Differential Diagnosis

of Abdominal Pain
Introduction
Abdominal pain
• a complaint seen commonly in
the outpatient setting
• may often be a symptom of a disease
process with a benign course
• it may also herald a severe, life-threatening
condition
• demands prompt recognition and
management
• general understanding of abdominal
anatomy, physiology, and pathophysiology
is vital
The abdominal organs
Three Types of Abdominal Pain
1. Visceral
• Autonomic nerves
• Poorly localized
• Dull ache, colicky
• Location is often midline
• Felt in the abdominal wall in the
area of embryonic origin of the pain
 Cont…
2. Somatic
• Typically sharp
• well localized
• Irritation of the parietal peritoneum
• parietal innervation is unilateral
• Felt directly over area of inflammation
 Cont…
3. Referred pain
• felt in cutaneous site distant from diseased
organ
• visceral afferents carrying stimuli from a
diseased organ enter the spinal cord at the
same level as somatic afferents
• typically well localized
• Awareness of the anatomy and innervation of
the abdominal viscera allows one to formulate
a differential diagnosis of abdominal pain
based on the location and distribution of the
pain
History

• Where is your pain? Has it always been there?

• Does the pain radiate anywhere?
• How did the pain begin (sudden vs. gradual
onset)? How long have you had the pain?
• What does the pain feel like?
• On a scale of 0–10, how severe is the pain?
• Does anything make the pain better or worse?
• Have you had the pain before?
 History cont…
• Although location of abdominal pain
guides the initial evaluation, associated
signs and symptoms can help narrow
the differential diagnosis
• change in bowel habit, blood loss per
rectum
• Presence of nausea/vomiting signs of an
upper GI cause
• Respiratory symptoms point to basal
pneumonia causing diaphragmatic irritation
• Dysuria or haematuria indicates a renal
cause
Physical Examination
• General appearance
• patient with peritonitis often lies completely
• a patient with renal colic may writhe in pain
• Vital Signs
• Abdomen
• Inspection
• Auscultation
• Percussion
• Palpation
 Differential Diagnosis
Abdominal Pain based on
Region
The position of abdominal pain used
abdomen region
Differential Diagnosis: RUQ pain
Differential Diagnosis: LUQ and
Epigastric pain
Differential Diagnosis: RLQ Pain
Gynecologic Causes of RLQ Pain
Differential Diagnosis: LLQ
Differential Diagnosis: Periumbilical
 Pain Patterns of
Abdominal Disease
 Substernal Epigastric

Onset Chronic Acute Acute Acute

Disease / Refluks Perforated Cholecystitis Pancreatitis

diagnosis esofagitis duodenal ulcer

Pain quality Burning; after Severe, ± history Steady / biliary Steady

meal / at of chronic ulcer colic
night pain

Pain referral Left arm ± back Tip of scapula Back

Pain Upper chest Rapid, over entire Intensity ± peritoneal

progression abdomen increases steady sign
over hours to
RUQ

Associated Guarding ; free Fever, gall Nausea,

finding peritonel air stone, vomiting
 Epigastric

Onset chronic chronic chronic

Disease / Duodenal ulcer Gastric ulcer Non ulcer dyspepsia

diagnosis

Pain quality Gnawing, burning Gnawing, Same as duodenal

before meals/ at night worsened by food ulcer, ± bloating

Pain referral ± Back Occasionally to None

the back

Pain None None None

progression

Associated Temporary relief with ± relief by ± relief with food or

finding food or antacids antacids antacid
 Periumbilical

Onset Acute Acute Acute Chronic Chronic

Disease / Appendici- Small bowel Intestinal Inflammato Intestinal

diagnosis tis obstruction infarction ry bowel angina
disease
Pain Cramping, Cramping Severe, Cramping, Colickly,
quality steady aching, diffuse aching aching,
in LQ diffuse
Pain ± Back or Back None None None
referral groin

Pain Localizatio None If Tx is None Pain relief

progressio n to RLQ delayed, 1-2 hour
n peritonitis
Associated Referred Peristaltic >, Unimpressive, Diarrhea, Weight loss
finding percusion nausea, occult blood blood+pus
tenderness vomite, stool, stool,
to RLQ delated bowel peristaltic - urgency,
tenesmus
 Lower Quadrant

Onset Acute Acute Chronic Chronic

Disease / Diverticulitis Colon Dissecting aortic Irritable bowel

diagnosis obstruction aneurysm syndrome

Pain quality Steady, aching, Crampy Sudden, severe, Cramping, steady

LLQ tearing, peri or itermittent
umbilical
Pain referral Back Back Flank, inguinal None
region

Pain None None None None

progression

Associated Palpable Vomiting, Shock, Cosntipation,

finding inflamatory constipation, abdominal bruit, diarrhea,
mass, fever, distention, abdomnal mass bloating
constipation, peristaltic >
leucocytosis
 Take Home Message
• Abdominal pain typically, but not always,
has characteristic locations : right upper,
right lower, epigastric, periumbilical, left
upper, left lower, and diffuse
• The location of pain is a useful starting
point and will guide further evaluation
• Performing a thorough history and physical
evaluation will allow the practitioner to
generate a differential diagnosis that will
guide further laboratory, imaging, and
management decisions