Acute abdominal pain DDx

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:  Seyedmahdi Pahlavani, M.D. [2]

| Classification of acute abdomen based

on etiology

| Presentation  | Clinical findings  | Diagnosis  | Comments

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Fever  | Rigors and Chills  | Abdominal Pain  | Jaundice  | Hypotension  | Guarding  | Rebound Tenderness  | Bowel sounds  | Lab Findings  | Imaging
Common causes of

Peritonitis

| Spontaneous bacterial peritonitis | \+  |  | Diffuse  | −  | −  | −  | −  | Hypoactive  |

* Ascitic fluid PMN>250 cells/mm³

* Culture: Positive for single organism

| Ultrasound for evaluation of liver cirrhosis  | \-
Perforated gastric and duodenal ulcer | \+  |  | Diffuse  | −  | \+  | \+  | \+  | N  |

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

| Air under diaphragm in upright CXR | Upper GI endoscopy for diagnosis
Acute suppurative cholangitis  | \+  | \+  | RUQ | \+  | \+  | \+  | \+  | ±  |  |  |
Acute cholangitis  | \+  | −  | RUQ | \+  | −  | −  | −  | N  | Abnormal LFT | Ultrasound shows biliary dilatation  | Biliary drainage (ERCP) + IV antibiotics
Acute cholecystitis | \+  |  | RUQ | \+  |  | −  | −  | Hypoactive  |

* Hyperbilirubinemia
* Leukocytosis

| Ultrasound shows gallstone and evidence of inflammation  | Murphy’s sign
Acute pancreatitis | \+  |  | Epigastric | ±  |  | −  | −  | N  | Increased amylase / lipase | Ultrasound shows evidence of inflammation | Pain radiation to back
Acute appendicitis | \+  |  | RLQ  | −  |  | \+  | \+  | Hypoactive  | Leukocytosis | Ultrasound shows evidence of inflammation | Nausea & vomiting, decreased appetite
Acute diverticulitis | \+  |  | LLQ  | ±  |  | \+  | −  | Hypoactive  | Leukocytosis | CT scan and ultrasound shows evidence of inflammation  |
Hollow Viscous Obstruction  | Small intestine obstruction  | −  |  | Diffuse  | −  |  | \+  | ±  | Hyperactive then absent  | Leukocytosis | Abdominal X ray | Nausea & vomiting associated with constipation, abdominal distention
Gall stone disease/Cholelithiasis | ±  | −  |  |  |  |  |  |  |  |  |
Volvulus | \-  |  | Diffuse  | \-  |  | \+  | \-  | Hypoactive  | Leukocytosis | CT scan and abdominal X ray | Nausea & vomiting associated with constipation, abdominal distention
Biliary colic | \-  |  | RUQ  | \+  |  | \-  | \-  | N  | Increased bilirubin and alkaline phosphatase | Ultrasound  | Nausea & vomiting
Renal colic | \-  |  | Flank pain | \-  |  | \-  | \-  | N  | Hematuria | CT scan and ultrasound  | Colicky abdominal pain associated with nausea & vomiting
Vascular Disorders  | Ischemic causes  | Mesenteric ischemia | ±  |  | Periumbilical  | \-  |  | \-  | \-  | Hyperactive  | Leukocytosis and lactic acidosis | CT scan  | Nausea & vomiting, normal physical examination
Acute ischemic colitis | ±  |  | Diffuse  | \-  |  | \+  | \+  | Hyperactive then absent  | Leukocytosis | CT scan  | Nausea & vomiting
Hemorrhagic causes  | Ruptured abdominal aortic aneurysm | \-  |  | Diffuse  | \-  |  | \-  | \-  | N  | Normal  | CT scan  | Unstable hemodynamics
Intra-abdominal or retroperitoneal hemorrhage | \-  |  | Diffuse  | \-  |  | \-  | \-  | N  | Anemia | CT scan  | History of trauma
Gynaecological Causes  | Fallopian tube  | Acute salpingitis | \+  |  | LLQ/ RLQ  | −  |  | ±  | ±  | N  | Leukocytosis | Pelvic ultrasound | Vaginal discharge
Ovarian cyst complications and endometrial disease  | Torsion of the cyst  | \-  |  | RLQ / LLQ  | \-  |  | ±  | ±  | N  | Increased ESR and CRP | Ultrasound  | Sudden onset sever pain with nausea and vomiting
Endometriosis  | \-  |  | RLQ/LLQ  | \-  |  | +/-  | +/-  | N  | Normal  | Laproscopy  | Menstrual-associated symptoms, pelvic

symptoms

Cyst rupture  | \-  |  | RLQ / LLQ  | \-  |  | +/-  | +/-  | N  | Increased ESR and CRP | Ultrasound  | Sudden onset sever pain with nausea and vomiting
Pregnancy  | Ruptured ectopic pregnancy | \-  |  | RLQ / LLQ  | \-  |  | \-  | \-  | N  | Positive pregnancy test | Ultrasound  | History of missed period and vaginal bleeding
Functional  | Irritable Bowel Syndrome  | \-  |  | Diffuse  | \-  | \-  | \-  | \-  | N  |

Clinical diagnosis

* ROME III/IV criteria
* Pharmacologic studies based criteria

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* High dietary fiber

* Osmotic laxatives
* Antispasmodicdrugs