Sandbox:Amd

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

Differential diagnosis

Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein

Classification of acute abdomen based on etiology Disease Clinical manifestations Diagnosis Comments Symptoms Signs Fever Rigors and chills Abdominal Pain Jaundice Hypo- tension Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Abdominal causes Inflammatory causes Pancreato-biliary disorders Acute suppurative cholangitis + + RUQ + + + + N Abnormal LFT WBC >10,000 Ultrasound shows biliary dilatation/stents/tumor Septic shock occurs with features of SIRS Acute cholangitis + − RUQ + − − − N Abnormal LFT Ultrasound shows biliary dilatation/stents/tumor Biliary drainage (ERCP) + IV antibiotics Acute cholecystitis + − RUQ + − − − Hypoactive Hyperbilirubinemia Leukocytosis Ultrasound shows gallstone and evidence of inflammation Murphy’s sign Acute pancreatitis + − Epigastric ± ± − − N Increased amylase / lipase Ultrasound shows evidence of inflammation Pain radiation to back Primary biliary cirrhosis − − RUQ/Epigastric + − − − N Increased AMA level, abnormal LFTs Primary sclerosing cholangitis + − RUQ + − − − N Increased liver enzymes Increased IgM, IgG4 Anti-neutrophil cytoplasmic antibody (p-ANCA) Anti-nuclear antibody (ANA) Anti-smooth muscle antibody (Anti-Sm) Anti-endothelial antibody Anti-cardiolipin antibody Cholelithiasis ± − RUQ/Epigastric ± − + + Ultrasound shows gallstone Murphy’s sign Gastric causes Peptic ulcer disease + Diffuse − + + N Ascitic fluid LDH > serum LDH Glucose < 50mg/dl Total protein > 1g/dl Air under diaphragm in upright CXR Upper GI endoscopy for diagnosis Gastritis Epigastric Gastroesophageal reflux disease Epigastric Gastric outlet obstruction Epigastric Hepatic causes Viral hepatitis + − RUQ Liver masses RUQ Budd-Chiari syndrome RUQ Cirrhosis RUQ Intestinal causes Acute appendicitis + RLQ − + + Hypoactive Leukocytosis Ultrasound shows evidence of inflammation Nausea & vomiting, decreased appetite Acute diverticulitis + LLQ ± + − Hypoactive Leukocytosis CT scan and ultrasound shows evidence of inflammation Inflammatory bowel disease Irritable bowel syndrome Whipple's disease Toxic megacolon Tropical sprue Celiac disease Peritoneal causes Spontaneous bacterial peritonitis + Diffuse − − − Hypoactive Ascitic fluid PMN>250 cells/mm³ Culture: Positive for single organism Ultrasound for evaluation of liver cirrhosis Hollow Viscous Obstruction Small intestine obstruction − Diffuse − + ± Hyperactive then absent Leukocytosis Abdominal X ray Nausea & vomiting associated with constipation, abdominal distention Volvulus − Diffuse − + − Hypoactive Leukocytosis CT scan and abdominal X ray Nausea & vomiting associated with constipation, abdominal distention Biliary colic − RUQ + − − N Increased bilirubin and alkaline phosphatase Ultrasound Nausea & vomiting Renal colic − Flank pain − − − N Hematuria CT scan and ultrasound Colicky abdominal pain associated with nausea & vomiting Vascular Disorders Ischemic causes Mesenteric ischemia ± Periumbilical − − − Hyperactive Leukocytosis and lactic acidosis CT scan Nausea & vomiting, normal physical examination Acute ischemic colitis ± Diffuse − + + Hyperactive then absent Leukocytosis CT scan Nausea & vomiting Hemorrhagic causes Ruptured abdominal aortic aneurysm − Diffuse − − − N Normal CT scan Unstable hemodynamics Intra-abdominal or retroperitoneal hemorrhage − Diffuse − − − N Anemia CT scan History of trauma Gynaecological Causes Ovarian Cyst Complications Torsion of the cyst − RLQ / LLQ − ± ± N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting 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 Acute salpingitis + ± LLQ/ RLQ − − ± ± N Leukocytosis Pelvic ultrasound Vaginal discharge Extra-abdominal causes Pulmonary disorders Pleural empyema + ± RUQ/Epigastric − − Cardiovascular disorders Myocardial Infarction − − Epigastric − + in cardiogenic shock