Differentials

Constipation

History
Exam
1st investigation
Other investigations

poor diet and fluid intake; hx of cerebral palsy, developmental delay, or spinal cord problems; psychological factors (e.g., depression, abuse, ADHD, autism, oppositional disorder), weaning, toilet training, start of schooling or other causes of stress may be present; vague abdominal pain, painful defecation (infants may extend their legs and squeeze anal and buttock muscles to prevent stooling; toddlers often rise up on their toes, shift back and forth, and stiffen their legs and buttocks), faecal incontinence; medication with known constipating agents (e.g., iron supplements); obesity, low birth weight

examination findings may be minimal (mild abdominal tenderness, stool in rectum); abdominal distension in severe cases or in small children; faecal mass palpable on abdominal or rectal examination; absence of peritonitis (guarding or rebound tenderness); sacral dimples or pits and/or tags/tufts indicative of spinal cord abnormality (i.e., spina bifida); anal fissure, haemorrhoids (rare in children; may be mistaken for skin tags from Crohn's disease); imperforate anus or anal stenosis; evidence of depression, abuse, autism, ADHD, or oppositional disorder

  • abdominal x-ray:

    stool visible throughout colon

    More
  • CT scan abdomen:

    stool throughout colon; absence of other aetiologies of abdominal pain

Acute appendicitis

History
Exam
1st investigation
Other investigations

hx of sharp or stabbing periumbilical pain that migrates to the RLQ; anorexia, fever, vomiting, and/or diarrhoea may be present; occurs in all age groups but is rare in infants

patient lies still, tries not to move (especially in severe cases with significant peritoneal irritation); positive McBurney's sign (RLQ pain and tenderness to palpation at a point two-thirds along a line from the umbilicus to the anterior superior iliac spine); positive Rovsing's sign (pain in the RLQ in response to left-sided palpation, suggesting peritoneal irritation); positive psoas sign (pain in the RLQ when child placed on left side and right hip gently hyperextended, suggesting irritation to the psoas fascia and muscle); positive obturator sign (RLQ pain on internal rotation of the flexed right thigh); rectal tenderness and/or palpable abscess in RLQ

  • FBC:

    normal or elevated WBC

    More
  • urinalysis:

    normal

    More
  • urine pregnancy test:

    negative

    More
  • abdominal ultrasound:

    dilated appendix, free fluid; appendicolith may be present

    More
  • CT scan abdomen and pelvis:

    dilated appendix, free fluid, mesenteric stranding, or appendicolith; abscess or phlegmon consistent with perforated appendicitis

    More
  • MRI scan abdomen and pelvis:

    dilated appendix; hyperintensity of the luminal contents of the appendix, periappendiceal tissue and thickened wall

    More

Gastroenteritis

History
Exam
1st investigation
Other investigations

vague abdominal pain with nausea and vomiting; diarrhoea with or without mucus in stool; recent travel or contact with sick individual(s) or ingestion of suspected food and drink; >10 days suggests parasitic or non-infectious cause; fever, chills, myalgia, rhinorrhoea, upper respiratory symptoms

diffuse abdominal pain without evidence of peritonitis (no guarding or rebound tenderness); abdominal distension; hyperactive bowel sounds; mucus in stool (bacterial or parasitic); signs of volume depletion (tachycardia, hypotension, dry mucous membranes, poor capillary refill, sunken fontanelle in infants); low-grade fever, lethargy and/or irritability, reduced response to noxious stimuli, abnormal temperature (elevated or low)

  • serum electrolytes:

    normal or low sodium and potassium

  • stool microscopy and culture:

    faecal leukocytes; ova or parasites; culture positive for infectious agent in bacterial gastroenteritis

    More
  • urea and creatinine:

    normal; may have evidence of renal failure in patients with haemolytic uraemic syndrome

  • urine dipstick:

    may detect presence of albumin or blood in haemolytic uraemic syndrome

  • FBC:

    variable

    More
  • blood culture:

    may be positive for infectious agent in presence of sepsis

    More
  • endoscopy with biopsy:

    variable

    More

Urinary tract infection

History
Exam
1st investigation
Other investigations

neonates and infants: fever, vomiting, lethargy, irritability, and poor feeding; older children: dysuria, urinary frequency and urgency, back pain if pyelonephritis

variable; fever >39°C (>102.2°F); suprapubic and/or costovertebral angle tenderness; irritability; foul-smelling urine; gross haematuria

  • urine dipstick:

    positive leukocyte esterase and/or positive nitrite

    More
  • urine microscopy:

    >4 WBC per high-power field or any bacteria

    More
  • urine culture:

    suprapubic aspirate: >1000 colony-forming units (CFU)/mL; catheter: >10,000 CFU/mL; clean-catch midstream: >100,000 CFU/mL

    More
  • renal ultrasound:

    abnormalities may be present such as dilatation of the renal pelvis or ureters, or distension of thick-walled bladder; renal abscess: area of radiolucency to the renal parenchyma with local hypoperfusion on colour Doppler; perinephric abscess: hypoechoic fluid

    More
  • voiding cystourethrogram (VCUG):

    if vesicoureteral reflux is present: contrast seen ascending out of the bladder into the upper urinary tract

    More

Abdominal trauma (blunt or penetrating)

History
Exam
1st investigation
Other investigations

hx of trauma; abdominal pain may be out of proportion to examination findings; may have multiple complaints; hx may suggest child abuse or non-accidental trauma (e.g., inconsistent or changing history)

abdominal tenderness; skin marks reflecting mechanism of injury (e.g., seatbelt mark); referred left shoulder pain (due to splenic injury); blood at the urethral meatus, or haematuria (indicate urinary tract or kidney injury); signs of non-accidental trauma may be present (e.g., cigarette burns, subdural haemorrhages in an infant/young toddler)

  • FBC:

    may be normal or show decreased haematocrit and haemoglobin

    More
  • abdominal CT scan with intravenous contrast:

    variable

    More
  • chest x-ray:

    may be normal or show compatible thoracic injury (e.g., pulmonary contusion, pneumothorax); free air under diaphragm (suggests perforation)

  • abdominal ultrasound:

    variable; may show free fluid in abdominal cavity

    More
  • full skeletal x-rays:

    variable

    More

Cholelithiasis/cholecystitis

History
Exam
1st investigation
Other investigations

recurrent, episodic RUQ pain, may radiate to the back and is classically colicky in nature; often occurs after eating, particularly fatty foods; nausea, vomiting, and anorexia may be present; persistent pain and fever may signify acute cholecystitis; referred pain to right shoulder can occur; presence of risk factors (e.g., sickle cell disease, cystic fibrosis)

right subcostal region tenderness; positive Murphy's sign (during palpation, deep inspiration causes pain to suddenly become worse and produces inspiratory arrest); palpable distended, tender gallbladder; fever suggests acute cholecystitis; jaundice rare

  • RUQ ultrasound:

    gall stones; thickened gallbladder wall (>4 mm); pericholecystic fluid; may also see ultrasonographic Murphy's sign

    More
  • LFTs:

    may see elevated alk phos, bilirubin and aminotransferase

    More
  • FBC:

    normal WBC (suggests cholelithiasis) or leukocytosis (suggests acute cholecystitis)

  • abdominal x-ray:

    opacities in RUQ consistent with gallstones

    More
  • hepatobiliary iminodiacetic acid (HIDA) scan:

    non-filling gallbladder

    More

Primary dysmenorrhoea

History
Exam
1st investigation
Other investigations

hx of recurrent crampy abdominal pain associated with menstruation

lower abdominal tenderness; normal pelvic examination

  • none:

    diagnosis is clinical

  • CT scan abdomen/pelvis:

    normal; however, useful to rule out other diagnoses

  • abdominal/pelvic ultrasound:

    normal; however, useful to rule out other diagnoses

Pneumonia

History
Exam
1st investigation
Other investigations

cough; purulent sputum production; upper respiratory tract symptoms (rhinorrhoea, sore throat, nasal congestion), shortness of breath, fever, and chills; splinting secondary to pain; vomiting, diarrhoea, anorexia

tachypnoea, cyanosis, decreased breath sounds, crackles/rales on auscultation, dullness on percussion; abdominal tenderness and distension without guarding or rebound

  • FBC:

    variable

    More
  • chest x-ray:

    infiltration, consolidation, effusion

  • sputum culture:

    growth of infecting organism

  • chest ultrasound:

    localised fluid collection

    More
  • CT scan chest with intravenous contrast:

    consolidation of lung parenchyma; extraparenchymal fluid with loculations suggests empyema

    More

Functional abdominal pain

History
Exam
1st investigation
Other investigations

hx may be acute, chronic, or cyclic (frequently girls ages 8-12 years), complaint of vague, persistent, central abdominal pain common, may be associated nausea and vomiting, particularly in chronic cases; FHx of functional disorders common (e.g., irritable bowel syndrome, anxiety, psychiatric disorders, and migraine); Rome IV criteria use symptoms for diagnosis[27]

periumbilical tenderness, abdomen is soft, non-distended, no guarding or rebound tenderness; examination of other systems normal

  • none:

    diagnosis is clinical after exclusion of possible organic causes

  • FBC:

    normal

  • ESR:

    normal

  • urinalysis:

    normal

  • stool microscopy:

    normal

Uncommon

Intussusception

History
Exam
1st investigation
Other investigations

usually infant between 3 months and 12 months of age presenting with colicky abdominal pain, flexing of the legs, fever, lethargy, and vomiting; Henoch-Schonlein purpura (HSP) may be initiating factor in an older child (usually <11 years of age); vague abdominal complaints; severe, cramp-like abdominal pain; child may be inconsolable

may see gross or occult blood that may be mixed with mucus and have 'red currant jelly ' appearance, abdominal tenderness, and palpable abdominal mass; signs of HSP may be present in older child (rash of palpable purpura, blood in the stools)

  • barium enema:

    filling defect or cupping in the head of contrast as it advances to the site of the intussusception

    More
  • CT scan abdomen and pelvis:

    target lesion: intraluminal soft-tissue density mass with an eccentrically placed fatty area; reniform mass: high attenuation peripherally and lower attenuation centrally; sausage-shaped mass: alternating areas of low and high attenuation representing closely spaced bowel wall, mesenteric fat and/or intestinal fluid and gas

    More
  • abdominal ultrasound:

    tubular mass in longitudinal view; target lesion in transverse view

    More
  • FBC:

    may show elevated WBC (suggests intestinal ischaemia)

Meckel's diverticulum

History
Exam
1st investigation
Other investigations

typically aged <2 years; may present with abdominal pain (may be intermittent or mimic acute appendicitis), and/or painless passage of bright red blood per rectum (haematochezia); often asymptomatic

dark red, maroon, or 'red currant jelly ' stools; abdominal tenderness with guarding and rebound (may suggest diverticulitis); palpable abdominal mass (may suggest intussusception)

  • abdominal ultrasound:

    tubular mass in longitudinal views and a doughnut or target appearance in transverse views suggests intussusception

    More
  • technetium-99m pertechnetate scan:

    positive

    More
  • CT scan abdomen and pelvis:

    may show intussusception, Meckel's diverticulitis, and/or dilated bowel consistent with bowel obstruction

    More

Mesenteric adenitis

History
Exam
1st investigation
Other investigations

diffuse abdominal pain; hx of recent or current upper respiratory tract infection

fever, abdominal tenderness not localised to RLQ, rhinorrhoea, hyperaemic pharynx or oropharynx (pharyngitis), and/or associated extramesenteric lymphadenopathy (usually cervical)

  • abdominal ultrasound:

    enlarged mesenteric lymph nodes

    More
  • CT scan abdomen and pelvis:

    enlarged mesenteric lymph nodes

    More

Hirschsprung's disease

History
Exam
1st investigation
Other investigations

males affected more commonly, mainly presents in early infancy (prior to 6 months); failure to pass meconium in first 36 hours of life strongly suggestive

abdominal distension, fullness in LLQ; palpable faecal mass on abdomen examination; absence of peritonitis (no guarding or rebound tenderness); small rectum and absence of stool on rectal examination; dysmorphic features of Down's syndrome may be present

  • abdominal x-ray:

    stool visible throughout colon, decreased air in rectum; air-fluid levels may be present

    More
  • contrast barium enema:

    proximal dilation with narrowing of the distal colon

    More
  • rectal biopsy:

    absence of ganglion cells and the presence of an excess of non-myelinated nerves; presence of increased acetylcholinesterase

    More
  • anorectal manometry:

    absent reflex

    More

Ulcerative colitis

History
Exam
1st investigation
Other investigations

positive FHx, bloody diarrhoea, cramping abdominal pain, anorexia, weight loss, fever, rash

evidence of weight loss, pallor, abdominal tenderness, abdominal mass, iritis (inflamed irritated eyes), arthritis, sacroiliitis, erythema nodosum, pyoderma gangrenosum

  • FBC:

    leukocytosis, anaemia, thrombocytosis

    More
  • colonoscopy with biopsy:

    continuous uniform rectal involvement, loss of vascular marking, diffuse erythema, mucosal granularity and friability, mucosal oedema ulcers, fistulas (rarely seen), normal terminal ileum (or mild backwash ileitis in pancolitis)

    More
  • ESR:

    elevated

    More
  • CRP:

    elevated

    More
  • plain abdominal x-rays:

    dilated loops with air-fluid level secondary to ileus; free air is consistent with perforation; in toxic megacolon, the transverse colon is dilated to 6 cm or more in diameter

    More
  • CT scan abdomen:

    thickened inflamed bowel mucosa, thumbprinting, intestinal dilatation or evidence of stricture; inflamed mesentery; intra-abdominal abscesses

    More
  • serologic markers: perinuclear antineutrophil cytoplasmic antibody (pANCA) and anti-Saccharomyces cerevisiae antibody (ASCA):

    positive pANCA

    More

Crohn's disease

History
Exam
1st investigation
Other investigations

crampy abdominal pain, intermittent diarrhoea, bloody diarrhoea if colitis a feature (blood less common in Crohn's disease (CD) than in ulcerative colitis), weight loss, fatigue, FHx of inflammatory bowel disease

aphthous ulcers, evidence of weight loss, pallor, abdominal tenderness, abdominal mass, perianal fistula, perirectal abscess, anal fissure, perianal skin tags; extraintestinal manifestations including iritis, arthritis, sacroiliitis, erythema nodosum, pyoderma gangrenosum

  • FBC:

    leukocytosis, anaemia, thrombocytosis

    More
  • CRP:

    elevated

    More
  • ESR:

    elevated

    More
  • colonoscopy with biopsy:

    may demonstrate inflammation, friability, ulcer formation, and oedema

    More
  • plain abdominal x-rays:

    small bowel or colonic dilatation; calcification; intra-abdominal abscesses

    More
  • upper GI series with small bowel follow-through:

    oedema and ulceration of the mucosa with luminal narrowing and strictures

    More
  • CT scan abdomen and pelvis:

    skip lesions, bowel wall thickening, surrounding inflammation, abscess, fistulas

    More
  • serological markers: perinuclear antineutrophil cytoplasmic antibody (pANCA) and anti-Saccharomyces cerevisiae antibody (ASCA):

    positive ASCA

    More

Small bowel obstruction

History
Exam
1st investigation
Other investigations

intolerant of feeding, with nausea and/or vomiting; abdominal pain may or may not be a feature; hx of previous abdominal surgery; hx of cystic fibrosis may be present

limited abdominal distension (with proximal obstructions in the duodenum or early jejunum); abdominal tenderness may or may not be present; rebound tenderness and guarding may occur if perforation, ischaemia, and peritonitis; hyperactive bowel sounds (early finding), hypoactive or absent bowel sounds (late finding); incarcerated femoral, obturator, umbilical or ventral hernia may be present

  • abdominal x-ray:

    dilated small bowel loops, air-fluid levels throughout abdomen

    More
  • abdominal ultrasound:

    may demonstrate focal area causing obstruction

    More
  • upper GI contrast study:

    dilated small intestine; may demonstrate a transition zone of obstruction

    More
  • lower GI contrast study:

    dilated small intestine; may demonstrate a transition zone of obstruction

    More
  • CT scan abdomen:

    dilated small intestine; may demonstrate a transition zone of obstruction, mass, tumour, abscess

    More

Volvulus

History
Exam
1st investigation
Other investigations

infant age group; hx of bilious vomiting; pain usually manifests as notable transition to an inconsolable state

often diffuse abdominal distension and tenderness; faint or no bowel sounds, rigid abdomen, guarding, rebound tenderness, fever, or haematochezia

  • abdominal x-ray:

    partial or complete obstruction; dilated bowel loops; air-fluid levels; abdominal free air with perforation

    More
  • FBC:

    elevated WBC (suggests intestinal ischaemia)

  • upper GI contrast study:

    bird beak sign of stricture at the site of the volvulus

    More
  • CT scan abdomen:

    bowel obstruction with whirl pattern of mesentery

    More

Large bowel obstruction

History
Exam
1st investigation
Other investigations

hx of risk factors: mental illness, inflammatory bowel disease, diabetes, poor diet, previous colorectal resection, laxative abuse, megacolon, or previous abdominal surgery; change in bowel habit with partial or complete obstruction, or change in calibre of stool; colicky abdominal pain becoming more constant and worse with movement, coughing or deep breathing as bowel approaches perforation; intolerant of feeding, with nausea or vomiting

tympanic, distended abdomen; hyperactive bowel sounds that become absent in advanced stages; abdominal rebound, guarding, and/or rigidity if perforation or close to perforation; empty rectum; incarcerated femoral, obturator, umbilical, or ventral hernia may be present

  • abdominal x-ray:

    gaseous distension of large bowel; volvulus suggested by kidney-bean-shape bowel loop

    More
  • abdominal ultrasound:

    may demonstrate focal area causing obstruction (e.g., intussusception)

  • lower GI contrast study:

    may indicate site of obstruction

    More
  • CT scan abdomen and pelvis:

    gaseous distension of large bowel; may demonstrate a transition zone of obstruction

    More
  • flexible/rigid sigmoidoscopy:

    flood of stool and mucus upon passing and decompressing apex of volvulus

    More

Necrotising enterocolitis

History
Exam
1st investigation
Other investigations

premature neonate weighing less than 1500 g; feeding intolerance, apnoea, lethargy, bloody stools

abdominal distension, tenderness, abdominal wall erythema, haematochezia, bradycardia

  • FBC:

    leukocytosis or leukopenia, anaemia, thrombocytopenia

    More
  • blood culture:

    negative

    More
  • serum electrolyte panel:

    hyponatraemia

  • abdominal x-ray:

    dilated loops of bowel, pneumatosis intestinalis, portal venous gas, free air, fixed loop of bowel, lack of normal intestinal gas pattern

    More
  • abdominal ultrasound:

    fluid collections, ascites

    More

Peptic ulcer disease

History
Exam
1st investigation
Other investigations

FHx of peptic ulcer disease; weight loss, vomiting, anorexia, and intermittent epigastric pain, usually related to eating meals; pain often nocturnal and usually relieved by antacids; melaena and/or haematemesis if blood vessel perforated

unremarkable or epigastric tenderness; melaena may be present on rectal examination or occult bleeding on stool haemoccult test

  • FBC:

    normal or leukocytosis; anaemia present if sustained blood loss

  • erect chest x-ray:

    usually normal

    More
  • upper GI series with water-soluble contrast:

    mucosal defect(s) consistent with ulcer or free intraperitoneal contrast consistent with perforation

    More
  • upper GI endoscopy:

    mucosal inflammation, ulceration, and haemorrhage

    More
  • Helicobacter pylori breath test or stool antigen test:

    positive result if H pylori present

    More

Viral hepatitis

History
Exam
1st investigation
Other investigations

multiple sexual partners, sexual intercourse with infected individuals (hepatitis B and/or C), travel to developing countries, pregnant (hepatitis E); early disease: malaise, muscle and joint aches, fever, nausea, vomiting, diarrhoea, headache, anorexia, dark urine, pale stool, abdominal pain; late disease: weight loss, easy bruising and bleeding tendencies

jaundice; early disease: tender hepatosplenomegaly, lymphadenopathy; late disease: generalised wasting, cachexia, gynaecomastia, ascites, altered sensorium, asterixis, or decreased deep tendon reflexes, caput medusa, ascites, hepatosplenomegaly, congestion secondary to right heart failure

  • serum LFTs:

    high direct bilirubin, AST, ALT, alk phos and gamma-GT

    More
  • serum IgM anti-HAV:

    positive if acute hepatitis A infection

  • serum hepatitis B surface antigen (HBsAg):

    positive if hepatitis B infection

    More
  • serum hepatitis B core antigen (HBcAg):

    positive if hepatitis B infection

    More
  • serum hepatitis B e antigen (HBeAg):

    positive if hepatitis B infection

    More
  • serum HCV RNA:

    positive if hepatitis C infection

    More
  • serum total (IgM and IgG) anti-HDV antibodies:

    positive if hepatitis D infection

    More
  • serum anti-HEV IgM antibodies:

    positive if acute hepatitis E infection

  • FBC:

    low or normal platelet count

    More
  • coagulation profile (PT, INR):

    May be elevated or normal

    More

Biliary dyskinesia

History
Exam
1st investigation
Other investigations

hx of previous negative work-up for cholelithiasis common; recurrent RUQ pain; nausea and vomiting; symptoms may or may not be associated with eating

may be equivocal; RUQ tenderness

  • LFTs:

    normal AST, ALT, alk phos, and bilirubin

  • RUQ ultrasound:

    normal

    More
  • hepatobiliary iminodiacetic acid (HIDA) scan:

    decreased (<35%) gallbladder ejection fraction

    More

Acute pancreatitis

History
Exam
1st investigation
Other investigations

nausea, vomiting, epigastric pain radiating to back; acute-onset abdominal pain

epigastric or upper abdominal tenderness; tachycardia and hypotension in severe cases; discoloration around the umbilicus (positive Cullen's sign) or flanks (positive Grey-Turner's sign) in cases of haemorrhagic pancreatitis; small children may demonstrate increased irritability and abdominal distension only

  • amylase:

    3 times upper limit of normal range

    More
  • lipase:

    can be elevated if amylase normal

    More
  • bilirubin:

    normal or elevated

    More
  • abdominal ultrasound:

    may appear normal early in disease course; enlargement of the pancreas; peripancreatic oedema; dilated pancreatic duct; may show underlying biliary disease

    More
  • CT scan abdomen with intravenous contrast:

    peripancreatic inflammation (fat stranding); may show gallstones

    More

Splenic infarction/cysts

History
Exam
1st investigation
Other investigations

varied; may be hx of trauma; cysts either asymptomatic or dull, left-sided abdominal pain; infarction typically causes fever as well as pain, but occasionally asymptomatic; left-sided shoulder and/or chest pain; presence of risk factors for splenic infarction (sickle cell disease, high altitude)

may be vague LUQ tenderness

  • Doppler ultrasound:

    infarction or cyst on spleen

    More
  • CT scan abdomen with intravenous contrast:

    infarction or cyst on spleen

    More

Nephrolithiasis

History
Exam
1st investigation
Other investigations

FHx of nephrolithiasis and/or gout; intermittent, severe, colicky flank and/or abdominal pain; nausea and vomiting; gross or microscopic haematuria; urinary frequency/urgency; atypical presentation common in younger children

ipsilateral costovertebral angle and flank tenderness; tachycardia and hypotension in pain-controlled patient may suggest concurrent urosepsis

  • ultrasound of the urinary tract:

    calcification seen within urinary tract; possible dilated proximal ureter and hydronephrosis

    More
  • urinalysis:

    may be normal or dipstick-positive for leukocytes, nitrites, blood; microscopic analysis positive for WBCs, RBCs, or bacteria

    More
  • abdominal x-ray:

    radio-opaque stones

    More
  • non-contrast CT scan abdomen and pelvis:

    calcification seen in renal collecting system or ureter; possible dilated proximal ureter and hydronephrosis

    More

Testicular torsion

History
Exam
1st investigation
Other investigations

acute-onset testicular pain; nausea, and vomiting; hx of recurrent episodes suggests repeated episodes of testicular torsion followed by spontaneous detorsion; hx of trauma may be present

tender, oedematous testicle; affected testicle may appear higher than unaffected testicle with horizontal lie; associated scrotal erythema and oedema; absent cremasteric reflex; usually no pain relief with elevation of the scrotum

  • grey-scale ultrasound:

    presence of fluid and the whirlpool sign (the swirling appearance of the spermatic cord from torsion as the ultrasound probe scans downward perpendicular to the spermatic cord)

    More
  • power Doppler ultrasound:

    absent or decreased blood flow in the affected testicle; decreased flow velocity in the intratesticular arteries, increased resistive indices in the intratesticular arteries

    More

Ovarian torsion

History
Exam
1st investigation
Other investigations

acute onset of one-sided lower abdominal or pelvic pain; nausea and vomiting common; hx of frequent, similar episodes; fever rare

tender pelvic mass (adnexal); in patients old enough to undergo pelvic examination, cervical motion tenderness may be elicited; typically no vaginal discharge, but may be some mild to moderate vaginal bleeding

  • pelvic ultrasound:

    solid appearance of the ovary, unilateral ovarian enlargement, ovarian peripheral cystic structures, marked stromal oedema, fluid in the pouch of Douglas

  • colour Doppler:

    reduced or absent intraovarian blood flow

    More
  • CT scan abdomen and pelvis:

    enlarged, oedematous ovary with or without vascular enhancement; free fluid in pelvis

    More

Ruptured ovarian cyst

History
Exam
1st investigation
Other investigations

rupture usually spontaneous, can follow history of trauma or sexual intercourse; mild chronic lower abdominal discomfort may suddenly intensify

adnexal tenderness; adnexal size unremarkable due to collapsed cyst; peritonism may be present in lower abdomen and pelvis

  • pelvic ultrasound:

    complex mass appearance; fluid in the pouch of Douglas

    More

    Pelvic inflammatory disease

    History
    Exam
    1st investigation
    Other investigations

    sexually active; multiple partners; hx may be suggestive of sexual abuse (particularly if young child); pain worse with sexual intercourse; dull, aching lower abdominal pain with or without dysuria; vaginal discharge, low-grade fever

    temperature >38.3°C (101°F); cervical motion tenderness, adnexal or uterine tenderness, vaginal or cervical mucopurulent discharge

    • wet mount of vaginal secretions:

      polymorphonuclear leukocytes (PMNs) seen

      More
    • pelvic ultrasound:

      normal or may demonstrate endometritis, hydrosalpinx, pyosalpinx, tubo-ovarian abscess

      More
    • genetic probe or culture of vaginal secretions for Neisseria gonorrhoeae and Chlamydia trachomatis:

      positive result indicates presence of organisms

      More
    • HIV serology:

      positive or negative

      More
    • hepatitis studies:

      positive or negative

      More
    • rapid plasma reagin (RPR):

      positive or negative

      More
    • laparoscopy:

      normal or may demonstrate endometritis, hydrosalpinx, pyosalpinx, tubo-ovarian abscess

      More

    Pregnancy complications

    History
    Exam
    1st investigation
    Other investigations

    hx of previous ectopic pregnancy or miscarriage, fallopian tube or pelvic surgery, pelvic inflammatory disease (PID); lower abdominal pain, amenorrhoea, and vaginal bleeding

    minimal abdominal tenderness and/or vaginal bleeding; pelvic examination may reveal a mass, eliciting cervical motion tenderness if haemoperitoneum is present; tubal rupture can cause haemodynamic instability

    • urine pregnancy test:

      positive

      More
    • quantitative beta-hCG:

      positive

      More
    • pelvic ultrasound:

      demonstrates free fluid in the pelvis and/or a periovarian mass

      More
    • transvaginal ultrasound:

      presence or absence of intrauterine pregnancy

      More
    • type and screen:

      variable

      More

    Empyema

    History
    Exam
    1st investigation
    Other investigations

    recent pneumonia, fever, cough, chest pain; malaise, anorexia, weight loss, or fatigue may occur; presence of risk factors (immunocompromise, comorbidities predisposing to the development of pneumonia, pre-existing lung disease, iatrogenic interventions in the pleural space, male sex)

    febrile, toxic patient, dullness on percussion, absence of breath sounds over affected area; abdominal tenderness and distension without guarding or rebound

    • FBC:

      elevated WBC count

    • chest x-ray:

      blunting of costophrenic angle or effusion on affected side, possible consolidation, pleurally based 'D' shape in empyema

      More
    • thoracentesis:

      frank pus in empyema, serous or cloudy in complicated parapneumonic effusions

      More
    • blood culture:

      positive for specific pathogens

      More
    • chest ultrasound:

      localised fluid collection

      More
    • CT scan chest with intravenous contrast:

      consolidation of lung parenchyma; extraparenchymal fluid with loculations suggests empyema

      More

    Use of this content is subject to our disclaimer