Abdominal pain DDx

Overview

Acute abdomen is abdominal pain in the presence of tenderness and rigidity and is a surgical emergency. Abdominal pain can be considered in terms of surgical, Ob/Gyn and medical causes.

• The causes of abdominal pain are best dealt with according to the different regions of the abdomen. If pain is localised to a specific region of the abdomen, also consider nearby regions as the possible source of the pain.
• Don’t forget the abdominal wall as a source of the pain (e.g. haematomas, herpes zoster, etc) and that abdominal pain may originate from above the diaphragm!
• See also medical causes of abdominal pain.

Causes

Generalised abdominal pain with tenderness and rigidity

• perforated peptic ulcer
• perforation of other intra-abdominal organs
• AAA rupture
• aortic dissection
• pancreatitis
• ectopic pregnancy
• ischaemic gut

Central/ peri-umbilical pain without abdominal signs

• acute small bowel ischemia
• acute appendicitis
• acute small bowel obstruction
• acute pancreatitis
• testicular torsion
• medical causes of abdominal pain

Epigastric pain

Gastrointestinal

• gastritis
• peptic ulcer
• reflux oesophagitis
• pancreatitis
• cancer (gastric, pancreatic)
• Boerhaave syndrome (esophageal rupture)
• dyspepsia
• irritable bowel syndrome

Pain from nearby areas

• abdominal: central, RUQ pain
• cardiac: e.g. myocardial infarction, pleuritis
• pulmonary: e.g. pneumonia, pleurisy

Right hypochondrium/ upper quadrant pain

Gall bladder

• biliary colic
• cholecystitis
• cholangitis

Liver

• hepatitis
• hepatomegaly (e.g. liver congestion in right heart failure)
• hemorrhage into hepatic tumour
• trauma
• hepatic or subdiaphragmatic abscess
• Fitz-Hugh-Curtis syndrome (peri-hepatitis due to PID)
• Pre-eclampsia and HELLP

Other gastrointestinal

• appendicitis with high appendix (e.g. pregnancy)
• perforated or penetrating duodenal ulcer
• colon cancer

Pain from nearby areas

• abdominal: epigastric, central, RIF, loin, groin pain
• right lower lobe pneumonia, pleurisy or other lung disease
• subphrenic abscess
• acute pyelonephritis

Left hypochondrium/ upper quadrant pain

• pancreatitis
• subphrenic abscess
• diverticulitis
• ruptured spleen
• acute pyelonephritis
• leaking aneurysm of the splenic artery
• acute gastric distention

Right iliac fossa pain

Gastrointestinal

• appendicitis
• Crohn’s disease
• inflamed Meckel diverticulum
• cholecystitis with low gall bladder
• mesenteric adenitis
• epiploic appendagitis
• colon cancer
• constipation
• irritable bowel syndrome

Reproductive (female)

• ectopic pregnancy
• acute ovarian event (cyst rupture, hemorrhage, torsion)
• Mittelschmerz (ovulation pain mid-cycle)
• Pelvic inflammatory disease
• Endometriosis

Reproductive (male)

• seminal vesiculitis
• undescended testicle pathology

Urinary

• renal colic
• UTI

Pain from nearby areas

• abdominal: RUQ, central, groin pain
• hip pathology
• psoas abscess
• rectus sheath haematoma
• right lower lobe pneumonia

Left iliac fossa pain

Gastrointestinal

• diverticulitis
• colitis
• colon cancer
• constipation
• irritable bowel syndrome

Reproductive (female)

• ectopic pregnancy
• acute ovarian event (cyst rupture, hemorrhage, torsion)
• Mittelschmerz (ovulation pain mid-cycle)
• Pelvic inflammatory disease
• Endometriosis

Reproductive (male)

• seminal vesiculitis
• undescended testicle pathology

Urinary

• renal colic
• UTI

Pain from nearby areas

• abdominal: LUQ, central, groin pain
• hip pathology
• psoas abscess
• rectus sheath haematoma
• left lower lobe pneumonia

Suprapubic pain

• urinary retention
• cystitis
• uterine in origin (e.g. PID, fibroid, menstruation)
• origin from RIF and/ or LIF causes

Loin pain

Renal tract

• infection e.g. pyelonephritis
• obstruction, e.g. renal colic
• renal carcinoma
• renal vein thrombosis
• polycystic kidney disease
• adrenal hemorrhage

Other

• retroperitoneal hemorrhage
• retroperitoneal infection
• vertebral pathology

Groin pain

• renal calculi
• scrotal pain e.g. testicular torsion, epididymo-orchitis, trauma
• inguinal hernia
• hip pathology
• pelvic fracture

CCC Differential Diagnosis Series
NEURO	Anosmia, Ataxia, Blepharospasm, Bulbar and Pseudobulbar palsy, Central Pontine Myelinosis, Cerebellar Disease, Chorea, Cranial nerve lesions, Dementia, Dystonia, Exophthalmos, Eye trauma, Facial twitches, Fixed dilated pupil, Horner syndrome, Loss of vision, Meningism, Movement disorders, Optic disc abnormality, Parkinsonism, Peripheral neuropathy, Radiculopathy, Red eye, Retinal Haemorrhage, Seizures, Sudden severe headache, Tremor, Tunnel vision
RESP	Bronchial breath sounds, Bronchiectasis, High airway pressures, Massive haemoptysis, Sore throat, Tracheal displacement
CVS	Atrial Fibrillation, Bradycardia, Cardiac Failure, Chest Pain, Murmurs, Post-resuscitation syndrome, Pulseless Electrical Activity (PEA), Pulsus Paradoxus, Shock, Supraventricular tachycardia (SVT), Tachycardia, VT and VF, SVC Obstruction
GIT	Abdominal distension, Abdominal mass, Abdominal pain, Asterixis, Dysphagia, Hepatomegaly, Hepatosplenomegaly, Large bowel obstruction, Liver palpation abnormalities, Lower GI haemorrhage, Malabsorption, Medical causes of abdominal pain, Rectal mass, Small bowel obstruction, Upper GI Haemorrhage
GUT	Genital ulcers, Groin lump, Scrotal mass, Urine colour, Urine Odour, Urine transparency,
MSK	Arthritis, Shoulder pain, Wasting of the small muscles of the hand
DERM	Palmar erythema, Serious skin signs in sick patients, Thickened Tethered Skin, Leg ulcers, Skin Tumour, Acanthosis Nigricans
ENDO	Diabetes Insipidus, Diffuse Goitre, Gynaecomastia, Hirsutism, Hypoglycaemia, SIADH, Weight Loss
HAEM	Splenomegaly
PAEDS	Floppy infant
MISC	Anaphylaxis, Autoimmune associated diseases, Clubbing, Parotid Swelling, Splinter haemorrhages, Toxic agents and abnormal vitals, Toxicological causes of cardiac arrest
IMAGING	CHEST: Atelectasis, Hilar adenopathy, Hilar enlargement on CXR, Honeycomb lung, Increased interstitial markings, Mediastinal widening on mobile CXR, Pulmonary fibrosis, Pseudoinfiltrates on CXR, Pulmonary opacities on CXR, ABDO: Gas on abdominal X-ray, Kidney mass, BRAIN: Intracranial calcification, Intracranial structures with contrast, Ventriculomegaly, OTHER: Pseudofracture on X-Ray,
LABS	LOW: Anaemia, Hypocalcaemia, hypochloraemia, Hypomagnesaemia,  HIGH: Bilirubin and Jaundice, Hyperammonaemia, Hypercalcaemia, Hyperchloraemia, Hyperkalaemia, Hypermagnesaemia,  ACID BASE: Acid base disorders, Resp. acidosis, Resp. alkalosis, Creatinine, CRP, Dipstick Urinalysis, Laboratory Urinalysis, Liver function tests (LFTs), Pleural fluid analysis, Urea, Urea Creatinine Ratio, Uric acid, Urinalysis, Urine Electrolytes

[cite]