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Toronto Notes 2019 Differential Diagnoses of Common Presentations Table 1. Differential Diagnosis of Acute Abdominal Pain (continued)
General Surgery and Thoracic Surgery GS5
Most Common Presentations of Surgical Pain
• Sudden onset with rigid abdomen =
perforated viscus
• Pain out of proportion to physical findings
= ischemic bowel
• Vague pain that subsequently localizes
= appendicitis or other intra-abdominal process that irritates the parietal peritoneum
• Waves of colicky pain = bowel obstruction
LUQ
Pancreatic
Pancreatitis (acute vs. chronic) Pancreatic pseudocyst Pancreatic tumours
Gastrointestinal
Gastritis
PUD
Splenic flexure pathology (e.g. CRC, ischemia)
Splenic
Splenic infarct/abscess Splenomegaly
Splenic rupture
Splenic artery aneurysm
Cardiopulmonary (see RUQ and Epigastric) Genitourinary (see RUQ)
LLQ
Gastrointestinal Diverticulitis
Diverticulosis Colon/sigmoid/rectal cancer Fecal impaction
Proctitis (ulcerative colitis, infectious; i.e. gonococcus or Chlamydia) Sigmoid volvulus
Hernia
Gynecological
See ‘suprapubic’
Genitourinary
See ‘suprapubic’
Extraperitoneal
Abdominal wall hematoma/abscess Psoas abscess
See Gynecology, Urology, Respirology, and Cardiology and Cardiac Surgery for further details regarding respective etiologies of acute abdominal pain
DIFFUSE
Gastrointestinal
Peritonitis
Early appendicitis, perforated appendicitis Mesenteric ischemia Gastroenteritis/colitis
Constipation
Bowel obstruction
Pancreatitis
Inflammatory bowel disease
Irritable bowel syndrome
Ogilvie’s syndrome
Cardiovascular/Hematological
Aortic dissection/ruptured AAA
Sickle cell crisis
Genitourinary/Gynecological
Perforated ectopic pregnancy PID
Acute urinary retention
Endocrinological
Carcinoid syndrome Diabetic ketoacidosis Addisonian crisis Hypercalcemia
EPIGASTRIC
Cardiac
Aortic dissection/ruptured AAA
MI
Pericarditis
Gastrointestinal Gastritis GERD/esophagitis PUD
Pancreatitis
Mallory-Weiss tear
SUPRAPUBIC
Gastrointestinal (see RLQ/LLQ)
Acute appendicitis
IBD
Gynecological
Ectopic pregnancy
PID
Endometriosis Threatened/incomplete abortion Hydrosalpinx/salpingitis Ovarian torsion Hemorrhagic fibroid Tubo-ovarian abscess Gynecological tumours
Genitourinary
Cystitis (infectious, hemorrhagic) Hydroureter/urinary colic Epididymitis
Testicular torsion
Acute urinary retention
Extraperitoneal
Rectus sheath hematoma
Other
Lead poisoning Tertiary syphilis
Abdominal Mass
Table 2. Differential Diagnosis of Abdominal Mass
Right Upper Quadrant (RUQ)
Gallbladder: cholecystitis, cholangiocarcinoma, peri-ampullary malignancy, cholelithiasis
Biliary tract: Klatskin tumour
Liver: hepatomegaly, hepatitis, abscess, tumour (hepatocellular carcinoma, metastatic tumour, etc.)
Right Lower Quadrant (RLQ)
Intestine: stool, tumour (CRC), mesenteric adenitis, appendicitis, appendiceal phlegmon or other abscess, typhlitis, intussusception, Crohn’s inflammation Ovary: ectopic pregnancy, cyst (physiological vs. pathological), tumour (serous, mucinous, struma ovarii, germ cell, Krukenberg)
Fallopian tube: ectopic pregnancy, tubo-ovarian abscess, hydrosalpinx, tumour
Upper Midline
Left Upper Quadrant (LUQ)
Spleen: splenomegaly, tumour, abscess, subcapsular splenic hemorrhage, can also present as RLQ mass if extreme splenomegaly
Stomach: tumour
Left Lower Quadrant (LLQ)
Intestine: stool, tumour, abscess (see RLQ)
Ovary: see RLQ
Fallopian tube: see RLQ
Pancreas: pancreatic adenocarcinoma, other pancreatic neoplasm, pseudocyst Abdominal aorta: AAA (pulsatile)
GI: gastric tumour (adenocarcinoma, gastrointestinal stromal tumour, carcinoid tumour), MALT lymphoma
Lower Midline
Uterus: pregnancy, leiomyoma (fibroid), uterine cancer, pyometra, hematometra GU: bladder distention, tumour
Pancreatitis can look like a surgical abdomen, but is rarely an indication for immediate surgical intervention