Acute abdomen Flashcards
Differential diagnosis for right upper quadrant pain
- Cholecystitis
- Ureteric colic
- Pyelonephritis
- Hepatitis
- Pneumonia
Differential diagnosis for left upper quadrant pain
- Ureteric colic
- Pyelonephritis
- Pneumonia
Differential diagnosis for right lower quadrant pain
- Appendicitis
- Inguinal hernia
- IBD
- Testicular torsion
- Gynaecological causes
- UTI
Differential diagnosis for left lower quadrant pain
- Diverticulitis
- Inguinal hernia
- IBD
- Testicular torsion
- Gynaecological causes
- UTI
Differential diagnosis for epigastric pain
- Peptic ulcer disease
- Pancreatitis
- Cholecystitis
- Myocardial infarction
Differential diagnosis for periumbilical region pain
- Appendicitis
- Small bowel obstruction
- Large bowel obstruction
- Abdominal aortic aneurysm
What clinical features would make you suspect that right upper quadrant pain was due to biliary colic / cholecystitis?
What diagnostic test would you perform?
Biliary colic: Recurrent attacks after fatty meal
Cholecystitis: fever, positive Murphy’s sign
Diagnostic test: Ultrasound
What clinical features would make you suspect that right upper quadrant pain was due to ascending cholangitis?
Diagnostic tests?
Charcot’s triad: RUQ pain, fever, jaundice
Dark urine, pale stools
Diagnostic tests: ultrasound, MRCP
What would make you suspect that right upper quadrant pain was due to viral hepatitis?
Diagnostic tests?
Jaundice, decompensated liver disease
Risk factors: IVDU, blood transfusion, tattoos
Diagnostic tests: LFTs, viral hepatitis serology
What clinical features would make you suspect that right upper quadrant pain was due to pyelonephritis?
Diagnostic tests?
Flank/loin pain, urinary symtoms
Nausea, vomiting, fever
Diagnostic tests: Urinalysis, FBC/U&Es/CRP
What clinical features would make you suspect the right upper quadrant pain was due to renal colic?
Flank/loin-to-groin pain, acute, severe, colicky
Nausea and vomiting
Diagnostic tests: Urinalysis, CT KUB
What clinical features would make you suspect that right/left upper quadrant pain was due to pneumonia?
Diagnostic tests?
Productive cough, pleuritic chest pain, SOB
Diagnostic test: CXR
A 28 year old male presents to the emergency department via ambulance following a road traffic accident.
You perform the primary survey and, on examination of the abdomen, the patient has severe pain in the left upper quadrant.
No other obvious injuries are found.
HR 130, BP 85/60, RR 24, SpO2 95%, Temp 36.5
What is the likely diagnosis?
Diagnostic tests?
Splenic injury/laceration
Diagnostic tests: FAST scan, CT abdomen
A 44 year old male presents to the emergency department via ambulance with severe, sudden onset epigasric pain. He has vomited several times and feels very thirsty.
Over the last few months, he has noticed that his stools have been bulky and difficult to flush.
He works at a supermarket and drinks half a bottle of vodka every day.
Observations: HR 135, BP 110/85, RR 22, SpO2 95%, Temp 37.2
What is the likely diagnosis?
Acute on chronic pancreatitis
Clinical features that would make you suspect that epigastric pain was due to pancreatitis?
Diagnostic tests?
Severe epigastric pain, nausea and vomiting, anorexia
Steatorrhoea: if acute-on-chronic
Cullen’s sign/Grey-Turner’s sign
Presence of risk factors: eg gallstone, alcohol excess
Diagnostic tests: Serum amylase or lipase
Consider USS or CT abdomen
Clinical features that would make you suspect epigastric pain was due to peptic ulcer disease?
Diagnostic tests?
Burning epigastric pain
Duodenal: worse when hungry, relieved by eating
Gastric: worse when eating
Nausea, vomiting, coffee-ground vomit, meleana
Diagnostic tests: Erect CXR (?perforation)
UGIE
H.Pylori breath test/stool antigen
Clinical features that would suggest epigastric pain is due to myocardial infarction?
Diagnostic tests?
Crushing pain, non-pleuritic, sweating
Cardiovascular risk factors
ECG
A 19 year old male presents to the emergency department with his mother due to a 3 day history of gradually worsening abdominal pain.
The pain has originally started around his belly button and has now moved towards the right iliac fossa.
He has felt nauseous, has a reduced appetite and feels slightly feverish.
Which scoring system is used to assess the likelihood of the underlying cause?
Alvarado score (eg migratory RIF pain, anorexia, fever WBC etc)
Clinical features which would suggest that right lower quadrant pain is due to Crohn’s disease?
Diagnostic tests?
RIght iliac fossa pain, diarrhoea, weight loss
Fever, anal fissures/fistulae/blood in stool
Diagnosstic tests: Faecal calprotectin
Colonoscopy
Clinical features which suggest that right lower quadrant pain is due to a hernia?
Diagnostic tests:
Groin mass, discomfort or pain with bulge
Clinical diagnosis
Clinical features which suggest that right lower quadrant pain is due to appendicitis?
Diagnostic tests?
Peri-umbilical pain migrating to right iliac fossa
Low grade fever, reduced appetite, nausea
Rovsing’s sign, obturator sign, psoas sign
Diagnostic tests: Clinical diagnosis
USS/abdominal CT
Clinical features which suggest that right/left lower quadrant pain is due to ectopic pregnancy?
Diagnostic tests?
Lower cramping, constant abdominal pain
Vaginal bleeding and amenorrhoea (6-8 weeks often)
Nausea, vomiting; dizziness, syncope suggest rupture
Diagnostic tests: beta HCG
Transvaginal ultrasound scan
A 12 year old boy presents to the emergency department with sudden-onset severe lower abdominal pain, particularly on the right hand side.
He has vomited twice with this pain and is walking with a waddling gait.
What is the likely diagnosis?
Testicular torsion
Clinical features which suggest that right/left lower quadrant pain is due to UTI?
Diagnostic test?
Suprapubic pain, dysuria, frequency, cloudy urine
Diagnostic test: urine dip
Clinical features which suggest that right lower quadrant pain is due to testicular torsion?
Diagnostic tests?
Sudden onset severe unilateral testicular pain
Nausea and vomiting; absent cremasteric reflex
Diagnostic tests: Clinical diagnosis
Occasionally USS
Clinical features which suggest that left lower quadrant pain is due to IBD (ulcerative colitis)?
Diagnostic tests?
Left lower quadrant pain, diarrhoea, mucus, fresh rectal bleeding
Faecal urgency and tenesmus
Diagnostic tests: Faecal calprotectin
Colonoscopy (not during acute flare as high risk of perforation)
Clinical features which would suggest the left lower quadrant pain is due to acute diverticulitis?
Diagnostic tests?
Fresh rectal bleeding, fever, history of constipation
Diagnostic test: CT abdomen/pelvis
A 56 year old male presents to the emergency department via ambulance with severe central abdominal pain.
He has a history of hypertension, type 2 diabetes mellitus. He has a 30 pack year smoking history.
Observations: HR 145, BP 92/45, SpO2 94%, Temp 37.1
What is the most likely diagnosis?
Abdominal aortic aneurysm
Diagnostic tests: abdominal USS
CT angiogram
