Abdominal pain and jaundice

Abdominal pain Microchapters

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Diffuse Abdominal Pain
Left Upper Quadrant
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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 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

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
Primary biliary cirrhosis | RUQ/Epigastric | −  | −  | −  | \+  | −  | −  | −  | −  | −  | −  | −  | N  |

* Increased AMA level, abnormal LFTs

* ERCP

* Pruritis

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

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

* WBC> 10,000

* Air under diaphragm in upright CXR

* Hamman's sign

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
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

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.

Cirrhosis | RUQ | −  | −  | −  | \+  | −  | −  | \+  | \+  | \+  | −  | −  | N  |

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

| US

* Nodular, shrunken liver
* Ascites

* Stigmata of liver disease
* Cruveilhier- Baumgarten murmur

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

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

* ↑ bilirubin and alkaline phosphatase

* Ultrasound