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DDxPro
Possible Diagnoses
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
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
Pancreatic cancer
Pancreatic cancer
Asthenia
Weight loss
Anorexia
Abdominal pain
Intermittent pain
Epigastric pain
Jaundice
Intermittent abdominal pain
New onset of diabetes mellitus
Nausea
Midepigastric pain
Upper abdominal pain
Radiate to back
Radiate to sides
Hepatomegaly
Vomiting
Courvoisier sign
Trousseau syndrome
Palpable periumbilical mass
Abdominal mass
Cholecystitis
Acute cholecystitis
Sudden onset
Pain persisting beyond 5 hours
Prolonged biliary pain
Prolonged right upper quadrant pain
Epigastric pain
Acute onset of upper abdominal pain
Upper abdominal pain
Abdominal pain
Steady pain
More severe than biliary colic
Severe pain
Positive murphy sign
Right upper quadrant pain
Unremitting right upper quadrant pain
Fever
Nausea
Murphy's sign
Vomiting
Previous episode of biliary pain
Low grade fever
Biliary colic
Biliary colic
Plateauing within an hour
Acute
Dull discomfort
Steady fullness
Upper abdominal pain
Epigastric pain
Right upper quadrant pain
Subsides gradually over 30 minutes to several hours
Sudden onset pain
Constant pain
Intense pain
Recurrent attacks
Gnawing pain
Last at least 30 minutes
Episodes separate in months
Episodes separate in weeks
Diaphoresis
Restlessness
Deep pain
Hours to years frequency
Intussusception
Intussusception
Abdominal pain
Constipation
Fever
Intermittent abdominal pain
Intermittent pain
Nausea
Vomiting
Weight loss
Rectal bleeding
Redcurrant jelly stools
Chronic
Progressive lethargy
Colicky pain
Intermittent partial bowel obstruction
Abdominal distention
Palpable abdominal mass
Leading to bowel perforation
Leading to secondary bacterial peritonitis
Peritonism
Hypovolemic shock
Choledochal cyst
Choledochal cyst
Abrupt onset abdominal pain
Acute abdominal pain
Cramping abdominal pain
Diffuse abdominal pain
Frank abdominal pain
Gastrointestinal colic
Gi disturbance
Left sided abdominal pain
Lower abdominal pain
Mid-abdominal pain
Periumbilical pain
Postprandial abdominal pain
Progressive abdominal pain
Recurrent abdominal pain
Right sided abdominal pain
Upper abdominal pain
Relieved by sitting up
Abdominal mass
Biliary lithiasis
Gradual
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
Chronic bacterial prostatitis
Chronic bacterial prostatitis
Bulk-related symptoms
Charcot triad
Constitutional symptoms
Cystitis
Cystitis symptoms
Fever
High grade fever
High-grade fever
Intermittent fever
Low grade fever
Mild fever
Pelvic pain
Perineal pain
Recurrent abdominal pain
Recurrent infection
Recurrent pain
Recurrent uti
Reynold pentad
Suprapubic pain
Symptoms onset six months
Biliary sod
Biliary sod
Presence of both elevated liver enzymes and a dilated cbd
Recurrent pain
Recurrent right upper quadrant pain
Epigastric pain
Last at least 30 minutes
Right upper quadrant pain
Exclusion of other structural disease explain symptoms
Moderate pain
Pain builds up to a steady level
Pain interrupt patients daily activities
Pain lead to an emergency department visit
Pain not relieved by antiacids
Pain not relieved by bowel movements
Pain not relieved by postural change
Recurrent symptoms occurring at different intervals not daily
Severe pain
Biliary type pain
Nausea
Pain awakening patient from sleep in middle of night
Pain radiating to back
Acute appendicitis
Acute appendicitis
Abdominal tenderness
Onset of abdominal pain
Right lower quadrant tenderness
Shift to the left
Anorexia
Mild vomiting
Nausea
Vague discomfort
Vague pain
More localized to right lower quadrant pain after several hours
Vague periumbilical pain
Migratory right iliac fossa pain
Pain migration from periumbilical to right lower quadrant
Mcburneys point tenderness
Sharper pain
Positive alvarado score
Rebound tenderness
Rebound tenderness in the right iliac fossa
Tenderness in the right iliac fossa
Fever
Mesenteric ischemia
Mesenteric ischemia
Over age 60 years
Early frequent passage of mucosal
Nonspecific abdominal pain
Severe periumbilical pain
Bloody diarrhea
Abdominal distension
Continuous pain
Diffused
Diffused abdominal pain
Early severe abdominal pain
Moderate tenderness
No bowel sounds
Severe pain
Abdominal bruits
Peritoneal signs
Hematochezia
Severe abdominal pain
Weight loss
Diarrhea
Massive fluid protein and electrolytes start to leak
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