Bowel obstruction differential diagnosis

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

## Overview

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Bowel obstruction must be differentiated from other diseases that cause abdominal pain, nausea and vomiting, and constipation, such as irritable bowel syndrome, volvulus and acute diverticulitis.

## Differentiating bowel obstruction from other Diseases

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Bowel obstruction must be differentiated from other diseases that cause abdominal pain, nausea and vomiting, and constipation, such as irritable bowel syndrome, volvulus and acute diverticulitis.

The following tables discusses differential diagnoses based on abdominal pain with nausea and vomiting:

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 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
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

Gastritis | Epigastric | ±  | −  | \+  | −  | −  | −  | Positive in chronic gastritis  | \+  | −  | −  | −  | N  |

* H.pylori infection diagnostic tests

* Endoscopy

* H.pylori gastritis guideline recommendation

Gastroesophageal reflux disease | Epigastric | −  | −  | ±  | −  | −  | −  | −  | −  | −  | −  | −  | N  | N  |

* Gastric emptying studies

* Esophageal manometry
* Endoscopy for alarm signs

Gastric outlet obstruction | Epigastric | −  | −  | ±  | −  | −  | −  | \+  | −  | −  | −  | −  | Hyperactive  |

* Complete blood count
* Basic metabolic panel

* Abdominal x-ray\- air fluid level
* Barium upper GI studies- narrowed pylorus

* Succussion splash

Gastroparesis  | Epigastric  | −  | −  | \+  | −  | −  | −  | \+  | −  | ±  | −  | −  | Hyperactive/hypoactive  |

* Hemoglobin
* Fasting plasma glucose
* Serum total protein, albumin, thyrotropin (TSH), and an antinuclear antibody (ANA) titer
* HbA1c

* Scintigraphic gastric emptying

* Succussion splash
* Single photon emission computed tomography (SPECT)
* Full thickness gastric and small intestinal biopsy

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

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

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

| CT scan

* Bowel wall thickening
* Edema

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

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

* Urinalysis
* Urine culture
* Blood culture

* CT
* MRI

* CVA tenderness

Renal colic | Flank pain | −  | −  | \+  | −  | −  | −  | −  | −  | −  | −  | −  | N  |

* Hematuria

* Ultrasound
* CT scan

* Colicky abdominal pain
* Dysuria

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

Volvulus | Diffuse  | \-  | −  | \+  | −  | \+  | −  | −  | −  | Positive in perforated cases  | \+  | \+  | Hyperactive then absent  |

* Leukocytosis

| CT scan and abdominal X ray

* U shaped sigmoid colon

* "Whirl sign"

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

* ↑ bilirubin and alkaline phosphatase

* Ultrasound

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
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
Torsion of the cyst  | RLQ / LLQ  | −  | −  | \+  | −  | −  | −  | −  | −  | −  | ±  | ±  | N  |

* ↑ ESR
* ↑ CRP

* Ultrasound

* Sudden onset & severe pain

Cyst rupture  | RLQ / LLQ  | −  | −  | \+  | −  | −  | −  | −  | −  | \+  | ±  | ±  | N  |

* ↑ ESR
* ↑ CRP

* Ultrasound

Ruptured ectopic pregnancy | RLQ / LLQ  | −  | −  | \+  | −  | −  | −  | −  | −  | \+  | \+  | \+  | N  |

* Positive pregnancy test

* Ultrasound

| History of

* Missed period
* Vaginal bleeding

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

### The following table discusses differential diagnoses of abdominal pain with constipation:

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

* Leukocytosis

* CT scan
* Ultrasound

* History of constipation

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

* High dietary fiber

* Osmotic laxatives
* Antispasmodic drugs

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

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

Volvulus | Diffuse  | \-  | −  | \+  | −  | \+  | −  | −  | −  | Positive in perforated cases  | \+  | \+  | Hyperactive then absent  |

* Leukocytosis

| CT scan and abdominal X ray

* U shaped sigmoid colon

* "Whirl sign"

## References

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