications and endometrial disease	Torsion of the cyst	-		RLQ / LLQ	-		±	±	N	Increased ESR and CRP	Ultrasound	Sudden onset sever pain with nausea and vomiting
		Endometriosis	-		RLQ/LLQ	-		+/-	+/-	N	Normal	Laproscopy	Menstrual-associated symptoms, pelvic symptoms
		Cyst rupture	-		RLQ / LLQ	-		+/-	+/-	N	Increased ESR and CRP	Ultrasound	Sudden onset sever pain with nausea and vomiting
	Pregnancy	Ruptured ectopic pregnancy	-		RLQ / LLQ	-		-	-	N	Positive pregnancy test	Ultrasound	History of missed period and vaginal bleeding
Functional	Irritable Bowel Syndrome		-		Diffuse	-	-	-	-	N	Clinical diagnosis ROME III/IV criteria Pharmacologic studies based criteria	-	High dietary fiber Osmotic laxatives Antispasmodicdrugs