Abdominal pain and GI bleeding

Abdominal pain Microchapters

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

Gastrointestinal perforation | Diffuse  | \+  | ±  | \-  | ±  | −  | −  | −  | \+  | \+  | \+  | ±  | Hyperactive/hypoactive  |

* WBC> 10,000

* Air under diaphragm in upright CXR

* Hamman's sign

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

* Leukocytosis

* CT scan
* Ultrasound

* History of constipation

Inflammatory bowel disease | Diffuse  | ±  | −  | −  | ±  | −  | \+  | \+  | \+  | −  | −  | −  | Normal or hyperactive  |

* Anti-neutrophil cytoplasmic antibody (P-ANCA) in Ulcerative colitis
* Anti saccharomyces cerevisiae antibodies (ASCA) in Crohn's disease

* String sign on abdominal x-ray in Crohn's disease

Extra intestinal findings:

* Uveitis
* Arthritis

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

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

| CT scan

* Bowel wall thickening
* Edema

Colon carcinoma  | Diffuse/localized  | −  | −  | −  | −  | ±  | ±  | \+  | \+  | ±  | −  | −  |

* 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

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  |

* Elevated serum aspartate aminotransferase and alanine aminotransferase levels may be more than five times the upper limit of the normal range.
* Elevated serum alkaline phosphatase and bilirubin levels, decreased serum albumin level.

|  | Findings on CT scan suggestive of Budd-Chiari syndrome include:

* Early enhancement of the caudate lobe and central liver around the inferior vena cava
* Delayed enhancement of the peripheral liver with accompanying central low density (flip-flop appearance)
* Peripheral zones of the liver show reversed portal venous blood flow
* In the chronic phase, there is caudate lobe enlargement and atrophy of the peripheral liver in affected areas

Ascitic fluid examination shows:

* Total protein more than 2.5 g per deciliter
* White blood cells are usually less than 500/μL.

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  |

* Hypoalbuminemia
* Prolonged PT
* Abnormal LFTs
* Hyponatremia
* Thrombocytopenia

| US

* Nodular, shrunken liver
* Ascites

* Stigmata of liver disease
* Cruveilhier- Baumgarten murmur

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