Mr. J is a previously healthy 63-year-old man with severe abdominal pain for 48 hours. The pain is periumbilical with severe crampy exacerbations that last for several minutes and then subside. He notes loud intestinal noises (borborygmi) during the periods of increased pain. The pain is associated with nausea and vomiting. He denies diarrhea. He reports decreased appetite with no oral intake in the last 48 hours. He denies having this pain previously.
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 point for Mr. J’s abdominal pain is its periumbilical location. A variety of diseases present with pain in this location, including AAA, appendicitis (early), bowel ischemia, bowel obstruction, diabetic ketoacidosis, gastroenteritis, IBS, and IBD (Figure 3-1). The second useful pivotal point to consider is the time course of Mr. J’s abdominal pain (Table 3-1). This allows us to further limit the differential diagnosis to those diseases causing acute periumbilical pain. Typically, IBS and IBD do not cause acute pain. Furthermore, diabetic ketoacidosis is unlikely (unless this is his presentation of diabetes). Gastroenteritis is also unlikely given the absence of diarrhea and the severity of the pain. Finally, Mr. J’s severe crampy abdominal pain suggests some type of visceral obstruction. The syndromes associated with pain of this quality include ureteral obstruction secondary to kidney stones, biliary obstruction, or intestinal obstruction (large or small bowel). The associated nausea and vomiting can be seen with any of those diseases. However, the combination of the location of the pain and the loud intestinal sounds that accompany the pain makes bowel obstruction the leading hypothesis. It will also be important to determine whether he has unexplained hypotension or abdominal distention during his exam. Table 3-11 lists the differential diagnoses for Mr. J.
Table 3-11.Diagnostic hypotheses for Mr. J. ||Download (.pdf) Table 3-11. Diagnostic hypotheses for Mr. J.
|Diagnostic Hypothesis ||Demographics, Risk Factors, Symptoms and Signs ||Important Tests |
|Leading Hypothesis |
|Bowel obstruction || |
Inability to pass stool or flatus
Prior abdominal surgery or altered bowel habits
Abdominal distention, hyperactive bowel sounds (with tinkling) or hypoactive bowel sounds
|Abdominal radiographs, CT scan |
|Active Alternatives—Must Not Miss |
|AAA || |
Smoking history, male sex, family history of AAA
Pulsatile abdominal mass
Decreased lower extremity pulses
Abdominal CT scan
Bedside emergency ultrasonography
|Appendicitis ||Migration of pain from periumbilical region to right lower quadrant || |
|Bowel ischemia: Acute mesenteric ischemia || |
Atrial fibrillation, valvular heart disease, heart failure, hypercoagulable state
Abrupt onset pain
Pain out of proportion to exam
|CT angiography |
|Bowel ischemia: Ischemic colitis ||Age > 60, vascular disease, hypotension (due to MI, sepsis), hematochezia, diarrhea ||Colonoscopy |