General Surgery Rotation

General Surgery: Abdominal pain

RUQ PAIN

Causes of right upper quadrant (RUQ) abdominal pain

RUQ Clinical features
Biliary
Biliary colic Intense, dull discomfort located in the RUQ or epigastrium. Associated with nausea, vomiting, and diaphoresis. Generally lasts at least 30 minutes, plateauing within one hour. Benign abdominal examination
Acute cholecystitis Prolonged (>4 to 6 hours) RUQ or epigastric pain, fever. Patients will have abdominal guarding and Murphy's sign
Acute cholangitis Fever, jaundice, RUQ pain
Sphincter of Oddi dysfunction RUQ pain is similar to other biliary pain
Hepatic
Acute hepatitis RUQ pain with fatigue, malaise, nausea, vomiting, and anorexia. Patients may also have jaundice, dark urine, and light-colored stools
Perihepatitis (Fitz-Hugh-Curtis syndrome) RUQ pain with a pleuritic component, pain is sometimes referred to the right shoulder
Liver abscess Fever and abdominal pain are the most common symptoms
Budd-Chiari syndrome Symptoms include fever, abdominal pain, abdominal distention (from ascites), lower extremity edema, jaundice, gastrointestinal bleeding, and/or hepatic encephalopathy
Portal vein thrombosis Symptoms include abdominal pain, dyspepsia, or gastrointestinal bleeding
Picmonic
Acute Abdomen DDx Upper Quadrants

The causes within the right upper quadrant (RUQ) include cholecystitis, biliary colic, cholangitis, perforated duodenal ulcer, and acute hepatitis; and the causes within the left upper quadrant (LUQ) include splenic rupture and irritable bowel syndrome in conjunction with splenic flexure syndrome.

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LUQ PAIN

Causes of left upper quadrant (LUQ) abdominal pain

LUQ Clinical features
Splenomegaly Pain or discomfort in LUQ, left shoulder pain, and/or early satiety
Splenic infarct Severe LUQ pain
Splenic abscess Associated with fever and LUQ tenderness
Splenic rupture May complain of LUQ, left chest wall, or left shoulder pain that is worse with inspiration
EPIGASTRIC PAIN

Causes of epigastric abdominal pain

Epigastric Clinical features
Acute myocardial infarction May be associated with shortness of breath and exertional symptoms
Acute pancreatitis Acute-onset, persistent upper abdominal pain radiating to the back
Chronic pancreatitis Epigastric pain radiating to the back
Peptic ulcer disease Epigastric pain or discomfort is the most prominent symptom
Gastroesophageal reflux disease Associated with heartburn, regurgitation, and dysphagia
Gastritis/gastropathy Abdominal discomfort/pain, heartburn, nausea, vomiting, and hematemesis
Functional dyspepsia The presence of one or more of the following: postprandial fullness, early satiation, epigastric pain, or burning
Gastroparesis Nausea, vomiting, abdominal pain, early satiety, postprandial fullness, and bloating
Picmonic
Acute Abdomen DDx Midepigatrium

Midepigastric pain can be due to pancreatitis, aortic dissection, peptic ulcer disease, and myocardial infarction. Causes within the lower quadrants include ovarian torsion, ectopic pregnancy, pyelonephritis, renal calculi and acute salpingitis. Appendicitis is most commonly associated with right lower quadrant (RLQ) pain; and causes within the left lower quadrant (LLQ) include sigmoid volvulus and sigmoid diverticulitis.

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LOWER ABDOMINAL PAIN

Causes of lower abdominal pain

Lower abdomen Localization Clinical features
Appendicitis Generally right lower quadrant Periumbilical pain initially that radiates to the right lower quadrant. Associated with anorexia, nausea, and vomiting
Diverticulitis Generally left lower quadrant; right lower quadrant more common in Asian patients The pain is usually constant and present for several days prior to presentation. May have associated nausea and vomiting
Nephrolithiasis Either Pain most common symptom varies from mild to severe. Generally, flank pain, but may have back or abdominal pain
Pyelonephritis Either Associated with dysuria, frequency, urgency, hematuria, fever, chills, flank pain, and costovertebral angle tenderness
Acute urinary retention Suprapubic Present with lower abdominal pain and discomfort; inability to urinate
Cystitis Suprapubic Associated with dysuria, frequency, urgency, and hematuria
Infectious colitis Either Diarrhea is the predominant symptom, but may also have associated abdominal pain, which may be severe
Picmonic
Acute Abdomen DDx Midepigatrium

Causes within the lower quadrants include ovarian torsion, ectopic pregnancy, pyelonephritis, renal calculi and acute salpingitis. Appendicitis is most commonly associated with right lower quadrant (RLQ) pain; and causes within the left lower quadrant (LLQ) include sigmoid volvulus and sigmoid diverticulitis.

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General Surgery: Gastrointestinal and Nutritional (PEARLS) (Prev Lesson)
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