Basic Principles Upper Abdominal Pain

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Basic Principles
Principal signs and symptoms: Pain, fever, vomiting, circulatory depression, hematologic changes, muscular guarding (rigidity), occasional retention of stool.
The differential diagnosis is reviewed in Table bellow, where the possible diagnoses arelisted in order of their frequency in the general hospital setting.

Differential diagnosis of upper abdominal pain
Diagnosis Sonographic signs
Common  
Acute cholecystitis Thickened, three-layered wall; possible gallbladder hydrops
Biliary colic Stone echo, acoustic shadow, obstructed duct
Less common  
Acute pancreatitis Pancreatic enlargement; hypoechoic, hazy internal echo
  pattern, circumscribed hypoechoic lesions
Impaired gastric emptying Greatly distended, fluid-filled stomach with internal echoes
Myocardial infarction Echocardiography : circumscribed abnormality of wall motion
Pulmonary embolism Peripheral embolism : wedge-shaped hypoechoic area
  (thoracic sonography)
Renal colic Obstructed, anechoic pyelocalyceal system; stone echo with
  twinkling artifact
Hernia Hernia sac, gap in peritoneum, possible thickening of bowel
  wall
Rare  
Perforated gastric or Detectable free air, possible wall thickening at the ulcer site
duodenal ulcer  
Perforated gallbladder Wedge-shaped parenchymal lesion, absence of flow by CDS
Splenic infarction Usually wedge-shaped, hypoechoic parenchymal lesion
Renal vein thrombosis Kidneys initially enlarged, then small; dilated veins
Subphrenic abscess Nonhomogeneous mass with ill-defined margins located
  between the diaphragm and the liver or spleen
Cholangitis Hypoechoic wall thickness, hypoechoic intraductal mass
Intraorgan bleeding Hypoechoic mass, usually with associated organ enlargement

Conditions that cannot be diagnosed with ultrasound
Common: Gastroenteritis, pleurisy Less common: Diabetic coma with pseudoperitonitis, uremia, thyrotoxicosis, Meckel diverticulum, Boerhave syndrome Rare: Hemolytic crisis, hepatic porphyria (e.g., acute intermittent porphyria), Addisonian
crisis, intoxication (lead, arsenic, mushroom, thallium), type I hypertriglyceridemia..

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