Abdominal pain, nausea and vomiting

Abdominal pain Microchapters

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Diffuse Abdominal Pain
Left Upper Quadrant
Left Flank
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Epigastric Quadrant
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Right Upper Quadrant
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Right Lower Quadrant
Intraperitoneal
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2],Iqra Qamar M.D.[3]

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

| 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
Acute suppurative cholangitis  | RUQ | \+  | \+  | \+  | \+  | −  | −  | −  | −  | \+  | \+  | \+  | N  |

* Abnormal LFT
* WBC >10,000

* Ultrasound shows biliary dilatation/stents/tumor

* Septic shock occurs with features of SIRS

Acute cholecystitis | RUQ | \+  | −  | \+  | \+  | −  | −  | −  | −  | −  | −  | −  | Hypoactive  |

* Hyperbilirubinemia
* Leukocytosis

| Ultrasound shows:

* Gallstone
* Inflammation

* Murphy’s sign

Acute pancreatitis | Epigastric | \+  | −  | \+  | ±  | −  | −  | −  | −  | ±  | −  | −  | N  |

* Increased amylase / lipase

* 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  |

* ↑ Alkaline phosphatase
* ↑ serum bilirubin
* ↑ gamma-glutamyl transpeptidase
* ↑ CA 19-9

* MDCT with  PET/CT
* MRI

Skin manifestations may include:

* Bullous pemphigoid
* Cicatricial pemphigoid
* Migratory superficial thrombophlebitis (classic Trousseau's syndrome)
* Pancreatic panniculitis

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
Cholelithiasis | RUQ/Epigastric | ±  | −  | ±  | ±  | −  | −  | −  | −  | −  | −  | −  | Normal to hyperactive for dislodged stone  |

* Leukocytosis

* Ultrasound shows gallstone

* Fatty food intolerance

Peptic ulcer disease | Diffuse  | ±  | −  | \+  | −  | −  | −  | \+  |

* Gastric ulcer- melena and hematemesis
* Duodenal ulcer- melena and hematochezia

| Positive if perforated  | Positive if perforated  | Positive if perforated  | N  |

* Ascitic fluid
* LDH > serum LDH
* Glucose < 50mg/dl
* Total protein > 1g/dl

* Air under diaphragm in upright CXR

* Upper GI endoscopy for diagnosis

Gastritis | Epigastric | ±  | −  | \+  | −  | −  | −  | Positive in chronic gastritis  | \+  | −  | −  | −  | N  |

* H.pylori infection diagnostic tests

* Endoscopy

* H.pylori gastritis guideline recommendation

Gastroesophageal reflux disease | Epigastric | −  | −  | ±  | −  | −  | −  | −  | −  | −  | −  | −  | N  | N  |

* Gastric emptying studies

* Esophageal manometry
* Endoscopy for alarm signs

Gastric outlet obstruction | Epigastric | −  | −  | ±  | −  | −  | −  | \+  | −  | −  | −  | −  | Hyperactive  |

* Complete blood count
* Basic metabolic panel

* Abdominal x-ray\- air fluid level
* Barium upper GI studies- narrowed pylorus

* Succussion splash

Gastroparesis  | Epigastric  | −  | −  | \+  | −  | −  | −  | \+  | −  | ±  | −  | −  | Hyperactive/hypoactive  |

* Hemoglobin
* Fasting plasma glucose
* Serum total protein, albumin, thyrotropin (TSH), and an antinuclear antibody (ANA) titer
* HbA1c

* Scintigraphic gastric emptying

* Succussion splash
* Single photon emission computed tomography (SPECT)
* Full thickness gastric and small intestinal biopsy

Dumping syndrome | Lower and then diffuse  | −  | −  | \+  | −  | −  | \+  | \+  | −  | \+  | −  | −  | Hyperactive  |

* Glucose challenge test
* Hydrogen breath test

* Upper GI series
* Gastric emptying study

* Postgastrectomy

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  |

* Leukocytosis

* Ct scan
* Ultrasound

* Positive Rovsing sign
* Positive Obturator sign
* Positive Iliopsoas sign

Acute diverticulitis | LLQ  | \+  | ±  | \+  | −  | \+  | ±  | −  | \+  | Positive in perforated diverticulitis  | \+  | \+  | Hypoactive  |

* Leukocytosis

* CT scan
* Ultrasound

* History of constipation

Infective colitis | Diffuse  | \+  | −  | ±  | −  | −  | \+  | −  | \+  | Positive in fulminant colitis  | ±  | ±  | Hyperactive  |

* Stool culture and studies
* Shiga toxin in bloody diarrhea
* PCR

| CT scan

* Bowel wall thickening
* Edema

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  |

* CBC
* Blood cultures
* Abnormal liver function tests

* US
* CT

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
Pyelonephritis  | Unilateral  | \+  | ±  | \+  | −  | −  | −  | −  | −  | \+  | −  | −  | Hypoactive  |

* Urinalysis
* Urine culture
* Blood culture

* CT
* MRI

* CVA tenderness

Renal colic | Flank pain | −  | −  | \+  | −  | −  | −  | −  | −  | −  | −  | −  | N  |

* Hematuria

* Ultrasound
* CT scan

* Colicky abdominal pain
* Dysuria

Small bowel obstruction  | Diffuse  | \+  | −  | \+  | −  | \+  | −  | \+  | −  | \+  | \+  | ±  | Hyperactive then absent  |

* Leukocytosis with left shift indicates complications

| 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  |

* Leukocytosis

| CT scan and abdominal X ray

* U shaped sigmoid colon

* "Whirl sign"

Biliary colic | RUQ  | −  | −  | \+  | \+  | −  | −  | −  | −  | −  | −  | −  | N  |

* ↑ bilirubin and alkaline phosphatase

* 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
Mesenteric ischemia | Periumbilical  | Positive if bowel becomes gangrenous  | −  | \+  | −  | −  | \+  | \+  | \+  | Positive if bowel becomes gangrenous  | Positive if bowel becomes gangrenous  | −  | Hyperactive to absent  |

* Leukocytosis and lactic acidosis
* Amylase levels
* D-dimer

| CT angiography

* SMA or SMV thrombosis

* Also known as abdominal angina that worsens with eating

Acute ischemic colitis | Diffuse  | \+  | ±  | \+  | −  | −  | \+  | \+  | \+  | \+  | \+  | \+  | Hyperactive then absent  |

* Leukocytosis

| Abdominal x-ray

* Distension and pneumatosis

CT scan

* Double halo appearance, thumbprinting
* Thickening of bowel

* May lead to shock

Ruptured abdominal aortic aneurysm | Diffuse  | ±  | −  | \+  | −  | −  | −  | \+  | \+  | \+  | −  | −  | N  |

* Fibrinogen
* D-dimer

* Focused Assessment with Sonography in Trauma (FAST)

* Unstable hemodynamics

Intra-abdominal or retroperitoneal hemorrhage | Diffuse  | ±  | −  | ±  | −  | −  | −  | −  | \+  | \+  | −  | −  | N  |

* ↓ Hb
* ↓ Hct

* CT scan

* History of trauma

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
Torsion of the cyst  | RLQ / LLQ  | −  | −  | \+  | −  | −  | −  | −  | −  | −  | ±  | ±  | N  |

* ↑ ESR
* ↑ CRP

* Ultrasound

* Sudden onset & severe pain

Cyst rupture  | RLQ / LLQ  | −  | −  | \+  | −  | −  | −  | −  | −  | \+  | ±  | ±  | N  |

* ↑ ESR
* ↑ CRP

* Ultrasound

Ruptured ectopic pregnancy | RLQ / LLQ  | −  | −  | \+  | −  | −  | −  | −  | −  | \+  | \+  | \+  | N  |

* Positive pregnancy test

* Ultrasound

| History of

* Missed period
* Vaginal bleeding

Pneumonia | RUQ/LUQ  | \+  | \+  | \+  | −  | −  | ±  | −  | −  | \+  | −  | −  | Normal or hypoactive  |

* ABGs
* Leukocytosis
* Pancytopenia

* CXR
* CT chest
* Bronchoscopy

* Shortness of breath
* Cough

Myocardial Infarction | Epigastric | ±  | −  | \+  | −  | −  | −  | −  | −  | Positive in cardiogenic shock  | −  | −  | N  |

* Cardiac enzymes

| ECG

Echocardiogram

* Wall motion abnormality
* Wall rupture
* Septal rupture

* Chest pain, tightness, diaphoresis

Complications:

* Arrythmias
* Mitral regurgitation
* Ventricular wall rupture
* Septal rupture