Differential Diagnosis of Acute Abdominal Pain

Differential Diagnosis of Acute Abdominal Pain

Cause grouping

Surgical

Differentials Peritonitis

Peptic ulcer Tumour Gallbladder Appendix Spleen AAA Ectopic SBP

Ruptured AAA

Appendicitis

Gallstones

Acute pancreatitis

Diverticulitis Renal colic

Bowel obstruction Acute mesenteric ischaemia Other surgical differentials

Classical history

Classic examination findings

Investigation findings (Initial test, diagnostic test)

Definitive management (remember ABCDE first)

?Severe generalised abdominal pain

?Shock ?No abdominal movement with

?Erect CXR: air under diaphragm ?Urgent laparotomy &

?CT abdo/pelvis: reveal cause

repair

respiration

?Guarding ?Firm, peritonitic abdomen

?Rebound tenderness ?Severe pain to light palpation

?Percussion tenderness

?Elderly

?Shock

?USS abdomen if freely available ?Aim for permissive

?Severe generalised abdominal

?Peritonitis

?CT only if stable

hypotension (SBP 100)

pain ?Back pain

?Expansile mass

?Don't delay theatre

?Activate `massive haemorrhage protocol' e.g.

?Reduced GCS/collapse

10U

?Urgent open repair (/

EVAR if stable)

?Young patient ?Periumbilical pain initially

?Tender RIF ?Worse at McBurney's point

Clinical diagnosis ?USS abdo/pelvis if gynae

?Appendicectomy

?Moves to RIF ?Anorexia, nausea

?Guarding/local peritonitis ?Rovsing's +ve

differentials ?Inflammatory markers: raised

?Urine HCG: rule out ectopic

Biliary colic

?LFTs: obstructive picture if CBD Biliary colic

?Intermittent RUQ pain

stones/cholangitis

?Analgesia

?Exacerbated by fatty food

?Inflammatory markers: raised ?OPT Cholecystectomy

Cholecystitis

in cholecystitis/cholangitis

Cholecystitis

?Continuous RUQ pain

?Abdominal USS

?Antibiotics (ciprofloxacin

?Murphy's +ve ?Tender + guarding RUQ

or cephalosporin) ?Cholecystectomy (hot/6w)

CBD stones

CBD stone

?Jaundice ?RUQ pain

?Continuous IVI (prevent hepato-renal syndrome)

Cholangitis

?ERCP

?Jaundice ?Fever/rigors

Cholangitis ?IV antibiotics (e.g.

?RUQ pain Acute pancreatitis

cipro/tazocin) ?Treat cause

(See column)

?Severe epigastric/central pain

?Epigastric tenderness

Clinical diagnosis

?Supportive management

?Radiating to back

?Tachycardia

?Amylase or lipase: raised

?Lots of IV crystalloids e.g.

?Relieved by sitting forwards ?Vomiting

?Fever ?Shock

?LFTs: deranged ?CT abdo if diagnostic

1L every 4h (third space sequestration)

?History of possible cause e.g.

?Jaundice

uncertainty

?Stop causative meds

gallstones, alcohol, trauma, surgery, medications etc

?Grey-Turner's and Cullen's signs (rare)

?Apache II / Glasgow score ABG required

?No antibiotics unless proven infection

Calcium

?Treat cause

?Confirm cause USS abdo (exclude

?ITU may be required

gallstones in all patients)

Triglycerides Immunoglobulins

?Elderly ?LIF pain

?Tender LIF ?Guarding/local peritonism

?Inflammatory markers: raised ?Flexible sigmoidoscopy or CT

?NBM + IV fluids ?Bowel antibiotics (Cef +

?Pyrexia

?PR (confirm no CA/abscess)

abdo/pelvis

Met)

?Spasms of loin to groin pain

?Soft abdomen

?Urine dip: microscopic

?Diclofenac analgesia

(excruciating)

?May be renal angle tenderness

haematuria

?Smooth muscle relaxants

?Nausea and vomiting ?Cannot lie still

?KUB X-ray ?CT KUB

(nifedipine/tamsulosin) ?Antibiotics (e.g.

cefuroxime) if infection

?Pelvic stone 2cm ? PCNL

?Ureteric stone 50y

?Hypovolaemia shock

?VBG: lactate

?Aggressive IV fluids

?Severe abdominal pain

?Soft abdomen (pain out of

?CT abdo/pelvis: ischaemic

?Antibiotics (e.g.

?Diarrhoea ?Risk factors: AF, CVS risk factors

proportion to exam)

bowel ?Mesenteric angiography: if

gentamicin + metronidazole)

required

?Surgical bowel resection

?Heparin may be used

Testicular torsion; volvulus; strangulated hernia; Meckel's diverticulum; mesenteric adenitis; adhesions; hepatic abscess; psoas abscess

? 2015 Dr Christopher Mansbridge at , a source of free OSCE exam notes for medical students' finals OSCE revision

Medical

Gastritis/ peptic ulcer

Pyelonephritis

Other medical differentials

?Epigastric pain

?Tender epigastrium

?FBC: may be microcytic

?PPI (omeprazole PO/

?Related to meals (peptic ulcer =

?Soft abdomen

anaemia

pantoprazole IV)

during meals; duodenal ulcer =

?Erect CXR: exclude perforation ?H Pylori eradication (if

before meals/at night)

?OGD: if severe

+ve)

?Risk factors e.g. NSAIDs, alcohol,

spicy food

?Fever, chills, rigors

?Loin tenderness

?Urine dip + culture: positive

?Antibiotics (e.g.

?Loin pain

?Renal angle tenderness

leukocytes and nitrites

ciprofloxacin or

?Urinary frequency and dysuria

?Inflammatory markers: raised cephalosporin)

Gastroenteritis; constipation; Crohn's disease; ulcerative colitis; MI; pneumonia; sickle cell crisis; DKA; pyelonephritis; IBS; Budd-Chiari

syndrome; addisonian crisis; hypercalcaemia; acute intermittent porphyria; hepatitis

Gynae

Ectopic pregnancy

Ovarian cyst rupture/ torsion/ haemorrhage Pelvic inflammatory disease

Other gynae differentials

?Severe unilateral pelvic pain ?~6-8 weeks pregnant/not using contraception/missed period

?Shoulder tip pain ?May have spotting ?Sudden unilateral pelvic pain ?May be light vaginal bleeding ?May be fever/vomiting

?Tenderness RIF/LIF ?Guarding ?Adnexal tenderness ? mass ?Cervical excitation

?Tenderness RIF/LIF ?Guarding ?Adnexal tenderness ? mass

?Urinary HCG: +ve ?Serum HCG + trend ?Transvaginal USS

?Transvaginal/abdo USS ?Urinary HCG: r/o ectopic

?Bilateral pelvic pain (gradual

?Suprapubic tenderness

?Inflammatory markers: raised

onset)

?Vaginal discharge, cervicitis

?Triple vaginal swabs

?Vaginal discharge

?Bilateral adnexal tenderness

?Dyspareunia and dysmenorrhoea ?Cervical excitation

?May be post-coital or inter-

?May be fever

menstrual bleeding

Salpingitis; pregnancy; fibroid degeneration; Fitz-Hugh?Curtis syndrome; endometriosis

?Laparoscopy/laparotomy (or methotrexate if uncomplicated) ?Anti-D prophylaxis (if required) ?Laparoscopy/laparotomy

?Broad spectrum antibiotics (e.g. metronidazole + doxycycline + quinolone)

? 2015 Dr Christopher Mansbridge at , a source of free OSCE exam notes for medical students' finals OSCE revision

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