1. Differentials

2. Acute appendicitis Epigastric/periumbilical pain(RUQ) Pain, anorexia, nausea and vomiting, fever (pain or vomiting will come first before anorexia) Tenderness of Mc Burney’s point with muscle guarding and rebound tenderness (+) Rovsing’s/ Psoas / Obturator sign Mild leukocytosis

3. Appendiceal Rupture 65 y/o – highest rate of rupture Suspect if fever (39C) or WBC >18,000/mm3 Generalized peritonitis if the walling of process

4. Acute diverticulitis Occur more often after the age of 40 LLQ pain and tenderness Leukocytosis CT scan: Contrast angiography – Pericolic stranding – Thickened fat – Extravasation of the dye if with contrast

5. Acute Cholecystitis Secondary to gallstones in 95% of cases Biliary colic, RUQ tenderness, guarding Murphy’s sign Mild to moderate leukocytosis

6. Acute Pancreatitis 80-90% caused by gallstones or alcholism Severe epigastric pain radiating to the back Elevated serum anylase Cullen’s sign, Grey Turner sign Massive third spacing

7. Thyphoid Ulcer perforation headache, fever, and malaise for 2 weeks followed by a dull pain suddenly getting worse and spreading, moderate tenderness, and guarding 3 rd or 4 th week of typhoid fever Severe abdominal pain, tenderness, rigidity Can have association with intestinal obstruction and protracted fever

8. Complicated Diverticulitis With abscess, obstruction, diffuse peritonitis, free perforation, fistula formation More often localized than generalized peritonitis Prior history of diverticulosis/diverticulitis

9. Volvulus Air filled colon twists about its mesentery Sudden onset of acute pain in the left hemiabdomen with abdominal distention, obstipation Fever and leukocytosis Bowel obstruction, may progress to strangulation, gangrene and perforation

10. Mesenteric Ischemia Embolic source usually coming from the heart Should have a high index of suspicion Severe abdominal pain disproportionate to abdominal findings – Bowel infarction: distention, peritonitis, bloody stools Vomiting and diarrhea