abdominal pain according to macalide with dds
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I now have excellent visual and textual material to provide a comprehensive Macleod's-style answer. Note: Macleod's Clinical Examination is not in the library, but the content below draws from the closest equivalents - Symptom to Diagnosis (evidence-based clinical reasoning guide) and Rosen's Emergency Medicine - which cover the same clinical examination framework for abdominal pain.
Abdominal Pain - Differential Diagnosis and Signs
Note: Macleod's Clinical Examination is not available in our medical textbook library. The following content is drawn from Symptom to Diagnosis: An Evidence-Based Guide, 4th Ed. and Rosen's Emergency Medicine - both of which use the same structured clinical examination approach to abdominal pain differential diagnosis.
Types of Abdominal Pain
Understanding the type of pain guides the differential:
| Pain Type | Character | Common Causes |
|---|---|---|
| Visceral | Dull, crampy, poorly localized, midline | Hollow organ distension (bowel obstruction, early appendicitis) |
| Somatic/Parietal | Sharp, well-localized, worsened by movement | Peritoneal irritation (peritonitis, late appendicitis) |
| Referred | Distant from the source | Diaphragmatic irritation - shoulder tip; biliary/renal colic - back |
| Colicky | Waxes and wanes in waves | Hollow viscus obstruction (ureter, bile duct, small bowel, large bowel) |
Characteristics of Colicky Pain
Ureteral colic is the most severe and rapid-cycling; large intestinal colic is slower and lower in intensity.
Differential Diagnosis by Location
Epigastric / Central
- Myocardial infarction (referred)
- Peptic ulcer disease (PUD)
- Pancreatitis - pain radiates straight through to mid-back
- Biliary disease
- Gastritis / GERD
- Early appendicitis (visceral, pre-migration)
Right Upper Quadrant (RUQ)
- Biliary colic / Cholecystitis - postprandial or nocturnal, dark urine
- Hepatitis (acute)
- Hepatomegaly from congestive heart failure
- Hepatic abscess
- Perforated ulcer
- RLL (right lower lobe) pneumonia
- Retrocecal appendicitis
- Myocardial ischemia (referred)
Left Upper Quadrant (LUQ)
- Gastritis / GERD / Pancreatitis
- Splenic pathology - referred pain to left shoulder tip
- Myocardial ischemia, Pericarditis, Myocarditis
- LLL (left lower lobe) pneumonia / Pleural effusion
Right Lower Quadrant (RLQ)
- Appendicitis - pain migrates from periumbilical to RLQ (McBurney's point)
- Meckel's diverticulum
- Cecal diverticulitis
- Ectopic pregnancy, Ovarian cyst, Ovarian torsion, PID
- Ureteral calculi
- Psoas abscess
- Mesenteric adenitis
- Incarcerated / strangulated hernia
- Endometriosis
- Mittleschmerz
Left Lower Quadrant (LLQ)
- Sigmoid diverticulitis
- Ectopic pregnancy, Ovarian torsion, Ovarian cyst, PID
- Tubo-ovarian abscess
- Endometriosis
- Ureteral calculi
- Psoas abscess
- Incarcerated / strangulated hernia
- Aortic aneurysm (AAA)
- UTI
Diffuse Abdominal Pain
- Peritonitis (from any cause)
- Pancreatitis
- Sickle cell crisis
- Early appendicitis (before localization)
- Mesenteric thrombosis / ischemia
- Gastroenteritis
- Dissecting or ruptured AAA - life-threatening
- Intestinal obstruction
- Diabetes mellitus / DKA
- Inflammatory bowel disease (IBD)
- Irritable bowel syndrome (IBS)
Referred Pain Patterns
| Source | Site of Referred Pain |
|---|---|
| Biliary colic | Right shoulder / right scapula / mid-back |
| Acute pancreatitis | Mid-back (straight through) |
| Renal colic | Flank - loin - groin |
| Ruptured spleen | Left shoulder tip (Kehr's sign) |
| Perforated duodenal ulcer | Right shoulder (diaphragmatic irritation) |
| Uterine / rectal pain | Sacrum / perineum |
Differential Diagnosis by Time Course
| Acute (First Episode) | Acute (Recurrent) | Subacute / Chronic |
|---|---|---|
| AAA | Biliary disease | Chronic mesenteric ischemia |
| Acute mesenteric ischemia | Diverticulitis | IBD |
| Appendicitis | DKA | IBS |
| Ectopic pregnancy | Nephrolithiasis | Hepatitis |
| Ovarian torsion | Pancreatitis | PUD |
| Splenic rupture | PID | |
| Bowel obstruction | Bowel obstruction | |
| Gastroenteritis / Peritonitis | ||
| MI |
Clinical Signs on Examination
| Sign | Description | Condition Suggested |
|---|---|---|
| Rebound tenderness | Pain worse on release than on pressure | Peritoneal irritation / peritonitis |
| Guarding | Involuntary muscle rigidity | Peritonitis |
| Rigidity ("board-like abdomen") | Constant involuntary rigidity | Perforated viscus |
| Murphy's sign | Inspiratory arrest on deep palpation RUQ | Acute cholecystitis |
| Rovsing's sign | LLQ palpation causes RLQ pain | Appendicitis |
| Psoas sign | Pain on hip extension | Retrocecal appendicitis / psoas abscess |
| Obturator sign | Pain on internal rotation of hip | Pelvic appendicitis / pelvic pathology |
| Kehr's sign | Left shoulder pain on lying flat | Splenic injury / free intraperitoneal blood |
| Carnett's sign | Pain worsens with tensed abdominal muscles | Abdominal wall (not intraperitoneal) |
| Cullen's sign | Periumbilical bruising | Haemoperitoneum (pancreatitis, ectopic) |
| Grey Turner's sign | Flank bruising | Retroperitoneal haemorrhage (pancreatitis) |
High-Risk Populations (Red Flags)
From Rosen's Emergency Medicine, certain groups require a lower threshold for serious diagnosis:
- Age > 60 years
- Pregnant women
- Previous abdominal surgery (especially bariatric)
- Immunocompromised patients (even low-dose steroids)
- Patients with known vascular disease
- Known abdominal/pelvic malignancy
Key Clinical Clues - "Must Not Miss" Diagnoses
| Clue | Diagnosis to Consider |
|---|---|
| Pain out of proportion to examination | Mesenteric ischemia |
| Syncope with abdominal pain | Ruptured AAA, ruptured ectopic pregnancy |
| Epigastric pain radiating to mid-back + vomiting | Acute pancreatitis |
| Periumbilical pain migrating to RLQ | Appendicitis |
| Left shoulder tip pain | Splenic pathology / diaphragmatic irritation |
| Postprandial pain + dark urine + fever | Biliary disease / cholecystitis |
| Colicky pain + inability to pass stool or flatus | Bowel obstruction |
Sources:
- Symptom to Diagnosis: An Evidence-Based Guide, 4th Ed. - Chapter 3 (Abdominal Pain)
- Rosen's Emergency Medicine, 9th Ed. - Chapter 23 (Abdominal Pain)
DDs according to 9 quardant of abdomin
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I now have all the foundational material needed. I have the 9-region diagram, the anatomical framework from Gray's Anatomy and S. Das, and the differential diagnosis content. Let me now compile the complete, well-structured answer.
Differential Diagnosis of Abdominal Pain by 9 Regions
The 9 Regions of the Abdomen
The abdomen is divided into 9 regions by 2 vertical lines (midclavicular/midinguinal) and 2 horizontal lines (subcostal/transpyloric plane above, intertubercular/transtubercular plane below):
| Region No. | Name | Referred pain from |
|---|---|---|
| 1 | Right Hypochondrium | Foregut (liver, gallbladder) |
| 2 | Epigastrium | Foregut (stomach, duodenum, pancreas) |
| 3 | Left Hypochondrium | Foregut (spleen, stomach, pancreas tail) |
| 4 | Right Lumbar (Right Flank) | Midgut (ascending colon, right kidney) |
| 5 | Umbilical | Midgut (small bowel, AAA) |
| 6 | Left Lumbar (Left Flank) | Midgut (descending colon, left kidney) |
| 7 | Right Iliac (Right Groin/Iliac Fossa) | Hindgut (appendix, caecum, right ureter) |
| 8 | Hypogastrium (Pubic/Suprapubic) | Hindgut (bladder, uterus, sigmoid colon) |
| 9 | Left Iliac (Left Groin/Iliac Fossa) | Hindgut (sigmoid colon, left ureter) |
Key rule (Gray's Anatomy): Foregut pain - epigastric; Midgut pain - umbilical; Hindgut pain - pubic/hypogastric.
Region-by-Region Differential Diagnosis
1. Right Hypochondrium (RHC)
Structures here: Liver (right lobe), gallbladder, hepatic flexure of colon, right kidney (upper pole), right suprarenal gland, subphrenic space.
| Cause | Key Features |
|---|---|
| Acute cholecystitis | Sudden onset RHC pain, Murphy's sign +ve, fever, vomiting, fatty food intolerance |
| Biliary colic | Colicky pain radiating to right shoulder/scapula, no fever |
| Hepatitis (acute) | RHC tenderness, jaundice, dark urine, pale stools, hepatomegaly |
| Liver abscess | Swinging fever, tender enlarged liver, raised R hemidiaphragm |
| Hepatomegaly (CCF, malignancy) | Smooth (CCF) vs. irregular (malignancy) |
| Subphrenic abscess | Follows perforation/surgery; tachycardia, tachypnea, R shoulder pain |
| Carcinoma hepatic flexure | Mass, anaemia, blood in stool, barium enema filling defect |
| Right renal colic | Loin-to-groin radiation, haematuria, writhing in pain |
| Right renal mass (hydronephrosis, carcinoma) | Ballottable, bimanually palpable, reniform |
| Right suprarenal tumour | Adrenal mass - Conn's/Cushing's/phaeochromocytoma features |
| Empyema of gallbladder | Tender palpable gallbladder, high fever, systemically unwell |
| Mucocele of gallbladder | Non-tender mobile cystic RHC mass, no fever |
| Carcinoma of gallbladder | Irregular hard RHC mass, jaundice, weight loss |
| Right basal pneumonia | Pleuritic chest pain, cough, fever; referred to abdomen |
| Right-sided pleural effusion | Dullness at base; referred abdominal pain |
| Parietal: Cold abscess (TB rib caries), lipoma, sebaceous cyst |
2. Epigastrium
Structures here: Stomach (body/pylorus), duodenum (1st/2nd part), pancreas (head/body), lower oesophagus, liver (left lobe), aorta, coeliac plexus.
| Cause | Key Features |
|---|---|
| Peptic ulcer disease | Burning epigastric pain, nocturnal, relieved by food/antacids; NSAID/H. pylori history |
| Acute gastritis | Epigastric pain, nausea, relation to alcohol/NSAIDs |
| Acute pancreatitis | Severe epigastric pain radiating to mid-back, nausea/vomiting, raised lipase/amylase |
| Perforated peptic ulcer | Sudden severe "board-like" rigidity, free air under diaphragm |
| Gastric carcinoma | Weight loss, dysphagia, early satiety, mass, anaemia |
| GERD / Oesophagitis | Heartburn, worse on lying, regurgitation |
| Myocardial infarction | Epigastric pain (inferior MI), diaphoresis, ECG changes |
| Aortic aneurysm (AAA) | Pulsatile epigastric mass, severe pain with rupture + shock |
| Acute mesenteric ischaemia | Pain out of proportion to examination |
| Subphrenic abscess | Post-operative/perforation; swinging fever, tachycardia |
| Carcinoma of pancreas (head) | Painless progressive jaundice, weight loss, Courvoisier's sign +ve |
| Acute pancreatitis complications (pseudocyst) | Epigastric mass, raised amylase, behind stomach on barium meal |
| Hiatus hernia | Heartburn, dysphagia; CXR shows gas shadow in mediastinum |
| Parietal: Epigastric hernia, cold abscess |
3. Left Hypochondrium (LHC)
Structures here: Spleen, stomach (fundus/body), splenic flexure of colon, tail of pancreas, left kidney (upper pole), left suprarenal gland.
| Cause | Key Features |
|---|---|
| Splenomegaly | Various - see below; notched medial border, moves diagonally toward RIF |
| - Malaria, visceral leishmaniasis | Tropical, massive splenomegaly |
| - Portal hypertension | Ascites, varices, hepatomegaly |
| - Haematological (lymphoma, CML, myelofibrosis) | Massive splenomegaly, blood film changes |
| - Haemolytic anaemia | Splenomegaly, anaemia, jaundice |
| Splenic rupture | Trauma; Kehr's sign (left shoulder pain), peritonism, haemorrhagic shock |
| Gastric pathology | Gastritis, PUD, carcinoma - features as in epigastric region |
| Splenic infarct | Sudden LHC pain, friction rub |
| Carcinoma splenic flexure | Mass, altered bowel habit, blood in stool, barium enema defect |
| Left renal colic / mass | As for right side, mirrored |
| Left suprarenal tumour | Adrenal features |
| LLL pneumonia / pleuritis | Referred LHC pain; chest signs |
| Pancreatitis (tail) / pancreatic pseudocyst | LHC fullness, raised amylase |
| Parietal: Cold abscess (rib caries), soft tissue tumours |
4. Right Lumbar (Right Flank)
Structures here: Ascending colon, right kidney (lower pole), right ureter (upper), right psoas muscle, quadratus lumborum.
| Cause | Key Features |
|---|---|
| Right ureteric colic | Loin-to-groin colicky pain, haematuria, nausea; stones on CT KUB |
| Right hydronephrosis | Loin ache, enlarged ballottable kidney |
| Right renal carcinoma | Classic triad: haematuria + loin pain + palpable mass |
| Carcinoma ascending colon | Mass, iron-deficiency anaemia, occult blood in stool |
| Crohn's disease | RLF pain + diarrhoea + weight loss + perianal disease |
| Retroperitoneal mass | Fixed, does not move with respiration; lymphoma, sarcoma |
| Psoas abscess | Fluctuant, pointing in the groin; hip held in flexion; Pott's disease |
| Acute pyelonephritis | Loin pain + fever + dysuria + renal angle tenderness (CVA tenderness) |
| Perinephric abscess | Fixed loin swelling, scoliosis towards the side, spiking fever |
| Parietal: Cold abscess (vertebral TB/lumbar rib) |
5. Umbilical Region
Structures here: Transverse colon, small intestine (jejunum/ileum), aorta (bifurcation), mesenteric lymph nodes, umbilicus.
| Cause | Key Features |
|---|---|
| Small bowel obstruction | Colicky central pain, vomiting, distension, constipation, tinkling bowel sounds |
| Mesenteric adenitis | Children, central pain + fever, tender mesenteric nodes |
| Crohn's disease | Central crampy pain, diarrhoea, weight loss, RIF mass |
| Gastroenteritis | Colicky pain, diarrhoea, vomiting, fever |
| Abdominal aortic aneurysm (AAA) | Expansile pulsatile central mass; rupture - sudden pain + collapse |
| Carcinoma transverse colon | Mass, obstruction signs, blood in stool |
| Umbilical hernia | Reducible umbilical swelling, cough impulse +ve |
| Para-umbilical hernia | Similar to above, just above/below umbilicus |
| Mesenteric cyst | Soft, fluctuant, mobile - moves perpendicular to mesenteric attachment |
| Early appendicitis | Pain begins central (visceral) before migrating to RIF |
| Intestinal TB | Ulcerative or hypertrophic; central pain, doughy abdomen, ascites |
| Lymphoma (mesenteric) | Central mass, "rubber" feel nodes, systemic B symptoms |
| Pancreatitis / pancreatic pseudocyst | Upper central mass following pancreatitis |
| Signs: Cullen's sign (periumbilical bruising) - haemoperitoneum (ruptured ectopic, pancreatitis) |
6. Left Lumbar (Left Flank)
Structures here: Descending colon, left kidney, left ureter (upper), left psoas muscle.
| Cause | Key Features |
|---|---|
| Left ureteric colic | Loin-to-groin pain, haematuria |
| Left hydronephrosis / renal mass | Ballottable mass, loin pain |
| Carcinoma descending colon | Obstruction features (colicky pain + distension), blood PR, barium enema defect |
| Diverticulitis | LLQ/left flank pain, fever, altered bowel habit, elderly |
| Psoas abscess | As for right side |
| Left pyelonephritis / perinephric abscess | Loin pain + fever, renal angle tenderness |
| Parietal: Cold abscess |
7. Right Iliac Fossa (Right Iliac Region / Right Groin)
Structures here: Caecum, appendix, terminal ileum, right ovary/tube (females), right ureter (lower), right iliacus/psoas, inguinal canal, right iliac vessels.
| Cause | Key Features |
|---|---|
| Acute appendicitis | Pain migrates from umbilicus to McBurney's point; Rovsing's sign, guarding, rebound; most common surgical emergency |
| Carcinoma caecum | Mass, iron-deficiency anaemia, occult blood, right-sided obstruction |
| Crohn's disease (ileo-caecal) | Chronic RIF pain + diarrhoea, perianal disease, RIF mass |
| Intestinal TB (ileo-caecal) | Hypertrophic - mass + obstruction; Ulcerative - pain + diarrhoea; doughy abdomen |
| Mesenteric adenitis | Children; self-limiting, no migration of pain; tender mobile nodes |
| Meckel's diverticulitis | Clinically indistinguishable from appendicitis; Tc-99m scan |
| Ovarian cyst (right) | Right-sided; smooth, mobile, non-tender unless complicated; pelvic USS |
| Ovarian torsion (right) | Sudden severe right pelvic/RIF pain, vomiting; USS Doppler |
| Ectopic pregnancy (right) | Missed period + RIF pain + bleeding; b-hCG +ve; haemoperitoneum |
| Pelvic inflammatory disease (PID) | Bilateral but often RIF; cervical excitation +ve, vaginal discharge, fever |
| Ureteric colic (right lower ureter) | Radiation to groin/testis/labia, haematuria |
| Right inguinal hernia | Groin swelling, cough impulse; strangulation - pain + irreducibility |
| Right femoral hernia | Below and lateral to pubic tubercle; high strangulation risk |
| Psoas abscess | Fluctuant, tracks to groin; hip flexion deformity |
| Iliopsoas bursitis / iliacus haematoma | Trauma history, hip flexion pain |
| Carcinoid tumour (ileum) | Flushing, diarrhoea, carcinoid syndrome |
| Lymphoma (ileo-caecal) | Mass, B symptoms |
| Parietal: Lipoma, spigelian hernia, cold abscess |
8. Hypogastrium (Pubic / Suprapubic Region)
Structures here: Bladder, sigmoid colon (lower), uterus/cervix, ovaries (partially), rectum, iliac vessels.
| Cause | Key Features |
|---|---|
| Acute urinary retention | Lower abdominal fullness, inability to void, palpable bladder; males (BPH) / females |
| Cystitis (UTI) | Suprapubic pain, frequency, dysuria, haematuria |
| Pelvic inflammatory disease (PID) | Bilateral lower abdominal pain, cervical excitation, vaginal discharge, fever |
| Ectopic pregnancy | Bilateral or midline pelvic pain, haemoperitoneum; b-hCG +ve |
| Fibroid uterus | Irregular firm midline mass arising from pelvis, menorrhagia |
| Ovarian cyst (bilateral/large) | Smooth, cystic, mobile pelvic mass |
| Carcinoma bladder | Haematuria + suprapubic pain; cystoscopy diagnostic |
| Diverticulitis (sigmoid) | LLQ/hypogastric pain, fever, altered bowel habit |
| Carcinoma sigmoid / rectum | Rectal bleeding, tenesmus, altered bowel habit, palpable on PR |
| Uterine/cervical carcinoma | Post-menopausal bleeding, hard irregular uterus |
| Endometriosis | Cyclical pelvic pain, dysmenorrhoea, dyspareunia |
| Ovarian torsion / ruptured ovarian cyst | Sudden pelvic pain, guarding, vomiting |
| Intestinal obstruction (sigmoid volvulus) | Gross distension + obstipation; bent inner-tube on plain AXR |
| Parietal: Diastasis recti, lipoma, lower midline hernia |
9. Left Iliac Fossa (Left Iliac Region / Left Groin)
Structures here: Sigmoid colon, left ovary/tube (females), left ureter (lower), left iliacus/psoas, left inguinal canal.
| Cause | Key Features |
|---|---|
| Sigmoid diverticulitis | Most common; "left-sided appendicitis", LIF pain + fever + altered bowel habit; elderly |
| Carcinoma sigmoid colon | Rectal bleeding, tenesmus, mucus, obstruction, palpable mass |
| Left ovarian cyst / torsion | As for right side |
| Left ectopic pregnancy | As for right side |
| PID | Bilateral, as above |
| Ulcerative colitis | LIF + lower abdominal cramps, bloody diarrhoea, urgency |
| Constipation | Hard faecal masses (mobile, indentable, transient) in LIF |
| Left ureteric colic (lower ureter) | Loin-to-groin colicky pain, haematuria |
| Left inguinal / femoral hernia | As for right side |
| Psoas abscess (left) | As for right side |
| Lymphoma / enlarged iliac nodes | Firm, rubbery, non-tender nodes |
| Endometriosis | Cyclical pain |
| Parietal: Lipoma, spigelian hernia |
Summary Diagram
| Right | Central | Left | |
|---|---|---|---|
| Upper | Right Hypochondrium (liver, GB, RHC colon) | Epigastrium (stomach, duodenum, pancreas) | Left Hypochondrium (spleen, gastric fundus) |
| Middle | Right Lumbar/Flank (ascending colon, R kidney) | Umbilical (small bowel, transverse colon, aorta) | Left Lumbar/Flank (descending colon, L kidney) |
| Lower | Right Iliac Fossa (appendix, caecum, R ovary) | Hypogastrium (bladder, uterus, sigmoid) | Left Iliac Fossa (sigmoid colon, L ovary) |
Sources:
- S. Das - A Manual on Clinical Surgery, 13th Ed. - Chapter on Examination of Abdomen and Differential Diagnosis of Abdominal Swellings
- Gray's Anatomy for Students - Nine Regions and Referred Pain Patterns
- Bailey & Love's Short Practice of Surgery, 28th Ed. - Chapter on Abdominal Examination
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