2.2 MTB Step 3 - General (Inflammation - Acute Diverticulitis, Diverticular Abscess, Acute Pancreatitis, Acute Appendicitis, CUC)

Question 1

INFLAMMATION

What are (3) Inflammatory causes of an Acute Abdomen?

Answer 1

1. Acute Diverticulitis
2. Acute Pancreatitis
3. Acute Appendicitis

Question 2

INFLAMMATION

What are (2) common question Descriptions of Abdominal Inflammation?

Answer 2

1. Gradual onset of constant abdominal pain that slowly builds up over several hours.
2. Initially, ill-defined pain that eventually becomes localized to the site of inflammation.

Question 3

ACUTE DIVERTICULITIS

What are (4) common Clinical Manifestations of Acute Diverticulitis?

Answer 3

1. Middle age or Older
2. Fever
3. Leukocytosis
4. Peritoneal Irritation/Pain in the LEFT LOWER QUADRANT with a Palpable Tender Mass

Question 4

ACUTE DIVERTICULITIS

In women, what are (2) other sources of Acute Abdomen that should be considered?

Answer 4

1. Fallopian Tubes
2. Ovaries

When diagnosing acute diverticulitis, don’t forget to order a Urine Pregnancy Test on all women of childbearing age

Question 5

ACUTE DIVERTICULITIS

What is the Most Common anatomical location for Diverticulosis?

Answer 5

Sigmoid Colon

The Sigmoid Colon has the smallest diameter and therefore the highest intraluminal pressure.

Question 6

ACUTE DIVERTICULITIS

What is the Most ACCURATE Diagnostic Test for Acute Diverticulitis?

Answer 6

CT Abdomen w/ Contrast

• To look for Abscess or Free Air.*
• Fat Stranding is common around the inflamed bowel.*

Question 7

ACUTE DIVERTICULITIS

What Exam is considered an Absolute Contraindication in Acute Diverticulitis, and why?

Answer 7

Colonoscopy

because it raises the risk of Perforation.

Question 8

ACUTE DIVERTICULITIS

What is the Treatment for Acute Diverticulitis in a patient with NO peritoneal signs?

Answer 8

Manage as Outpatient with Antibiotics

Question 9

ACUTE DIVERTICULITIS

What is the Treatment for Acute Diverticulitis in a patient with Localized Peritoneal Signs and Abscess?

Answer 9

• NPO
• IV Fluids
• IV Antibiotics
• CT-guided Percutaneous Drainage of Abscess

Question 10

ACUTE DIVERTICULITIS

What is the Treatment for Acute Diverticulitis in a patient with Generalized Peritonitis or Perforation?

Answer 10

EMERGENCY Surgery

Question 11

ACUTE DIVERTICULITIS

What is the Treatment for Acute Diverticulitis in a patient with Recurrent Attacks of Diverticulitis?

Answer 11

ELECTIVE Surgery

Question 12

DIVERTICULAR ABSCESS​

What is the Cause of Diverticular Abscess?

Answer 12

Pus Collecting in a Diverticular Pouch

Question 13

DIVERTICULAR ABSCESS​

When should you suspect a Diverticular Abscess?

Answer 13

Suspect a Diverticular Abscess in patients with UNCOMPLICATED DIVERTICULITIS who have one of the following despite 3 days of Antibiotic treatment:

• NO improvement in Abdominal Pain, or
• Persistent Fever

Question 14

DIVERTICULAR ABSCESS​

What Test is used to diagnose Diverticular Abscess?

Answer 14

CT Abdomen

Question 15

DIVERTICULAR ABSCESS​

What is the Treatment for a Diverticular Abscess?

Answer 15

Percutaneous or Surgical DRAINAGE

Start Antibiotics to Prevent Spread of the Infection

Question 16

ACUTE PANCREATITIS​

What are (4) Presenting Characteristics in a patient with Acute Pancreatitis?

Answer 16

1. Alcoholic
2. Acute Upper Abdominal Pain (over several hours)
3. Radiation to the Back
4. Nausea and Vomiting

Question 17

ACUTE PANCREATITIS​

What are the (3) Types of Acute Pancreatitis?

Answer 17

1. Edematous
2. Hemorrhagic
3. Suppurative (pancreatic abscess)

Question 18

ACUTE PANCREATITIS​

What are (6) Risk Factors for Acute Pancreatitis?

Answer 18

1. Alcoholism
2. Gallstones
3. Medications
4. Hypertriglyceridemia
5. Trauma
6. Post-ERCP

Question 19

ACUTE PANCREATITIS​

What are (6) MEDICATIONS considered Risk Factors for Acute Pancreatitis?

Answer 19

1. Didanosine
2. Pentamidine
3. Flagyl
4. Tetracycline
5. Thiazides
6. Furosemide

Question 20

ACUTE PANCREATITIS​

What are (2) Late Complications of Acute Pancreatitis?

Answer 20

1. Pancreatic Pseudocyst
2. Chronic Pancreatitis

Question 21

ACUTE PANCREATITIS​

What is the Best INITIAL Diagnostic Test for Acute Pancreatitis?

Answer 21

Amylase or Lipase (serum or urinary)

Amylase = Highest Sensitivity

Lipase = Highest Specificity

• Serum from 12 - 48 hours*
• Urinary from 3rd - 6th days*

Question 22

ACUTE PANCREATITIS​

What is the Most ACCURATE Diagnostic Test for Acute Pancreatitis?

Answer 22

CT Abdomen

Perform if diagnosis is uncertain.

Question 23

ACUTE PANCREATITIS​

What are (3) Warning Signs for HEMORRHAGIC Pancreatitis?

Answer 23

1. Lower Hematocrit that continues to fall the day AFTER presentation.
2. Very High WBC ( > 18,000), Glucose, BUN
3. Very Low Calcium

Question 24

ACUTE PANCREATITIS​

How can Pancreatitis lead to Hypocalcemia?

Answer 24

• Pancreatitis can lead to Hypocalcemia due to the presence of Insoluble Calcium Salts in the Pancreas.
• The Free Fatty Acids (FFAs) avidly Chelate the salts, resulting in Calcium deposition in the Retroperitoneum>

Question 25

**ACUTE PANCREATITIS​** What are the (3) Treatments used for Acute Pancreatitis?

Answer 25

1. **NPO** 2. **NGT Suction** 3. **IV Fluids**

Question 26

**ACUTE PANCREATITIS** What are (3) Complications of Acute Pancreatitis?

Answer 26

1. **Abscess** - often appears 10 days after onset with persistent fevers and high WBC count. Surgical drainage. 2. **Pseudocyst** - appears 5 weeks after initial symptoms, when a collection of pancreatic juice causes anorexia, pain, and a palpable mass. 3. **Chronic Damage** - causes Diabetes and Steatorrhea. Treat with Insulin and Pancreatic Enzyme supplements.

Question 27

**ACUTE APPENDICITIS** What are (4) Steps in how Acute Appendicitis presents?

Answer 27

1. Begins with **Anorexia**. 2. Followed by **vague Periumbilical Pain**. 3. Several hours **later becomes Sharp, Severe, Constant, and Localized to the Right Lower Quadrant (RLQ)** of the Abdomen. 4. **Tenderness, Guarding, and Rebound** are found to the Right and Below the Umbilicus (but not elsewhere in the abdomen).

Question 28

**ACUTE APPENDICITIS** What is a Rovsing Sign?

Answer 28

**Palpation of LLQ Increases the Pain felt in RLQ**

Question 29

**ACUTE APPENDICITIS** 1. What is the Best INITIAL Method for Diagnosing Acute Appendicitis? 2. Which Diagnostic Tests should be performed if the Diagnosis is unclear after the initial method?

Answer 29

1. Look for **Fever and Leukocytosis** (*10,000 - 15,000 range*) with Neutrophilia and Immature forms 2. **CT Abdomen** or **US Abdomen**

Question 30

**ACUTE APPENDICITIS** What are (4) Antibiotic combinations that can be given IV prior to Appendectomy?

Answer 30

1. **Ciprofloxacin + Metronidazole** 2. **Ampicillin/Sulbactam** 3. **Levofloxacin + Clindamycin** 4. **Cefoxitin** or **Cefotetan**

Question 31

**ACUTE APPENDICITIS** How is the Treatment determined for a Perforated Appendix?

Answer 31

* **Continue IV Antibiotics** * **Treatment is determined by CT Scan finding:** * *Phlegmon is treated with Antibiotics* * *Abscess is Drained* * *Frank Performation is treated Surgically*

Question 32

**CHRONIC ULCERATIVE COLITIS (CUC)** ## Footnote TREATMENT How is Chronic Ulcerative Colitis (CUC) usually managed?

Answer 32

**Medically**

Question 33

**CHRONIC ULCERATIVE COLITIS (CUC)** ## Footnote TREATMENT Under which (**4**) situations is Elective Surgery the answer for Chronic Ulcerative Colitis (CUC)?

Answer 33

1. **\> 20 years of Disease** present (*high incidence of malignant degeneration*) 2. **Multiple Hospitalizations** 3. **High-dose Steroids** or **Immunosuppressant** necessary 4. **Toxic Megacolon** (*abdominal pain, fever, leukocytosis, epigastric tenderness, massively distended transverse colon on x-rays with gas in the wall of the colon*)

Question 34

**CHRONIC ULCERATIVE COLITIS (CUC)** ## Footnote BASIC SCIENCE CORRELATE What portion of the Colon does Ulcerative Colitis (UC) affect?

Answer 34

**Ulcerative Colitis** (**UC**) extends from the ***Anal Verge*** in an _UNINTERRUPTED_ pattern through the ***Entire Colon***.