Gallstone disease differential diagnosis: Difference between revisions

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Revision as of 14:44, 29 November 2017

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

Overview

Gallstone disease must be differentiated from other diseases that cause epigastric, and left and right hypochondriac pain (right upper quadrant) such as: Abdominal pain, esophageal chest pain,gastroesophageal reflux disorder, peptic ulcer disease, non-ulcer dyspepsia,hepatitis, functional gallbladder disorder, sphincter of Oddi dysfunction,appendicitis, bile duct stricture, chronic pancreatitis, irritable bowel syndrome, ischemic heart disease, pyelonephritis, ureteral calculi and complications of gallstone disease include: acute cholecystitis, choledocholithiasis, acute pancreatitis, and acute cholangitis.^[1]^[2]

Differentiating Gallstone disease from other Diseases

As Gallstone disease manifests in a variety of clinical forms, differentiation must be established in accordance with the particular subtype. The presence of biliary colic is an important diagnostic feature to distinguish between gallstones and non-biliary disorders. It has been shown that this feature is predictive of finding stones on imaging. ^[3] However, it is important to note that biliary colic concomitant in patients with other biliary disorders such as acute cholecystitis, choledocholithiasis, sphincter of Oddi dysfunction, and functional gallbladder disorder.

Laboratory studies can be helpful, along side clinical presentation in making a preliminary diagnosis:

Liver biochemical tests (serum aminotransferases, total bilirubin, alkaline phosphatase), which may be abnormal in patients with hepatitis, biliary tract obstruction, or (less commonly) acute cholecystitis
Serum amylase and lipase, which are elevated in acute pancreatitis
Complete blood count, which may show an elevated white blood cell count in patients with acute cholecystitis or acute cholangitis
Urine analysis, which may show indicate a urinary tract infection or ureteral calculi^[4]

Other tests that may be indicated depending upon the patient's symptoms and history including:

Upper endoscopy to look for peptic ulcer disease
Endoscopic ultrasonography to look for chronic pancreatitis
Endoscopic retrograde cholangiopancreatography (ERCP) with sphincter of Oddi manometry to look for sphincter of Oddi dysfunction
Cholescintigraphy with or without cholecystokinin (CCK)-stimulation to look for acute cholecystitis and functional gallbladder disorder, respectively
Testing for ischemic heart disease
Esophageal manometry to look for esophageal sources of chest pain, such as esophageal spasm^[5]^[6]

To review a table of differential diagnoses for disease symptoms including jaundice, abdominal pain and fever, please click here:

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, 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 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

Ultrasound shows gallstone and evidence of 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

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

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

Leukocytosis

Ultrasound shows gallstone

Fatty food intolerance

Gastric causes

Gastrointestinal perforation

Diffuse

+

±

−

+, depends on site

+

±

Hyperactive/hypoactive

WBC> 10,000

Air under diaphragm in upright CXR

Hamman's sign

Intestinal causes

Inflammatory bowel disease

Diffuse

±

−

±

Hematochezia

−

N/ Hyperactive

String sign on abdominal x-ray in Crohn's disease

Extra intestinal findings:

Whipple's disease

Diffuse

±

−

±

+

−

±

−

N

Endoscopy is used to confirm diagnosis.

Images used to find complications

Extra intestinal findings:

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

N

CBC
LFTs

USG

Liver abscess

RUQ

+

±

-

+

±

Normal/hypoactive

CBC
Blood cultures
Abnormal liver function tests

US
CT

Hepatocellular carcinoma/Metastasis

RUQ

+

-

+

-

Normal
Hyperactive if obstruction present

High levels of AFP in serum
Abnormal liver function tests

US
CT
Liver biopsy

Other symptoms:

Budd-Chiari syndrome

RUQ

±

−

±

−

+ in liver failure leading to varices

−

N

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.

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

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References

↑ Portincasa P, Moschetta A, Palasciano G (2006). "Cholesterol gallstone disease". Lancet. 368 (9531): 230–9. doi:10.1016/S0140-6736(06)69044-2. PMID 16844493.
↑ Center SA (2009). "Diseases of the gallbladder and biliary tree". Vet. Clin. North Am. Small Anim. Pract. 39 (3): 543–98. doi:10.1016/j.cvsm.2009.01.004. PMID 19524793.
↑ Kraag N, Thijs C, Knipschild P (1995). "Dyspepsia--how noisy are gallstones? A meta-analysis of epidemiologic studies of biliary pain, dyspeptic symptoms, and food intolerance". Scand. J. Gastroenterol. 30 (5): 411–21. PMID 7638565.
↑ Poupon R, Rosmorduc O, Boëlle PY, Chrétien Y, Corpechot C, Chazouillères O, Housset C, Barbu V (2013). "Genotype-phenotype relationships in the low-phospholipid-associated cholelithiasis syndrome: a study of 156 consecutive patients". Hepatology. 58 (3): 1105–10. doi:10.1002/hep.26424. PMID 23533021.
↑ Shaffer EA (2005). "Epidemiology and risk factors for gallstone disease: has the paradigm changed in the 21st century?". Curr Gastroenterol Rep. 7 (2): 132–40. PMID 15802102.
↑ Julliard O, Hauters P, Possoz J, Malvaux P, Landenne J, Gherardi D (2016). "Incisional hernia after single-incision laparoscopic cholecystectomy: incidence and predictive factors". Surg Endosc. 30 (10): 4539–43. doi:10.1007/s00464-016-4790-4. PMID 26895902.

Template:WH Template:WS |}

[pmid16844493-1] Portincasa P, Moschetta A, Palasciano G (2006). "Cholesterol gallstone disease". Lancet. 368 (9531): 230–9. doi:10.1016/S0140-6736(06)69044-2. PMID 16844493.

[pmid19524793-2] Center SA (2009). "Diseases of the gallbladder and biliary tree". Vet. Clin. North Am. Small Anim. Pract. 39 (3): 543–98. doi:10.1016/j.cvsm.2009.01.004. PMID 19524793.

[pmid7638565-3] Kraag N, Thijs C, Knipschild P (1995). "Dyspepsia--how noisy are gallstones? A meta-analysis of epidemiologic studies of biliary pain, dyspeptic symptoms, and food intolerance". Scand. J. Gastroenterol. 30 (5): 411–21. PMID 7638565.

[pmid23533021-4] Poupon R, Rosmorduc O, Boëlle PY, Chrétien Y, Corpechot C, Chazouillères O, Housset C, Barbu V (2013). "Genotype-phenotype relationships in the low-phospholipid-associated cholelithiasis syndrome: a study of 156 consecutive patients". Hepatology. 58 (3): 1105–10. doi:10.1002/hep.26424. PMID 23533021.

[pmid15802102-5] Shaffer EA (2005). "Epidemiology and risk factors for gallstone disease: has the paradigm changed in the 21st century?". Curr Gastroenterol Rep. 7 (2): 132–40. PMID 15802102.

[pmid26895902-6] Julliard O, Hauters P, Possoz J, Malvaux P, Landenne J, Gherardi D (2016). "Incisional hernia after single-incision laparoscopic cholecystectomy: incidence and predictive factors". Surg Endosc. 30 (10): 4539–43. doi:10.1007/s00464-016-4790-4. PMID 26895902.

[1]

[2]

[3]

[4]

[5]

[6]

@@ Line 60: / Line 60: @@
 ! style="background:#4479BA; color: #FFFFFF;" align="center" |Imaging
 |-
-! rowspan="47" style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal causes
+! rowspan="15" style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal causes
-! colspan="1" rowspan="34" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Inflammatory causes
+! colspan="1" rowspan="15" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Inflammatory causes
-! rowspan="9" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Pancreato-biliary disorders
+! rowspan="6" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Pancreato-biliary disorders
 | colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Acute suppurative cholangitis
 | style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[RUQ]]
@@ Line 130: / Line 130: @@
 * CT scan shows severity of pancreatitis
 | style="padding: 5px 5px; background: #F5F5F5;" align="left" |Pain radiation to back
-|-
-| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Chronic pancreatitis]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Epigastric]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* Increased [[amylase]] / [[lipase]]
-* Stool fat content
-* Pancreatic function test
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan
-* Calcification
-* Pseudocyst
-* Dilation of main pancreatic duct
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Predisposes to pancreatic cancer
-|-
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Pancreatic carcinoma]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Epigastric]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |+
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |+
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |N
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* ↑ [[Alkaline phosphatase]]
-* ↑ [[Bilirubin|serum bilirubin]]
-* ↑ [[gamma-glutamyl transpeptidase]]
-* ↑ [[CA 19-9]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* [[Computed tomography|MDCT]] with   [[Positron emission tomography|PET]]/[[Computed tomography|CT]]
-* MRI
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-[[Skin]] manifestations may include:
-* [[Bullous pemphigoid]]
-* [[Mucous membrane pemphigoid|Cicatricial pemphigoid]]
-* [[Thrombophlebitis|Migratory superficial thrombophlebitis]] (classic [[Trousseau's syndrome]])
-* [[Panniculitis|Pancreatic panniculitis]]
-|-
-| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Primary biliary cirrhosis]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[RUQ]]/[[Epigastric]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + in late presentation
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* Increased AMA level, abnormal [[LFTs]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
 |-
 | colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Primary sclerosing cholangitis]]
@@ Line 237: / Line 173: @@
 | style="padding: 5px 5px; background: #F5F5F5;" align="left" |Fatty food intolerance
 |-
-! colspan="1" rowspan="7" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Gastric causes
+!Gastric causes
-| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Peptic Ulcer Disease|Peptic ulcer disease]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |
-* Gastric ulcer- [[melena]] and [[hematemesis]]
-* Duodenal ulcer- [[melena]] and [[hematochezia]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + in perforated
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* Ascitic fluid
-** [[LDH]] > serum [[LDH]]
-** Glucose < 50mg/dl
-** Total protein > 1g/dl
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Air under [[diaphragm]] in upright [[CXR]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Upper GI [[endoscopy]] for diagnosis
-|-
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Gastritis|Gastritis]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Epigastric]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + in chronic gastritis
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[H.pylori infection diagnostic tests]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Endoscopy]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[H.pylori gastritis guideline recommendation]]
-|-
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Gastroesophageal reflux disease|Gastroesophageal reflux disease]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Epigastric]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Esophageal]] [[manometry]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Gastric emptying studies
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Endoscopy]] for alarm signs
-|-
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Gastric outlet obstruction|Gastric outlet obstruction]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Epigastric]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* [[Complete blood count]]
-* [[Basic metabolic panel]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* [[Abdominal x-ray]]- air fluid level
-* Barium upper GI studies- narrowed pylorus
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Succussion splash
-|-
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Gastroparesis
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Epigastric
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Hyperactive/hypoactive
-|style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-*Hemoglobin
-*Fasting plasma glucose
-*Serum total protein, albumin, thyrotropin (TSH), and an antinuclear antibody (ANA) titer
-*HbA1c
-|style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-*Scintigraphic gastric emptying
-|style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-*Succussion splash
-*Single photon emission computed tomography (SPECT)
-*Full thickness gastric and small intestinal biopsy
-|-
 | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Gastrointestinal perforation]]
 | style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse
@@ Line 347: / Line 190: @@
 | style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Hamman's sign]]
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Dumping syndrome]]
+! rowspan="2" |Intestinal causes
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Lower and then diffuse
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* Glucose challenge test
-* Hydrogen breath test
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* Upper GI series
-* Gastric emptying study
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Postgastrectomy
-|-
-! rowspan="10" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Intestinal causes
-| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Acute appendicitis]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Starts in [[epigastrium]], migrates to RLQ
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +in pyogenic appendicitis
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + in perforated appendicitis
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* [[Leukocytosis]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound shows evidence of [[inflammation]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Nausea and vomiting|Nausea & vomiting]], [[decreased appetite]]
-|-
-| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Diverticulitis|Acute diverticulitis]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |LLQ
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | [[Hematochezia]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + in perforated diverticulitis
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* [[Leukocytosis]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan and ultrasound shows evidence of inflammation
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |History of [[constipation]]
-|-
 | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Inflammatory bowel disease]]
 | style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse
@@ Line 418: / Line 210: @@
 * [[Uveitis]]
 * [[Arthritis]]
-|-
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Irritable bowel syndrome]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Tests done to exclude other diseases as it diagnosis of exclusion
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Tests done to exclude other diseases as it diagnosis of exclusion
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Symptomatic treatment
-* High [[dietary fiber]]
-* [[Osmotic]] [[laxatives]]
-* [[Antispasmodic]] drugs
 |-
 | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Whipple's disease]]
@@ Line 468: / Line 241: @@
 * [[Ascites]]
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Toxic megacolon]]
+! rowspan="5" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Hepatic causes
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* [[Anemia]]
-*[[Leukocytosis]] especially in patients with [[Clostridium difficile infection|''Clostridium difficile'' infection]]
-*[[Hypoalbuminemia]]
-*[[Metabolic alkalosis]] associated with a poor [[prognosis]]
-*[[Metabolic acidosis]] secondary to [[ischemic colitis]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan shows:
-*Dilated [[transverse colon]]
-*Loss of colonic haustrations
-*Segmental parietal thinning
-*[[Intraluminal]] soft-tissue masses
-[[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
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-|-
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Tropical sprue]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* Fat soluble vitamin deficiency
-* [[Hypoalbuminemia]]
-* Fecal stool test
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Barium studies show dilation and edema of mucosal folds
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Steatorrhea]]- 10-40 g/day (Normal=5 g/day)
-|-
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Celiac disease]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* [[IgA]] endomysial antibody
-* [[IgA]] [[tissue transglutaminase]] antibody
-* [[Anti-gliadin antibodies|Anti-gliadin antibody]]
-* Small bowel biopsy
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |USG
-* Bull’s eye or target pattern
-* Pseudokidney sign
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Gluten allergy
-|-
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Infective colitis]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Hematochezia]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + in fulminant colitis
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* [[Stool culture]] and studies
-* Shiga toxin in bloody diarrhea
-* [[PCR]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan
-* Bowel wall thickening
-* Edema
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-|-
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Colon carcinoma
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse/localized
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |+
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* Normal
-* Hyperactive if obstruction present
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* CBC
-* Carcinoembryonic antigen (CEA)
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* Colonoscopy
-* Flexible sigmoidoscopy
-* Barium enema
-* CT colonography
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |PILLCAM 2: A colon capsule for CRC screening may be used in patients with an incomplete colonoscopy who lacks obstruction
-|-
-! rowspan="7" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Hepatic causes
 | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Hepatitis|Viral hepatitis]]
 | style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[RUQ]]
@@ Line 617: / Line 278: @@
 | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Liver abscess]]
 | style="padding: 5px 5px; background: #F5F5F5;" align="center" |RUQ
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |+
+| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |+
+| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |+
+| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
 | style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
+| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |+
+| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |+
+| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
 | style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
 | style="padding: 5px 5px; background: #F5F5F5;" align="center" |Normal/hypoactive
@@ Line 637: / Line 298: @@
 | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Hepatocellular carcinoma]]/Metastasis
 | style="padding: 5px 5px; background: #F5F5F5;" align="center" |RUQ
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |+
+| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
+| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |+
+| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
+| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
+| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
+| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
+| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
+| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
 | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
 * Normal
@@ Line 689: / Line 350: @@
 *[[Total protein]] more than 2.5 g per deciliter
 *[[White blood cells]] are usually less than 500/μL.
-|-
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Hemochromatosis]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |RUQ
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + in cirrhotic patients
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |N
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* >60% TS
-* >240 μg/L SF
-* Raised LFT <br>Hyperglycemia
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound shows evidence of cirrhosis
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Extra intestinal findings:
-* Hyperpigmentation
-* Diabetes mellitus
-* Arthralgia
-* Impotence in males
-* Cardiomyopathy
-* Atherosclerosis
-* Hypopituitarism
-* Hypothyroidism
-* Extrahepatic cancer
-* Prone to specific infections
-|-
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Cirrhosis|Cirrhosis]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[RUQ]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[varices]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* [[Hypoalbuminemia]]
-* Prolonged PT
-* Abnormal LFTs
-* [[Hyponatremia]]
-* [[Thrombocytopenia]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |USG
-* Nodular, shrunken liver
-* [[Ascites]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* Stigmata of liver disease
-* Cruveilhier- Baumgarten murmur
 |-
 ! style="padding: 5px 5px; background: #DCDCDC;" align="center" | Peritoneal causes
@@ Line 760: / Line 369: @@
 | style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound for evaluation of liver cirrhosis
 | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-|-
-! colspan="2" rowspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Renal causes
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Pyelonephritis
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Lumbar region
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |+
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |+
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Hypoactive
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* Urinalysis
-* Urine culture
-* Blood culture
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* CT
-* MRI
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-*Renal punch positive
-|-
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Renal colic]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Flank pain]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Hematuria]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan and ultrasound
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* Colicky [[abdominal pain]]
-* [[Dysuria]]
-|-
-! colspan="2" rowspan="3" style="padding: 5px 5px; background: #DCDCDC;" align="center" | Hollow Viscous Obstruction
-| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Small intestine obstruction
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive then absent
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]] with left shift indicates complications
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Abdominal X-ray|Abdominal X ray]]
-* dilated loops of bowel with air fluid levels
-* gasless abdonen
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* "Target sign"– , indicative of intussusception
-* Venous cut-off sign" –  suggests thrombosis
-|-
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Volvulus]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +in perforated cases
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +in perforated cases
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive then absent
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan and [[Abdominal x-ray|abdominal X ray]]
-* U shaped sigmoid colon
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |"Whirl sign"
-|-
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Biliary colic]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |RUQ
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Increased [[bilirubin]] and [[alkaline phosphatase]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Nausea and vomiting|Nausea & vomiting]]
-|-
-! rowspan="4" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Vascular Disorders
-! rowspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Ischemic causes
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Mesenteric ischemia]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Periumbilical
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + if bowel becomes gangrenous
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Hematochezia]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + if bowel becomes gangrenous
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + if bowel becomes gangrenous
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive to absent
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* [[Leukocytosis]] and [[lactic acidosis]]
-* [[Amylase]] levels
-* [[D-dimer]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT angiography
-* SMA or SMV thrombosis
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Also known as abdominal angina, worsens with eating
-|-
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Ischemic colitis|Acute ischemic colitis]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Diffuse
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Massive
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki>
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive then absent
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Abdominal x-ray]]
-* Distension and pneumatosis
-CT scan
-* Double halo appearance, thumbprinting
-* Thickening of bowel
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Can lead to shock
-|-
-! rowspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Hemorrhagic causes
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Ruptured abdominal aortic aneurysm]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Diffuse
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Herald to massive
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* [[Fibrinogen]]
-* [[D-dimer]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Focused Assessment with Sonography in Trauma (FAST)
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Unstable hemodynamics
-|-
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Intra-abdominal or [[retroperitoneal hemorrhage]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Diffuse
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Massive
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Anemia]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |History of [[trauma]]
-|-
-! rowspan="4" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Gynaecological Causes
-! rowspan="3" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Tubal causes
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Torsion of the cyst
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |RLQ / LLQ
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |−
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Increased [[ESR]] and [[CRP]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Sudden onset & severe pain with [[nausea and vomiting]]
-|-
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Salpingitis|Acute salpingitis]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |RLQ / LLQ
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Leukocytosis]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Pelvic ultrasound]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Vaginal discharge]]
-|-
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Cyst rupture
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |RLQ / LLQ
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Increased [[ESR]] and [[CRP]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Sudden onset sever pain with [[nausea and vomiting]]
-|-
-! style="padding: 5px 5px; background: #DCDCDC;" align="center" |Pregnancy
-| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Ruptured [[ectopic pregnancy]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |RLQ / LLQ
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Positive [[pregnancy test]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Ultrasound
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |History of missed period and [[vaginal bleeding]]
-|-
-! rowspan="4" style="background:#4479BA; color: #FFFFFF;" align="center" |Extra-abdominal causes
-! rowspan="3" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Pulmonary disorders
-| colspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Pleural empyema]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[RUQ]]/[[Epigastric]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Thoracentesis]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Chest X-ray]]
-* Pleural opacity
-USG
-* Localization of effusion
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Physical examination
-* Crackles
-* [[Egophony]]
-* Increased [[tactile fremitus]]
-|-
-| colspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Pulmonary embolism
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |RUQ/LUQ
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |N
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* ABGs
-* D-dimer
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* CXR
-* V/Q scan
-* Spiral [[CT pulmonary angiogram]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-|-
-! colspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Pneumonia
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |RUQ/LUQ
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |+
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |+
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |+
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |-
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |N/Hypoactive
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* ABGs
-* Eosinophilia
-* Pancytopenia
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |
-* CXR
-* CT chest
-* Bronchoscopy
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |
-|-
-! style="padding: 5px 5px; background: #DCDCDC;" align="center" |Cardiovascular disorders
-| colspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Myocardial Infarction]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Epigastric]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + in cardiogenic shock
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="center" | −
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
-* [[ECG]]
-* [[Cardiac enzymes]]
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Echocardiogram]]
-* Wall motion abnormality
-* Wall rupture
-* Septal rupture
-| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Complications:
-* [[Arrythmias]]
-* [[Mitral regurgitation]]
-* Ventricular wall rupture
-* Septal rupture
 |-
 |}
 |}
-</small>
 {|
 |-
 |
-[[Image:Right_upper_quadrant.PNG|link=Right upper quadrant abdominal pain resident survival guide|339x339px]]
+<figure-inline>[[Image:Right_upper_quadrant.PNG|link=Right upper quadrant abdominal pain resident survival guide|339x339px]]</figure-inline>
 |
-[[Image:Epigastric_quadrant_pain.PNG|link=Epigastric pain resident survival guide|179x179px]]
+<figure-inline>[[Image:Epigastric_quadrant_pain.PNG|link=Epigastric pain resident survival guide|179x179px]]</figure-inline>
 |
-[[Image:Left_upper_quadrant.PNG|link=Left upper quadrant abdominal pain resident survival guide|329x329px]]
+<figure-inline>[[Image:Left_upper_quadrant.PNG|link=Left upper quadrant abdominal pain resident survival guide|329x329px]]</figure-inline>
 |-
 |
-[[Image:Right_flank_quadrant.PNG|link=Right flank pain resident survival guide|338x338px]]
+<figure-inline>[[Image:Right_flank_quadrant.PNG|link=Right flank pain resident survival guide|338x338px]]</figure-inline>
 |
-[[Image:Umbilical_pain.PNG|link=Umbilical region pain resident survival guide|165x165px]]
+<figure-inline>[[Image:Umbilical_pain.PNG|link=Umbilical region pain resident survival guide|165x165px]]</figure-inline>
 |
-[[Image:Left_flank_quadrant.PNG|link=Left flank quadrant abdominal pain resident survival guide|335x335px]]
+<figure-inline>[[Image:Left_flank_quadrant.PNG|link=Left flank quadrant abdominal pain resident survival guide|335x335px]]</figure-inline>
 |-
 |
-[[Image:Right_lower_quadrant.PNG|link=Right lower quadrant abdominal pain resident survival guide|338x338px]]
+<figure-inline>[[Image:Right_lower_quadrant.PNG|link=Right lower quadrant abdominal pain resident survival guide|338x338px]]</figure-inline>
 |
-[[Image:Hypogastric.PNG|link=Hypogastric pain resident survival guide|199x199px]]
+<figure-inline>[[Image:Hypogastric.PNG|link=Hypogastric pain resident survival guide|199x199px]]</figure-inline>
 |
-[[Image:Left_lower_quadrant.PNG|link=Left lower quadrant abdominal pain resident survival guide|335x335px]]
+<figure-inline>[[Image:Left_lower_quadrant.PNG|link=Left lower quadrant abdominal pain resident survival guide|335x335px]]</figure-inline>
 |}

Gallstone disease differential diagnosis: Difference between revisions

Revision as of 14:44, 29 November 2017

Overview

Differentiating Gallstone disease from other Diseases

Differential diagnosis

References

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