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EMED Unit 1 > 5 Acute Abdomen > Flashcards

5 Acute Abdomen Flashcards

1
Q

______ is the leading cause of ER visits and hospital admissions

A

Abdominal pain - 35%

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2
Q

Up to 30% of patients with acute abdominal pain will be discharged with…

A

No specific diagnosis

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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
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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
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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
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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

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7
Q

PE RED FLAGS for abdominal pain

A

Rigid abdomen
Signs of shock
Involuntary guarding

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8
Q

Where does pain refer to:

Gallbladder disease

A

Right subscapular area

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9
Q

Where does pain refer to:

Perforated duodenal ulcer

A

Shoulders

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10
Q

Where does pain refer to:

Urethral obstruction

A

Testicles

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11
Q

Where does pain refer to:

MI

A

Epigastric area, jaw, neck, upper extremity

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12
Q

Where does pain refer to:

GYN

A

Low back

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13
Q

Describe visceral pain

A

Dull, aching, colicky

Poorly localized

Distention, ischemia, inflammation, or spasm of a hollow organ

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14
Q

Describe parietal pain

A

Sharp

Well localized

Peritoneal irritation, ischemia, inflammation/stretching of parietal peritoneum

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15
Q

Things that can present with abrupt, excruciating abdominal pain

A 
Biliary colic
Ureteral colic
MI
Perforated ulcer
Ruptured aneurysm
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16
Q

Things that can present with rapid onset of severe constant abdominal pain

A

Acute pancreatitis
Mesenteric thrombosis
Strangulated bowel
Ectopic pregnancy

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17
Q

Things that can present with gradual, steady abdominal pain

A 
Acute cholecystitis
Acute cholangitis
Acute hepatitis
Appendicitis
Acute salpingitis
Diverticulitis
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18
Q

Things that can present with intermittent, colicky pain, crescendo with free intervals

A 
Early pancreatitis (rare)
Small bowel obstruction
IBD
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19
Q

What aggravating/alleviating factors must you ask about when taking an abdominal pain Hx?

A

BM
Eating
Antacid use
Exertion

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20
Q

Why must we ask about prior abdominal surgery?

A

B/c they can develop adhesions —> small bowel obstruction

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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)

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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)

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23
Q

What must you remember to do in all patients with lower quadrant/hypogastric pain?

A

Testicular exam/pelvic exam and rectal exam

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24
Q

Marker of tissue hypoxia

A

Lactic acid - order if worried about organ ischemia

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25
Q

What Dx do you need to request an urgent surgical referral for?

A 
Obstruction
Perforation
Peritonitis
Ischemic bowel
Dissection

Rapid symptom evolution (inc tenderness/rigidity, pain is severe/out of proportion)

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26
Q

Causes of perforation of the GI tract

A

Spontaneous due to inflammatory changes (gallbladder, appendix)

Bowel obstruction

Trauma

Instrumentation

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27
Q

Clinical manifestation of perforation

A

Depends on organ affected

Air
Stool
Succus entericus (specific to pancreas)

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28
Q

Why is succus entericus so bad

A

Perforation of pancreas, releases various enzymes (lipase, lactase, amylase) and mucus to blood —> extremely damaging to tissue

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29
Q

GI perforations are more common in what age groups?

A

> 50 years or <10 years

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30
Q

How will the pain change if the inflammed organ perforates?

A

More diffuse pain after localized tenderness

Pain may be relieved, followed by peritonitis

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31
Q

Peritonitis occurs after _____ and will likely include what SSx

A

After perforation

High fever
May lead to sepsis/death
Localized = contained by surrounding viscera/omentum
Generalized = gross spillage into peritoneal cavity

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32
Q

When to suspect Spontaneous bacterial peritonitis vs secondary bacterial peritonitis

A

In patients with ascites, liver cirrhosis, fever, AMS, abdominal pain +/- hypotension (ALCOHOLICS)

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33
Q

How do you treat Spontaneous bacterial peritonitis?

A

Perform paracentesis but NO EXPLORATORY LAPAROTOMY

Mortality rate is 80% if laparotomy is attempted

Treat with Cefotaxime

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34
Q

When should you suspect secondary bacterial peritonitis?

A

Patients with possible perforation (peptic ulcer, appendicitis) with ascites, fever, AMS, abdominal pain +/- hypotension

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35
Q

How do you treat Secondary bacterial peritonitis

A

Perform paracentesis

MUST perform exploratory laparotomy - mortality rate of 100% if you don’t

Treat with Cefotaxime

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36
Q

Acute cholecystitis is usually associated with _________ that is usually related to __________

A

Gallbladder inflammation

Gallstone disease

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37
Q

Most common surgical emergency in the elderly

A

Acute cholecystitis (b/c they don’t feel as much pain)

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38
Q

How does acute cholecystitis present?

A

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

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39
Q

How will acute cholecystitis appear on labs/imaging?

A

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

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40
Q

How do you manage acute cholecystitis?

A

IV fluids, analgesia
NPO
Abx (Ceftriaxone, cefuroxime)
Surgical consult —> cholecystectomy

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41
Q

What is a non-operative option for acute cholecystitis?

A

Percutaneous Drainage
For unstable patients
Saves surgery until patient is more stable
Radiologic guidance necessary

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42
Q

Presence of gallstones within the common bile duct

A

Acute choledocholithiasis

Not just the cystic duct - so both liver and gallbladder effected

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43
Q

Most common cause of acute choledocholithiasis

A

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)

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44
Q

In what patients might primary choledocholithiasis occur?

A

CF patients

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45
Q

How does choledocholithiasis present

A

RUQ/epigastric pain

Palpable gallbladder (Courvoiseier’s sign - edema of gallbladder)

+/- jaudice

Elevated LFTs (vs no in cholecystitis…)

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46
Q

Test of choice for acute choledocholithiasis

A

Transabdominal U/S for presence of stones in gallbladder/common bile duct

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47
Q

Treatment for choledocholithiasis

A

Consult Surgery, GI

High risk patients: ERCP (85-90% success rate) to remove stone via endoscopy followed by elective cholecystectomy

Low risk patients: cholecystectomy

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48
Q

Complications of choledocholithiasis include…

A

Acute pancreatitis and acute cholangitis

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49
Q

Ascending bacterial infection due to obstruction of the biliary ducts

A

Acute cholangitis

Choledocholithiasis is the most common cause

Other causes: Biliary calculi, malignancy, benign stenosis

Medical emergency!

50
Q

What is the presentation of acute cholangitis?

A

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
Q

Management of acute cholangitis

A 
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
Q

Presentation of Hep A

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
Q

Treatment for Hep A

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
Q

Acute inflammatory process of the pancreas

A

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
Q

What type of pancreatitis involves well localized pain with rapid onset?

A

Gallstone pancreatitis

56
Q

Other types of pancreatitis that cause less well localized, slower progressing pain

A

Alcohol (large amounts, chronically)
Drugs (Amiodarone, antivirals, diuretics, NSAIDs, abx)
Severe HLD
Idiopathic

57
Q

Presentation of pancreatitis

A

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
Q

Specialized PE findings for pancreatitis

A

Cullen’s sign - periumbilical superficial edema and bruising

Grey Turner sign - ecchymotic discoloration along the flanks due to retroperitoneal bleeding from pancreatic necrosis

59
Q

How to diagnose pancreatitis

A

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
Q

To diagnose pancreatitis and move straight to management w/o imaging, you need two of the following three criteria to be met:

A

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
Q

How is pancreatitis managed?

A 
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
Q

Risk factors for PUD

A

NSAID use
H. pylori infection
Smoking
Excessive vomiting

63
Q

Splenic abscess typically results from…

A

Endocarditis or seeding from another site

Presentation:
LUQ pain+/- splenomegaly
Fever
+/- left side pleural effusion

64
Q

How to diagnose splenic abscess

A

CT scan with IV contrast

65
Q

Treatment of splenic abscess

A 
Admit
NPO
IV fluids
Abx
Consult Surg for splenectomy, +/- ID consult if not sure of source
66
Q

Splenic artery or sub-branch occluded by embolus, clot or by infection

A

Splenic infarct

Risk factors:
Hypercoagulable state (malignancy)
Embolic disease (afib, infective endocarditis)
Sickle cell disease
Trauma
Complication of mononucleosis
67
Q

Why do you get splenomegaly with mono?

A

Because the infection causes compression of the splenic artery

68
Q

Presentation of splenic infarct

A 
Acute LUQ pain
\+/- splenomegaly 
Fever
N/V
Elevated LDH
Leukocytosis
69
Q

Splenic infarct is diagnosed with…

A

CT scan with IV contrast

70
Q

Treatment for splenic infarct

A

Varies due to cause

Uncomplicated —> analgesia, monitor

Complicated (abscess, sepsis, hemorrhage) —> surgical eval for splenectomy

Consult GI, surgery

71
Q

Atraumatic hx —> splenic rupture

A 
Neoplasm*** (esp leukemia, lymphoma) - most common
Infection (mono, CMV, HIV)
Inflammatory disease
Drug (anticoagulants)
Mechanical (pregnancy related)
Idiopathic
72
Q

Presentation of splenic rupture

A

Pain, fullness in LUQ
Referred pain to left shoulder
Pleuritic pain
Early satiety

73
Q

How is a splenic rupture diagnosed?

A

U/S (gold standard)

Maybe CT with IV contrast

74
Q

Treatment for splenic rupture

A

NPO
IVF
Type and cross for transfusion
Immediate surgical splenectomy

75
Q

Most common cause of small bowel obstruction

A

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
Q

What is obstipation?

A

Inability to pass flatus or stool

77
Q

What will abdominal xray show in SBO?

A

Dilated loops of bowel with air fluid levels

Proximal bowel dilation with distal bowel collapse

78
Q

Advantage of CT over abdominal xray for SBO

A

Can ID severity
Masses, inflammatory changes
Necrosis, perforation, ischemia

79
Q

Viable bowel ______ with IV contrast

A

Enhances (you’ll see a lighter outline)

Nonviable (ischemic) bowel will not enhance

80
Q

Treatment for SBO

A

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
Q

Decreased or no perfusion to section of the colon due to occlusive process (embolic, thrombotic, atherosclerotic)

A

Acute mesenteric ischemia

Risks:
Cardiac arrhythmias
Advanced age
Low cardiac output states
Valvular heart disease
MI
Malignancy
82
Q

Presentation of arterial thrombotic/embolic mesenteric ischemia

A

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
Q

In diagnosing acute mesenteric ischemia, what do the plain abdominal films tell us?

A

Free air and signs of dead bowel —> laparotomy (for embolectomy or colon resection)

Otherwise, do an abdominal CT angiography with contrast

84
Q

How to treat acute mesenteric ischemia

A

Admit with IVF, NPO, foley

Empiric abx (ceftriaxone and metronidazole)

Consider systemic anticoagulation

Consult GI, Surg, vascular/CV

85
Q

Most common abdominal emergency

A

Appendicitis - blockage of appendix w/ stool, appendicolith, tumor with secondary infection

86
Q

Patients <4 who have appendicitis have a _____ chance of perforation

A

70-90%

87
Q

What is special about appendicitis pain in pregnancy?

A

Can present as RUQ in third trimester

88
Q

Diagnosing appendicitis

A

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
Q

What abx do you start with appendicitis

A

Cefoxitin or cefazolin + metronidazole

90
Q

How does Diverticulitis present?

A

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
Q

Hyperactive bowel sounds suggest _______

Hypoactive suggests ________

A

Obstruction

Peritonitis

92
Q

Preferred imaging for diverticulitis

A

CT with contrast - localized bowel thickening, colonic diverticula, abscesses, fistulas, dilated loops of bowel

93
Q

Uncomplicated diverticulitis treatment

A

Home with oral abx (cipro and metro)

Close f/u within 2 days with GI

94
Q

Complicated diverticulitis treatment

A

(If perforation, abscesses, fistula, obstruction)

Admit
IVF
NPO
IV abx (varies)
Consult GI +/- surgery
95
Q

Toxic megacolon occurs most commonly as a complication of …

A

IBD

Can also be due to volvulus, diverticulitis, obstructive colon cancer, C. diff, CMV in HIV+ patients

96
Q

How does toxic megacolon present?

A 
Severe, bloody diarrhea
Toxic appearance
AMS
Tachycardia
Fever
Postural hypotension
Abdominal distention and tenderness
97
Q

Plain abdominal films of a patient with toxic megacolon will show…

A

Transverse/right colon most dilated (up to 15 cm), +/- airfluid levels

98
Q

Criteria for clinical dx of toxic megacolon

A 
Enlarged, dilated colon on xray
Fever >38C
HR >120bpm
Neutrophilic leukocytosis >10,500
Anemia
Plus:
Dehydration
AMS
Electrolyte disturbance
Hypotension
99
Q

Treatment for toxic megacolon

A

No anti-motility agents/opioids

Broad spectrum IV abx (ampicillin, gentamicin, metro)

IV steroids

Surgical consult

100
Q

What type of bleeding do you see with hemorrhoids?

A

Bright red, copious rectal bleeding

Can also see anal pruritis, Prolapse

Acute perianal pain or lump due to thrombosis

101
Q

How to treat a thrombosis hemorrhoid

A

Can incise overlying skin and evacuate small clot

Provides immediate relief

Depends on non-surgical practitioner comfort level

102
Q

Non-surgical treatment options for hemorrhoids

A

Increased fluids

Increased fiber in diet

103
Q

Severe pain in anal area, less commonly feverish but with an area of fluctuate/indurated skin

No findings on DRE

A

Perianal abscess

104
Q

Treatment for perianal abscess

A

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
Q

PE findings for rectal FB

A

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
Q

What are the two approaches to management of rectal FB?

A

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
Q

When would you perform a transvaginal U/S?

A

Suspected ovarian neoplasms, masses
Torsion
Ectopic pregnancy

CT for further evaluation if needed following U/S

MRI in pregnant women

108
Q

____% of ectopic pregnancies occur in…

A

Fallopian tubes

109
Q

How does ectopic pregnancy present?

A

Vaginal bleeding with pain, typically 6-8 weeks after last menses

Can present with life-threatening hemorrhage if ruptured so monitor H&H

110
Q

Ectopic pregnancy can be treated with _______ so long as…

A

Methotrexate

Not used if:
High hCG concentration
Fetal heart activity noted
Large ectopic size
Renal/liver disease
Breastfeeding
111
Q

Suspected tubal rupture or hemodynamically unstable ectopic pregnancy patients will need…

A

Salpingectomy

Consult GYN

112
Q

85% of PID cases are ______ related

A

STI - N. gonorrhea/C. trachomatis

Consider also testing for HIV/syphilis

113
Q

Consider PID in patients with…

A

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
Q

Treatment of PID

A

IVF
Pain control
Anti-emetic

Abx:
Inpatient - Cefoxitin + doxy
Outpatient - Ceftriaxone + doxy

Blood cultures x 2 if admitting

115
Q

Partial or complete rotation of ovary, often resulting in ischemia

A

Ovarian torsion

Presents with acute onset of pain, N/V, and adnexal mass on exam

May have abnormal genital tract bleeding

116
Q

What is a marker of necrosis in patients with ovarian torsion?

A

Fever

117
Q

What tumor marker indicates ovarian cancer?

A

CA 125

118
Q

How does ovarian cancer present?

A

Adnexal mass and abdominal distention, bloating, early satiety

Weight loss

Urinary urgency and frequency

Acute - may be malignant effusion or SBO

119
Q

Common cause of postpartum febrile mortality

A

Infection of endometrium after delivery

Presents with fever/chills and uterine tenderness

Foul smelling discharge (lochia)

Uterus may be soft, +/- excessive uterine bleeding

120
Q

How is postpartum endometriosis treated?

A

Admit

IV abx (clindamycin and gentamicin IV)

Consult GYN

EMED Unit 1 (5 decks)

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