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Toronto Notes 2019 Differential Diagnosis of Common Complaints Table 2. Differential Diagnosis of Common Presenting Complaints (continued)
Gastroenterology G5
IBD Is a common cause of bloody diarrhea but can be diagnosed only if mimickers are excluded. Chiefly, infection, ischemia and medication side-effects
CHRONIC DIARRHEA
*Causes of bloody diarrhea
Inflammatory
IBD*
Infectious
(TB, CMV, HSV) Ischemic* bowel Radiation colitis Neoplasia
C. difficile rarely causes bleeding
Organic
Stimulant laxatives Post-ileal resection/ cholecystectomy (bile salts) Bacterial toxins
Vasculitis
Neoplasia* (colon ca, carcinoid, VIPoma) Addison’s disease Congenital syndromes
Functional
IBS
Constipation (overflow diarrhea)
Anal sphincter dysfunction
Colorectal cancer Stricture
Extrinsic compression Anal disease Rectocele
Medications (narcotics, antidepressants, calcium channel blockers) Metabolic (DM, thyroid, hypercalcemia)
Neurologic (Parkinson’s, MS, stroke)
Collagen vascular disease (scleroderma, dermatomyositis)
Secretory
Steatorrhea
Giardia lamblia
Celiac sprue Chronic pancreatitis Chronic cholestasis
Osmotic
Osmotic laxatives Lactose intolerance Chewing gum (sorbitol, mannitol)
CONSTIPATION: if no associated rectal bleeding/weight loss, etc., usually no cause found (and dysmotility assumed)
NAUSEA/ VOMITING
DYSPEPSIA
UPPER GI BLEED
LOWER GI BLEED
DYSPHAGIA
ODYNOPHAGIA
ABDOMINAL DISTENTION
With Abdominal Pain
Without Abdominal Pain
Relieved by Vomiting
Gastric outlet obstruction Small bowel obstruction GERD (regurgitation more common)
Common
Functional dyspepsia Drug side effect Peptic ulcer
GERD (esophagitis)
Common
Ulcers (H. pylori, ASA, NSAIDs) Esophageal varices Mallory-Weiss tears
Erosive esophagitis
Erosive gastritis
Common
Diverticulosis
Ischemia Angiodysplasia (elderly) Infectious
Not Relieved by Vomiting
Gallbladder disease Pancreatitis Myocardial infarction Hepatitis
Infectious Gastroenteritis
Headache/Dizziness
Cerebral tumour Migraine Vestibular disease Increased ICP
Uncommon
Angina
Crohn’s disease
Cancer (stomach, pancreas, liver) Gallstones
Aerophagia
Uncommon
Tumours
Arteriovenous malformation Dieulafoy’s lesion (arterial) Gastric antral vascular ectasia (GAVE)
Portal hypertensive gastropathy
Uncommon
Upper GI bleed (brisk) Post-polypectomy Radiation colitis
IBD
Motility (Solids and Liquids)
Achalasia
Diffuse esophageal spasm Scleroderma
Drugs
Quinidine
Iron
Vitamin C
Antibiotics (e.g. tetracycline) Bisphosphonates
Feces
Constipation Colonic obstruction Dysmotility
No Other Symptoms
Drugs
Uremia
Pregnancy Metabolic
(e.g. hypercalcemia) Gastroparesis
(e.g. DM) Ketoacidosis
Rare
Giardia lamblia Malabsorption (celiac sprue) Pancreatitis
Rare
Aorto-enteric fistulas Hemobilia
Rare
Intussusception Vasculitides Stercoral ulcer Coagulopathies
Other
Commonly Forgotten Causes of Vomiting
• Drugs
• Uremia
• CNS Disease
• Pregnancy
• Marijuana (cannabinoid hyperemesis)
Anorectal (hemorrhoids, fissure, ulcer)
Mechanical (Solids)
Peptic stricture/cancer Eosinophilic esophagitis Extrinsic compression Schatzki ring/esophageal web Zenker’s diverticulum
Infection
Candida
Herpes
CMV (common in those who are immunosuppressed)
Difference Between Dysphagia and Foreign body Odynophagia
Fluid (Ascites)
Portal HTN
Cirrhosis Cardiac failure Hepatic vein thrombosis
Normal Portal Pressure
Cancer (especially ovarian) Pancreatitis TB
Inflammation/Ulceration
Caustic damage Eosinophilic esophagitis
Flatulence
Functional bowel disease (e.g. IBS)
Fibre
Lactose intolerance Chewing gum (e.g. sorbitol, mannitol)
Eosinophilic esophagitis
Other
Radiation
Other
Pregnancy (fetus)
Obesity (fat)
Blood
Large tumours (fatal growth)
• Dysphagia: Difficulty swallowing due to mechanical obstruction or dysmotility of the esophagus or pharynx
• Odynophagia: Pain when swallowing
due to ulceration or inflammation (e.g. eosinophilic esophagitis) in the esophagus pharynx
Differential Diagnosis of Abdominal Distention
6Fs
Fat
Feces
Fetus
Flatus
Fluid
Fatal Growth