2 - ABD Overview Flashcards
Study radiographs in sequence (ABCDEF):
Adequacy
Bones
Calcifications
Deformity / density
Extraluminal / peritoneal air
Foreign bodies / fractures
What film finding may suggest splenomegaly?
Gastric bubble displaced medially
Briefly describe CT:
Slices of the body available in axial, sagittal, or coronal views
Appears as if we are standing at the patients feet looking toward the head
Marking on the inside of the stomach
Rugae
Markings on small intestine
Plicae circulares / valvulae conniventes
Markings on the colon
Haustra
Air is expected in the stomach and colon - if it’s absent, must r/o:
Gastric outlet obstruction
If you have air in the stomach and small bowel but not the colon, must r/o:
Obstruction
Air is normally NOT seen in small intestine - if visible, must r/o:
Ileus or obstruction
Describe ileus
Impaired GI tract motility
Common after surgery (anesthesia) or irritation of the viscera
Presents c N/V, ABD pain, (-) bowel sounds
Air in stomach, small and large bowel (no flatus being passed)
Contrast does not move through to colon
Txt of ileus?
NPO, NG-tube, IV-fluid
AVOID NARCS
Prevention of ileus
Good OR technique
Minimize bowel manipulation during surgery
Replete electrolytes
What drug is given pre-op as a pro-motility drug to prevent or minimize narcotic-induced ileus?
Alvimopan (Mu blocker)
Obstruction presents with:
Pain Distention Present bowel sounds Fever Peritoneal signs
Air-fluid levels on upright films
What is open-loop obstruction?
Able to decompress (solid mass)
What is closed-loop obstruction?
Unable to decompress (volvlus / internal hernia)
How is obstruction treated?
NG tube decompression
Close observation
Fluid resuscitation
*higher incidence of surgery compared to ileus
Air seen under the right diaphragm on upright films - suspect:
Pneumoperitoneum
Air seen under left diaphragm on upright films - suspect:
Pneumoperitoneum OR possibly just a stomach bubble
Name some intraabdominal organs that can have either pathologic or benign calcifications:
Gall bladder
Kidney
Ureters
Arteries
Before giving any kind of contrast, you wanna order what labs?
BUN/Creatinine to assess kidney function
What med do we hold for 48-72 hrs after administration of contrast?
Metformin
Describe barium contrast:
Thick, chalky
Coats the walls of hollow organs well
Describe Gastrografin:
Thinner, not as caustic if extravasated
Used in suspected perforation
BAD IF ASPIRATED
Describe the upper GI tract studies
X-rays
Barium swallow (evaluate esophagus)
UGI - esophagus, stomach, duodenum
UGI with small bowel follow-through (UGI plus add’l timed radiograph to assess small bowel)
A barium enema is used to asses:
The lower GI tract (bowel)
ACBE - requires prep
BE - requires no prep, used to r/o obstruction, can be therapeutic
US best for:
Fluid-filled and semi-solid structures
Good for detecting free air / fluid in the abdomen
US poor for:
Air-filled structures
What are the three main areas to divide the abdomen into?
- GI tract (mouth to anus)
- Biliary (liver, gall bladder, pancreas)
- Genito-Urinary-Kidney -> urethra
General ROS q’s:
Fever
Appetite changes
Malaise
Trauma
GI ROS Q’s:
N/V/D
Hematochezia / melena
Prior colonoscopy or EGD
Biliary ROS Q’s:
Jaundice
Hepatitis
Gall stones
Pancreatitis
GU ROS Q’s
Hernia LMP OCP’s Gravida/parity STI’s BPH Testicular pain UTI
Chest ROS Q’s
Cough
COPD
URI
Patient moving vs lying still - differentials:
Lying still - peritonitis
Moving/restless - obstructive
Name the four general abdominal appearances:
Scaphoid
Flat
Rounded
Protuberant
Cullen’s Sign and Grey’s Turner’s Sign - suggestive of:
Acute pancreatitis
What is peristalsis:
Segmental contraction and relaxation of the muscles within the GI tract
ABD percussion - how do solid organs and fluid sound?
Lower tones
ABD percussion - how does free air sound?
Hypertympanic
Tenderness to percussion may suggest:
Peritonitis (follow-up with a heel tap to evaluate for rebound tenderness)
ABD palpation - pain out of proportion in older CAD patient suggests:
Bowel ischemia - suspect mesenteric ischemia
Most ABD complaint patients will get which labs:
CBC CMP HCG Amylase/lipase UA
(If surgical - PT/INR, aPTT)
*if critical, ABG
Return criteria for patients with home disposition:
Fever, increased N/V, intractable pain
If surgery is likely:
Order consult
NPO
Start maintenance fluids
Interventions for patients admitted for observation:
Pain control NG tube Maintenance fluids (mIVF) Labs (repeat) Films (repeat) Vitals (repeat)
Examples of emergent (do immediately or they die) surgical candidates:
Blunt trauma
Penetrating trauma
Ruptured AAA
Aortic transection
Examples of urgent (within 24hrs) surgical candidates
Appendicitis
Ectopic pregnancy
Incarcerated hernia
3 way abd:
Flat
Upright
CXR
Transverse view is AKA:
Axial view (MC view on CT)
Why shouldn’t we see air in the small bowel?
Peristalsis is constant, emulsifying the air
CVA tenderness - high index of suspicion for:
Pyelonephritis
ADC-VAN-DISMEL
Admit (what unit)
Diagnosis (and comorbities)
Condition (stable, guarded, grave)
Vitals (how often to take, usually q4hrs on regular floor)
Activity (what they can do, fall risk)
Nursing orders (I and O, weights, etc)
Diet (NPO, DM, etc)
IVF
Studies (tests)
Meds
Allergies
Labs
Statistically….
9 out of 10 injections are in vein.
