Differentials
Pancreatic cancer
SIGNS / SYMPTOMS
A change in the severity of pain, fear of food (due to pain), weight loss, and jaundice may occur.
INVESTIGATIONS
CT, MRI, or EUS may detect a pancreatic mass or duct stricture.
Other differentiating tests include biopsy and elevated blood tumor markers (cancer antigen 19-9, carcinoembryonic antigen).
Exclusion of malignancy frequently requires surgical resection to ensure a reliable histopathologic examination.
Pancreatitis, acute
SIGNS / SYMPTOMS
Symptoms of mild acute pancreatitis are similar to chronic pancreatitis.
Distinguishing features of severe acute pancreatitis include evidence of persistent organ failure (respiratory insufficiency, renal insufficiency, hypotension, and altered mentation).
Biliary colic
SIGNS / SYMPTOMS
Right upper quadrant pain, nausea, vomiting, and anorexia, which is exacerbated by eating fatty foods.
The duration of pain is shorter (1-2 hours) than in chronic pancreatitis.
INVESTIGATIONS
Abdominal ultrasound may show cholelithiasis, and the diagnosis can be confirmed by cholescintigraphy.
Elevated liver enzymes and common bile duct dilation occur with choledocholithiasis and biliary strictures.
Peptic ulcer disease
SIGNS / SYMPTOMS
Distinguishing features include upper abdominal discomfort, nausea, belching, bloating, iron-deficiency anemia, and possibly melena and hematemesis.
INVESTIGATIONS
Esophagogastroduodenoscopy or upper gastrointestinal series will demonstrate ulceration.
Empiric trial of appropriate management, such as proton-pump inhibitor, resulting in symptomatic improvement would help differentiate from chronic pancreatitis.
Mesenteric ischemia
SIGNS / SYMPTOMS
Periumbilical, postprandial abdominal pain, fear of food (due to pain), and weight loss with a soft abdomen suggest chronic mesenteric insufficiency.
Acute mesenteric ischemia typically presents with acute onset of severe periumbilical pain.
INVESTIGATIONS
Acute and chronic mesenteric insufficiency can be diagnosed by clinical suspicion and angiography. Diagnosis requires clinical suspicion because serum elevation in lipase and amylase can occur in this setting and lead to an erroneous diagnosis of pancreatitis.
Aneurysm, abdominal aorta
SIGNS / SYMPTOMS
Usually asymptomatic until rupture or dissection, when the patient will present with abdominal or back pain, a pulsatile abdominal mass, and hypotension.
INVESTIGATIONS
Typically diagnosed incidentally with abdominal ultrasound, CT scan, or MRI.
myocardial infarction
SIGNS / SYMPTOMS
Inferior wall myocardial infarction may present with epigastric pain, nausea, vomiting, diaphoresis, and dyspnea.
INVESTIGATIONS
Diagnosed by ECG, cardiac enzymes.
Intestinal obstruction
SIGNS / SYMPTOMS
Typical symptoms include a crescendo-decrescendo pattern of abdominal pain accompanied by nausea and vomiting.
INVESTIGATIONS
Diagnosed by abdominal films and/or CT imaging studies. Diagnosis requires clinical suspicion because serum elevation in lipase and amylase can occur in this setting and lead possibly to an erroneous diagnosis of pancreatitis.
Irritable bowel syndrome
SIGNS / SYMPTOMS
Common condition that presents with abdominal pain and altered bowel habit.
INVESTIGATIONS
Clinical diagnosis.
Gastroparesis
SIGNS / SYMPTOMS
A motility disorder characterized by nausea, vomiting, early satiety, and weight loss. Common etiologies include diabetes mellitus, post-viral, scleroderma, and medications (e.g., opiates).
INVESTIGATIONS
Diagnosed by gastric emptying study with or without manometry.
Somatization disorders
SIGNS / SYMPTOMS
Occur in patients with neuropsychiatric disease who describe pain and gastrointestinal, sexual, and neurologic symptoms.
INVESTIGATIONS
Clinical diagnosis.
Radiculopathy
SIGNS / SYMPTOMS
Pain is constant and/or precipitated by positional changes, such as torsion of spine and leg lifts, and may be reproducible with palpation of chest wall and spine.
Unilateral abdominal pain localizes to a dermatome distribution, possibly wrapping around or radiating to the back.
INVESTIGATIONS
Diagnosed using spine imaging studies and electromyogram.
Post-herpetic neuralgia
SIGNS / SYMPTOMS
Pain may be persistent after the disappearance of shingles. Typically a burning pain with altered sensation.
Examination may show evidence of skin erythema or vesicles localizing to a dermatome.
INVESTIGATIONS
Clinical diagnosis.
Abdominal wall pain
SIGNS / SYMPTOMS
Consider focal abdominal wall nerve impingement if there are scars, abdominal wall hernia, or abdominal wall hematoma.
INVESTIGATIONS
Investigate with abdominal wall ultrasound or CT to exclude abdominal wall hernia and rectus sheath hematoma. Nerve impingement responds typically to trigger point injection.
Nephrolithiasis
SIGNS / SYMPTOMS
May present with unilateral pain localizing or radiating to a linear distribution from the groin/testicle to the abdomen and back.
Associated symptoms may include nausea, vomiting, dysuria, urinary urgency, and hematuria.
INVESTIGATIONS
Noncontrast helical CT scan detects renal collecting system opacities.
Additional imaging methods include ultrasonography, abdominal x-ray, and intravenous pyelogram.
Urinalysis detects microscopic hematuria.
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