Abdominal pain, nausea and vomiting

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2],Iqra Qamar M.D.[3]

Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram

	Abdominal Pain	Fever	Rigors and chills	Nausea or vomiting	Jaundice	Constipation	Diarrhea	Weight loss	GI bleeding	Hypo- tension	Guarding	Rebound Tenderness	Bowel sounds	Lab Findings	Imaging
Disease	Clinical manifestations													Diagnosis		Comments
	Symptoms									Signs				Diagnosis
Acute suppurative cholangitis	RUQ	+	+	+	+	−	−	−	−	+	+	+	N	Abnormal LFT WBC >10,000	Ultrasound shows biliary dilatation/stents/tumor	Septic shock occurs with features of SIRS
Acute cholecystitis	RUQ	+	−	+	+	−	−	−	−	−	−	−	Hypoactive	Hyperbilirubinemia Leukocytosis	Ultrasound shows: Gallstone Inflammation	Murphy’s sign
Acute pancreatitis	Epigastric	+	−	+	±	−	−	−	−	±	−	−	N	Increased amylase / lipase	Ultrasound shows evidence of inflammation CT scan shows severity of pancreatitis	Pain radiation to back
Chronic pancreatitis	Epigastric	−	−	±	±	−	+	+	−	−	−	−	N	Increased amylase / lipase Increased stool fat content Pancreatic function test	CT scan Calcification Pseudocyst Dilation of main pancreatic duct	Predisposes to pancreatic cancer
Pancreatic carcinoma	Epigastric	−	−	+	+	−	+	+	−	−	−	−	N	↑ Alkaline phosphatase ↑ serum bilirubin ↑ gamma-glutamyl transpeptidase ↑ CA 19-9	MDCT with PET/CT MRI	Skin manifestations may include: Bullous pemphigoid Cicatricial pemphigoid Migratory superficial thrombophlebitis (classic Trousseau’s syndrome) Pancreatic panniculitis
Disease	Abdominal Pain	Fever	Rigors and chills	Nausea or vomiting	Jaundice	Constipation	Diarrhea	Weight loss	GI bleeding	Hypo- tension	Guarding	Rebound Tenderness	Bowel sounds	Lab Findings	Imaging	Comments
Cholelithiasis	RUQ/Epigastric	±	−	±	±	−	−	−	−	−	−	−	Normal to hyperactive for dislodged stone	Leukocytosis	Ultrasound shows gallstone	Fatty food intolerance
Peptic ulcer disease	Diffuse	±	−	+	−	−	−	+	Gastric ulcer- melena and hematemesis Duodenal ulcer- melena and hematochezia	Positive if perforated	Positive if perforated	Positive if perforated	N	Ascitic fluid LDH > serum LDH Glucose < 50mg/dl Total protein > 1g/dl	Air under diaphragm in upright CXR	Upper GI endoscopy for diagnosis
Gastritis	Epigastric	±	−	+	−	−	−	Positive in chronic gastritis	+	−	−	−	N	H.pylori infection diagnostic tests	Endoscopy	H.pylori gastritis guideline recommendation
Gastroesophageal reflux disease	Epigastric	−	−	±	−	−	−	−	−	−	−	−	N	N	Gastric emptying studies	Esophageal manometry Endoscopy for alarm signs
Gastric outlet obstruction	Epigastric	−	−	±	−	−	−	+	−	−	−	−	Hyperactive	Complete blood count Basic metabolic panel	Abdominal x-ray– air fluid level Barium upper GI studies- narrowed pylorus	Succussion splash
Gastroparesis	Epigastric	−	−	+	−	−	−	+	−	±	−	−	Hyperactive/hypoactive	Hemoglobin Fasting plasma glucose Serum total protein, albumin, thyrotropin (TSH), and an antinuclear antibody (ANA) titer HbA1c	Scintigraphic gastric emptying	Succussion splash Single photon emission computed tomography (SPECT) Full thickness gastric and small intestinal biopsy
Dumping syndrome	Lower and then diffuse	−	−	+	−	−	+	+	−	+	−	−	Hyperactive	Glucose challenge test Hydrogen breath test	Upper GI series Gastric emptying study	Postgastrectomy
Disease	Abdominal Pain	Fever	Rigors and chills	Nausea or vomiting	Jaundice	Constipation	Diarrhea	Weight loss	GI bleeding	Hypo- tension	Guarding	Rebound Tenderness	Bowel sounds	Lab Findings	Imaging	Comments
Acute appendicitis	Starts in epigastrium, migrates to RLQ	+	Positive in pyogenic appendicitis	+	−	−	±	−	−	Positive in perforated appendicitis	+	+	Hypoactive	Leukocytosis	Ct scan Ultrasound	Positive Rovsing sign Positive Obturator sign Positive Iliopsoas sign
Acute diverticulitis	LLQ	+	±	+	−	+	±	−	+	Positive in perforated diverticulitis	+	+	Hypoactive	Leukocytosis	CT scan Ultrasound	History of constipation
Infective colitis	Diffuse	+	−	±	−	−	+	−	+	Positive in fulminant colitis	±	±	Hyperactive	Stool culture and studies Shiga toxin in bloody diarrhea PCR	CT scan Bowel wall thickening Edema
Viral hepatitis	RUQ	+	−	+	+	−	Positive in Hep A and E	+	−	Positive in fulminant hepatitis	Positive in acute	+	N	Abnormal LFTs Viral serology	US	Hep A and E have fecal-oral route of transmission Hep B and C transmits via blood transfusion and sexual contact.
Liver abscess	RUQ	+	+	+	+	−	±	+	−	+	+	±	Normal or hypoactive	CBC Blood cultures Abnormal liver function tests	US CT
Disease	Abdominal Pain	Fever	Rigors and chills	Nausea or vomiting	Jaundice	Constipation	Diarrhea	Weight loss	GI bleeding	Hypo- tension	Guarding	Rebound Tenderness	Bowel sounds	Lab Findings	Imaging	Comments
Pyelonephritis	Unilateral	+	±	+	−	−	−	−	−	+	−	−	Hypoactive	Urinalysis Urine culture Blood culture	CT MRI	CVA tenderness
Renal colic	Flank pain	−	−	+	−	−	−	−	−	−	−	−	N	Hematuria	Ultrasound CT scan	Colicky abdominal pain Dysuria
Small bowel obstruction	Diffuse	+	−	+	−	+	−	+	−	+	+	±	Hyperactive then absent	Leukocytosis with left shift indicates complications	Abdominal X ray Dilated loops of bowel with air fluid levels Gasless abdomen	“Target sign”– , indicative of intussusception Venous cut-off sign” – suggests thrombosis
Volvulus	Diffuse	–	−	+	−	+	−	−	−	Positive in perforated cases	+	+	Hyperactive then absent	Leukocytosis	CT scan and abdominal X ray U shaped sigmoid colon	“Whirl sign”
Biliary colic	RUQ	−	−	+	+	−	−	−	−	−	−	−	N	↑ bilirubin and alkaline phosphatase	Ultrasound
Disease	Abdominal Pain	Fever	Rigors and chills	Nausea or vomiting	Jaundice	Constipation	Diarrhea	Weight loss	GI bleeding	Hypo- tension	Guarding	Rebound Tenderness	Bowel sounds	Lab Findings	Imaging	Comments
Mesenteric ischemia	Periumbilical	Positive if bowel becomes gangrenous	−	+	−	−	+	+	+	Positive if bowel becomes gangrenous	Positive if bowel becomes gangrenous	−	Hyperactive to absent	Leukocytosis and lactic acidosis Amylase levels D-dimer	CT angiography SMA or SMV thrombosis	Also known as abdominal angina that worsens with eating
Acute ischemic colitis	Diffuse	+	±	+	−	−	+	+	+	+	+	+	Hyperactive then absent	Leukocytosis	Abdominal x-ray Distension and pneumatosis CT scan Double halo appearance, thumbprinting Thickening of bowel	May lead to shock
Ruptured abdominal aortic aneurysm	Diffuse	±	−	+	−	−	−	+	+	+	−	−	N	Fibrinogen D-dimer	Focused Assessment with Sonography in Trauma (FAST)	Unstable hemodynamics
Intra-abdominal or retroperitoneal hemorrhage	Diffuse	±	−	±	−	−	−	−	+	+	−	−	N	↓ Hb ↓ Hct	CT scan	History of trauma
Disease	Abdominal Pain	Fever	Rigors and chills	Nausea or vomiting	Jaundice	Constipation	Diarrhea	Weight loss	GI bleeding	Hypo- tension	Guarding	Rebound Tenderness	Bowel sounds	Lab Findings	Imaging	Comments
Torsion of the cyst	RLQ / LLQ	−	−	+	−	−	−	−	−	−	±	±	N	↑ ESR ↑ CRP	Ultrasound	Sudden onset & severe pain
Cyst rupture	RLQ / LLQ	−	−	+	−	−	−	−	−	+	±	±	N	↑ ESR ↑ CRP	Ultrasound
Ruptured ectopic pregnancy	RLQ / LLQ	−	−	+	−	−	−	−	−	+	+	+	N	Positive pregnancy test	Ultrasound	History of Missed period Vaginal bleeding
Pneumonia	RUQ/LUQ	+	+	+	−	−	±	−	−	+	−	−	Normal or hypoactive	ABGs Leukocytosis Pancytopenia	CXR CT chest Bronchoscopy	Shortness of breath Cough
Myocardial Infarction	Epigastric	±	−	+	−	−	−	−	−	Positive in cardiogenic shock	−	−	N	Cardiac enzymes	ECG Echocardiogram Wall motion abnormality Wall rupture Septal rupture	Chest pain, tightness, diaphoresis Complications: Arrythmias Mitral regurgitation Ventricular wall rupture Septal rupture