Abdominal Pain in Upper Quadrants

Abdominal Pain in Upper Quadrants: Excerpt from In a Page: Signs and Symptoms

Upper abdominal pain is a common presenting symptom. A complete differential diagnosis should be developed based on the organs in the upper abdomen in addition to the associated history and physical examination. Gallbladder disease and gastritis are two of the most common causes of upper abdominal pain. Be sure to consider nonabdominal etiologies in the differential of abdominal pain (e.g., pulmonary embolus, pneumonia, myocardial ischemia)

Differential Diagnosis

Right upper quadrant pain

• Cholecystitis
• Fatty liver or NASH
• Congested liver (e.g., secondary to heart failure)
• Cholangitis
• Hepatitis
• Gastritis or pancreatitis (see below)
• Pneumonia
• Fitz-Hugh-Curtis syndrome (gonococcal perihepatitis secondary to pelvic inflammatory disease)

Epigastric pain
• Gastritis
• PUD
• Pancreatitis
• Gastroenteritis
• Intestinal obstruction
• Myocardial infarction
• Aortic aneurysm
  Left upper quadrant pain
• Peptic ulcer disease
• Gastritis
• GERD
• Splenic infarct
• Pulmonary embolism
• Pancreatitis
• Acute splenomegaly (e.g., mononucleosis)
• Left lower lobe pneumonia
  Nonfocal pain
• Herpes
• Sickle cell crisis
• Irritable bowel
• Mesenteric ischemia
• Peritonitis
• Pleurisy
• Uremia
• Lead poisoning
• Porphyria
• Toxin ingestion

Workup and Diagnosis

• History of associated symptoms; relation of pain to eating; anorexia; alcohol use; and location, quality, and intensity of pain
• Physical exam should focus on heart, lungs, abdomen, and back examinations
• Initial laboratory tests may include CBC with differential, electrolytes, urinalysis, BUN/creatinine, liver function tests, LDH, amylase/lipase, magnesium, and PT/PTT/INR
• Chest and abdominal X-rays
• Abdominal ultrasound and/or CT scan
• Hepatitis viral serology
• Percutaneous transhepatic cholangiography (PTCA) and/or ERCP
• Upper GI endoscopy (EGD) or upper GI series with barium swallow
• Cultures of blood, urine, and trachea/gastric aspirates
• Evaluation of possible cardiac and pulmonary etiologies may require ECG (pulmonary embolus may show S in I, Q in III, inverted T in III), cardiac isoenzymes, pleural tap, echocardiogram, and stress test

Treatment

• Rule out or treat serious causes of pain (e.g., bowel obstruction, cholangitis, MI, PE)
• Urgent surgical intervention may be indicated for aortic aneurysm, splenic infarct, perforated viscus, and intestinal obstruction or infarct
• Esophagitis, gastritis, PUD, and GERD are primarily treated with lifestyle changes (e.g., avoid causative foods or medications) and PPIs or H2 blockers
  –Rule out malignancies in older patients or those with suggestive histories
• Pancreatitis: Aggressive IV hydration for lost fluids and third spacing; antibiotics; nasogastric tube insertion if vomiting; bowel rest; and narcotics for pain
• Gastroenteritis: Rehydration, correct electrolytes
• Intestinal obstruction: Bowel rest, surgery
• Cardiac and pulmonary etiologies are treated per protocols (e.g., supplemental O₂, aspirin, β-blocker, nitrates for MI; O₂, heparin and/or thrombolytics for PE; O₂, appropriate antibiotics for pneumonia)

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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