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,

Causes of Hemoptysis Disease Clinical manifestations/association Diagnosis Comments Symptoms Signs Amount Fever Chest pain Weight loss Lab Findings Imaging Hemoptysis Disorders of airway Pancreato-biliary disorders Airway trauma RUQ + + + − − − − − + + − − − − Acute pancreatitis Epigastric + + + ± − − Chronic pancreatitis Epigastric − ± + − − − Pancreatic carcinoma Epigastric − + + − − − Disease Abdominal Pain Fever Nausea or vomiting Weight loss Hypo- tension Guarding Rebound Tenderness Lab Findings Imaging Comments RUQ/Epigastric − − − − − − Increased AMA level, abnormal LFTs ERCP Pruritis Primary sclerosing cholangitis RUQ + − − − − − Cholelithiasis RUQ/Epigastric ± ± − − − − Leukocytosis Ultrasound shows gallstone Fatty food intolerance Gastric causes Peptic ulcer disease Diffuse ± + + Positive if perforated Positive if perforated Positive if perforated 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 Nausea or vomiting Weight loss Hypo- tension Guarding Rebound Tenderness Lab Findings Imaging Comments Gastritis Epigastric ± + Positive in chronic gastritis − − − H.pylori infection diagnostic tests Endoscopy H.pylori gastritis guideline recommendation Gastroesophageal reflux disease Epigastric − ± − − − − N Gastric emptying studies Esophageal manometry Endoscopy for alarm signs Gastric outlet obstruction Epigastric − ± + − − − Complete blood count Basic metabolic panel Abdominal x-ray- air fluid level Barium upper GI studies- narrowed pylorus Succussion splash Gastroparesis Epigastric − + + ± − − 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 Gastrointestinal perforation Diffuse + - − + + ± WBC> 10,000 Air under diaphragm in upright CXR Hamman's sign Dumping syndrome Lower and then diffuse − + + + − − Glucose challenge test Hydrogen breath test Upper GI series Gastric emptying study Postgastrectomy Intestinal causes Disease Abdominal Pain Fever Nausea or vomiting Weight loss Hypo- tension Guarding Rebound Tenderness Lab Findings Imaging Comments Acute appendicitis Starts in epigastrium, migrates to RLQ + + − Positive in perforated appendicitis + + Leukocytosis Ct scan Ultrasound Positive Rovsing sign Positive Obturator sign Positive Iliopsoas sign Acute diverticulitis LLQ + + − Positive in perforated diverticulitis + + Leukocytosis CT scan Ultrasound History of constipation Inflammatory bowel disease Diffuse ± − + − − − 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 Irritable bowel syndrome Diffuse − − + − − − Normal Normal Symptomatic treatment High dietary fiber Osmotic laxatives Antispasmodic drugs Whipple's disease Diffuse ± − + ± − − 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 Nausea or vomiting Weight loss Hypo- tension Guarding Rebound Tenderness Lab Findings Imaging Comments Toxic megacolon Diffuse + − − + ± + 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 + − + − − − 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) Celiac disease Diffuse − − + − − − IgA endomysial antibody IgA tissue transglutaminase antibody Anti-gliadin antibody Small bowel biopsy US: Bull’s eye or target pattern Pseudokidney sign Gluten allergy Infective colitis Diffuse + ± − Positive in fulminant colitis ± ± Stool culture and studies Shiga toxin in bloody diarrhea PCR CT scan Bowel wall thickening Edema Disease Abdominal Pain Fever Nausea or vomiting Weight loss Hypo- tension Guarding Rebound Tenderness Lab Findings Imaging Comments Colon carcinoma Diffuse/ RLQ/LLQ − − + ± − − 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 Hepatic causes Viral hepatitis RUQ + + + Positive in fulminant hepatitis Positive in acute + 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 + + + + + ± CBC Blood cultures Abnormal liver function tests US CT Hepatocellular carcinoma/Metastasis RUQ + − + − − − 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 Nausea or vomiting Weight loss Hypo- tension Guarding Rebound Tenderness Lab Findings Imaging Comments Budd-Chiari syndrome RUQ ± − − − − − 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. Hemochromatosis RUQ − − − − − − >60% TS >240 μg/L SF Raised LFT Hyperglycemia Ultrasound shows evidence of cirrhosis Extra intestinal findings: Hyperpigmentation Diabetes mellitus Arthralgia Impotence in males Cardiomyopathy Atherosclerosis Hypopituitarism Hypothyroidism Extrahepatic cancer Prone to specific infections Cirrhosis RUQ − − + + − − Hypoalbuminemia Prolonged PT Abnormal LFTs Hyponatremia Thrombocytopenia US Nodular, shrunken liver Ascites Stigmata of liver disease Cruveilhier- Baumgarten murmur Disease Abdominal Pain Fever Nausea or vomiting Weight loss Hypo- tension Guarding Rebound Tenderness Lab Findings Imaging Comments Peritoneal causes Spontaneous bacterial peritonitis Diffuse + − − ± + + Ascitic fluid PMN>250 cells/mm³ Culture: Positive for single organism Ultrasound for evaluation of liver cirrhosis Renal causes Pyelonephritis Unilateral + + − + − − Urinalysis Urine culture Blood culture CT MRI CVA tenderness Renal colic Flank pain − + − − − − Hematuria Ultrasound CT scan Colicky abdominal pain Dysuria Hollow Viscous Obstruction Small bowel obstruction Diffuse + + + + + ± 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 + + Leukocytosis CT scan and abdominal X ray U shaped sigmoid colon "Whirl sign" Biliary colic RUQ − + − − − − ↑ bilirubin and alkaline phosphatase Ultrasound Disease Abdominal Pain Fever Nausea or vomiting Weight loss Hypo- tension Guarding Rebound Tenderness Lab Findings Imaging Comments Vascular Disorders Ischemic causes Mesenteric ischemia Periumbilical Positive if bowel becomes gangrenous + + Positive if bowel becomes gangrenous Positive if bowel becomes gangrenous − 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 + + + + + + Leukocytosis Abdominal x-ray Distension and pneumatosis CT scan Double halo appearance, thumbprinting Thickening of bowel May lead to shock Hemorrhagic causes Ruptured abdominal aortic aneurysm Diffuse ± + + + − − Fibrinogen D-dimer Focused Assessment with Sonography in Trauma (FAST)  Unstable hemodynamics Intra-abdominal or retroperitoneal hemorrhage Diffuse ± ± − + − − ↓ Hb ↓ Hct CT scan History of trauma Disease Abdominal Pain Fever Nausea or vomiting Weight loss Hypo- tension Guarding Rebound Tenderness Lab Findings Imaging Comments Gynaecological Causes Tubal causes Torsion of the cyst/ovary RLQ / LLQ − + − − ± ± ↑ ESR ↑ CRP Ultrasound Sudden onset & severe pain Acute salpingitis RLQ / LLQ + − − − ± ± Leukocytosis Pelvic ultrasound Vaginal discharge Cyst rupture RLQ / LLQ − + − + ± ± ↑ ESR ↑ CRP Ultrasound Pregnancy Ruptured ectopic pregnancy RLQ / LLQ − + − + + + Positive pregnancy test Ultrasound History of Missed period Vaginal bleeding Extra-abdominal causes Pulmonary disorders Pleural empyema RUQ/Epigastric + − + − − − Thoracentesis Chest X-ray Pleural opacity Localization of effusion Physical examination Crackles Egophony Increased tactile fremitus Pulmonary embolism RUQ/LUQ ± − − ± − − ABGs D-dimer CXR V/Q scan Spiral CT pulmonary angiogram Dyspnea Tachycardia Pleuretic chest pain Pneumonia RUQ/LUQ + + − + − − ABGs Leukocytosis Pancytopenia CXR CT chest Bronchoscopy Shortness of breath Cough Cardiovascular disorders Myocardial Infarction Epigastric ± + − Positive in cardiogenic shock − − Cardiac enzymes ECG Echocardiogram Wall motion abnormality Wall rupture Septal rupture Chest pain, tightness, diaphoresis Complications: Arrythmias Mitral regurgitation Ventricular wall rupture Septal rupture

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