ABD

Question 1

Etiologies of the acute abdomen

Answer 1

Inflammatory: bacterial, chemical Mechanical Neoplastic Vascular Congenital Traumatic

Question 2

Visceral anatomy

Answer 2

Helps determine where pain may be referred Epigastric– foregut Periumbilical– midgut Lower abdominal– hindgut

Question 3

Three types of pain

Answer 3

Visceral Somatic Referred (T10-11 dermatome, lower lobe pneumonia)

Question 4

Visceral pain

Answer 4

Results from stretching of autonomic fibers surrounding a hollow or solid viscus Crampy, colicky, gassy Usually intermittent Obstruction is common cause Usually ill-defined, diffuse May not have a point tenderness Pure visceral pain is midline

Question 5

Visceral pain: Dx

Answer 5

Appendicitis Cholecystitis Bowel obstruction Renal colic Any hollow organ can cause visceral pain– bladder, GB, ureters

Question 6

Somatic pain

Answer 6

Occurs when pain fibers located in parietal peritoneum are irritated by chemical or bacterial inflammation Represents inflammation occurring subsequent to obstruction or visceral pain Generally: sharper, more constant, more precisely localized to area of disease, usually tenderness localized to area of pathology

Question 7

If perforation is suspected….

Answer 7

DO NOT GIVE PO CONTRAST BARIUM Use Gastrografin or VoLumen (iodine)

Question 8

Referred Pain

Answer 8

Pain felt any distance from diseased organ Frequently follows classical patterns GB– radiates to R scapula Renal colic– radiates into groin/testes Diaphragmatic irritation– radiates to subraclavicular region

Question 9

Origins of intra-abdominal pain

Answer 9

Peritoneal inflammation Obstruction of a hollow viscus Vascular disorder

Question 10

Peritoneal inflammation

Answer 10

Somatic pain caused by inflammation of the peritoneum by an irritant Aseptic: gastric juice, pancreatic juice, bile, blood, urine Bacterial: Primary/spontaneous (cirrhosis, ascites) or secondary (disease or trauma to abdomen)

Question 11

Obstruction of a hollow viscus

Answer 11

Obstruction of intesting, ureter, biliary tree produces typical colicky pain Intestinal obstruction leads to N/V Intensity increased with proximal obstruction Common causes: neoplasm, adhesions, volvulus, hernia, intussusception, pyloric stenosis

Question 12

Vascular disorders

Answer 12

Bowel ischemia, infarction and aortic dissection, leakage or rupture are major abdominal vascular emergencies May present with atypical s/sxs Increased incidence with increasing age Almost always catastrophic consequences

Question 13

Abdominal wall pain

Answer 13

Usually secondary to trauma: muscle strain, contusion, hematoma

Question 14

PE of abdominal exam

Answer 14

Visual: Visceral pain– often doubled over, writhing for comfortable position Peritonitis pain– lie completely still, even gently tapping stretcher causes severe pain Ominous: diaphoresis, cyanosis, pallor, tachycardia, hypotension, orthostatic changes

Question 15

Cullen’s sign

Answer 15

Ecchymosis to peri-umbilical region

Question 16

Grey-turner sign

Answer 16

Ecchymosis to flank or abdomen

Question 17

Imaging studies in abdominal pain

Answer 17

Abdominal x-ray: flat and upright US CT– most definitive testing

Question 18

Elderly

Answer 18

Higher tolerance for pain results in later presentation Lower abdominal muscle mass results in paucity of findings Less physiologic reserve Paucity of findings results in significant delay in going to OR Delay in going to OR results in significant mortality, morbidity

Question 19

Infants, children

Answer 19

Causes of pain are similar, but may not be able to verbalize More common: acute appendicitis, volvulus, intussusception, pyloric stenosis

Question 20

Top 5 life threats

Answer 20

Abdominal aortic aneurysm Splenic rupture Ectopic pregnancy Acute MI Mesenteric infarction

Question 21

Acute appendicitis

Answer 21

RLQ pain, localizes from periumbilical region N/V, fever, occasionally diarrhea MCC of surgical acute abdomen in patients obstruction –> ischemia

Question 22

Dx of appendicitis

Answer 22

H&P: anorexia, N/V, fever, RLQ abdominal pain, peri-umbilical abdominal pain CBC w/diff: leukocytosis with shift to left UA Amylase/lipase: nonspecific Beta HCG (female) and trans-vag US

Question 23

Imaging for appendicitis

Answer 23

US– children CT scan– adults

Question 24

Questions to ask before surgery

Answer 24

NPO status Underlying comorbidities Surgical hx (esp. abdominal procedures) Allergies (to meds, family allergies) Coag (if suspicion)

Question 25

What is the most common surgical procedure in the western hemisphere?

Answer 25

Appendectomy

Question 26

What fluid would be good for management?

Answer 26

LR (unless renal disease)

Question 27

What abx would be good?

Answer 27

Know the hospital protocol Cephalosporin, most likely Cover gram negatives

Question 28

Treatment for appendicitis

Answer 28

Appendectomy Interval appendectomy Laparoscopy vs laparotomy Hydration Antibiotics Acute vs gangrenous vs perforated