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Differential Diagnosis of Abdominal Pain

INTRODUCTION The evaluation of abdominal pain requires an understanding of the possible mechanisms responsible for pain, a broad differential of common causes, and recognition of typical patterns and clinical presentations. All patients do not have classic presentations. Thus, unusual causes of abdominal pain must also be considered, especially in elderly and immunocompromised patients. NEUROLOGIC BASIS OF ABDOMINAL PAIN Pain receptors in the abdomen respond to mechanical and chemical stimuli. Stretch is the principal mechanical stimulus involved in visceral nociception, although distention, contraction, traction, compression, and torsion are also perceived. Visceral receptors responsible for these sensations are located on serosal surfaces, within the mesentery, and within the walls of hollow viscera, in which they exist between the muscularis mucosa and submucosa. Localization of pain The type and density of visceral afferent nerves makes the localization of visceral pain imprecise. However, a few general rules are useful at the bedside: Most digestive tract pain is perceived in the midline because of bilaterally symmetric innervation. Pain that is clearly lateralized most likely arises from the ipsilateral kidney, ureter, ovary, or somatically innervated structures, which have predominantly unilateral innervation. Exceptions to this rule include the gallbladder and ascending and descending colons which, although bilaterally innervated, have predominant innervation located on their ipsilateral sides. Visceral pain is perceived in the spinal segment at which the visceral afferent nerves enter the spinal cord. As an example, afferent nerves mediating pain arising from the small intestine enter the spinal cord between T8 to L1. Thus, distension of the small intestine is usually perceived in the periumbilical region. Referred pain Pain originating in the viscera may sometimes be perceived as originating from a site distant from the affected organ. One explanation is that visceral afferent nerve fibers enter the spinal cord close to inputs from somatic receptors, and both types of inputs activate the same spinothalamic pathways. Because the density of somatic inputs is higher than visceral inputs and because somatic inputs are more commonly stimulated, the brain tends to associate the stimulation with a somatic source.

Referred pain is usually located in the cutaneous dermatomes sharing the same spinal cord level as the visceral inputs. As an example, nociceptive inputs from the gallbladder enter the spinal cord at T5 to T10. Thus, pain from an inflamed gallbladder may be perceived in the scapula. Precise localization of the pain to the right upper quadrant in patients with acute cholecystitis usually occurs once the overlying parietal peritoneum (which is somatically innervated) becomes inflamed. The quality of referred pain is aching and perceived to be near the surface of the body. In addition to pain, two other correlates of referred pain can be detected: skin hyperalgesia and increased muscle tone of the abdominal wall (which accounts for the abdominal wall rigidity sometimes observed in patients with an acute abdomen). UPPER ABDOMINAL PAIN SYNDROMES The different pain syndromes typically, but not always, have characteristic locations. Biliary disease Disorders involving the liver, biliary organs, pancreas, kidneys, stomach, intestines, diaphragms, and lung may cause right upper quadrant pain. The biliary tract syndromes are classified according to the source of pain and the pathogenesis of the disorder (eg, distention of a duct, inflammation, or infection). Acute pancreatitis Almost all patients with acute pancreatitis have acute upper abdominal pain at the onset. The pain is steady and may be in the mid-epigastrium, right upper quadrant, diffuse, or, infrequently, confined to the left side. Biliary colic, which may herald or progress to acute pancreatitis, may occur postprandially, while acute pancreatitis related to alcohol frequently occurs one to three days after a binge or cessation of drinking. Unlike biliary colic, which lasts a maximum of six to eight hours, the pain of pancreatitis lasts days. Its onset is rapid, but not as abrupt as that with a perforated viscus; in many cases, the pain of pancreatitis reaches maximum intensity within 10 to 20 minutes. One characteristic of the pain that is present in about one-half of patients and suggests a pancreatic origin is band-like radiation to the back. Painless disease is uncommon (5 to 10 percent) but may be complicated and fatal. The abdominal pain is typically accompanied (approximately 90 percent) by nausea and vomiting that may persist for many hours. Restlessness, agitation, and relief on bending forward are other notable symptoms. Patients with fulminant attacks may present in shock or coma. Dyspepsia -The differential diagnosis of dyspepsia includes gastroesophageal reflux disease, peptic ulcer disease, biliary disease, irritable bowel syndrome, chronic pancreatitis, gastric cancer, drug-

induced dyspepsia, psychiatric disease, diabetic gastroparesis, metabolic diseases, gastrointestinal and pancreatic malignancies, ischemic heart disease, and abdominal wall pain. A detailed description of a patient with these syndromes is discussed elsewhere. Hiatus hernia Both sliding and paraesophageal hernias can occasionally become incarcerated and cause severe chest and epigastric pain requiring emergency surgery. Hiatal hernias may also develop following surgery that involves the diaphragm, including partial gastrectomy, fundoplication and bariatric surgery. Pneumonia Pneumonia involving the lower lobes of the lung is a common cause of abdominal pain syndromes, presumably related to diaphragmatic irritation, and may be confused with acute cholecystitis or, rarely, an acute abdomen. Abdominal pain is occasionally the sole presenting complaint in a patient with lower lobe pneumonia. Myocardial infarction Upper abdominal pain can be the presenting symptom of an acute myocardial infarction. Any patient with cardiac risk factors should have an electrocardiogram. Splenic abscess or infarction Splenic abscesses typically are associated with fever and tenderness in the left upper quadrant, and may also be associated with splenic infarction. Splenic infarction also presents with severe left upper quadrant pain. This syndrome should be considered in any patient with atrial fibrillation or other conditions associated with peripheral embolism. LOWER ABDOMINAL PAIN SYNDROMES Appendicitis Acute appendicitis is a major consideration in the assessment of any patient with acute abdominal disease. Acute appendicitis typically presents with periumbilical pain initially that radiates to the right lower quadrant; however, occasional patients present with epigastric or generalized abdominal pain. The pain localizes to the right lower quadrant when the appendiceal inflammation begins to involve the peritoneal surface. Diverticular disease Some of these patients complain of symptoms such as cramping, bloating, flatulence, and irregular defecation. Diverticulitis represents microscopic or macroscopic perforation of a diverticulum. The clinical presentation of diverticulitis depends upon the severity of the underlying inflammatory process and whether or not complications are present. Left lower quadrant

pain is the most common complaint in Western countries, occurring in 70 percent of patients. Right-sided diverticulitis occurs in only 1.5 percent of patients. Pain is often present for several days prior to presentation, which aids in the differentiation of diverticulitis from other causes of acute abdominal symptoms. Kidney stones Kidney stones usually cause symptoms when the stone passes from the renal pelvis into the ureter. Pain is the most common symptom and varies from a mild and barely noticeable ache, to discomfort that is so intense it requires hospitalization and parenteral medications. The pain typically waxes and wanes in severity and develops in waves or paroxysms that are related to movement of the stone in the ureter and to associated ureteral spasm. Paroxysms of severe pain usually last 20 to 60 minutes. Bladder distension Patients with bladder outlet obstruction leading to acute bladder distension, as may occur in some patients with benign prostatic hypertrophy, can present with lower abdominal pain. Pelvic pain Lower abdominal pain in women is frequently due to disorders of the reproductive organs. DIFFUSE ABDOMINAL PAIN SYNDROMES Diffuse abdominal pain syndromes often represent severe and potentially life-threatening disease. Examples include mesenteric ischemia and infarction, ruptured abdominal aortic aneurysm, and diffuse peritonitis. Mesenteric ischemia and infarction Mesenteric infarction presents with the acute and severe onset of diffuse and persistent abdominal pain, while chronic mesenteric ischemia may be manifested by a variety of symptoms including abdominal pain after eating ("intestinal angina"), weight loss, nausea, vomiting, and diarrhea. Ruptured aneurysm A ruptured abdominal aortic aneurysm can present with diffuse or localized abdominal symptoms and can mimic other acute conditions such as renal colic, diverticulitis, pancreatitis, inferior wall coronary ischemia, mesenteric ischemia, or biliary tract disease. Peritonitis Patients with peritonitis attempt to minimize abdominal pain by lying still, often in a supine position with the knees flexed. The pain may be greatest over the region of the abdomen near the abdominal viscera from which the pain originated (as in acute cholecystitis) but may spread rapidly to involve the entire abdomen as inflammation progresses. Physical examination may reveal fever and evidence for hypovolemia (tachycardia and hypotension). Abdominal examination should be performed gently, since it can worsen pain. It is usually unnecessary to elicit rebound tenderness (sudden severe pain caused by rapid

release of the hand following abdominal palpation), since peritonitis can usually be suspected from more gentle palpation. A similar approach (elicitation of pain after bumping against the bed) is also usually unnecessary. Abdominal wall rigidity (involuntary guarding) may be present due to activation of primary afferent visceral and cutaneous pain receptors. Intestinal obstruction Severe, acute diffuse abdominal pain can be caused by either partial or complete obstruction of the intestines. The most common causes in adults are an incarcerated hernia, adhesions, intussusception, and volvulus. Intestinal obstruction should be considered when the patient complains of pain, vomiting, and constipation. Physical findings of abdominal distention and tenderness to palpation are common. OTHER CAUSES Abdominal pain can be caused by myriad illnesses. These may include: Metabolic disorders ranging from diabetic ketoacidosis to acute intermittent porphyria Abdominal malignancies Lactose intolerance Helminthic and other tropical infectious diseases Functional disorders Psychogenic etiologies Aortic dissection involving the descending aorta Systemic vasculitis, which can lead to mesenteric ischemia