ABD Flashcards
Etiologies of the acute abdomen
Inflammatory: bacterial, chemical Mechanical Neoplastic Vascular Congenital Traumatic
Visceral anatomy
Helps determine where pain may be referred Epigastric– foregut Periumbilical– midgut Lower abdominal– hindgut
Three types of pain
Visceral Somatic Referred (T10-11 dermatome, lower lobe pneumonia)
Visceral pain
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
Visceral pain: Dx
Appendicitis Cholecystitis Bowel obstruction Renal colic Any hollow organ can cause visceral pain– bladder, GB, ureters
Somatic pain
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
If perforation is suspected….
DO NOT GIVE PO CONTRAST BARIUM Use Gastrografin or VoLumen (iodine)
Referred Pain
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
Origins of intra-abdominal pain
Peritoneal inflammation Obstruction of a hollow viscus Vascular disorder
Peritoneal inflammation
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)
Obstruction of a hollow viscus
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
Vascular disorders
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
Abdominal wall pain
Usually secondary to trauma: muscle strain, contusion, hematoma
PE of abdominal exam
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
Cullen’s sign
Ecchymosis to peri-umbilical region
Grey-turner sign
Ecchymosis to flank or abdomen
Imaging studies in abdominal pain
Abdominal x-ray: flat and upright US CT– most definitive testing
Elderly
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
Infants, children
Causes of pain are similar, but may not be able to verbalize More common: acute appendicitis, volvulus, intussusception, pyloric stenosis
Top 5 life threats
Abdominal aortic aneurysm Splenic rupture Ectopic pregnancy Acute MI Mesenteric infarction
Acute appendicitis
RLQ pain, localizes from periumbilical region N/V, fever, occasionally diarrhea MCC of surgical acute abdomen in patients obstruction –> ischemia
Dx of appendicitis
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
Imaging for appendicitis
US– children CT scan– adults
Questions to ask before surgery
NPO status Underlying comorbidities Surgical hx (esp. abdominal procedures) Allergies (to meds, family allergies) Coag (if suspicion)
