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3. E Med & Surgery > 2 - Acute Abdomen > Flashcards

2 - Acute Abdomen Flashcards

1
Q

Pt presents w/ acute onset of constant pain followed by emesis onset ≤ 72 hrs. On exam pt has rigid abdomen, signs of shock (hypotension, tachycardia) and involuntary guarding.

Is this pt concerning for an acute abdomen?

A

Yes! Sx are all red flags

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2
Q

GB pain will radiate where?

A

Right shoulder/subscapula

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3
Q

Perforated duodenal ulcer pain will radiate where?

A

Shoulders

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4
Q

Ureteral obstruction pain in men will radiate where?

A

Testicles

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5
Q

Chest pain due to an MI will radiate where?

A

Epigastric, jaw, neck, UE

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6
Q

GYN or prostrate pain will radiate where?

A

Low back

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7
Q

What is the difference b/w visceral and parietal pain?

A

Visceral pain is DULL, aching, colicky & poorly localized.

Parietal pain is sharp, well localized

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8
Q

What hx question is important in pts that present with acute abd pain?

A

Prior abdominal surgery

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9
Q

What will a lactic acid test tell you?

A

Tissue ischemia/necrosis

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10
Q

A CT w/o contrast is imaging of choice for what?

A

Renal stones, obstruction

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11
Q

CT w/ IV contrast is imaging of choice for what?

A

Ischemic bowel, diverticulitis, peritonitis, AAA

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12
Q

CT w/ oral contrast is imaging of choice for what?

A

Really skinny adults, children, need for enhanced imaging

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13
Q

US is imaging of choice for what?

A

GB, free fluid, kidneys, ovaries, testicles

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14
Q

What is the general tx for pts w/ acute abdomens?

A

IV fluids, anti-emetics, analgesia (IV if surgery consult), anti-pyretic, NPO, +/- ABX

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15
Q

What conditions required URGENT surgical referral?

A
  • Obstruction, perforation, peritonitis, ischemic bowel, dissection
  • Rapid sx evolution (out of proportion pain, increased tenderness and rigidity)
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16
Q

What pt populations can presents atypically?

A

Elderly, diabetic, IMC

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17
Q

Clinical presentation of a GI perforation depends on what?

A

Organ affect and contents released

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18
Q

What are the causes of GI perf?

A
  • Spontaneous (cholecystitis, appendicitis)
  • Bowel obstruction
  • Trauma
  • Instrumentation
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19
Q

When will peritonitis occur?

A

After perforation

  • Will cause high fever, +/- sepsis/death, can be localized or generalized
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20
Q

Perforation is more common in what age groups?

A

> 50 yrs & < 10 yrs

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21
Q

The following are concerning for what?

Ill appearing
Motionless
\+ Rebound tenderness
Pain w/ light bumps
Diminished bowel sounds
Anorexia/low urine output
Inability to pass stool or gas
A

peritonitis

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22
Q

How does a pt w/ a spontaneous bacterial peritonitis present?

A
  • Ascites, liver cirrhosis, fever, AMS, abd pain
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23
Q

What is used to dx spontaneous bacterial peritonitis?

A

Paracentesis

NO exploratory laparotomy (increases mortality)

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24
Q

What is the med tx for spontaneous and secondary bacterial peritonitis?

A

ABX: Cefotaxime
Albumin (if renal failure develops)
D/C BB

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25
How does pt w/ secondary bacterial peritonitis present?
Possible perf (PUD, appendicitis) w/ ascites, fever, AMS, abd pain
26
What is used to dx secondary bacterial peritonitis?
Paracentesis | Exploratory laparotomy REQUIRED
27
Pt presents w/ severe constant RUQ pain > 6 hrs, N/V and increased pain after fatty food intake. ON exam pt w/ guarding, RUQ TTP, + Murphy's sign, tachycardia and no jaundice. What is your suspected dx?
Acute cholecystitis
28
Labs show: - Leukocytosis w/ bands - Elevated CRP - Normal Alk phos - Normal bili You decided to order a RUQ US to confirm your suspected. What is your suspected dx?
Acute cholecystitis
29
What does RUQ US show for pt w/ acute cholecystitis?
GB wall thickening Sonographic Murphy's sign Gallstones or sludge Pericholecystic fluid
30
What is the management for acute cholecystitis?
NPO & IV fluids Analgesia ABX: Ceftriaxone, cefuroxime Surgery consult
31
It pt elects for non-operative management of acute cholecystitis but does not improve within 1-2 days what is the next step?
Surgery
32
In unstable pts that present w/ cholecystitis, what procedure can be done to relieve pain until they are more stable for surgery?
Percutaneous drainage (performed under radiologic guidance)
33
What is acute choledocholithiasis?
Gallstones WITHIN the common bile duct (most common cause is secondary to passage of stones from GB to common bile duct vs. less commonly the formation of stones w/in the common bile duct)
34
Pt presents w/ colicky RUQ pain w/ radiation to epigastric and N/V. On exam you note RUQ/epigastric TTP and Courvoisier's sign (palpable GB). Labs show elevated bili, alk phos, transaminases and GTT. What do you suspect?
Acute choledocholithiasis
35
What is first line imaging for acute choledocholithiasis?
Transabdominal US (for presence of stones in the GB/CBD
36
What is the tx for HIGH risk pts w/ acute choledocholithiasis?
GI, Surgery consult => ERCP for removal of stones | Then Elective cholecystectomy
37
What is the tx for LOW risk pts w/ acute choledocholithiasis?
GI, Surgery consult => cholecystectomy
38
What are complications of choledocholithiasis?
Pancreatitis and acute cholangitis
39
What is an obstruction of the biliary ducts that leads to an ascending bacterial infections?
Cholangitis
40
What is the most common cause of acute cholangitis?
Choledocholithiasis
41
Acute cholangitis will often present w/ Charcot's triad. What sx does this include?
Fever/chills RUQ pain Jaundice
42
If pt with acute cholangitis presents with Charcot's triad + AMS and hypotension what is this called?
Reynold's pentad Charcot's Triad: - Fever/chills - RUQ pain - Jaundice
43
Labs for a pt w/ acute cholangitis will show - Elevated Alk phos, GGT, bilirubin, AST/ALT - Leukocytosis What other lab value is elevated?
Pancreatic enzymes
44
What imaging is performed on a pregnant pt w/ suspected cholangitis?
US is done first, then if ERCP needed, fetal shielding is used
45
Will a CT have high sensitivity for evaluating bile duct stones in a pt w/ suspected cholangitis?
No. Will show bile duct dilation and biliary stenosis, but low sensitivity for bile duct stone
46
Imaging for acute cholangitis is dependent on what?
Severity of illness - Transabdominal US - EUS - ERCP (dx and therapeutic) /MRCP - CT
47
What is the tx for pt w/ acute cholangitis?
``` Admit NPO surgery/GI consult ABX biliary drainage (ERCP) w/in 24 hrs ```
48
What empiric ABX therapy is given to pts w/ acute cholangitis?
Ceftriaxone + metronidazole
49
How is mild pancreatitis defined?
No organ failure or systemic complications
50
How is moderate pancreatitis defined?
Transient organ failure (resolved w/in 48 hrs)
51
How is severe pancreatitis defined?
Persistent organ failure 1+ organ
52
How will a pt w/ gallstone pancreatitis present?
Well localized pain w/ rapid onset
53
Pt presents with N/V and acute epigastric/RUQ pain that radiates to the back. Pain is relieved by leaning forward. What is your suspected dx?
Pancreatitis
54
On exam for pt w/ pancreatitis what sign's can be present?
Cullen's sign (umbilical bruising) | Grey-turner sign (flank bruising)
55
Labs for pt w/ pancreatitis will show what?
``` Elevated lipase (w/in 4-8 hrs) and amylase (w/in 6-12 hrs) 3x normal Increased CRP ```
56
What imaging for pancreatitis is not as sensitive in early disease but will show diffuse enlargement, necrosis, and stones?
CT w/ IV contrast
57
What imaging for pancreatitis is sensitive in early disease?
MRI
58
What will US for pancreatitis show?
Diffusely enlarged pancreas, +/- gallstones
59
What is the dx criteria for pancreatitis?
Must meet 2 of the following: 1. Acute onset of constant, severe epigastric pain radiation to the back 2. Elevation in serum lipase or amylase ≥ 3x normal 3. Characteristic findings of acute pancreatitis on imaging *IF 1 & 2 are met, NOT imaging is needed for dx, imaging helpful to r/o necrosis, etc.
60
What is the tx for pt w/ pancreatitis?
``` Admit (ICU common) NPO NG tube Foley catheter Serial labs (amylase and lytes) ```
61
What is the tx for gallstone pancreatitis?
GI consult => ERCP
62
What disease is due to a defect in gastric or duodenal mucosa and frequently associated w/ GERD?
PUD
63
What are the 2 biggest RF for PUD?
NSAID use | H. Pylori infection
64
PUD may presents atypically in what population?
Elderly
65
Pt presents w/ epigastric pain w/ radiation to thoracic region, heartburn, early satiety, SOB/cough when lying flat and hematemesis/melena. What is the suspected dx?
PUD
66
If pt w/ PUD presents with hematochezia what should you be concerned for?
Perforation
67
What labs do you want to check for PUD?
CBC - Hgb/HCT BMP - lytes (excessive vomiting) Hemoccult
68
What imaging is recommended for PUD?
KUB, CXR (check for free air)
69
What is the tx for PUD?
IV fluids IV PPI GI consult => endoscopy w/ biopsy, d/c NSAIDs, tx H. pylori, if perf then surgery
70
What is the most common cause of a splenic abscess?
Endocarditis or seeding from another site of infection
71
What is the presentation for pt w/ suspected splenic abscess?
LUQ pain | Fever
72
What imaging is needed to evaluated splenic abscess?
CT w/ IV contrast
73
What is the tx for splenic abscess?
Admit NPO & IV fluids ABX Surgery (splenectomy) and ID consults
74
If splenic artery or sub branch becomes occluded by embolus, clot or infection what should you be concerned about?
Splenic infart
75
Malignancy, Afib, infective endocarditis, sickle cell, trauma, and complications for mono are RF for what?
Splenic infarct
76
How will a pt w/ splenic infarct present?
Acute LUQ pain Fever N/V +/- splenomegaly
77
What labs will be elevated in pt w/ splenic infarct?
LDH (tissue damage) | Leukocytosis
78
What imaging is needed to evaluated splenic infarct?
CT w/ IV constrast
79
What is the tx for uncomplicated splenic infarct (most common)?
Analgesia, monitor | Consult GI/Surgery
80
What is the tx for complicated splenic infarct (abscess, sepsis, hemorrhage)?
Surgery eval for splenectomy | Consult GI/Surgery
81
Splenic rupture can occur w/o trauma (infection, drugs, malignancy, pregnancy, idiopathic) or due to trauma. What is the presentation?
Pain, fullness in LUQ Referred pain to left shoulder Pleuritic pain Early satiety
82
What labs do you want to check w/ splenic rupture?
CBC - Hct/Hbg
83
What imaging is gold standard for splenic rupture?
US
84
What is the tx for splenic rupture?
Admit NPO & IVF Type and cross for transfusion Emergency splenectomy
85
What is the presentation for SBO?
N/V Periumbilical cramping Obstipation (inability to pass flatus or stool)
86
Fever, leukocytosis, tachycardia (not responding to fluid), POOP, and metabolic acidosis are concerning for what GI finding?
Bowel ischemia
87
Abd XR in pt w/ suspected SBO will show what?
Dilated loops of bowel w/ air fluid levels | Proximal bowel dilation w/ distal bowel collapse
88
CT for pt w/ suspected SBO will be helpful for what?
Determining severity
89
What is the tx for pt w/ pt w/ SBO?
``` Admit NPO & IVF Anti-emetics NG tubes Surgery consult ```
90
When would pt w/ SBO have surgical intervetion?
Sx no resolved w/ NG tube and bowel rest
91
When is a pt w/ SBO given ABX and taken to surgery emergently?
Complicated bowel obstruction
92
What is acute mesenteric ischemia?
Decreased or no perfusion to section of colon
93
What are non-occlusive causes of acute mesenteric ischemia?
Vasoconstrictive meds, sepsis, HF
94
How might a pt w/ occlusive (due to ARTERIAL thrombosis/emboli) mesenteric ischemia present? What is the mortality risk?
Rapid onset N/V Severe periumbilical POOP Post prandial pain High mortality risk
95
How might a pt w/ occlusive (due to VENOUS thrombosis) mesenteric ischemia present? What is the mortality risk?
Indolent course Less associated mortality
96
Labs for pt w/ acute mesenteric ischemia will be non-specific in early course. What normal lab finding can help r/o acute mesenteric ischemia?
D-dimer
97
If Abd XR shows free air or signs of "dead bowel" in pts w/ acute mesenteric ischemia what is the tx?
Laparotomy
98
If Abd XR DOES NOT shows free air or signs of "dead bowel" in pts w/ acute mesenteric ischemia what is the next step?
Abd CTA (IV contrast)
99
What is the tx for acute mesenteric ischemia?
Admit NPO and IVF Foley Empiric ABX (Ceftriaxone, metronidazole) Consults dependent on cause ( GI, surgery, cardio)
100
What is the most common abdominal emergency?
Appendicitis
101
What is presentation/exam for normally located appendicitis?
``` RLQ pain (starts periumbilical & migrates) + Rebound tenderness/ + Rovsing's sign ```
102
What is presentation/exam for appendicitis in a retrocecal located appendix?
Back/flank/testicular pain | + Psoas sign
103
What is presentation/exam for appendicitis in a pelvic located appendix?
Suprapubic/rectal pain/dysuria/diarrhea more common | + Obturator sign
104
Pain can present where for pt in 3rd trimester w/ appendicitis?
RUQ
105
What is a the most common lab finding for appendicitis?
Leukocytosis | *If extreme elevated consider perf
106
Is imaging needed if clinical appendicitis?
No
107
What imaging is needed if dx of appendicitis is unclear?
CT w/ IV or oral contrast (inflammation, wall thickening, fluid collection, abscess, fat stranding)
108
What imaging is needed in pregnant pts if dx of appendicitis is unclear?
MRI w/ contrast
109
What peri-operative ABX are given for pts w/ appendicitis?
Cefoxitin or cefazolin + metronidazole
110
PT presents with LLQ pain that is steady, deep, and constant. They report urinary frequency and change in bowel habits. On exam you note rebound tenderness and guarding, + stool guaiac and changes in bowel sounds. What is your suspected DX?
Diverticulitis
111
Hyperactive or hight pitched bowels sounds indicate what in pt w/ diverticulitis?
Obstruction
112
Hypoactive/absent bowel sounds indicated what in pt w/ diverticulitis?
Peritonitis
113
Labs for pt w/ diverticulitis will show what?
Elevated C-reactive protein | UA: pyruia
114
What is the preferred imaging for diverticulitis?
CT w/ IV and oral contrast (localized bowel thickening, colonic diverticula, abscess, fistulas, dilated loops of bowl/BO)
115
What is the tx for uncomplicated diverticulitis?
Outpatient - Ciprofloxacin + metronidazole - Follow up w/ GI w/in 2 days
116
What are the criteria for complicated diverticulitis?
``` Perforation, abscess, fistula, obstruction Sepsis IMC Fever > 102.5 > 70 y/o Significant leukocytosis Significant comorbidities ```
117
What is the tx for complicated diverticulitis?
Inpatient NPO & IVF IV abx Consult GI +/- surgery
118
What is the most common complication of IBD?
Toxic megacolon
119
Toxic megacolon can also presents secondary to what?
C. diff infection | CMV in HIV+ pts
120
How will a pt w/ toxic megacolon present?
Severe, bloody diarrhea Fever Toxic appearing/AMS Abdominal distention and tenderness
121
What is the DX criteria for toxic megacolon?
Enlarged, dilated colon (> 6cm) on Abd XR PLUS 3 of the following: - Fever > 100.4 - HR > 120 bpm - Neutrophilic leukocytosis - Anemia PLUS 1 of the following: - Dehydration - AMS - Lyte disturbance - Hypotension
122
What is the tx for toxic megacolon
``` Admit NPO & IVF NG tube NO anti-motility agents, opioids CT w/ IV and oral contrast Broad spectrum IV ABX (ampicillin/gentamycin/metronidazole) IV steroids (prednisolone or methlyprednisolone) Surgery consult ```
123
What are the complications associated w/ toxic megacolon?
Perforation, massive hemorrhage, progression of dilation
124
Pt presents with bright red rectal bleeding, anal pruritus (+/- prolapse), perianal pain (+/- lump). What are you concerned about?
Hemorrhoid
125
PE for pt w/ suspected hemorrhoids includes what?
Visual inspection DRE Anoscopy +/- Other endoscopic procedures
126
T or F: Internal or external hemorrhoids can be excised in the ED?
TRUE (also done by surgery)
127
What is the tx for thrombosed hemorrhoid?
Incise overlying skin and evacuate small clot *will provide immediate relief
128
What are the general tx recommendations for pts w/ hemorrhoids?
Increase fluids and fiber in diet
129
Is a fever common in pts w/ perianal abscess?
No (unless cellulitis/extension)
130
Will DRE for pt w/ perianal abscess have any acute findings?
No
131
How will a pt w/ a perianal abscess present?
Sever pain in anal area w/ fluctuance/indurated skin in perianal area
132
Is imaging needed for pts w/ perianal abscess?
Only if deep anorectal abscess is suspected. CT, MRI or endorectal US
133
What is the tx for simple anorectal abscess?
I and D Sitz bath at home +/- ABX
134
When are abx given for pts w/ perianal abscess? What abx are recommended?
Extension/cellulitis, signs of systemic infection, DM, valvular heart disease, IMC Augmentin or Cipro + Metronidazole (must also perform wound culture)
135
What is the tx for extensive, non-superficial perianal abscess?
Admit | Surgical I & D + imaging to determine extension
136
What is common in pts presenting w/ rectal FB?
Long delay before seeking medical treatment
137
If unable to palpate rectal FB on DRE does this exclude presence?
No Order flat, upright abdominal XR If radio-opaque, follow up w/ CT
138
What is the tx for rectal FB?
Removal transanal approach (relax w/ IV sedation) OR Surgical removal (laparoscopy, colotomy)
139
What is needed after removal or rectal FB?
Rigid protoscopy or flex sig
140
What is first line imaging for evaluating female pelvic pain in non-pregnant women?
US transvaginal | - followed by CT if further eval needed)
141
What is first line imaging for evaluating female pelvic pain in pregnant women?
MRI
142
Pt presents w/ vaginal bleeding w/ pain 6-8 wks after last menses and lower pelvic pain. What are you concerned about?
Ectopic pregnancy
143
What tests are need to evaluate ectopic pregnancy (+HCG)?
Pelvic exam Blood type and screen RhD typing (if not previously done in prior pregnancy) Monitor H/H
144
What imaging is needed to evaluate ectopic pregnancy?
``` Fast US (R/o intraperitoneal hemorrhage) Transvaginal US ```
145
If pt w/ ectopic pregnancy is stable, no fetal cardiac activity and will comply w/ close follow up what is the tx?
Methotrexate Do not use methotrexate if: - Hemodynamically unstable - High hCG - fetal heart activity - Large ectopic size - Renal/liver disease - Breastfeeding
146
What is the tx for ectopic pregnancy if suspected tubal rupture/hemodynamically unstable?
Salpingectomy
147
What is the tx for ectopic pregnancy & hemodynamically stable?
Salpingostomy or salpingectomy | GYN consult
148
PID is most commonly related to what STIs?
N. gonorrhea | C. trachomatis
149
New vaginal discharge, +chandelier sign, cervical friability, +/- RUQ pain (fitz-hugh curtis syndrome) are concerning for what?
PID
150
When do you hospitalized pt w/ PID? (5)
``` Severe clinical illness Unable to tolerate POs Complicated PID w/ abscess Pregnancy or post partum Pain control ```
151
What is the inpt tx for PID?
``` IVF Pain control Anti-emetic ABX: Cefoxitin + doxycycline (+ metronidazole if pelvic abscess) Blood cultures GYN consult ```
152
What is the outpt tx for PID?
ABX: Ceftriaxone + doxycycline | GYN consult
153
What is defined as partial or complete rotation of ovary that often results in ischemia?
Ovarian torsion
154
What is the most common GYN emergency?
Ovarian torsion
155
What pt population is at an increased risk of ovarian torsion?
Pregnant
156
How will a pt w/ ovarian torsion present?
Acute onset of pain, N/V, adnexal mass on exam
157
If pt w/ ovarian torsion presents with a fever, this is concerning for what?
Necrosis
158
What imaging is needed to evaluate ovarian torsion?
US w/ duplex for BF (transvaginal + transabdominal)
159
What is the tx for ovarian torsion in premenopausal women w/ viable ovary and no malignancy?
Consult GYN/surgery | Laparoscopic detorsion
160
What is the tx for ovarian torsion in post-menopausal women w/ nonviable ovary or suspected malignancy?
Consult GYN/surgery | Salpingo-oophrectomy
161
F pt presents with adnexal mass, abdominal distention, weight loss, and urinary frequency. What are you concerned about?
Ovarian CA *If acute presentation also consider malignant effusion or SBO
162
What is needed for dx of ovarian CA?
Imaging: Transvaginal and transabdominal US Labs: tumor markers (CA 125)
163
What is the tx for ovarian CA?
Consult surgery, Oncology/GYN
164
What is infection of the endometrium after delivery?
Postpartum endometritis
165
What will exam for pt w/ postpartum endometritis show?
Fever, foul smelling discharge (lochia), soft uterus w/ tenderness
166
What is needed for dx of postpartum endometritis?
Clinical + elevated WBC w/ bands
167
What is the tx for postpartum endometritis?
Admit IV ABX (clindamycin + gentamycin) GYN consult
168
T or F: significant abd pain can be due to gastroenteritis?
FALSE. NEVER attribute significant abd pain to gastroenteritis

3. E Med & Surgery (19 decks)

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