Acute Abdominal Pain

An Introduction for 3rd year medical students

Peter Clarke, M.D.

Check out these six patients with acute abdominal pain! They have a spectrum of conditions you are likely to encounter. I’ll be putting you in the “hot seat” with similar cases!

Case 1: 25 year old male with sudden onset of right lower quadrant pain, fever, and chills

What is your differential diagnosis?

Which test would be best - ultrasound, CT, or MRI?

Can you point out the inflamed mesentery?

Do you see any lymph nodes?

25 year old male with sudden onset of right lower quadrant pain

Can you point out the appendix?

…the base of the cecum?

Describe the findings.

25 year old male with sudden onset of right lower quadrant pain

Case 2: 56 year old alcoholic with abdominal pain, nausea, and vomiting

What is your differential diagnosis?

Which is the best test, plain film, ultrasound, or MRI, and why?

Can you identify the pancreatic duct?

Can you identify the pancreas?

Do you see the inflamed fat?

56 year old alcoholic with abdominal pain, nausea, and vomiting

Case 3: 40 year old woman with acute onset of flank pain and hematuria

What are the advantages of CT over intravenous pyelography (IVP)?

Can you identify the renal pelves?

Was this study done with or without IV contrast? Why?

40 year old woman with acute onset of flank pain and hematuria

Can you point out the ureters?

Can you account for the difference in the fat between the two sides?

40 year old woman with acute onset of flank pain and hematuria

Do you see the cause of the patient’s flank pain?

40 year old woman with acute onset of flank pain and hematuria

Case 4: 73 year old male with left lower quadrant pain and fever

Differential diagnosis?

Advantages of CT vs. barium enema?

Can you identify the sigmoid colon?

Do you see a diverticulum?

Can you point out the inflamed fat?

73 year old male with left lower quadrant pain and fever

Is all the gas you see intraluminal?

Case 5: 45 year old cabdriver with catastrophic abdominal pain and diaphoresis. History of chronic antacid use. What study would you do next?

What type of contrast would you use? …why?

Do you see the leak?

Where is it?

45 year old cabdriver with catastrophic abdominal pain

Gastrohepatic ligament

Free air!

45 year old cabdriver with catastrophic abdominal pain

Case 6: 79 year old retired hypertensive bricklayer suddenly collapses. He complains of back pain. His blood pressure is 100/60, pulse 130. What is your differential diagnosis?

Do you see the aorta? What is the aorta’s normal caliber

Point out the cause of the pain!

79 year old retired hypertensive bricklayer suddenly collapses

Where is the hematoma?

Do you see a normal-calibered aorta?

Aorta < 3 cm.

Perinephric space 79 year old retired hypertensive bricklayer suddenly collapses

(A higher slice)