Abdominal pain and fever

Abdominal pain Microchapters

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Diffuse Abdominal Pain
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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, US = Ultrasound

| 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 cholangitis | RUQ | \+  | −  | −  | \+  | −  | −  | −  | −  | −  | −  | −  | N  |

* Abnormal LFT

* Ultrasound shows biliary dilatation/stents/tumor

* Biliary drainage (ERCP) + IV antibiotics

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

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
Primary sclerosing cholangitis | RUQ | \+  | −  | −  | \+  | −  | −  | −  | −  | −  | −  | −  | N  |

* Increased liver enzymes
* Increased IgM, IgG4
* Anti-neutrophil cytoplasmic antibody (p-ANCA)
* Anti-nuclear antibody (ANA)
* Anti-smooth muscle antibody (Anti-Sm)
* Anti-endothelial antibody
* Anti-cardiolipin antibody

| ERCP and MRCP shows

* Multiple segmental strictures
* Mural irregularities
* Biliary dilatation and diverticula
* Distortion of biliary tree

* The risk of cholangiocarcinoma in patients with primary sclerosing cholangitis is 400 times higher than the risk in the general population.

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

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
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 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

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)

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
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

Hepatocellular carcinoma/Metastasis  | RUQ  | \+  | −  | −  | \+  | −  | −  | \+  | −  | −  | −  | −  |

* Normal
* Hyperactive if obstruction present

* High levels of AFP in serum
* Abnormal liver function tests

* US
* CT
* Liver biopsy

Other symptoms:

* Splenomegaly
* Variceal bleeding
* Ascites
* Spider nevi
* Asterixis

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.

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
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

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

* Urinalysis
* Urine culture
* Blood culture

* CT
* MRI

* CVA tenderness

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

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
Acute salpingitis | RLQ / LLQ  | \+  | ±  | −  | −  | −  | −  | −  | −  | −  | ±  | ±  | N  |

* Leukocytosis

* Pelvic ultrasound

* Vaginal discharge

Pleural empyema | RUQ/Epigastric | \+  | ±  | −  | −  | −  | −  | \+  | −  | −  | −  | −  | N  |

* Thoracentesis

| Chest X-ray

* Pleural opacity

* Localization of effusion

| Physical examination

* Crackles
* Egophony
* Increased tactile fremitus

Pulmonary embolism | RUQ/LUQ  | ±  | −  | −  | −  | −  | −  | −  | −  | ±  | −  | −  | N  |

* ABGs
* D-dimer

* CXR
* V/Q scan
* Spiral CT pulmonary angiogram

* Dyspnea
* Tachycardia
* Pleuretic chest pain

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