Differential Diagnosis of Acute Abdominal Pain

Type of Pain Notes

RUQ Pain
Acute cholangitis: Right upper quadrant pain, fever, jaundice.
Bilirubin generally >4 mg/dL; AST and ALT levels may exceed
1000 U/L.
Pneumonia: Cough and shortness of breath, chest or upper
abdominal pain.
Acute viral hepatitis: Jaundice; AST and ALT levels generally
>1000 U/L.
Acute alcoholic hepatitis: Recent alcohol intake. Fever,
leukocytosis; AST level usually 2-3_ greater than ALT level;
bilirubin level generally >4 mg/dL.
Cholecystitis :Epigastrium and RUQ pain that radiates to the right
shoulder. Mildly elevated bilirubin and aminotransferase levels.
Ultrasound shows thickened gallbladder, pericholecystic fluid.

Mid-epigastric/Periumbilical Pain
Acute pancreatitis: Mid-epigastric pain radiating to the back,
nausea, vomiting, elevated amylase and lipase. Usually secondary
to gallstones or alcohol. Pain from penetrating peptic ulcer may
also present similarly.
Inferior myocardial infarction: Chest/mid-epigastric pain,
diaphoresis, shortness of breath, elevated cardiac enzymes,
acutely abnormal electrocardiogram.
Perforated peptic ulcer: Sudden RUQ or mid-epigastric pain,
possible hematemesis and/or melena. Normal bilirubin,
aminotransferase levels. Amylase and lipase may be high; free air
under the diaphragm.
Mesenteric ischemia: Postprandial abdominal pain, weight loss,
and abdominal bruit. Pain out of proportion to tenderness on
palpation. Anion-gap metabolic acidosis may be present.
Abdominal plain films may show the classic thumbprinting sign.
Small bowel obstruction: Pain is colicky. Obstructive pattern is
seen on CT or abdominal series.
Aortic dissection/rupture: Elderly patient with vascular disease
and sudden onset with very severe pain that radiates to the back
and lower extremity.
Diabetic ketoacidosis: Blood glucose is always elevated, anion
gap present.

RLQ Pain
Acute appendicitis: Mid-epigastric pain radiating to RLQ.
Ultrasound and CT may confirm diagnosis.
Ectopic pregnancy: May be RLQ or LLQ. Abdominal pain,
nausea, fever, leukocytosis. Suspect in female with unilateral pain.
ovarian cyst/torsion
Pelvic inflammatory disease: May be RLQ or LLQ. Fever,
abdominal tenderness, uterine/adnexal tenderness, cervical
motion tenderness, cervical discharge.
Nephrolithiasis: Right or left flank pain that may radiate to the
groin; hematuria.
Pyelonephritis: Fever, dysuria, pain in the right or left flank that
may radiate to the lower quadrant. Urinalysis shows leukocytes
and leukocyte casts.

LLQ Pain
Acute diverticulitis: Pain usually in the LLQ but can be RLQ if
ascending colon is involved. CT scan can diagnose complicated
diverticular disease with abscess formation.
Toxic megacolon: Dilation of the transverse and descending
colon and systemic toxicity. Associated with inflammatory bowel
disease and infection (e.g., C. difficile).
Notes:ALT = alanine aminotransferase; AST = aspartate aminotransferase; LLQ = left lower
quadrant; RLQ = right lower quadrant; RUQ = right upper quadrant.