Sandbox:iqra: Difference between revisions

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! style="background:#4479BA; color: #FFFFFF;" align="center" |Imaging
! style="background:#4479BA; color: #FFFFFF;" align="center" |Imaging
|-
|-
! rowspan="46" |Abdominal causes
! rowspan="47" |Abdominal causes
! rowspan="33" |Inflammatory causes
! rowspan="34" |Inflammatory causes
! rowspan="8" |Pancreato-biliary disorders
! rowspan="9" |Pancreato-biliary disorders
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Cholangitis|Acute cholangitis]]  
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Cholangitis|Acute cholangitis]]  
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | [[RUQ]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | [[RUQ]]
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* [[Thrombophlebitis|Migratory superficial thrombophlebitis]] (classic [[Trousseau's syndrome]])
* [[Thrombophlebitis|Migratory superficial thrombophlebitis]] (classic [[Trousseau's syndrome]])
* [[Panniculitis|Pancreatic panniculitis]]
* [[Panniculitis|Pancreatic panniculitis]]
|-
!Disease
!Abdominal Pain
! colspan="1" rowspan="1" |Fever
!Rigors and chills
!Jaundice
!Diarrhea
!GI Bleed
!Hypo-
tension
! colspan="1" rowspan="1" |Guarding
!Rebound Tenderness
!Bowel sounds
! colspan="1" rowspan="1" |Lab Findings
!Imaging
!Comments
|-
|-
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Primary biliary cirrhosis]]
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Primary biliary cirrhosis]]
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<figure-inline>[[Image:Right_upper_quadrant.PNG|link=Right upper quadrant abdominal pain resident survival guide|339x339px]]</figure-inline>
<figure-inline><figure-inline>[[Image:Right_upper_quadrant.PNG|link=Right upper quadrant abdominal pain resident survival guide|339x339px]]</figure-inline></figure-inline>
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<figure-inline>[[Image:Epigastric_quadrant_pain.PNG|link=Epigastric pain resident survival guide|179x179px]]</figure-inline>
<figure-inline><figure-inline>[[Image:Epigastric_quadrant_pain.PNG|link=Epigastric pain resident survival guide|179x179px]]</figure-inline></figure-inline>
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<figure-inline>[[Image:Left_upper_quadrant.PNG|link=Left upper quadrant abdominal pain resident survival guide|329x329px]]</figure-inline>
<figure-inline><figure-inline>[[Image:Left_upper_quadrant.PNG|link=Left upper quadrant abdominal pain resident survival guide|329x329px]]</figure-inline></figure-inline>
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<figure-inline>[[Image:Right_flank_quadrant.PNG|link=Right flank pain resident survival guide|338x338px]]</figure-inline>
<figure-inline><figure-inline>[[Image:Right_flank_quadrant.PNG|link=Right flank pain resident survival guide|338x338px]]</figure-inline></figure-inline>
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<figure-inline>[[Image:Umbilical_pain.PNG|link=Umbilical region pain resident survival guide|165x165px]]</figure-inline>
<figure-inline><figure-inline>[[Image:Umbilical_pain.PNG|link=Umbilical region pain resident survival guide|165x165px]]</figure-inline></figure-inline>
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<figure-inline>[[Image:Left_flank_quadrant.PNG|link=Left flank quadrant abdominal pain resident survival guide|335x335px]]</figure-inline>
<figure-inline><figure-inline>[[Image:Left_flank_quadrant.PNG|link=Left flank quadrant abdominal pain resident survival guide|335x335px]]</figure-inline></figure-inline>
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<figure-inline>[[Image:Right_lower_quadrant.PNG|link=Right lower quadrant abdominal pain resident survival guide|338x338px]]</figure-inline>
<figure-inline><figure-inline>[[Image:Right_lower_quadrant.PNG|link=Right lower quadrant abdominal pain resident survival guide|338x338px]]</figure-inline></figure-inline>
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<figure-inline>[[Image:Hypogastric.PNG|link=Hypogastric pain resident survival guide|199x199px]]</figure-inline>
<figure-inline><figure-inline>[[Image:Hypogastric.PNG|link=Hypogastric pain resident survival guide|199x199px]]</figure-inline></figure-inline>
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<figure-inline>[[Image:Left_lower_quadrant.PNG|link=Left lower quadrant abdominal pain resident survival guide|335x335px]]</figure-inline>
<figure-inline><figure-inline>[[Image:Left_lower_quadrant.PNG|link=Left lower quadrant abdominal pain resident survival guide|335x335px]]</figure-inline></figure-inline>
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Revision as of 14:15, 29 November 2017

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

Classification of pain in the abdomen based on etiology Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Abdominal Pain Fever Rigors and chills Jaundice Diarrhea GI Bleed Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Abdominal causes Inflammatory causes Pancreato-biliary disorders Acute cholangitis RUQ + + N Ultrasound shows biliary dilatation/stents/tumor Biliary drainage (ERCP) + IV antibiotics
Acute cholecystitis RUQ + + Hypoactive Ultrasound shows gallstone and evidence of inflammation Murphy’s sign
Acute pancreatitis Epigastric + ± ± - - N
  • Ultrasound shows evidence of inflammation
  • CT scan shows severity of pancreatitis
Pain radiation to back
Chronic pancreatitis Epigastric ± + N
  • Pancreatic function test
CT scan
  • Calcification
  • Pseudocyst
  • Dilation of main pancreatic duct
Predisposes to pancreatic cancer
Pancreatic carcinoma Epigastric - - + + - - - - N

Skin manifestations may include:

Disease Abdominal Pain Fever Rigors and chills Jaundice Diarrhea GI Bleed Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Primary biliary cirrhosis RUQ/Epigastric + + in late presentation N
  • Increased AMA level, abnormal LFTs
Primary sclerosing cholangitis RUQ + + N 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 ± ± N to hyperactive for dislodged stone Ultrasound shows gallstone Fatty food intolerance
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 ± + in chronic gastritis N H.pylori infection diagnostic tests Endoscopy H.pylori gastritis guideline recommendation
Gastroesophageal reflux disease Epigastric N Esophageal manometry Gastric emptying studies Endoscopy for alarm signs
Gastric outlet obstruction Epigastric Hyperactive 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
Gastrointestinal perforation Diffuse + ± ± +, depends on site + + ± Hyperactive/hypoactive
  • WBC> 10,000
Air under diaphragm in upright CXR Hamman's sign
Dumping syndrome Lower and then diffuse + + Hyperactive
  • Glucose challenge test
  • Hydrogen breath test
  • Upper GI series
  • Gastric emptying study
Postgastrectomy
Intestinal causes Acute appendicitis Starts in epigastrium, migrates to RLQ + +in pyogenic appendicitis + in perforated appendicitis + + Hypoactive Ultrasound shows evidence of inflammation Nausea & vomiting, decreased appetite
Acute diverticulitis LLQ + ± ± Hematochezia + in perforated diverticulitis + + Hypoactive CT scan and ultrasound shows evidence of inflammation History of constipation
Inflammatory bowel disease Diffuse ± ± ± Hematochezia N/ Hyperactive String sign on abdominal x-ray in Crohn's disease

Extra intestinal findings:

Irritable bowel syndrome Diffuse ± + N Tests done to exclude other diseases as it diagnosis of exclusion Tests done to exclude other diseases as it diagnosis of exclusion Symptomatic treatment
Whipple's disease Diffuse ± ± + ± N Endoscopy is used to confirm diagnosis.

Images used to find complications

Extra intestinal findings:
Toxic megacolon Diffuse + + + ± Hypoactive CT scan shows:

Ultrasound shows:

  • Loss of haustra coli of the colon
  • 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 + + N Barium studies show dilation and edema of mucosal folds Steatorrhea- 10-40 g/day (Normal=5 g/day)
Celiac disease Diffuse + Hyperactive USG
  • Bull’s eye or target pattern
  • Pseudokidney sign
Gluten allergy
Infective colitis Diffuse + + Hematochezia + in fulminant colitis ± ± Hyperactive CT scan
  • Bowel wall thickening
  • Edema
Colon carcinoma Diffuse/localized - - - ± + ± - -
  • Normal
  • 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
Hepatic causes Viral hepatitis RUQ + + + in Hep A and E + in fulminant hepatitis +in acute + N
  • Abnormal LFTs
  • Viral serology
USG Hep A and E have fecoral route of transmission and Hep B and C transmits via blood transfusion and sexual contact.
Liver masses RUQ + + in Liver abscess ± + in Hepatocellular carcinoma + in sepsis + in Liver abscess + in Liver abscess N
  • CBC
  • LFTs
USG
Liver abscess RUQ + + + ± - + + ± Normal/hypoactive
  • US
  • CT
Hepatocellular carcinoma/Metastasis RUQ + - + - - - - -
  • Normal
  • Hyperactive if obstruction present
  • US
  • CT
  • Liver biopsy

Other symptoms:

Budd-Chiari syndrome RUQ ± ± + in liver failure leading to varices N
Findings on CT scan suggestive of Budd-Chiari syndrome include:
Ascitic fluid examination shows:
Hemochromatosis RUQ + in cirrhotic patients N
  • >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 + varices + N USG
  • Stigmata of liver disease
  • Cruveilhier- Baumgarten murmur
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
Renal causes Pyelonephritis Lumbar region + ± - - - + ± ± Hypoactive
  • Urinalysis
  • Urine culture
  • Blood culture
  • CT
  • MRI
  • Renal punch positive
Renal colic Flank pain N Hematuria CT scan and ultrasound
Hollow Viscous Obstruction Small intestine obstruction Diffuse + + + ± Hyperactive then absent Leukocytosis with left shift indicates complications Abdominal X ray
  • dilated loops of bowel with air fluid levels
  • gasless abdonen
  • "Target sign"– , indicative of intussusception
  • Venous cut-off sign" – suggests thrombosis
Volvulus Diffuse +in perforated cases +in perforated cases + + Hyperactive then absent Leukocytosis CT scan and abdominal X ray
  • U shaped sigmoid colon
"Whirl sign"
Biliary colic RUQ + N Increased bilirubin and alkaline phosphatase Ultrasound Nausea & vomiting
Vascular Disorders Ischemic causes Mesenteric ischemia Periumbilical + if bowel becomes gangrenous + Hematochezia + if bowel becomes gangrenous + if bowel becomes gangrenous Hyperactive to absent CT angiography
  • SMA or SMV thrombosis
Also known as abdominal angina, worsens with eating
Acute ischemic colitis Diffuse + ± + Massive + + + Hyperactive then absent Leukocytosis Abdominal x-ray
  • Distension and pneumatosis

CT scan

  • Double halo appearance, thumbprinting
  • Thickening of bowel
Can lead to shock
Hemorrhagic causes Ruptured abdominal aortic aneurysm Diffuse ± Herald to massive + N Focused Assessment with Sonography in Trauma (FAST)  Unstable hemodynamics
Intra-abdominal or retroperitoneal hemorrhage Diffuse ± Massive + 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 & severe 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 Thoracentesis Chest X-ray
  • Pleural opacity

USG

  • Localization of effusion
Physical examination
Pulmonary embolism RUQ/LUQ ± - - - - ± - - N
  • ABGs
  • D-dimer
Pneumonia RUQ/LUQ + + - - - + - - N/Hypoactive
  • ABGs
  • Eosinophilia
  • Pancytopenia
  • CXR
  • CT chest
  • Bronchoscopy
Cardiovascular disorders Myocardial Infarction Epigastric + in cardiogenic shock N Echocardiogram
  • Wall motion abnormality
  • Wall rupture
  • Septal rupture
Complications:

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