Tell me diffrencials of abdominal pain
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Differentials of Abdominal Pain
Abdominal pain is one of the most common ED presentations. The differential is vast - ranging from benign (IBS) to immediately life-threatening (ruptured AAA). The most useful framework is anatomic location, combined with time course, peritoneal signs, hemodynamic status, and special populations.
Framework for Narrowing the Differential
| Pivotal Feature | What It Suggests |
|---|---|
| Acute first episode, severe | AAA, mesenteric ischemia, perforated viscus, ectopic pregnancy |
| Recurrent acute episodes | Biliary colic, renal colic, IBD, intermittent bowel obstruction |
| Chronic / subacute | IBS, peptic ulcer disease, IBD, malignancy |
| Peritoneal signs (rebound, rigidity, guarding) | Peritonitis, perforated viscus, pancreatitis, PID |
| Unexplained hypotension | Ruptured AAA, ruptured ectopic pregnancy, sepsis, bowel infarction |
| Abdominal distention | Bowel obstruction, free air, ascites, hemorrhage |
By Location
Right Upper Quadrant (RUQ)
- Biliary colic, cholecystitis, cholangitis
- Hepatitis (viral, alcoholic, ischemic), hepatic abscess
- Peptic ulcer disease / perforated ulcer
- Pancreatitis
- Hepatomegaly due to congestive heart failure
- Retrocecal appendicitis
- Myocardial ischemia / infarction (inferior wall)
- Right lower lobe (RLL) pneumonia, pleurisy
- Fitz-Hugh-Curtis syndrome (perihepatitis from PID)
- Renal calculi, pyelonephritis
Left Upper Quadrant (LUQ)
- Gastritis, GERD
- Pancreatitis
- Splenic pathology (splenomegaly, rupture, infarct, abscess)
- Myocardial ischemia / pericarditis / myocarditis
- Left lower lobe (LLL) pneumonia, pleural effusion
- Herpes zoster
- Aortic dissection
Right Lower Quadrant (RLQ)
- Appendicitis (most common surgical cause)
- Meckel's diverticulum
- Cecal diverticulitis
- Ectopic pregnancy, ovarian cyst, ovarian torsion
- Pelvic inflammatory disease (PID), tubo-ovarian abscess
- Endometriosis, mittelschmerz
- Ureteral calculi
- Mesenteric adenitis
- Psoas abscess
- Incarcerated / strangulated inguinal hernia
- Urinary tract infection (UTI)
- Regional enteritis (Crohn's disease)
Left Lower Quadrant (LLQ)
- Sigmoid diverticulitis (most common cause in adults >40)
- Aortic aneurysm (leaking/ruptured)
- Ectopic pregnancy, ovarian torsion, ovarian cyst
- PID, tubo-ovarian abscess, endometriosis
- Ureteral calculi
- Psoas abscess
- Incarcerated / strangulated hernia
- UTI
Epigastric / Central Upper
- Peptic ulcer disease (gastric or duodenal)
- GERD / esophagitis
- Pancreatitis (radiates to back)
- Aortic dissection / AAA
- Myocardial infarction (referred)
- Gastroenteritis
Periumbilical
- Early appendicitis (visceral pain before migration to RLQ)
- Small bowel obstruction
- Mesenteric ischemia / thrombosis
- Gastroenteritis
- Early AAA
Hypogastric / Suprapubic
- Cystitis, urinary retention
- PID, endometritis
- Uterine pathology (fibroids, adenomyosis)
- Ectopic pregnancy
- Prostatitis
Diffuse Abdominal Pain
- Peritonitis (any cause)
- Pancreatitis
- Mesenteric ischemia / thrombosis
- Bowel obstruction / perforation
- Dissecting or ruptured AAA
- Gastroenteritis
- IBD (Crohn's, ulcerative colitis)
- IBS
- Sickle cell crisis
- Diabetic ketoacidosis
- Addisonian crisis
- Early appendicitis
Referred Pain Patterns
- Shoulder tip pain - diaphragmatic irritation (ruptured spleen, hemoperitoneum, subphrenic abscess)
- Back pain - pancreatitis, aortic aneurysm, renal colic
- Epigastric pain - inferior MI (referred via T6-T9)
- Scapular pain - biliary colic
Extra-Abdominal Causes (Must Not Miss)
| System | Cause |
|---|---|
| Cardiac | Inferior/posterior MI, pericarditis |
| Pulmonary | Lower lobe pneumonia, pulmonary embolism, pleuritis |
| Metabolic | DKA, Addisonian crisis, hypercalcemia, porphyria |
| Toxicologic | Heavy metal poisoning (lead), black widow spider envenomation |
| Neurologic | Herpes zoster (before rash), radiculopathy (T7-T12) |
| Hematologic | Sickle cell crisis |
Life-Threatening Diagnoses to Never Miss
These require immediate action:
- Ruptured / leaking AAA - pulsatile mass, tearing back pain, shock
- Ruptured ectopic pregnancy - amenorrhea + LLQ/RLQ pain + shock
- Acute mesenteric ischemia - pain out of proportion to exam, atrial fibrillation history
- Bowel perforation - peritoneal signs, free air on imaging
- Bowel infarction / strangulated hernia - obstruction + fever + peritoneal signs
- Inferior MI - epigastric pain, EKG changes
- Aortic dissection - tearing pain radiating to back, pulse differential
High-Risk Populations
- Elderly (>60) - higher rates of AAA, mesenteric ischemia, volvulus; often atypical presentations even with appendicitis
- Pregnant women - ruptured ectopic pregnancy (emergent), appendicitis (displaced anatomy), abruption
- Immunocompromised - subtle presentations, unreliable WBC, broader infections to consider (CMV colitis, atypical organisms)
- Post-bariatric surgery - internal hernia, anastomotic breakdown, bleeding
- Prior abdominal surgery - adhesion-related small bowel obstruction is the leading cause
Sources: Rosen's Emergency Medicine, 9e, Ch. 23 | Symptom to Diagnosis: An Evidence-Based Guide, 4e, Ch. 3 | Textbook of Family Medicine, 9e, Table 38-1 | Yamada's Textbook of Gastroenterology, 7e
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