Ms. R is a 50-year-old woman who comes to the office complaining of abdominal pain. The patient reports that she has been having “episodes” or “attacks” of abdominal pain over the last month, with about 3 “attacks” during this time. The last attack was 4 days previously. She reports that the attacks of pain are in the epigastrium, last up to 4 hours, and often awaken her at night. The pain is described as a severe cramping-like sensation that is very intense and steady for hours. Occasionally, the pain radiates to the right back. The pain is associated with emesis. She reports that the color of her urine and stool are normal. On physical exam, her vital signs are stable. She is afebrile. On HEENT exam, she is anicteric. Her lungs are clear, and cardiac exam is unremarkable. Abdominal exam is soft with only mild epigastric discomfort to deep palpation. Murphy sign (tenderness in the right upper quadrant [RUQ] with palpation during inspiration) is negative. Rectal exam reveals guaiac-negative stool.
At this point, what is the leading hypothesis, what are the active alternatives, and is there a must not miss diagnosis? Given this differential diagnosis, what tests should be ordered?
RANKING THE DIFFERENTIAL DIAGNOSIS
The first pivotal feature of Ms. R’s abdominal pain is its epigastric location. Common causes of epigastric pain include PUD, pancreatitis, and biliary colic (Figure 3-1). The second pivotal feature of Ms. R’s abdominal pain is its time course, with multiple acute episodes. Many diseases cause well-defined recurrent discrete episodes of abdominal pain (Table 3-1) but of these, only pancreatitis and biliary colic tend to occur in the epigastrium. PUD is a common cause of epigastric abdominal pain and obviously needs to be considered. However, the pain in PUD is typically more chronic than acute, and not typically discrete or so severe, making this a less likely possibility. Ms. R does not have other pivotal clues such as peritoneal findings, unexplained hypotension, or abdominal distention that could focus the differential. The final clinical clue is the severe crampy quality of the pain. Severe intense crampy abdominal pain (“colicky”) suggests obstruction of a hollow viscera, which can be caused by biliary, bowel, or ureteral obstruction (due to biliary stones, bowel obstruction, or nephrolithiasis, respectively). Taken together, the epigastric location, multiple discrete episodes, quality and intensity of the pain, make biliary colic the leading hypothesis. Table 3-8 lists the differential diagnosis.
Table 3-8.Diagnostic hypotheses for Ms. R. ||Download (.pdf) Table 3-8. Diagnostic hypotheses for Ms. R.
|Diagnostic Hypotheses ||Demographics, Risk Factors, Symptoms and Signs ||Important Tests |
|Leading Hypothesis |
|Biliary colic ||Episodic and crampy pain may radiate to back ||Ultrasonography |
|Active Alternatives—Most Common |
|Peptic ulcer disease || |
Helicobacter pylori infection
Pain relieved by eating or by antacids
H pylori, stool antigen assay...