Sandbox:Amd

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

Differential diagnosis

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, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein

Classification of acute abdomen based on etiology Disease Clinical manifestations Diagnosis Comments Symptoms Signs Fever Rigors and chills Abdominal Pain Jaundice Hypo- tension Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Abdominal causes Inflammatory causes Pancreato-biliary disorders 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 and evidence of inflammation Murphy’s sign Acute pancreatitis + − Epigastric ± ± − − N Increased amylase / lipase Ultrasound shows evidence of inflammation Pain radiation to back Primary biliary cirrhosis − − RUQ/Epigastric + − − − N Increased AMA level, abnormal LFTs 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 Cholelithiasis ± − RUQ/Epigastric ± − + + Ultrasound shows gallstone Murphy’s sign Gastric causes Peptic ulcer disease ± − Diffuse − + in 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 Gastroesophageal reflux disease − − Epigastric − − − − Gastric outlet obstruction − − Epigastric − ± Hepatic causes Viral hepatitis + − RUQ + − Liver masses + + in Liver abscess RUQ ± + in sepsis Budd-Chiari syndrome ± − RUQ − Cirrhosis + − RUQ + − Intestinal causes Acute appendicitis + +in pyogenic appendicitis Starts in epigastrium, migrates to RLQ − + in perforated appendicitis + + Hypoactive Leukocytosis Ultrasound shows evidence of inflammation Nausea & vomiting, decreased appetite Acute diverticulitis + ± LLQ − − + − Hypoactive Leukocytosis CT scan and ultrasound shows evidence of inflammation Inflammatory bowel disease ± − Diffuse Irritable bowel syndrome ± − Diffuse Whipple's disease ± − Diffuse Toxic megacolon + − Diffuse − + ± − Tropical sprue + − Diffuse Celiac disease − − Diffuse ±, also dermatitis herpetiformis − − − Hyperactive (increased sounds) Peritoneal causes Spontaneous bacterial peritonitis + − Diffuse + in cirrhotic patients ± − − Hypoactive Ascitic fluid PMN>250 cells/mm³ Culture: Positive for single organism Ultrasound for evaluation of liver cirrhosis Hollow Viscous Obstruction Small intestine obstruction − − Diffuse − − + ± Hyperactive then absent Leukocytosis Abdominal X ray Nausea & vomiting associated with constipation, abdominal distention 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 Tubal causes Torsion of the cyst − − RLQ / LLQ − ± ± N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting Acute salpingitis + ± RLQ / LLQ − − ± ± N Leukocytosis Pelvic ultrasound Vaginal discharge 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 Extra-abdominal causes Pulmonary disorders Pleural empyema + ± RUQ/Epigastric − − − − N Cardiovascular disorders Myocardial Infarction − − Epigastric − + in cardiogenic shock − − N