Clinical Pearl Series Edited from Yale-G First Aid: Crush USMLE Step 2CK & Step 3 by Yale Gong, MD, Sr. Medical Advisor at www.medicine.net (Copyrighted)
Abdominal pain is a very common symptom. Most patients have a benign and/or self - limited cause, and the initial goal and challenge is to identify those patients with a serious etiology that may require urgent intervention. A detailed history and focused physical examination (P/E) are important for most differential diagnosis, which may require further evaluation with laboratory testing and/or imaging.
Summary: Brief Differentiations of Abdominal Pain
I. Left Upper Quadrant (LUQ)
| Condition | Symptoms |
|---|---|
| Gastritis | LUQ or epigastric pain or discomfort, heartburn, nausea, vomiting, and hematemesis |
| Gastric ulcer | LUQ or epigastric pain or discomfort associated with food intake |
| Others | splenic rupture, infarct, abscess; splenomegaly; IBS (splenic flexure syndrome) |
II. (Middle) Epigastrium
| Condition | Symptoms |
|---|---|
| Acute pancreatitis | Acute, persistent upper abdominal pain radiating to the back; usually after big meals/alcohol |
| Chronic pancreatitis | Chronic epigastric pain radiating to the back; associated with pancreatic insufficiency |
| Peptic ulcer disease | Epigastric pain or discomfort; occasionally localized to one side |
| GERD | Epigastric pain associated with heartburn, regurgitation, and dysphagia |
| Gastritis/gastropathy | Abdominal discomfort/pain, heartburn, nausea, vomiting, and hematemesis; may have history of ingestion of alcohol or NSAIDs |
| Functional dyspepsia | The presence of one or more of the following: postprandial fullness, early satiation, epigastric pain, or burning; no evidence of structural disease |
| Gastroparesis | Nausea, vomiting, abdominal pain, early satiety, postprandial fullness, and bloating. Most causes are idiopathic, diabetic, or postsurgical |
III. Right Upper Quadrant (RUQ)
| Condition | Symptoms |
|---|---|
| Biliary colic | Intense, dull pain located in the RUQ or epigastrium; associated with nausea, vomiting, and diaphoresis; usually lasting > 30 min and alleviated within 1 hour; generally benign P/E results |
| Acute cholecystitis | Prolonged (> 4 hours) RUQ or epigastric pain typically following fatty foods; fever. Patients will have abdominal guarding and Murphy’s sign |
| Acute cholangitis | Triad of fever, jaundice, RUQ pain; may have atypical presentation in older or immuno - suppressed patients |
| Sphincter of Oddi dysfunction | RUQ pain similar to other biliary type pain without other apparent causes |
| Acute hepatitis | Dull RUQ pain with fatigue, malaise, nausea, vomiting, and anorexia; +/- jaundice, dark urine, and light - colored stools. Causes include hepatitis A, alcohol, and drug - induction |
| Perihepatitis (Fitz - Hugh - Curtis syndrome) | RUQ pain with a pleuritic condition; pain may radiate to the right shoulder; aminotransferases are usually normal or only slightly elevated |
| Budd - Chiari syndrome | Fever, abdominal pain and distention (from ascites), lower extremity edema, jaundice, gastrointestinal bleeding, and/or hepatic encephalopathy |
| Portal vein thrombosis | RUQ pain, dyspepsia, or gastrointestinal bleeding; most commonly associated with cirrhosis |
| Others | duodenal ulcer (perforation), hepatic abscess |
IV. Right Lower Quadrant (RLQ)
| Condition | Symptoms |
|---|---|
| Appendicitis | Initial periumbilical pain that radiates to the right lower quadrant; associated with anorexia, nausea, and vomiting |
| Cecal diverticulitis | Constant RLQ pain and low fever for several days; may have nausea and vomiting but no lower GI bleeding |
| Others | ectopic pregnancy, ovarian torsion |
V. Left Lower Quadrant (LLQ)
| Condition | Symptoms |
|---|---|
| (Sigmoid) diverticulitis | Constant LLQ pain and low fever for several days; may have palpable sigmoid mass but no lower GI bleeding |
| (Sigmoid) diverticulosis | LLQ colicky pain and relieved by defecation; may also have typical painless rectal bleeding or hematochezia (melena) |
| Others | sigmoid volvulus, ectopic pregnancy, ovarian torsion |
VI. Lower Abdomen (left or right)
| Condition | Symptoms |
|---|---|
| Infectious colitis | Diarrhea and associated abdominal pain +/- fever. Clostridium difficile infection can show acute abdomen and peritoneal signs in the setting of perforation and fulminant colitis |
| Nephrolithiasis | Usually mild to severe flank pain (left or right); may have back or abdominal pain |
| Ectopic pregnancy | Triad of amenorrhea, unilateral lower abdominal pain, and spotting vaginal bleeding (1 - 2 weeks after last menstrual period--LMP) |
| Others | twisted/ruptured ovary cyst, endometriosis, intestinal obstruction, abdominal abscess |
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