Sandbox:iqra

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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

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 + - N
  • Increased AMA level, abnormal LFTs
ERCP
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 ± ± Normal to hyperactive for dislodged stone Ultrasound shows gallstone Fatty food intolerance
Gastric causes Peptic ulcer disease Diffuse ± 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
Disease Abdominal Pain Fever Rigors and chills Jaundice Diarrhea GI Bleed Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
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 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 + ± ± Positive, 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
Disease Abdominal Pain Fever Rigors and chills Jaundice Diarrhea GI Bleed Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Intestinal causes Acute appendicitis Starts in epigastrium, migrates to RLQ + Positive in pyogenic appendicitis Positive in perforated appendicitis + + Hypoactive Ct scan and

Ultrasound

Nausea & vomiting, decreased appetite
Acute diverticulitis LLQ + ± ± Hematochezia Positive in perforated diverticulitis + + Hypoactive CT scan and ultrasound shows evidence of inflammation History of constipation
Inflammatory bowel disease Diffuse ± ± + Hematochezia Normal or hyperactive String sign on abdominal x-ray in Crohn's disease

Extra intestinal findings:

Irritable bowel syndrome Diffuse - ± N Normal Normal Symptomatic treatment
Whipple's disease Diffuse ± ± + ± N Endoscopy is used to confirm diagnosis.

Images used to find complications

Extra intestinal findings:
Disease Abdominal Pain Fever Rigors and chills Jaundice Diarrhea GI Bleed Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Toxic megacolon Diffuse + + + ± + Hypoactive 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 + + 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 Positive in fulminant colitis ± ± Hyperactive CT scan
  • Bowel wall thickening
  • Edema
Disease Abdominal Pain Fever Rigors and chills Jaundice Diarrhea GI Bleed Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
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 + + Positive in Hep A and E Positive in fulminant hepatitis Positive in acute + N
  • Abnormal LFTs
  • Viral serology
US Hep A and E have fecoral route of transmission and Hep B and C transmits via blood transfusion and sexual contact.
Liver abscess RUQ + + + ± - + + ± Normal or hypoactive
  • US
  • CT
Hepatocellular carcinoma/Metastasis RUQ + - + - - - - -
  • Normal
  • Hyperactive if obstruction present
  • US
  • CT
  • Liver biopsy

Other symptoms:

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

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
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 + + + N USG
  • Stigmata of liver disease
  • Cruveilhier- Baumgarten murmur
Disease Abdominal Pain Fever Rigors and chills Jaundice Diarrhea GI Bleed Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
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 Unilateral + ± - - - + - - Hypoactive
  • Urinalysis
  • Urine culture
  • Blood culture
  • CT
  • MRI
  • CVA tenderness
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 abdomen
  • "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
Disease Abdominal Pain Fever Rigors and chills Jaundice Diarrhea GI Bleed Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Vascular Disorders Ischemic causes Mesenteric ischemia Periumbilical + if bowel becomes gangrenous + + + 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 + ± + + + + + Hyperactive then absent 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 ± + + N Focused Assessment with Sonography in Trauma (FAST)  Unstable hemodynamics
Intra-abdominal or retroperitoneal hemorrhage Diffuse ± + + N Anemia CT scan History of trauma
Disease Abdominal Pain Fever Rigors and chills Jaundice Diarrhea GI Bleed Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
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
  • Dyspnea
  • Tachycardia
  • Pleuretic chest pain
Pneumonia RUQ/LUQ + + - - - + - - Normal or hypoactive
  • ABGs
  • Eosinophilia
  • Pancytopenia
  • CXR
  • CT chest
  • Bronchoscopy
Cardiovascular disorders Myocardial Infarction Epigastric ± + in cardiogenic shock N ECG

Echocardiogram

  • Wall motion abnormality
  • Wall rupture
  • Septal rupture
Complications:

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