Abdominal Pain Differential Diagnosis PDF

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Summary

Abdominal Biliary Hiatus Ruptured Bowel Renal Ulcerative Urinary Testicular FBC, LFT, amylase, CRP, glucose, culture, coagulation screen, test in all women of child bearing age with abdo MSU for supine erect, Ectopic Ovarian PAIN DIFFERENTIAL pain time sharp worse radiate to after RUQ have RUQ radia...

Description

Abdominal pain Upper Hepatobiliary RUQ: • Biliary colic • Acute cholecystitis • Cholangitis Epigastric: • Pancreatitis

Upper GI Epigastric: • Ruptured peptic ulcer • Hiatus hernia

Lower

Central Medical

Vascular

• Myocardial

• Ruptured AAA

infarction • Pneumonia

• Abdominal

• Pericarditis

aortic dissection • Mesenteric ischaemia

Lower GI

Medical

Urological

Central: • Bowel obstruction

• DKA

• Renal colic

• Crohn's disease

Central -> RIF

• Pyelonephritis

• Ulcerative colitis

• Appendicitis

• Urinary retention

• Gastroenteritis

• Testicular torsion

LIF • Diverticulitis

Investigations: • Bloods – FBC, U+E, LFT, amylase, CRP, glucose, culture, coagulation screen, G+S, crossmatch • VBG/ABG – lactate • Pregnancy test in all women of child bearing age with abdo pain! • Urinalysis, MSU for MC&S • AXR supine +/- erect, CXR • USS Abdo/KUB, CT/MRI

Gynaecological • Ectopic pregnancy • PID • Ovarian torsion • Endometriosis • Mitterschmerz

ABDOMINAL PAIN DIFFERENTIAL DIAGNOSIS Condition

UPPER GASTROINTESTINAL

Perforated peptic ulcer Duodenal epigastric pain relieved by eating Peptic – pain worsened by eating

Symptoms • • • • •

Hiatus hernia

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Sliding (85-95%) Paraoesophageal (rolling)

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Biliary colic

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Female Forties Fat Fair Fair

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Signs

Epigastric pain – 1-3 hr postprandial Night time waking Relieved by food, antacid Bloating, distention Perforation – sudden onset sharp pain, haematemesis, malaena

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Heartburn worse on bending/lying GORD/dysphagia Epigastric pain

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Epigastric/RUQ pain (intermittent) May radiate to back Worse after fatty food, N+V common

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Continuous RUQ pain Fever, N+V

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Epigastric tenderness May have signs of peritonitis

Investigations •

• • • •

Usually normal

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Normal Tender RUQ/epigastric

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HEPATOBILIARY

Cholecystitis

• •

• Cholangitis

Acute pancreatitis

Charcot’s triad • Jaundice • RUQ pain • Fever • • • •

Severe epigastric pain radiating to back Relieved by sitting forward Vomiting Hx of gall stones, alcohol, trauma, surgery, medications

• • • • • • • • •

General • Education, modify RFs – stop medication such as NSAIDs, alendronate, stop smoking, alcohol intake, healthy diet, smaller meals, exercises Acute • Fluid resuscitation, blood transfusion, FFP/platelets • Endoscopy clipping/thermal coagulation or Surgical laparotomy/laparoscopic Medical • H. Pylori eradication Rx – 1/52 course PPI + Amox 1g + Clarithromycin 500mg/Metronidazole 400mg – all 3 given BD • PPI, H2 receptor antagonist

CXR – diagnostic for paraoesophageal hiatus hernia Barium studies Endoscopy Oesophageal manometry

General • Education - avoid eating late, smaller meals, weight loss, stop smoking, ETOH Medical • PPIs – symptomatic relief, antacids, H2 antagonists Surgical • Nissen’s or modified fundoplication

Urinalysis, CXR, ECG – exclude other causes USS – IOC to see stones Bloods – LFT (↑cBili, ↑ALT/AST, ↑↑ALP), CRP, U+E, FBC (N) ERCP – diagnose CBD stones

Non-surgical • Analgesia – morphine PO, IV pethidine, PR diclofenac • Anti-emetic, fluid rehydration • Healthy lifestyle – regular physical activity, healthy diet Surgical • Laparoscopic cholecystitis – Elective

Bloods – LFT (↑cBili, ↑ALT/AST,

Non-surgical • Analgesia – morphine PO, IV pethidine, PR diclofenac • IV ABx, anti-emetic, fluid rehydration • Healthy lifestyle – regular physical activity, healthy diet Surgical - Laparoscopic cholecystitis (ideally within 48hrs) NBM

Murphy’s sign + (pain on inspiration) Tender abdo

•

↓BP, ↑HR Altered mental status Pyrexia Tenderness

• • • •

Blood culture, amylase Abdo USS, X-Ray KUB Contrast CT, MRI, MRCP

Epigastric tenderness ↑HR, ↓BP Pyrexia Jaundice Grey-Turner’s or Cullen’s

•

Scoring – Glasgow, Ranson, APACHE II Bloods – FBC, LFT (deranged), ↓Ca, ↑amylase, ↑lipase, lipids, ↑CRP, glucose Erect AXR, CXR (ARDS if severe) Contrast CT abdo, USS, MRI Diagnostic laparoscopy

↑↑ALP), CRP, U+E, FBC (↑WBC)

•

USS – thickened GB wall >3mm

Bloods – LFT (↑cBili, ↑ALT/AST, ↑↑ALP), CRP, U+E, FBC (↑WBC)

•

• • •

Management

Bloods – FBC (↓Fe anaemia), G+S, crossmatch (bleeding), coag, LFT, U+E, Ca Carbon13 urea breath test/ stool antigen test – H. Pylori OGD Erect XR – perforation CT abdo

Acute • Fluid resuscitation, correct coagulopathy, analgesia, broad-spectrum ABx • ERCP 24-48hrs later to relieve obstruction

Acute • Fluid resuscitation (1L/4hr) + NBM, analgesia (pethidine/buprenorphine +/- IV benzodiazepine) Morphine C/I due to spastic effect on sphincter of Oddi • NG tube if severe vomiting, IV ABx if evidence of pancreatic necrosis • Treat cause – stop causative meds, ITU may be required Surgical • cholecystectomy if gallstones, ERCP if obstructed biliary system • Necrosis – surgical debridement/radiological drainage/necrosectomy

Mesenteric infarction

•

RFs – arterial emboli (MI, AF, atherosclerosis)

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Colicky/constant, poorly localised pain Physical findings < degree of pain Diarrhoea

• •

VASCULAR

• Abdominal aortic dissection

•

Ruptured AAA

•

•

• • • Crohn’s disease

LOWER GI

INFLAMMATORY BOWEL DISEASE

RF: smoking, FHx

Ulcerative colitis

• • • • •

• • • • •

Small bowel obstruction

•

Adhesions, Strangulated hernia, malignancy, volvulus

• • •

Tearing pain in chest/back/groin Hypertension

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Sudden, severe pain in abdo, back or loin Syncope, shock, collapse, sweaty Cold, vomiting Known aneurysm

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Diarrhoea Abdo pain Weight loss, anorexia Fever, malaise Extra-intestinal: arthritis, skin, eyes (episcleritis), mouth, fistulae

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Bloody diarrhoea Urgency/tenesmus Abdo pain (LUQ) Fever, weight loss Extra-intestinal: arthritis, uveitis, PSC, skin

•

Diffuse, central pain – colicky in nature Vomiting (may be faeculent) Constipation No flatus/faeces

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•

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Peritonism in advance stage Rebound guarding and tenderness ↓BP (shock)

• •

Bloods – FBC(↑WCC), U+E, Cr, glucose, amylase, LFT ABG/VBG– metabolic acidosis, ↑lactate AXR, CT, angiography (GOLD) USS, MRI, ECG(AF/infarct), ECHO

Acute • Large bore cannula for fluid resus, oxygen, NBM, heparin Surgical • Angioplasty to superior mesenteric artery • Embolectomy • Aortomesenteric bypass and bowel resection if gangrene develops

Acute AR (early diastolic) Absent of peripheral pulse

• • • • •

CXR – widened mediastinum CT angio/TO ECHO ECG – signs of MI USS, CT abdo, MRI FBC, U+E, GS, Crossmatch

Acute • O2, analgesia (IV morphine), bed rest, transfer to ITU/HDU • Large bore IV access – IV labetalol (↓sBP 100-120), blood transfusion (6 units) Surgical • Stents/grafts – endovascular repair/open repair

Pulsatile, expansile mass Abdo bruit Grey-Turner’s – flank bruising Weak thready pulse, ↓BP Dehydration, cachexic ↓BP, ↑HR (acute) Tender abdo Distended abdo Mouth ulcers Anal, perianal lesions – skin tags, abscess Pale, febrile, dehydrated ↓BP, ↑HR (acute) Tenderness, distension

•

Bloods – FBC(↑WBC), G+S, crossmatch, U+E, LFT, CRP AXR, USS, CT angio (diagnostic)

Acute • Large bore IV access – Fluid resus. Blood, FFP, platelets should be available • Oxygen, analgesia • Surgical referral immediately – NBM Surgical • Emergency endovascular aneurysm repair

Bloods – FBC (anaemia), ↑CRP, U+E, LFT, ↓B12, vit D, folate Stool culture, faecal calprotectin Colonoscopy + biopsy – all layers, granulomas, ↑goblet cells CT/MRI – skip lesions Bowel enema – Kantor’s string sign, rose thorn ulcers, fistulae

General • Education, support, smoking cessation, referral to specialist for surveillance • Symptom control – Loperamide (C/I in active disease), colestyramine, antispasmodic Inducing remission • 1st line - PO/IV/Top glucocorticoids – prednisolone (risk of osteoporosis) • 2nd line – 5 ASA – Mesalazine/Sulfasalazine • Add on (if >1 flare up a year) – 1st Azathioprine; 2nd Methotrexate; 3rd Infliximab Maintaining remission • 1st line: Azathioprine; 2nd line: Methotrexate Surgical – resection depends on site General • Education, support, stool bulking agents/laxatives, regular surveillance Inducing remission • Proctitis/Proctosigmoiditis – 1st : Mesalazine/Sulfasalazine PR +/- PO; 2nd Prednisolone • Left sided disease – 1st: Mesalazine/Sulfasalazine PO; 2nd Prednisolone PO Maintaining remission • Proctitis(+sigmoid): Mesalazine PO +/- PR; Left sided: Mesalazine PO • If uncontrolled, add 1st Azathioprine PO, 2nd Infliximab Surgical – Colectomy (curative) Acute • Fluid resuscitation, electrolyte replacement, analgesia, anti-emetic • Drip & suck – NG tube + IV fluids, NBM Surgical • Strangulation/closed loop – emergency laparotomy/laparoscopy Non-surgical Endoscopic stenting – palliative care

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Distended, tender abdo Tinkling bowel sound

• • • •

Bloods – FBC (anaemia), ESR, CRP, U+E, LFT, ↓B12, vit D, folate, iron studies, pANCA Stool culture, faecal calprotectin Colonoscopy + biopsy continuous, crypt abscess AXR, CT/MRI – skip lesions Bowel enema – pseudopolyps, drain pipe colon, loss of haustra AXR + erect – distended bowel loop, multiple fluid level Fluid charts – monitor input/output (catheterise) Bloods – FBC, U+E, Cr, G+S, crossmatch, glucose, amylase Non-contrast CT abdo, USS, MRI

LOWER GASTROINTESTINAL

Large bowel obstruction

•

Colon Ca Volvulus Stricture

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Appendicitis

•

• •

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Diverticulitis

• • • • • • •

Renal colic

• • •

GYNAECOLOGICAL

UROLOGICAL

•

Diffuse, central pain – colicky in nature Vomiting (may be faeculent) Constipation Marked abdo distention Periumbilical pain moves to RIF Movement and cough worsen pain N+V, anorexia Constipated Low grade fever LIF pain – constant/ intermittent colicky Change in bowel habit, N+V Fever, anorexia Common in elderly

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Sudden, severe pain Loin to groin Constant and persistent – restless Dysuria, retention

•

•

Distended, tender abdo Tinkling bowel sound

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Guarding Rebound tenderness Rovsing’s + Shallow breathing Psoas sign + ↑HR, pyrexia Localised tenderness/ palpable mass ↓ bowel sound PR exam

Tenderness over renal angle Microscopic haematuria

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Pyelonephritis

Pelvic inflammatory disease Chlamydia Gonorrhoea IUD – copper Termination of pregnancy

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Acute onset 1-2days High fever, rigors Pain – dull ache UTI Sx + vomiting Anorexia

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Bilateral pelvic pain Gradual onset Vaginal discharge Dyspareunia, dysmenorrhoea IMB, PCB Fever

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Fever Localised tenderness on kidney(s) and suprapubic Suprapubic tenderness Cervical excitation B/l adnexa tenderness PV purulent discharge

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AXR + erect – distended bowel loop, multiple fluid level Fluid charts – monitor input/output (catheterise) Bloods – FBC, U+E, Cr, G+S, crossmatch, glucose, amylase Non-contrast CT abdo, USS, MRI Bloods – FBC, U+E, LFT, CRP↑, Coag, G+S, crossmatch, amylase, culture, VBG – lactate Urinalysis (UTI), Pregnancy test USS abdo, eAXR, CT, MRI Diagnostic laparoscopy Scoring system Bloods – FBC (↓Hb, ↑WBC & Plt), ↑CRP, U+E, LFT, culture Erect AXR, CT with contrast Contrast enema – limited value Flexisigmoidoscopy

Urinalysis – haematuria, WBC + nitrates (infection), pH (>7 urea splitting organism – Proteus;...