5 Acute Abdomen Flashcards
1
Q
______ is the leading cause of ER visits and hospital admissions
A
Abdominal pain - 35%
2
Q
Up to 30% of patients with acute abdominal pain will be discharged with…
A
No specific diagnosis
3
Q
What are the life-threatening DDx you must R/O for abdominal pain?
A
AAA or dissection GI perforation Incarcerated hernia Acute bowel obstruction Mesenteric ischemia Ectopic pregnancy Placental abruption Splenic rupture
4
Q
Top 10 Dx in patients with abdominal pain in the ER
A
Appendicitis Biliary tract disease SBO GYN disease Pancreatitis Renal colic Perforated ulcer Cancer Diverticular disease Non-specific abd pain
5
Q
Red flags in Patient Hx for acute abdominal pain
A
Age >65 Alcoholism Immunocompromised CVD Comorbidities Prior surgery Recent GI instrumentation Early pregnancy
6
Q
Pain characteristics that are RED FLAGS in abdominal pain pt
A
Acute onset
Significant pain at onset
Pain followed by emesis
Constant pain for <2 days
7
Q
PE RED FLAGS for abdominal pain
A
Rigid abdomen
Signs of shock
Involuntary guarding
8
Q
Where does pain refer to:
Gallbladder disease
A
Right subscapular area
9
Q
Where does pain refer to:
Perforated duodenal ulcer
A
Shoulders
10
Q
Where does pain refer to:
Urethral obstruction
A
Testicles
11
Q
Where does pain refer to:
MI
A
Epigastric area, jaw, neck, upper extremity
12
Q
Where does pain refer to:
GYN
A
Low back
13
Q
Describe visceral pain
A
Dull, aching, colicky
Poorly localized
Distention, ischemia, inflammation, or spasm of a hollow organ
14
Q
Describe parietal pain
A
Sharp
Well localized
Peritoneal irritation, ischemia, inflammation/stretching of parietal peritoneum
15
Q
Things that can present with abrupt, excruciating abdominal pain
A
Biliary colic Ureteral colic MI Perforated ulcer Ruptured aneurysm
16
Q
Things that can present with rapid onset of severe constant abdominal pain
A
Acute pancreatitis
Mesenteric thrombosis
Strangulated bowel
Ectopic pregnancy
17
Q
Things that can present with gradual, steady abdominal pain
A
Acute cholecystitis Acute cholangitis Acute hepatitis Appendicitis Acute salpingitis Diverticulitis
18
Q
Things that can present with intermittent, colicky pain, crescendo with free intervals
A
Early pancreatitis (rare) Small bowel obstruction IBD
19
Q
What aggravating/alleviating factors must you ask about when taking an abdominal pain Hx?
A
BM
Eating
Antacid use
Exertion
20
Q
Why must we ask about prior abdominal surgery?
A
B/c they can develop adhesions —> small bowel obstruction
21
Q
Meds you want to make sure you ask about in Patient Hx for abdominal pain
A
Bleeding risk
Pain meds (can mask acute pain)
Pepto-bismol (can make stool black)
22
Q
What does patient movement/lack of movement tell us with regards to abdominal pain?
A
Restless patient who can’t sit still - more likely to be something like renal colic
Patient lying perfectly still/supine - more likely peritonitis (b/c movement —> excruciating pain)
23
Q
What must you remember to do in all patients with lower quadrant/hypogastric pain?
A
Testicular exam/pelvic exam and rectal exam
24
Q
Marker of tissue hypoxia
A
Lactic acid - order if worried about organ ischemia
25
What Dx do you need to request an urgent surgical referral for?
```
Obstruction
Perforation
Peritonitis
Ischemic bowel
Dissection
```
Rapid symptom evolution (inc tenderness/rigidity, pain is severe/out of proportion)
26
Causes of perforation of the GI tract
Spontaneous due to inflammatory changes (gallbladder, appendix)
Bowel obstruction
Trauma
Instrumentation
27
Clinical manifestation of perforation
Depends on organ affected
Air
Stool
Succus entericus (specific to pancreas)
28
Why is succus entericus so bad
Perforation of pancreas, releases various enzymes (lipase, lactase, amylase) and mucus to blood —> extremely damaging to tissue
29
GI perforations are more common in what age groups?
>50 years or <10 years
30
How will the pain change if the inflammed organ perforates?
More diffuse pain after localized tenderness
| Pain may be relieved, followed by peritonitis
31
Peritonitis occurs after _____ and will likely include what SSx
After perforation
High fever
May lead to sepsis/death
Localized = contained by surrounding viscera/omentum
Generalized = gross spillage into peritoneal cavity
32
When to suspect Spontaneous bacterial peritonitis vs secondary bacterial peritonitis
In patients with ascites, liver cirrhosis, fever, AMS, abdominal pain +/- hypotension (ALCOHOLICS)
33
How do you treat Spontaneous bacterial peritonitis?
Perform paracentesis but NO EXPLORATORY LAPAROTOMY
Mortality rate is 80% if laparotomy is attempted
Treat with Cefotaxime
34
When should you suspect secondary bacterial peritonitis?
Patients with possible perforation (peptic ulcer, appendicitis) with ascites, fever, AMS, abdominal pain +/- hypotension
35
How do you treat Secondary bacterial peritonitis
Perform paracentesis
MUST perform exploratory laparotomy - mortality rate of 100% if you don’t
Treat with Cefotaxime
36
Acute cholecystitis is usually associated with _________ that is usually related to __________
Gallbladder inflammation
| Gallstone disease
37
Most common surgical emergency in the elderly
Acute cholecystitis (b/c they don’t feel as much pain)
38
How does acute cholecystitis present?
Severe, constant RUQ pain, typically >6h
Can radiate to epigastric area and right shoulder
N/V, increased pain with FATTY FOOD INTAKE
Guarding, RUQ pain with palpation
+ Murphy’s sign
Ill appearing, tend to lie still
Tachycardia
39
How will acute cholecystitis appear on labs/imaging?
Leukocytosis with bands
Elevated CRP
Normal LFTs and bilirubin (b/c only gallbladder affected)
RUQ U/S: gallbladder wall thickening, gallstones or sludge, pericholecystic fluid
40
How do you manage acute cholecystitis?
IV fluids, analgesia
NPO
Abx (Ceftriaxone, cefuroxime)
Surgical consult —> cholecystectomy
41
What is a non-operative option for acute cholecystitis?
Percutaneous Drainage
For unstable patients
Saves surgery until patient is more stable
Radiologic guidance necessary
42
Presence of gallstones within the common bile duct
Acute choledocholithiasis
Not just the cystic duct - so both liver and gallbladder effected
43
Most common cause of acute choledocholithiasis
Secondary to passage of stones from gallbladder to common bile duct
Primary is much less common (refers to formation of stones within the common bile duct itself)
44
In what patients might primary choledocholithiasis occur?
CF patients
45
How does choledocholithiasis present
RUQ/epigastric pain
Palpable gallbladder (Courvoiseier’s sign - edema of gallbladder)
+/- jaudice
Elevated LFTs (vs no in cholecystitis...)
46
Test of choice for acute choledocholithiasis
Transabdominal U/S for presence of stones in gallbladder/common bile duct
47
Treatment for choledocholithiasis
Consult Surgery, GI
High risk patients: ERCP (85-90% success rate) to remove stone via endoscopy followed by elective cholecystectomy
Low risk patients: cholecystectomy
48
Complications of choledocholithiasis include...
Acute pancreatitis and acute cholangitis
49
Ascending bacterial infection due to obstruction of the biliary ducts
Acute cholangitis
Choledocholithiasis is the most common cause
Other causes: Biliary calculi, malignancy, benign stenosis
Medical emergency!
50
What is the presentation of acute cholangitis?
Charcot’s triad:
• Fever/chills
• RUQ abdominal pain
• Jaundice
Reynold’s Pentad:
• Charcot’s triad
• AMS
• Hypotension
Leukocytosis with left shift
Elevated LFTs and bilirubin
Elevated amylase indicated pancreatic involvment
51
Management of acute cholangitis
```
Admit
NPO and IV fluids
Analgesia
Consult GI +/- ID
Monitor for sepsis (blood cultures x 2)
Empiric abx (ceftriaxone + metronidazole)
Biliary drainage (ERCP) - both dx and tx
```
52
Presentation of Hep A
```
Abrupt onset RUQ pain, N/V, anorexia
Fever/malaise
Dark urine, pale stools
Jaundice/sclera icterus
Hepatomegaly (80%)
Splenomegaly (less common)
```
Elevated LFT and bilirubin
53
Treatment for Hep A
Symptomatic
Fecal oral spread most common so counsel on hygiene
Patient contagious for 28d incubation period and up to one week following onset of jaundice
54
Acute inflammatory process of the pancreas
Pancreatitis
Mild: No organ failure or systemic complications
Moderate: Transient organ failure that resolves within 48 hours
Severe: Persistent organ failure that can be >1 organ
55
What type of pancreatitis involves well localized pain with rapid onset?
Gallstone pancreatitis
56
Other types of pancreatitis that cause less well localized, slower progressing pain
Alcohol (large amounts, chronically)
Drugs (Amiodarone, antivirals, diuretics, NSAIDs, abx)
Severe HLD
Idiopathic
57
Presentation of pancreatitis
Persistent, severe, boring, acute epigastric or RUQ pain that radiates to the back
Pain may be relieved by LEANING FORWARD
+/- dyspnea due to diaphragmatic inflammation
N/V
Bloating
58
Specialized PE findings for pancreatitis
Cullen’s sign - periumbilical superficial edema and bruising
Grey Turner sign - ecchymotic discoloration along the flanks due to retroperitoneal bleeding from pancreatic necrosis
59
How to diagnose pancreatitis
Lipase up to 3x normal
Amylase up to 3x normal
+/- leukocytosis (typically mild if present)
Increased CRP
U/S: diffusely enlarged pancreas, +/- gallstones
CT with contrast: not as sensitive early on but will see necrosis and stones later
MRI: sensitive in early disease
60
To diagnose pancreatitis and move straight to management w/o imaging, you need two of the following three criteria to be met:
Acute onset of constant, severe epigastric pain radiating to back
Elevation of serum lipase or amylase to 3x or greater the ULN
Characteristic findings of acute pancreatitis on imaging
61
How is pancreatitis managed?
```
Admit to ICU for monitoring
NPO
IV fluids
NG tube
Foley
Serial labs (amylase and electrolytes)
Analgesia (opiates)
Consult GI for gallstone pancreatitis (b/c needs ERCP)
```
62
Risk factors for PUD
NSAID use
H. pylori infection
Smoking
Excessive vomiting
63
Splenic abscess typically results from...
Endocarditis or seeding from another site
Presentation:
LUQ pain+/- splenomegaly
Fever
+/- left side pleural effusion
64
How to diagnose splenic abscess
CT scan with IV contrast
65
Treatment of splenic abscess
```
Admit
NPO
IV fluids
Abx
Consult Surg for splenectomy, +/- ID consult if not sure of source
```
66
Splenic artery or sub-branch occluded by embolus, clot or by infection
Splenic infarct
```
Risk factors:
Hypercoagulable state (malignancy)
Embolic disease (afib, infective endocarditis)
Sickle cell disease
Trauma
Complication of mononucleosis
```
67
Why do you get splenomegaly with mono?
Because the infection causes compression of the splenic artery
68
Presentation of splenic infarct
```
Acute LUQ pain
+/- splenomegaly
Fever
N/V
Elevated LDH
Leukocytosis
```
69
Splenic infarct is diagnosed with...
CT scan with IV contrast
70
Treatment for splenic infarct
Varies due to cause
Uncomplicated —> analgesia, monitor
Complicated (abscess, sepsis, hemorrhage) —> surgical eval for splenectomy
Consult GI, surgery
71
Atraumatic hx —> splenic rupture
```
Neoplasm*** (esp leukemia, lymphoma) - most common
Infection (mono, CMV, HIV)
Inflammatory disease
Drug (anticoagulants)
Mechanical (pregnancy related)
Idiopathic
```
72
Presentation of splenic rupture
Pain, fullness in LUQ
Referred pain to left shoulder
Pleuritic pain
Early satiety
73
How is a splenic rupture diagnosed?
U/S (gold standard)
Maybe CT with IV contrast
74
Treatment for splenic rupture
NPO
IVF
Type and cross for transfusion
Immediate surgical splenectomy
75
Most common cause of small bowel obstruction
Prior abdominal/pelvic surgery (adhesions)***
```
Other causes:
Abdominal wall/groin hernia
Intestinal inflammation
Neoplasm (more common in large bowel)
Prior irradiation
FB ingestion
Intussusception/volvulus (both rare in adults)
```
76
What is obstipation?
Inability to pass flatus or stool
77
What will abdominal xray show in SBO?
Dilated loops of bowel with air fluid levels
| Proximal bowel dilation with distal bowel collapse
78
Advantage of CT over abdominal xray for SBO
Can ID severity
Masses, inflammatory changes
Necrosis, perforation, ischemia
79
Viable bowel ______ with IV contrast
Enhances (you’ll see a lighter outline)
Nonviable (ischemic) bowel will not enhance
80
Treatment for SBO
Admit, NPO, IVF, Anti-emetics
NG tube
Consult surgery, GI
Surgical intervention if not resolved with NG tube and bowel rest
Immediate surgery/abx if complicated
81
Decreased or no perfusion to section of the colon due to occlusive process (embolic, thrombotic, atherosclerotic)
Acute mesenteric ischemia
```
Risks:
Cardiac arrhythmias
Advanced age
Low cardiac output states
Valvular heart disease
MI
Malignancy
```
82
Presentation of arterial thrombotic/embolic mesenteric ischemia
Rapid onset, severe periumbilical pain out of proportion to PE
N/V common
Possible forceful bowel evacuation
Post-prandial pain (15-30 min)
+/- hematochezia
High mortality! (Venous thrombus —> more indolent course with lower mortality)
83
In diagnosing acute mesenteric ischemia, what do the plain abdominal films tell us?
Free air and signs of dead bowel —> laparotomy (for embolectomy or colon resection)
Otherwise, do an abdominal CT angiography with contrast
84
How to treat acute mesenteric ischemia
Admit with IVF, NPO, foley
Empiric abx (ceftriaxone and metronidazole)
Consider systemic anticoagulation
Consult GI, Surg, vascular/CV
85
Most common abdominal emergency
Appendicitis - blockage of appendix w/ stool, appendicolith, tumor with secondary infection
86
Patients <4 who have appendicitis have a _____ chance of perforation
70-90%
87
What is special about appendicitis pain in pregnancy?
Can present as RUQ in third trimester
88
Diagnosing appendicitis
No imaging needed if clinical appendicitis
If Dx unclear:
Abdominal xray (+/- appendicolith, free air)
U/S - limited
CT with contrast (shows inflammation, abscesses, fat stranding, fluid collection
MRI with contrast in pregnant patients
89
What abx do you start with appendicitis
Cefoxitin or cefazolin + metronidazole
90
How does Diverticulitis present?
Usually LLQ due to sigmoid involvment
N/V
+/- abdominal distension (esp if ileus)
Change in bowel habits
Urinary urgency, freq, dysuria
Low grade fever
Rebound and guarding
Localized tenderness
91
Hyperactive bowel sounds suggest _______
| Hypoactive suggests ________
Obstruction
Peritonitis
92
Preferred imaging for diverticulitis
CT with contrast - localized bowel thickening, colonic diverticula, abscesses, fistulas, dilated loops of bowel
93
Uncomplicated diverticulitis treatment
Home with oral abx (cipro and metro)
Close f/u within 2 days with GI
94
Complicated diverticulitis treatment
(If perforation, abscesses, fistula, obstruction)
```
Admit
IVF
NPO
IV abx (varies)
Consult GI +/- surgery
```
95
Toxic megacolon occurs most commonly as a complication of ...
IBD
Can also be due to volvulus, diverticulitis, obstructive colon cancer, C. diff, CMV in HIV+ patients
96
How does toxic megacolon present?
```
Severe, bloody diarrhea
Toxic appearance
AMS
Tachycardia
Fever
Postural hypotension
Abdominal distention and tenderness
```
97
Plain abdominal films of a patient with toxic megacolon will show...
Transverse/right colon most dilated (up to 15 cm), +/- airfluid levels
98
Criteria for clinical dx of toxic megacolon
```
Enlarged, dilated colon on xray
Fever >38C
HR >120bpm
Neutrophilic leukocytosis >10,500
Anemia
```
```
Plus:
Dehydration
AMS
Electrolyte disturbance
Hypotension
```
99
Treatment for toxic megacolon
No anti-motility agents/opioids
Broad spectrum IV abx (ampicillin, gentamicin, metro)
IV steroids
Surgical consult
100
What type of bleeding do you see with hemorrhoids?
Bright red, copious rectal bleeding
Can also see anal pruritis, Prolapse
Acute perianal pain or lump due to thrombosis
101
How to treat a thrombosis hemorrhoid
Can incise overlying skin and evacuate small clot
Provides immediate relief
Depends on non-surgical practitioner comfort level
102
Non-surgical treatment options for hemorrhoids
Increased fluids
| Increased fiber in diet
103
Severe pain in anal area, less commonly feverish but with an area of fluctuate/indurated skin
No findings on DRE
Perianal abscess
104
Treatment for perianal abscess
Simple anorectal abscess - can be drained in ER
Anesthetize the area, open wound, evacuate pus, irrigate well
DO NOT pack
Sits bath at home
Abx if assoc with cellulitis, signs of symptomatic infection, DM, valvular heart disease, or immunosuppression (Augmenting or Cipro AND metronidazole)
105
PE findings for rectal FB
Normal to diffuse peritonitis
Absence of palpable FB on DRE does NOT exclude presence
Plain radiography, flat and upright of abdomen, followed by CT scan if radio-opaque object
106
What are the two approaches to management of rectal FB?
Transanal removal with relaxation via IV sedation (painful and difficult)
Surgical removal
• Abd palpation —> caudal pressure and stabilization
• Laparascopy
• Colotomy with primary closure
Following removal, further evaluate with rigid proctoscopy or flex sig
107
When would you perform a transvaginal U/S?
Suspected ovarian neoplasms, masses
Torsion
Ectopic pregnancy
CT for further evaluation if needed following U/S
MRI in pregnant women
108
____% of ectopic pregnancies occur in...
Fallopian tubes
109
How does ectopic pregnancy present?
Vaginal bleeding with pain, typically 6-8 weeks after last menses
Can present with life-threatening hemorrhage if ruptured so monitor H&H
110
Ectopic pregnancy can be treated with _______ so long as...
Methotrexate
```
Not used if:
High hCG concentration
Fetal heart activity noted
Large ectopic size
Renal/liver disease
Breastfeeding
```
111
Suspected tubal rupture or hemodynamically unstable ectopic pregnancy patients will need...
Salpingectomy
Consult GYN
112
85% of PID cases are ______ related
STI - N. gonorrhea/C. trachomatis
Consider also testing for HIV/syphilis
113
Consider PID in patients with...
Fever/chills
New vaginal discharge (mucopurulent) and intermenstrual bleeding
Pelvic organ tenderness on palpation
Cervical friability
PResence of abundant WBCs on saline microscopy of vaginal fluid
114
Treatment of PID
IVF
Pain control
Anti-emetic
Abx:
Inpatient - Cefoxitin + doxy
Outpatient - Ceftriaxone + doxy
Blood cultures x 2 if admitting
115
Partial or complete rotation of ovary, often resulting in ischemia
Ovarian torsion
Presents with acute onset of pain, N/V, and adnexal mass on exam
May have abnormal genital tract bleeding
116
What is a marker of necrosis in patients with ovarian torsion?
Fever
117
What tumor marker indicates ovarian cancer?
CA 125
118
How does ovarian cancer present?
Adnexal mass and abdominal distention, bloating, early satiety
Weight loss
Urinary urgency and frequency
Acute - may be malignant effusion or SBO
119
Common cause of postpartum febrile mortality
Infection of endometrium after delivery
Presents with fever/chills and uterine tenderness
Foul smelling discharge (lochia)
Uterus may be soft, +/- excessive uterine bleeding
120
How is postpartum endometriosis treated?
Admit
IV abx (clindamycin and gentamicin IV)
Consult GYN
