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Abdominal pain and jaundice

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

Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
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
Acute suppurative cholangitis RUQ + + + + βˆ’ βˆ’ βˆ’ βˆ’ + + + N
  • Abnormal LFT
  • WBC >10,000
  • Ultrasound shows biliary dilatation/stents/tumor
  • Septic shock occurs with features of SIRS
Acute cholangitis RUQ + βˆ’ βˆ’ + βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ N
  • Ultrasound shows biliary dilatation/stents/tumor
  • Biliary drainage (ERCP) + IV antibiotics
Acute cholecystitis RUQ + βˆ’ + + βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ Hypoactive Ultrasound shows:
  • Gallstone
  • Inflammation
Acute pancreatitis Epigastric + βˆ’ + Β± βˆ’ βˆ’ βˆ’ βˆ’ Β± βˆ’ βˆ’ N
  • Ultrasound shows evidence of inflammation
  • CT scan shows severity of pancreatitis
  • Pain radiation to back
Chronic pancreatitis Epigastric βˆ’ βˆ’ Β± Β± βˆ’ + + βˆ’ βˆ’ βˆ’ βˆ’ 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 βˆ’ βˆ’ + + βˆ’ + + βˆ’ βˆ’ βˆ’ βˆ’ N

SkinΒ manifestations may include:

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
Primary biliary cirrhosis RUQ/Epigastric βˆ’ βˆ’ βˆ’ + βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ N
  • Increased AMA level, abnormal LFTs
  • ERCP
  • Pruritis
Primary sclerosing cholangitis RUQ + βˆ’ βˆ’ + βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ N ERCP and MRCP shows
  • Multiple segmentalΒ strictures
  • Mural irregularities
  • BiliaryΒ dilatation and diverticula
  • Distortion of biliary tree
  • The risk ofΒ cholangiocarcinomaΒ in patients with primary sclerosing cholangitis is 400 times higher than the risk in the general population.
Cholelithiasis RUQ/Epigastric Β± βˆ’ Β± Β± βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ Normal to hyperactive for dislodged stone
  • Fatty food intolerance
Gastrointestinal perforation Diffuse + Β± – Β± βˆ’ βˆ’ βˆ’ + + + Β± Hyperactive/hypoactive
  • WBC> 10,000
Inflammatory bowel disease Diffuse Β± βˆ’ βˆ’ Β± βˆ’ + + + βˆ’ βˆ’ βˆ’ Normal or hyperactive

Extra intestinal findings:

Whipple’s disease Diffuse Β± βˆ’ βˆ’ Β± βˆ’ + + βˆ’ Β± βˆ’ βˆ’ N Endoscopy is used to confirm diagnosis.

Images used to find complications

Extra intestinal findings:
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
Viral hepatitis RUQ + βˆ’ + + βˆ’ Positive in Hep A and E + βˆ’ 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 + + + + βˆ’ Β± + βˆ’ + + Β± Normal or hypoactive
  • US
  • CT
Hepatocellular carcinoma/Metastasis RUQ + βˆ’ βˆ’ + βˆ’ βˆ’ + βˆ’ βˆ’ βˆ’ βˆ’
  • Normal
  • Hyperactive if obstruction present
  • US
  • CT
  • Liver biopsy

Other symptoms:

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
Budd-Chiari syndrome RUQ Β± βˆ’ βˆ’ Β± βˆ’ βˆ’ βˆ’ Positive in liver failure leading to varices βˆ’ βˆ’ βˆ’ N
Findings on CT scan suggestive of Budd-Chiari syndrome include:
Ascitic fluid examination shows:
Cirrhosis RUQ βˆ’ βˆ’ βˆ’ + βˆ’ βˆ’ + + + βˆ’ βˆ’ N US
  • Stigmata of liver disease
  • Cruveilhier- Baumgarten murmur
Spontaneous bacterial peritonitis Diffuse + βˆ’ βˆ’ Positive in cirrhotic patients βˆ’ + βˆ’ βˆ’ Β± + + Hypoactive
  • Ascitic fluid PMN>250 cells/mmΒ³
  • Culture: Positive for single organism
  • Ultrasound for evaluation of liver cirrhosis
Biliary colic RUQ βˆ’ βˆ’ + + βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ N
  • Ultrasound

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