2.1 MTB Step 3 - General (Acute Abdomen, SBP, Perforation, Obstruction) Flashcards
Cards Complete:
ACUTE ABDOMEN
What the (4) Main Causes of an Acute Abdomen?
- Perforation
- Obstruction
- Inflammatory/Infection
- Ischemia
ACUTE ABDOMEN
What is the Most Important split-decision you must make when presented a case of an Acute Abdomen?
When to OPERATE
vs.
When to TREAT MEDICALLY
ACUTE ABDOMEN
What is the definition of Primary Peritonitis?
Spontaneous Inflammation in:
- Children with NEPHROSIS
- Adults with ASCITES and Mild ABDOMINAL PAIN (even if there is fever and leukocytosis).
ACUTE ABDOMEN
Under which (4) conditions is “Treat Medically” the answer for an Acute Abdomen?
- Pancreatitis
- Cholangitis - a GI medical emergency, and intervention with an emergency ERCP is the Treatment of Choice.
- Ruptured Ovarian Cysts
-
Things that Mimic an Acute Abdomen:
- Lower Lobe Pneumonia: Look for infiltrate on CXR
- Myocardial Ischemia: Look for ECG changes
- Pulmonary Embolism: Always suspect this in any immobilized patient
SPONTANEOUS BACTERIAL PERITONITIS (SBP)
“A 64-year-old man with a History of Hepatitis C presents with abdominal fullness, bloating, and chills. He says he has noted this his abdomen has become bigger and his pants do not fit as well as they used to. Exam shows shifting dullness and a fluid wave. VS show the patient is febrile (101.0F) and tachycardic. Labs show thrombocytopenia, low albumin, and INR of 2.3. “
What is the Best NEXT Step in the management of this patient?
Abdominal Paracentesis
This patient likely has cirrhosis and elevated portal hypertension based on his lab findings, low platelet count, low albumin, history of hepatitis C, and elevated INR – markers of impaired hepatic function.
SPONTANEOUS BACTERIAL PERITONITIS (SBP)
How is SBP Diagnosed, specifically?
Diagnosis of SBP is made by Paracentesis IF the fluid contains Neutrophils > 250 cells per mm3.
SPONTANEOUS BACTERIAL PERITONITIS (SBP)
What are the (2) Medical Treatments for SBP?
- Antibiotics (i.e., Ceftriaxone)
-
Albumin
- 1.5 g/kg on Day 1 & Day 3 of hospitalization
SPONTANEOUS BACTERIAL PERITONITIS (SBP)
What are (2) Nonsurgical CARDIAC causes of an Acute Abdomen?
- Myocardial Infarction
- Acute Pericarditis
SPONTANEOUS BACTERIAL PERITONITIS (SBP)
What are (2) Nonsurgical PULMONARY causes of an Acute Abdomen?
- Lower Lobe Pneumonia
- Pulmonary Infarction
SPONTANEOUS BACTERIAL PERITONITIS (SBP)
What are (2) Nonsurgical ABDOMINAL causes of an Acute Abdomen?
- Hepatitis
- GERD
SPONTANEOUS BACTERIAL PERITONITIS (SBP)
Other than the Cardiac, Pulmonary, and Abdominal Nonsurgical causes, what are (4) additional Nonsurgical causes of an Acute Abdomen?
- DKA
- Adrenal Insufficiency
- Sickle Cell Crisis
- Acute Porphyria
PERFORATION
GASTROINTESTINAL PERFORATION
What is the Clinical Manifestation of GI Perforation?
Acute Abdominal Pain that is Sudden, Severe, Constant, and Generalized.
Pain is excruciating with any movement (it may be blunted in elderly patients).
PERFORATION
GASTROINTESTINAL PERFORATION
What are the (2) Most Common causes of GI Perforation?
- Diverticulitis: Elderly patient with Lower Abdominal Pain and Fever
- Perforated Peptic Ulcer: Epigastric Pain that classically Wakes patient at night and, possibly, referred pain to the Scapula
PERFORATION
GASTROINTESTINAL PERFORATION
How is GI Perforation Diagnosed?
Chest X-Ray (erect or left lateral decubitus if too sick to stand)
PERFORATION
GASTROINTESTINAL PERFORATION
What are the (3) Steps in Treating GI Perforation?
- NPO and IVF
-
IV Antibiotics:
- Metronidazole
- 2nd-generation Cephalosporins (cefotetan or cefoxitin)
- Ampicillin-Sulbactam
- Piperacillin-Tazobactam
- Emergency Surgery
PERFORATION
ESOPHAGEAL PERFORATION
What is the Most Common cause of Esophageal Perforation?
Iatrogenic (accident by healthcare provider)
PERFORATION
ESOPHAGEAL PERFORATION
What are (3) Presenting Signs/Symptoms of Esophageal Perforation?
- Chest Pain or Upper Abdominal Pain
- Dysphagia or Odynophagia
- Subcutaneous Emphysema shortly after Endoscopy
PERFORATION
ESOPHAGEAL PERFORATION
What is the Best INITIAL Test for Esophageal Perforation?
Gastrografin Contrast Esophagram
OBSTRUCTION
What are (5) Symptoms that should cause you to suspect Obstruction?
- Severe Colicky pain
- Absence of Flatus or Feces
- High-pitched Bowel Sounds
- Nausea and Vomiting in patients with risk factors
- Constant Movement (patient tries to find comfortable position)
OBSTRUCTION
What are the (6) Risk Factors in a patient with Nausea and Vomiting that should be concern for Obstruction?
- Prior abdominal surgery (adhesions)
- Elderly with weight loss and anemia or melanotic stools (tumor)
- Hx of Recurrent Lower abdominal pain (diverticulitis)
- Hx of Hernia (incarcerated)
- Sudden abdominal pain in Elderly (volvulus)
- Vascular events (ischemia, perforation/diverticulitis, AAA, or dissection)
OBSTRUCTION
Which (3) Diagnostic Tests should be performed on a patient with suspected Obstruction?
- CBC and Lactate level (elevated)
-
Supine and Erect Abdominal X-Ray:
- Dilated loops of bowel
- Air-fluid levels
- Absence of Gas in rectum
- Bird’s Beak sign for Volvulus
-
CT Abd/Pel w/ contrast (Most ACCURATE Test)
- Can show a Transition Point - location at which the obstruction has occurred.
OBSTRUCTION
What are the (5) Treatments for Obstruction?
- NPO, NGT, and IVF
- Consider Gastrografin contrast study (until perforation has been ruled out).
- Sigmoid Volvulus: perform Proctosigmoidoscopy and leave the Rectal Tube in place. Perform Sigmoid Resection for recurrent cases.
- Hernia: perform Immediate Surgery if case describes Fever, Leukocytosis, Constant Pain, and Signs of Peritoneal Irritation (strangulated obstruction.
- All other Obstructions: perform Emergency Surgery
