Abdominal pain and diarrhea

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
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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
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

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

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

Irritable bowel syndrome | Diffuse  | −  | −  | −  | −  | ±  | ±  | \+  | −  | −  | −  | −  | N  | Normal  | Normal  | Symptomatic treatment

* High dietary fiber

* Osmotic laxatives
* Antispasmodic drugs

Whipple's disease | Diffuse  | ±  | −  | −  | ±  | −  | \+  | \+  | −  | ±  | −  | −  | N  |

* Thrombocytopenia
* Hypoalbuminemia
* Small intestinal biopsy for Tropheryma whipplei

| Endoscopy is used to confirm diagnosis.

Images used to find complications

* Chest and joint x-ray
* CT
* MRI
* Echocardiography

| Extra intestinal findings:

* Uveitis
* Endocarditis
* Encephalitis
* Dementia
* Hepatosplenomegaly
* Arthritis
* Ascites

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  |

* Anemia
* Leukocytosis especially in patients with Clostridium difficile infection
* Hypoalbuminemia
* Metabolic alkalosis associated with a poor prognosis
* Metabolic acidosis secondary to ischemic colitis

| 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  |

* Fat soluble vitamin deficiency
* Hypoalbuminemia
* Fecal stool test

| Barium studies:

* Dilation and edema of mucosal folds

* Steatorrhea\- 10-40 g/day (Normal=5 g/day)

Celiac disease | Diffuse  | −  | −  | −  | −  | −  | \+  | \+  | −  | −  | −  | −  | Hyperactive  |

* IgA endomysial antibody
* IgA tissue transglutaminase antibody
* Anti-gliadin antibody
* Small bowel biopsy

| US:

* Bull’s eye or target pattern
* Pseudokidney sign

* Gluten allergy

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

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

| 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/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

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

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

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

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

* ABGs
* Leukocytosis
* Pancytopenia

* CXR
* CT chest
* Bronchoscopy

* Shortness of breath
* Cough