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DDxPro
Possible Diagnoses
Intestinal obstruction
Intestinal obstruction
Abdominal distension
Vomiting
Appear critically ill
Crampy pain
Colicky pain
Abdominal pain
Early abnormally active bowel sounds
Nausea
Peritoneal irritation
Constipation
Abdominal tenderness
Inability to pass flatus
Abdominal mass
Early high-pitched bowel sounds
Percussion reveal tympany
Empty rectal vault
Peritoneal signs
Rectal mass
Weight loss
Constant pain
Gastroparesis
Gastroparesis
Nausea
Upper abdominal pain
Easy satiety
Pain with sleeping
Mild bloating
Gastric residual in four hours
Vomiting
Exacerbate after eating
Bloating
Postprandial fullness
Weight loss
Epigastric pain
Postprandial nausea
Abdominal discomfort
Burning sensation
Crampy sensation
Epigastric distention
Epigastric tenderness
Gastric retention
Localized pain
Sigmoid volvulus
Sigmoid volvulus
Abdominal pain
Tenderness
Abdominal distension
Obstipation
Constipation
Nausea
Colicky pain
Continuous pain
Severe pain
Tympanitic abdomen
Recurrent pain
Vomiting
Lead to gangrene
Peritonitis
Sepsis
Ileus
Ileus
After abdominal operations
Inability to pass flatus
Nausea
Early reduction of bowel sounds
Early lack of bowel sounds
Abdominal distension
Obstipation
Vomiting
Mild diffuse tenderness
Abdominal pain
Abdominal tympany
Bloating
Dehydration
Delayed passage flatus
Diffuse abdominal pain
Diffuse pain
Gassiness
Inability to tolerate an oral diet
Last several days
Mild pain
Hereditary angioedema
Hereditary angioedema
Extremities skin swelling
Face skin swelling
Genitals skin swelling
Skin swelling
Exacerbating by oral contraceptives
Abdominal distension
Abdominal pain
Gastrointestinal colic
Nausea
Vomiting
Diarrhea
Exacerbating by stress
Skin sensation of fullness
Skin sensation of irritation
Skin tingling
Chicken-wire pattern of erythematous discoloration
Erythema marginatum
Erythematous discoloration
Exacerbating by bacteriuria
Exacerbating by bicycle riding
Ectopic pregnancy
Ruptured ectopic pregnancy
Extrauterine gestational sac with a yolk sac
Amenorrhea more than 4 weeks
Distended abdomen
First-trimester vaginal bleeding
Sudden onset
Abdominal pain
Staining
Vaginal bleeding
Amenorrhea
Late menstrual period
Menstrual cycle abnormalities
Missed menstrual period
Amenorrhea preceded vaginal bleeding
Intermittent vaginal bleeding
Adnexal mass
Breast tenderness
Frequent urination
Nausea
Pregnancy discomforts
Right pelvic pain
None
Giardiasis
Diarrhea
Malaise
Abdominal pain
Flatulence
Foul-smelling stools
Abdominal cramps
Belching
Bloating
Nausea
Frequent belching
Weight loss
Anterior uveitis
Cystic fibrosis
Immunocompromised individuals
Ingestion of contaminated water
Ingestion of raw food
Ingestion of uncooked food
Ingestion of untreated water
Poor sanitary conditions
Travelers
Pancreatitis
Acute pancreatitis
Nausea
Vomiting
Mild discomfort
Left upper quadrant pain
Alleviated in fetal position
Worsens with movement
Acute upper abdominal pain
Boring pain
Periumbilical pain
Relief on bending forward
Relieved by sitting up
Epigastric pain
Pain radiate to back
Signs of hypovolemia
Anorexia
Hypotension
Abdominal distention
Blue-red-purple of flanks
Clinical signs of hypocalcemia
Gradual pain
Gastric outlet obstruction
Gastric outlet obstruction
Epigastric pain
Vomiting
Increase of postprandial abdominal pain
Succussion splash
Nausea
Weight loss
Early satiety
Bloating
Malnutrition
Hypochloremic metabolic alkalosis
Hypokalemic hypochloremic metabolic alkalosis
Recurrent vomiting
Presence of chronic dehydration
Dilated stomach
Epigastric tympanitic mass
Left upper quadrant tympanitic mass
Palpable abdominal mass
Premenstrual syndrome
Premenstrual syndrome
Post pubescent
Premenopausal period
Increased interpersonal conflicts
Relieved by calcium supplementation
Relieved by exercise
Relieved by high complex carbohydrates diet
Relieved by magnesium
Relieved by primrose oil
Relieved by relaxation techniques
Relieved by vitamin b6
Relieved by vitamin e
Adverse effect on life
Decrease in work productivity
Increase in work absenteeism
Dizziness
Ovarian hyperstimulation syndrome
Ovarian hyperstimulation syndrome
Abdominal discomfort
Abdominal distension
Bilateral ovarian enlargement
Corpus luteum cysts
Mild nausea
Multiple follicular
After using human chorionic gonadotropin
Anuria
Bloating
Dyspnea
Enlarged ovaries
Hypovolemia
Increased intraabdominal pressure
Increased vascular permeability
Intractable nausea
Low blood venous pressure
Low central venous pressure
Oliguria
Reduced liver perfusion
Severe abdominal pain
Liver disease
Liver disease
Fatigue
Increased need for sleep
Lack of stamina
Lethargy
Listlessness
Malaise
Poor energy
Weakness
Abdominal distention
Afternoon fatigue
Fatigue after activity
Intestinal bleeding
Itching
Nausea
Poor appetite
Right upper quadrant pain
Intermittent fatigue
Abdominal pain
Bloating
Gynecomastia
Acute Abdominal Pain
History and physical examination
Unstable or Obvious surgical indication
Consider: Hemorrhage Perforation Acute peritonitis Bowel obstruction Ischemia
Resuscitation
Surgical consultation
LAPAROTOMY
Stable
Observation
Exclude: Medical causes
Consider: Inadequate physical manifestations
Further studies
Decreased pain
Observation
Continued pain Increased pain
Surgical Consultation
Chronic Abdominal Pain
History Physical examination, Laboratory tests
Evidence suggestive of visceral organ source
Stomach
Consider: Peptic ulcer Gastric tumor
Endoscopy Upper GI Series
Small bowel
Consider: Inflammation Tumor Obstruction
Small Bowel Follow-Through or Enteroclysis CT
Pancreas
Consider: Pancreatitis Cyst/tumor
Ultrasonography CT ERCP Pancreatic Function Test
Hepatobiliary
Consider: Gallstones Biliary obstruction Tumor/cyst Infiltration Chronic hepatitis Engorgement
Ultrasonography CT ERCP Liver Biopsy
Renal
Consider: Pyelonephritis Nephrolithiasis Tumor/cyst
Ultrasonography CT IV Pyelography
Colon
Consider: Inflammation Tumor Obstruction Diverticulosis
Barium Enema and/or Endoscopy
Abdominal wall source
Referred spinal nerve source
Vascular aneurysm
Ultrasonography CT Angiography
Pelvic source
Ultrasonography Laparoscopy
Nonlocalized or inapparent source
Consider: Metabolic disorders
Functional pain/dysmotility
IBS Nonulcer dyspepsia Postcholecystectomy syndrome
Chronic mesenteric ischemia Vasculitis
Angiography
Consider: Drug effect Lead toxicity
Consider: Tumor/cyst Infection Inflammatory process: Peritoneum Mesentery Omentum Retroperitoneum
Ultrasonography CT Laparoscopy Laparotomy
Nausea and Vomiting
1. History, see PE & Lab
Assess for mechanical obstruction, peritonitis, dehydration, or bleeding
YES (mechanical obstruction, peritonitis, dehydration, or bleeding)
Replace fluids, Consider hospitalization
NO (mechanical obstruction, peritonitis, dehydration, or bleeding)
Regurgitation of undigested food? rumination, esophageal stricture, Zenker’s diverticulitis
Assess for pharmacologic or toxic causes
YES (pharmacologic or toxic causes)
Discontinue offending agent Treat toxicity
NO (pharmacologic or toxic causes)
Constant or recurrent, intermittent
Consider: Migraines, Seizure disorder, Cyclic vomiting, CNS lesions
Duration < 1 wk
Consider: Food poisoning, Gastroenteritis
Fluid and electrolyte replacement, observation, antiemetics
Duration > 7 days
Predominantly AM vomiting
Consider: Pregnancy, Uremia, Alcohol use, Increased intracranial pressure
Focal defects, Brainstem Posterior fossa, Abdominal migraine
Etiology still uncertain
Consider: Electrogastrography, MRI of brain
Vomiting > 1 hr after meal
Gastric emptying study
Prolonged emptying
Consider: Gastroparesis, Trial prokinetic agents, Gastric outlet obstructions
EGD
Normal emptying
Consider: Conversion reaction, Depression
Psychological evaluation
Vertigo
Consider: Labyrinthine disorder
Etiology still uncertain
Consider: Electrogastrography, MRI of brain
Vomiting immediately after meals
Consider: Gastroesophageal reflux disease, Bulimia
Etiology still uncertain
Consider: Electrogastrography, MRI of brain
Chronic orthostatic hypotension, hyponatremia
Consider: Adrenal insufficiency
Etiology still uncertain
Consider: Electrogastrography, MRI of brain
Weight loss
Consider: Malignancy, Gastroparesis, Gastric outlet obstruction
EGD
Etiology still uncertain
Consider: Electrogastrography, MRI of brain
2.Physical examination, see History & Lab
Assess for mechanical obstruction, peritonitis, dehydration, or bleeding
YES (mechanical obstruction, peritonitis, dehydration, or bleeding)
Replace fluids, Consider hospitalization
NO (mechanical obstruction, peritonitis, dehydration, or bleeding)
Regurgitation of undigested food? rumination, esophageal stricture, Zenker’s diverticulitis
Assess for pharmacologic or toxic causes
YES (pharmacologic or toxic causes)
Discontinue offending agent Treat toxicity
NO (pharmacologic or toxic causes)
Constant or recurrent, intermittent
Consider: Migraines, Seizure disorder, Cyclic vomiting, CNS lesions
Duration < 1 wk
Consider: Food poisoning, Gastroenteritis
Fluid and electrolyte replacement, observation, antiemetics
Duration > 7 days
Predominantly AM vomiting
Consider: Pregnancy, Uremia, Alcohol use, Increased intracranial pressure
Focal defects, Brainstem Posterior fossa, Abdominal migraine
Etiology still uncertain
Consider: Electrogastrography, MRI of brain
Vomiting > 1 hr after meal
Gastric emptying study
Prolonged emptying
Consider: Gastroparesis, Trial prokinetic agents, Gastric outlet obstructions
EGD
Normal emptying
Consider: Conversion reaction, Depression
Psychological evaluation
Vertigo
Consider: Labyrinthine disorder
Etiology still uncertain
Consider: Electrogastrography, MRI of brain
Vomiting immediately after meals
Consider: Gastroesophageal reflux disease, Bulimia
Etiology still uncertain
Consider: Electrogastrography, MRI of brain
Chronic orthostatic hypotension, hyponatremia
Consider: Adrenal insufficiency
Etiology still uncertain
Consider: Electrogastrography, MRI of brain
Weight loss
Consider: Malignancy, Gastroparesis, Gastric outlet obstruction
EGD
Etiology still uncertain
Consider: Electrogastrography, MRI of brain
3.Laboratory evaluation, see also History & PE
Assess for mechanical obstruction, peritonitis, dehydration, or bleeding
YES (mechanical obstruction, peritonitis, dehydration, or bleeding)
Replace fluids, Consider hospitalization
NO (mechanical obstruction, peritonitis, dehydration, or bleeding)
Regurgitation of undigested food? rumination, esophageal stricture, Zenker’s diverticulitis
Assess for pharmacologic or toxic causes
YES (pharmacologic or toxic causes)
Discontinue offending agent Treat toxicity
NO (pharmacologic or toxic causes)
Constant or recurrent, intermittent
Consider: Migraines, Seizure disorder, Cyclic vomiting, CNS lesions
Duration < 1 wk
Consider: Food poisoning, Gastroenteritis
Fluid and electrolyte replacement, observation, antiemetics
Duration > 7 days
Predominantly AM vomiting
Consider: Pregnancy, Uremia, Alcohol use, Increased intracranial pressure
Focal defects, Brainstem Posterior fossa, Abdominal migraine
Etiology still uncertain
Consider: Electrogastrography, MRI of brain
Vomiting > 1 hr after meal
Gastric emptying study
Prolonged emptying
Consider: Gastroparesis, Trial prokinetic agents, Gastric outlet obstructions
EGD
Normal emptying
Consider: Conversion reaction, Depression
Psychological evaluation
Vertigo
Consider: Labyrinthine disorder
Etiology still uncertain
Consider: Electrogastrography, MRI of brain
Vomiting immediately after meals
Consider: Gastroesophageal reflux disease, Bulimia
Etiology still uncertain
Consider: Electrogastrography, MRI of brain
Chronic orthostatic hypotension, hyponatremia
Consider: Adrenal insufficiency
Etiology still uncertain
Consider: Electrogastrography, MRI of brain
Weight loss
Consider: Malignancy, Gastroparesis, Gastric outlet obstruction
EGD
Etiology still uncertain
Consider: Electrogastrography, MRI of brain
Dyspepsia
Assess symptoms
Heartburn and/or regurgitation are presenting complaint, predominant or frequent
Manage as GERD (acid suppression)
NSAID/COX-2 inhibitor use
Consider discontinuing/PPI ... see desc ...
Dyspepsia without obvious GERD or NSAID use
Age >55 yr or alarm symptoms present
Esophagogastroduodenoscopy (EGD)
Age < 55 yr No alarm symptoms
Test for H. pylori
Negative
PPI trial 4–6 wk
Fails
Provide reassurance, Reassess diagnosis
Consider EGD
Abnormal endoscopic findings
Biopsies/treatments based on endoscopic findings
Normal endoscopy
Consider: H. pylori tests ... see desc ...
H. pylori—negative functional dyspepsia (normal endoscopy) and failed adequate trial of PP
Reevaluate the symptoms and diagnosis .. see desc ...
If symptoms persist with no other cause ... see desc ...
Positive
Positive Treat for H. pylori
Fails
PPI trial 4 wk
Fails
Provide reassurance, Reassess diagnosis
Consider EGD
H. pylori—negative functional dyspepsia (normal endoscopy) and failed adequate trial of PP
Flatulence
History / Physical examination
If stools are loose, examine for ova, parasites...see sesc...
Abnormal
Treat Accordingly
Normal
Eliminate offending agents in diet
Effective
No further evaluation
Not effective
Sigmoidoscopy and Barium Enema or Colonoscopy
Abnormal
Treat Accordingly
Normal
Consider: Upper GI and small bowel x-ray series Abdominal ultrasonography
Abnormal
Treat Accordingly
Normal
Consider: Gut motility testing or hygrogen breath testing
Consider: Treatment with bulking agents, antispasmodics, or stress reduction
Eliminate offending agents in diet
Effective
No further evaluation
Not effective
Sigmoidoscopy and Barium Enema or Colonoscopy
Abnormal
Treat Accordingly
Normal
Consider: Upper GI and small bowel x-ray series Abdominal ultrasonography
Abnormal
Treat Accordingly
Normal
Consider: Gut motility testing or hygrogen breath testing
Consider: Treatment with bulking agents, antispasmodics, or stress reduction
Asymptomatic Abnormal Liver Aminotransferases
Elevated ALT and AST<5 times normal
History and physical examination,* Discontinuation of hepatotoxic medications
Confirm abnormality if an error is suspected
Liver chemistries, PT, albumin ... see desc ...
Negative serology, asymptomatic patient without hepatic decompensation
Lifestyle modification: ...see desc ...
6 months
Repeat liver chemistries
Normal
Observation
Abnormal
Ultrasound and serologic evaluation: ...see desc...
Liver biopsy