Abdominal Pain Differential Diagnosis
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1 Abdominal Pain Differential Diagnosis Herszényi László 2nd Dept. Internal Medicine Semmelweis University 2016
2 Acute abdominal pain Key questions What is the possible diagnosis? Dose the patient need an emergency operation? perhaps more importantly
3 Anatomy, quadrants and abdominal pain Gallblodder Spleen Liver Cecum Kidney Pancreas Stomach Transpyloric line Colon Small bowel Appendix Uterus Urinary bladder
4 General Considerations Site of Pain Epigastric pain: Peptic Ulcer Disease; Acute Pancreatitis; Biliary colic Lower abdominal pain: Gynaecological problems, Acute appendicitis, Diverticulitis Right upper quadrant Acute cholecystitis Right iliac fossa Appendicitis Left iliac fossa Diverticulitis Lumbal area Renal colic
5 Pancreatic pain: Radiation of Pain radiates through to the middle of the back Gallbladder pain: radiates around the right side to back Myocardial pain (inferior ischaemia): radiates to the epigastrium Renal pain General Considerations starts in the loin-lumbal area, radiates to the groin
6 General Considerations Relieving and exacerbating factors Peptic Ulcer Disease: pain exacerbated or relieved by food Acute pancreatitis: relieved by sitting forward while holding the abdomen Bowel obstruction: vomiting may relieve pain
7 General Considerations Past Medical History History of constipation acute obstruction Elderly patient with known aortic aneurysm Known gallstones acute cholecystitis Risk factors for acute pancreatitis: Gallstones Alcohol Recent ERCP
8 Acute abdomen Most common causes Perforation Acute Cholecystitis Acute Pancreatitis Nephro-ureterolithiasis Appendicitis Diverticulitis Aortic Aneurysm-Dissection
9 Perforation Pain Abdominal quarding or rigidity ( déffence ) Poor general conditions Collaps, Shock Local peritonitis Diffuse peritonitis
10 Il Schiavo morente (Michelangelo Louvre)
11 Plain radiograph Pneumoperitoneum = Perforation
12 Perforation Pneumoperitoneum Free air Abdominal CT
13 Ulcer Perforation Differential Diagnosis Myocardial infarction (inferior) Pleuro-pneumonia Pulmonary Embolism Other organ (bowel) perforation Acut pancreatitis Acut cholecystitis Aortic dissection Schönlein-Henoch purpura Porphyria
14 Acute abdomen Most common causes Perforation Acute Cholecystitis Acute Pancreatitis Nephro-ureterolithiasis Appendicitis Diverticulitis Aortic Aneurysm-Dissection
15 Biliary pain - colic Four F Female Forty Fetty Fair Following heavy meal Epigastric or right upper quadrant colicative pain Radiates to the back Vomiting Differential Dg.: Peptic Ulcer Disease (PUD) Nephro-ureterolithiasis Basal Pleuro-Pneumonia
16 Acut cholecystitis Normal gallbladder Inflammed gallbladder Gallstsones Abdominal US Biliary colic Fever Inflammatory markers Differential Dg: Acute Pyelonephritis Basal Pleuro-Pneumonia Acute Pancreatitis
17 Acute cholecystitis - Complications Normal gallbladder Inflammed gallbladder Gallstsones Acute cholangitis Charcot-triade pain fever jaundice Acute biliary pancreatitis
18 Acute abdomen Most common causes Perforation Acute Cholecystitis Acute Pancreatitis Nephro-ureterolithiasis Appendicitis Diverticulitis Aortic Aneurysm-Dissection
19 Acute Pancreatitis Diagnosis Clinical picture + Lab (amylase, lipase) + Radiology (US, CT)
20 Acute Pancreatitis Clinical picture Abdominal pain Sudden onset of severe epigastric pain which radiates to the back Vomiting Pre-existing history: Biliary tract disease Alcohol abuse
21 Acute Pancreatitis Physical examination Severe pancreatitis Gray-Turner sign: ecchymosis, bruising in the flanks: Cullen sign: periumbilical ecchymosis-suffusion Gray-Turner sign Retroperitoneal necrosis and haemorrhage Differential Dg.: Peptic Ulcer Disease (PUD) Biliary stones-cholecystitis Pleuro-Pneuomonia Myocardial infarction Cullen sign
22 Acute Pancreatitis Radiology Plain radiography Sentinel loop Abdominal US Diffúse enlarged pancreas Abdominal CT Acute necrotising pancreatitis
23 Acute abdomen Most common causes Perforation Acute Cholecystitis Acute Pancreatitis Nephro-ureterolithiasis Appendicitis Diverticulitis Aortic Aneurysm-Dissection
24 Nephro-ureterolithiasis Very intensive pain Dysuria Haematuria Nausea, vomiting Reflex bowel paresis (paralytic ileus)
25 Acute pyelonephritis Back-Lumbal pain Dysuria High-grade fever Nausea-vomiting Urine examination: Bacteriuria-Pyuria/; Culture Inflammatory markers Abdominal US Diff. Diagnosis: Basal Pleuro-pneumonia Acute cholecystitis Acute urocystitis
26 Acute abdomen Most common causes Perforation Acute Cholecystitis Acute Pancreatitis Nephro-ureterolithiasis Appendicitis Diverticulitis Aortic Aneurysm-Dissection
27 Acute appendicitis Clinical picture Central abdominal pain + vomiting right lower quadrant pain (McBurney point) Rebound pain Blumberg-sign Psoas-sign Epigastrium Peritoneal irritation progresses Urinary symptoms (!) Loss of appetite Low grade fever Inflammatory markers
28 Acute appendicitis - Alvarado score Abdominal US Abdominal CT-scan Ohle et al. Biomed Med 2011; 9: 139.
29 Acute appendicitis Right lower quadrant pain Differential Diagnosis Nephro-ureterolithiasis (right sided) Gynecological: Adnexitis, extrauterin gravidity Lymphadenitis mesenterialis Meckel diverticulitis M. Crohn (ileitis terminalis) Cecal tumor
30 Acute abdomen Most common causes Perforation Acute Cholecystitis Acute Pancreatitis Nephro-ureterolithiasis Appendicitis Diverticulitis Aortic Aneurysm-Dissection
31 Diverticulitis Hinchey-classification Left-sided appendicitis Signs Abdominal pain, nausea, vomiting Constipation / Diarrhoea Fever, CRP, ESR, Leucocytosis Urinary smptoms (!) Severe complications (20%) Bleeding Abscess Perforation Peritonitis Fistule Stricture-obstruction
32 Diverticulitis Left lower quadrant pain Differential Diagnosis Nephro-ureterolithiasis - Pyelonephritis Gynecological: Adnexitis, extrauterin gravidity Colon tumor-perforation Sigma stenosis Ulcerative colitis Ischaemic colitis
33 Acute abdomen Most common causes Perforation Acute Cholecystitis Acute Pancreatitis Nephro-ureterolithiasis Appendicitis Diverticulitis Aortic Aneurysm-Dissection
34 Abdominal Aoritic Aneurysm - Dissection Age: > 60 yrs Chest-back pain Abdominal pain: bilateral, generalized Suddenly disappeared periph. pulse Abdominal pulsatile mass Ecchymosis-Suffusion Acute ischaemia: Lower extremities Renal insufficiency US CT-scan
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