Differentials
Common
GERD
History
burning epigastric/chest pain, regurgitation, worse with some foods and recumbency; improved by antacids
Exam
enamel erosion
1st investigation
- therapeutic trial of proton pump inhibitors:
relief of symptoms
More
Other investigations
- esophagogastroduodenoscopy (EGD):
esophagitis or other abnormality explaining pain
More - 24-hour pH probe testing:
increased acid exposure to esophagus correlated with symptom occurrence
Peptic ulcer disease
History
epigastric pain, may be worsened or relieved by food; pain often worse at night; bloody or coffee-ground emesis or dark black tarry stool indicative of active bleeding and requiring urgent endoscopic evaluation; nonsteroidal anti-inflammatory drug (NSAID) and alcohol use predispose to ulcer disease; Helicobacter pylori more common in certain ethnicities, especially South and Central Americans and Asians
Exam
epigastric tenderness, pallor, Hemoccult-positive stool or black tarry stool
1st investigation
- esophagogastroduodenoscopy:
visualization of gastric or duodenal ulcer
More
Other investigations
Infectious gastroenteritis
History
history of travel to endemic areas; greasy, foul-smelling stools; diarrhea (may be bloody, depending on organism, but most chronic forms are nonbloody); tenesmus, fever, chills; immunosuppressed patients at higher risk
Exam
exam is nonspecific
1st investigation
- stool culture:
positive culture for Escherichia coli, Shigella, Salmonella, or Campylobacter
- stool ova and parasites:
positive
Lactase deficiency
History
abdominal pain, bloating, gas, and/or loose stool after ingestion of dairy products (or any product that contains the sugar lactose)[70]
Exam
exam is nonspecific
1st investigation
- trial of dietary lactose elimination:
resolution of symptoms once lactose-containing dairy and nondairy products are eliminated from diet; resumption of symptoms when reintroduced
Other investigations
- lactose breath test:
rise in breath hydrogen above normal
Chronic cholecystitis, Chronic cholelithiasis
History
colicky right upper quadrant (RUQ) pain, fever, jaundice, symptoms beginning 30 minutes to 1 hour after eating and worse with high-fat meals (usually a source of acute abdominal pain; however, patients can have a chronic cholecystitis or acute recurrent cholecystitis with passage of microcalculi, sludge, or small stones)
Exam
fever, scleral icterus, jaundice, RUQ tenderness, positive Murphy sign
1st investigation
- LFT:
elevated in an obstructive pattern (alk phos and gamma GT 2-10 times normal); elevated total bilirubin
More - RUQ ultrasound:
pericholecystic fluid, gallbladder wall thickening, common bile duct dilation, cholelithiasis
Other investigations
Nephrolithiasis
History
colicky flank pain that radiates to groin; nausea; bloody or amber urine; history of renal stones or recurrent urinary tract infections; may present as episodes of recurrent acute pain versus chronic pain
Exam
tenderness on deep abdominal palpation or with back tapping, usually unilateral; hematuria
1st investigation
- urinalysis:
blood (macro- or microscopic)
- noncontrast CT abdomen:
hydronephrosis, obstructing stone
- stone analysis:
stones/debris sent for analysis to determine etiology of nephrolithiasis
Other investigations
- renal ultrasound:
urinary tract calcification or dilation
More
Pelvic inflammatory disease (PID)
History
fever, pelvic pain, vaginal discharge, painful intercourse, history of sexually transmitted infection or intrauterine device use[85]
Exam
adnexal tenderness, vaginal discharge, cervical motion tenderness, cervical discharge, friable cervix, erythematous cervix
1st investigation
- CBC:
leukocytosis
- C-reactive protein:
elevated
- erythrocyte sedimentation rate:
elevated
- gonococcal and chlamydia culture or nucleic acid amplification test:
presence of organism
Other investigations
- pelvic ultrasound:
classic signs are tubal wall thickness >5 mm, incomplete septae within the tube, fluid in the cul-de-sac, and a cog-wheel appearance on the cross-section of the tubal view; may also see tubo-ovarian abscess
Irritable bowel syndrome
History
abdominal pain relieved with defecation; pain associated with alteration of bowel habit (change in stool frequency and/or form); exacerbated by psychosocial stressors[31]
Exam
usually normal
1st investigation
- clinical diagnosis:
other causes of abdominal pain excluded
More
Other investigations
- fecal calprotectin:
<50 micrograms/g makes inflammatory bowel disease unlikely, and irritable bowel syndrome more likely[41]
Gastroparesis
History
early satiety, fullness, nausea, vomiting; all symptoms are worse after ingestion of meals; history of diabetes mellitus or Parkinson disease; previous abdominal surgery that may result in vagal nerve injury
Exam
succussion splash rarely detected; weight loss; no other specific physical findings
1st investigation
Functional dyspepsia
History
bothersome postprandial fullness, early satiation; epigastric pain and burning that are unexplained after a routine clinical evaluation; may be associated with nausea and vomiting, and exacerbated by psychosocial stressors[36]
Exam
usually normal
1st investigation
- clinical diagnosis:
other causes of abdominal pain excluded
More
Other investigations
Centrally mediated abdominal pain syndrome (CAPS)
History
chronic abdominal pain without obvious organic etiology, not affected by eating or defecation, exacerbated by psychosocial stressors
Exam
usually normal
1st investigation
- clinical diagnosis:
other causes of abdominal pain excluded
More
Other investigations
Chronic abdominal wall pain
History
localized anterior abdominal pain accentuated by physical activity
Exam
positive Carnett test to show precise localization of the pain[29]
1st investigation
- clinical and physical examination:
abdominal imaging by ultrasound, CT, or MRI may be needed to exclude internal organ pathology or abdominal hernia (e.g., Spigelian hernia)
Other investigations
Referred pain
History
abdominal pain can be referred from multiple extra-abdominal sources, including the chest (e.g., angina, pneumonia, pleurisy, malignancy), musculoskeletal structures (e.g., rib fracture, abdominal cutaneous nerve entrapment), nerves (e.g., herpes zoster, radiculopathy), or pelvis (e.g., interstitial cystitis, endometriosis, ectopic pregnancy, gynecological malignancies such as ovarian cancer, adhesions, urethral syndrome, changes or dysfunction of the pelvic muscles, prostatitis, prostate cancer), and intermittent/recurrent testicular torsion
Exam
exam varies depending on underlying etiology
1st investigation
- directed by suspected source of referred pain:
may include imaging of spine, chest, or pelvis
Other investigations
Uncommon
Crohn disease
History
crampy abdominal pain, often localized to the right lower quadrant and worse postprandially;[62] intermittent diarrhea, bloody diarrhea if colitis a feature, weight loss, fatigue, family history of inflammatory bowel disease
Exam
aphthous ulcers, evidence of weight loss, pallor, abdominal tenderness, abdominal mass, perianal fistula, perirectal abscess, anal fissure, perianal skin tags; extraintestinal manifestations including iritis, arthritis, sacroiliitis, erythema nodosum, pyoderma gangrenosum
1st investigation
- colonoscopy:
aphthous ulcers, hyperemia, edema, cobblestoning, skip lesions
More - CBC:
microcytic anemia, thrombocytosis
- erythrocyte sedimentation rate/C-reactive protein:
elevated
Ulcerative colitis
History
bloody diarrhea, watery diarrhea, weight loss, abdominal pain, mucus per rectum, urgency and tenesmus; weight loss indicates more severe disease[68]
Exam
evidence of weight loss, pallor, abdominal tenderness, abdominal mass, iritis, arthritis, sacroiliitis, erythema nodosum, pyoderma gangrenosum
1st investigation
- flexible sigmoidoscopy:
rectal involvement, continuous colonic involvement, diffuse erythema, mucosal granularity
More - CBC:
microcytic anemia, thrombocytosis
- erythrocyte sedimentation rate/C-reactive protein:
elevated
Other investigations
- colonoscopy:
rectal involvement, continuous colonic involvement, diffuse erythema, mucosal granularity; backwash ileitis may be present in pancolitis
More
Subacute intestinal obstruction
History
abdominal pain with features of obstruction including, but not limited to, constipation, obstipation, and nausea with bilious or feculent emesis; history of abdominal surgery, radiation, or hernia
Exam
high-pitched bowel sounds, absence of bowel sounds, abdominal scars, hernia
1st investigation
- abdominal x-ray:
dilated loops of bowel, air-fluid levels, no air in rectum
Other investigations
- CT abdomen:
obstruction, hernia, transition point at site of obstruction, volvulus
Celiac disease
History
nonspecific abdominal pain, bloating; diarrhea; greasy, foul-smelling stools; weight loss; anemia, ataxia, osteoporosis
Exam
pale conjunctiva, aphthous stomatitis, dermatitis herpetiformis, ataxia
1st investigation
Chronic pancreatitis
History
chronic postprandial pain; history of recurrent acute pancreatitis, alcohol misuse, or smoking;[71] brittle diabetes; greasy, foul-smelling stools and weight loss suggest exocrine insufficiency
Exam
weight loss, epigastric tenderness consistent with the diagnosis but not diagnostic, and palmar erythema suggest alcohol misuse
1st investigation
- serum amylase and lipase:
elevated (3 times the upper limit of normal)
More - CT abdomen:
atrophic, calcified pancreas; pancreatic duct abnormalities, strictures, pseudocysts
Esophageal cancer
History
weight loss, dysphagia, history of Barrett esophagitis
Exam
signs of weight loss, pallor, stool that is positive for occult blood
1st investigation
- esophagogastroduodenoscopy:
visualization of esophageal cancer
More
Other investigations
- CT abdomen:
extent of disease, metastatic lesions
Gastric cancer
History
weight loss, early satiety, nausea and vomiting, dysphagia if proximal lesion
Exam
signs of weight loss, pallor, palpable abdominal mass, palpable periumbilical or supraclavicular lymph nodes, Hemoccult-positive stool
1st investigation
- esophagogastroduodenoscopy:
visualization of gastric cancer
More
Other investigations
- CT abdomen:
extent of disease, metastatic lesions
Colorectal cancer
History
weight loss, blood in stool, change in bowel habit, anemia
Exam
signs of weight loss, pallor, palpable abdominal mass, hepatomegaly if metastatic spread has occurred, multiple seborrheic keratoses (sign of Lesser-Trelat, a rare sign associated with adenocarcinoma), occult blood-positive in stool
1st investigation
Other investigations
- CT abdomen:
extent of disease, metastatic lesions
Pancreatic cancer
History
weight loss, epigastric pain, depression, jaundice, history of chronic pancreatitis
Exam
signs of weight loss, palpable abdominal mass, jaundice
1st investigation
- CT abdomen:
pancreatic mass, dilated pancreatic duct
Other investigations
- endoscopic retrograde cholangiopancreatography (ERCP)/magnetic resonance cholangiopancreatography (MRCP):
dilated pancreatic duct
More
Hepatocellular cancer
Cholangiocarcinoma
History
weight loss, jaundice
Exam
signs of weight loss, jaundice
1st investigation
- abdominal ultrasound:
intrahepatic duct dilation
- liver tests:
elevated alkaline phosphatase and serum gamma-GT (obstructive/cholestatic pattern); conjugated bilirubin elevated in obstructive jaundice
Ovarian cancer
History
symptoms are often vague and nonspecific; common symptoms are abdominal bloating, nausea and emesis, early satiety, dyspepsia, increased abdominal girth, abdominal cramping, or a change in bowel habit suggestive of advanced disease
Exam
variable: may include ascites, pleural effusion, palpable mass on pelvic exam, and abdominal distension that is dull to percussion; patients may appear malnourished if they have significant gastrointestinal symptoms; findings consistent with ascites (e.g., fluid wave, shifting dullness) or a right-sided pleural effusion (e.g., diminished breath sounds or rales present) can often be detected; on pelvic exam, a mass might be appreciated in the adnexa or rectovaginal space
1st investigation
- serum CA-125:
≥35 IU/mL
More
Other investigations
- ultrasound of abdomen and pelvis:
presence of solid, complex, septated, multiloculated mass; high blood flow
More
Chronic mesenteric ischemia
History
chronic recurrent abdominal pain, usually worse after eating (referred to as abdominal angina); may lead to food phobia and weight loss; acute presentation with abdominal pain and bloody diarrhea may be secondary to acute ischemic colitis; presence of risk factors for vascular disease including diabetes, hypertension, renal disease, cardiovascular disease, and/or smoking[79]
Exam
subjective complaint of abdominal pain out of proportion to exam findings; signs of peripheral vascular disease may be present, such as diminished peripheral pulses or cool extremities; with severe atherosclerotic disease, an abdominal bruit may be heard
1st investigation
- CT or MRI angiography, or duplex ultrasound of abdomen:
stenosis, thrombus, or reduced blood flow in the celiac artery, superior mesenteric artery, or inferior mesenteric artery
More
Other investigations
- abdominal arteriogram:
diminished blood flow to the intestine
Superior mesenteric artery syndrome
History
chronic postprandial abdominal pain that usually begins after a period of weight loss (the weight loss may be intentional and predate the pain), early satiety, bloating, nausea with bilious emesis
Exam
evidence of weight loss
1st investigation
- CT abdomen:
loss of fat planes surrounding superior mesenteric and celiac arteries; compression of distal duodenum by superior mesenteric artery, with proximal dilation of small bowel
- CT or MRI angiography, or duplex ultrasound of abdomen:
stenosis, thrombus, or reduced blood flow in the celiac artery, superior mesenteric artery, or inferior mesenteric artery; signs of atherosclerosis
More
Other investigations
- abdominal arteriogram:
diminished blood flow at the superior mesenteric and celiac arteries
Acute intermittent porphyria
History
abdominal pain with neuropsychiatric features[81]
Exam
urine may be pigmented
1st investigation
- 24-hour urine collection:
elevated alpha-aminolevulinate and porphobilinogen >5-10 times upper limit of normal
Other investigations
Heavy metal poisoning (lead, arsenic)
History
pica, lead paint exposure, occupational exposure; abdominal pain may be severe[82]
Exam
exam may mimic an acute abdomen
1st investigation
- heavy metal toxicology tests:
elevated lead or arsenic levels
Other investigations
- CBC:
basophilic stippling of red cells, anemia
Familial Mediterranean fever
History
positive family history, recurrent/chronic episodes of fever and serositis with pain in abdomen, chest, joints, and muscles; rash may be present[83]
Exam
exam may mimic an acute abdomen
1st investigation
- CBC:
leukocytosis
- erythrocyte sedimentation rate/C-reactive protein:
elevated
Other investigations
- CT abdomen:
nonspecific mesenteric pathology, which may include engorged mesenteric vessels, thickened mesenteric folds, and mesenteric and/or retroperitoneal lymphadenopathy
Paroxysmal nocturnal hemoglobinuria
Chronic pyelonephritis
History
dysuria, fever, flank pain; increased risk if underlying renal tract abnormalities (e.g., children with vesicoureteral reflux), episodes of recurrent acute pyelonephritis, inadequately treated acute pyelonephritis, or history of diabetes
Exam
fever, flank tenderness
1st investigation
- urinalysis:
positive for white blood cells and nitrates
- CBC:
leukocytosis
Other investigations
- renal ultrasound/CT abdomen:
abscess
Endometriosis
History
perimenstrual chronic pelvic/abdominal pain, dysmenorrhea, dyspareunia, dysuria, hematuria, urinary frequency
Exam
tender pelvic nodules, retroverted uterus, tender uterus
1st investigation
- clinical diagnosis:
history and examination findings in a female patient of reproductive age are usually sufficient for diagnosis
Other investigations
- pelvic ultrasound:
ovarian endometrioma, if present
- laparoscopy with biopsy:
histologic confirmation of extrauterine endometrial tissue
- MRI:
atypical symptoms (e.g., deep pelvic endometriosis)[86]
Ovarian cystic disease
History
lower pelvis/abdominal discomfort, dyspareunia, may be cyclical, severe pain if torsion or hemorrhage into cyst
Exam
palpable mass on bimanual pelvic exam
1st investigation
- pelvic ultrasound:
cystic adnexal lesion, free fluid in the peritoneum
Other investigations
Narcotic bowel syndrome
History
chronic narcotic use
Exam
usually normal
1st investigation
- clinical diagnosis:
other causes of abdominal pain excluded
Other investigations
Abdominal migraine
History
recurrent attacks of periumbilical or diffuse abdominal pain, lasting 1-72 hours, several times per year, accompanied by anorexia, nausea, vomiting, and pallor; few or no gastrointestinal complaints between attacks; migraine headaches in family and/or patient; exacerbation by stressors such as mental stress, tiredness, missing a meal, travel, and certain foods; usually occurs in childhood, with only few patients continuing to exhibit symptoms into adulthood[90]
Exam
usually normal
1st investigation
- clinical diagnosis:
other causes of abdominal pain excluded
More
Other investigations
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