Abdomen Flashcards
PEDIATRIC PRESENTATION
A child between the ages of 6 months and 6 years who ingested a coin, as witnessed by or reported to a caregiver.
Followed by coughing, choking, drooling, refusal to eat, and/or difficulty swallowing.
Initial symptoms are often transient and self-resolving.
Up to 50% of children may have no signs or symptoms of ingestion at all.
ADULT PRESENTATION
Adult patient will typically have a sudden onset of pain or dysphagia during a meal. Often, the patient is an elderly individual who is attempting to swallow inadequately masticated food.
Common symptoms include retrosternal pain, dysphagia, odynophagia, and drooling.
This condition is commonly associated with an underlying pathology in adults, such as strictures, eosinophilic esophagitis, dysmotility disorders, esophageal diverticulum, esophageal web, Schatzki ring, or malignancy
esophageal FB
-80% of all cases are pediatric
-Peds = often objects like coins (MC), toys, pen caps, magnets
-Symptoms: Coughing, choking, drooling, refusal to eat, vomiting, painful swallow
-Possible perforation: Neck swelling, pain, or crepitus
-Possible airway compression by foreign body: Wheezing or stridor
-Adults = Often food impaction (meat) and bones
-Retrosternal chest pain, retching, odono-/dys-phagia, choking, coughing
-PE may include oropharyngeal erythema, neck tenderness, or swelling.
-Possible perforation: Crepitus
-Intentional ingestions are more likely to occur in those with psychiatric disorders, intellectual disability, prisoners, body packers
-Psych and prisoners -> Razors, spoons, etc.
-90% of esophageal foreign bodies will pass through the GI system spontaneously
esophageal FB: Where do objects tend to get stuck?
Cricopharyngeus muscle (C6/T1) (MC peds)
Aortic arch (T4)
GE junction (T11) (MC adults)
esophageal FB: dx
-Diagnostic tests
-History and physical alone are enough to make diagnosis
-Laboratory tests are not often needed in uncomplicated cases
-XR imaging: helpful, but many objects are not radio-opaque
-AP/Lateral soft tissue neck
-AP/Lateral chest xray
-AP/Lateral abdominal xr
-Serial XRAYS for monitoring progression
-CT is preferred for locating small, radiolucent objects or if there is concern for perforation
-Chicken or fish bone
-Small plastic pieces
-Endoscopy = locates / removes the FB, procedure of choice!
diff dx: esophageal FB
Tracheal foreign body
Esophageal spasm- nutcracker
Infectious esophagitis
Pill esophagitis
Reflux esophagitis
Globus pharyngeus (globus sensation)
esophageal FB: when do we do endoscopy
-Urgent GI consult for endoscopy within 4-6 hrs if:
-*Button battery – most dangerous
-Persistent or Severe symptoms (cannot tolerate secretions or airway compromise)
-Multiple magnets, or, single magnet PLUS metallic objects
-> 24 hours without passing the pylorus
-Sharp objects in esophagus that can perforate
-Large size (width>2.5 or length>6 cm)
-Multiple objects
-Coin at the criopharyngeous
-Urgent EGD can be performed within 24 hours in patients without concerning symptoms or history
coin ingestion
-35% asymptomatic
-Trachea = sagittal plane
-Esophagus = frontal plane
-Tx: Endoscopy
-Prior to endoscopy, protect the airway =ET tube
-Asymptomatic= within 24 hours
-Symptomatic (respiratory symptoms, drooling) = emergent
button battery
-TRUE EMERGENCY
-Burns within 4 hours
-Perforation within 6 hours
-XR: “double halo” (sometimes)
-Consult GI for EMERGENT endoscopy
-Start broad spectrum antibiotics
-!Honey can be given at regular intervals to patients with button battery ingestion
-Honey acts by neutralizing the tissue pH, which helps to reduce the severity of tissue damage by the button battery.
-If passed pylorus and asymptomatic can monitor
-Should pass within 2-3 days!
objects pass the pylorus
-2 year old swallowed two nails approximately 4cm in length
-XR showed passed pylorus
-No evidence of perforation
-Opted for medical management
-Successful passing after 4 days
-lets the kid poop it out…if it perforates you need surgery anyways -> wait
esophageal food impaction
-Meat = give time and sedation, often passes spontaneously, do not allow to sit > 12 hours in esophagus
-Treatment options
-!Endoscopic retrieval
-!Glucagon: 0.5-1mg IV relaxes lower esophageal sphincter (side effect: nausea + vomiting)
-Nitroglycerin SL 0.4mg has been described in case reports to resolve impaction in adults
-Nifedipine: 10mg SL reduces lower esophageal tone (caution: hypotension)
-Not recommended:
-Carbonated beverage: gaseous distension to push it down
-Meat tenderizer – causes perforations!
-Consider WHY they had an impaction
-Esophageal dysmotility?
-Anatomic barriers such as schatzkis ring, strictures, malignancy?
disposition for esophageal FB
-Admission
-Those with esophageal foreign bodies and related complications require immediate consultation with a gastroenterologist or surgeon and may need retrieval within 6 hours.
-These patients likely require admission to the operating room or ICU:
-Patients with inability to tolerate oral intake
-Patients with persistent symptoms
-Discharge home
-Patients who pass their foreign body or have removal without complication can be safely discharged home.
-Follow-up with primary care and gastroenterology should be considered in all patients, especially those with food impaction, due to the high rate of underlying pathology.
-Caregivers should have education on home safety and avoidance of high-risk objects.
approach to N/V
-MC in adults: Gastritis, Gastroenteritis, Febrile systemic illness, Drug effects
-MC in peds: Infections
-Expand your differentials past GI
-Alcohol
-Drug toxicities
-Infections – Viral syndromes, Sepsis
-Neuro – brain bleeds, pseudotumor
-Cardiovascular – MI
-Endocrine – DKA
-Pregnancy – Hyperemesis gravidarum
-Vestibular system
-Cancer side effects
-Miscellaneous – Glaucoma, psychiatric, cannabinoid hyperemesis syndrome
key concepts for abdominal pain
-Acute abdominal pain = pain of non traumatic origin for max 5 days
-Abdominal pain accounts for 7-10% of all ED visits in the US
-dx challenge:
-dx of “non-specific abdominal pain” (31%)
-dx of renal colic (31%)
-Conventional plain film is of limited utility as routine investigation
-Only valuable in patients with suspected perforated viscus and LBO
-Surgery begets surgery
-After an appropriate evaluation showing no emergent cause of abdominal pain, a trial of oral intake, a repeat abdominal physical exam … a clear timeline for follow up and strict return to ED precautions should be discussed. Remind the patient that some causes of abdominal pain only reveal themselves in time.
top 5 CANT MISS causes of abdominal pain
-aortic dissection
-ruptured AAA
-mesenteric ischemia
-intestinal obstruction
-perforated viscus
-ectopic pregnancy
-extra-abdominal diseases
-ALWAYS consider a pelvic exam in females, and a testicular exam in males
-ALWAYS consider pulmonary or cardiac cause for upper abdominal pain
general lab eval
-Basic Labs are generally within normal limits
-Lipase =
-Lactate is often elevated in sepsis and bowel ischemia / mesenteric ischemia
-Troponin consideration in epigastric pain
-UA
-Hematuria is found in cystitis, nephrolithiasis, renal vein occlusion, AAA
-Pyuria is found in UTI and sometimes appendicitis
-Pregnancy testing
imaging in abdominal pain
-Plain radiography
-Not generally helpful. Can be a good screening for bowel obstruction, bowel perforation (upright CXR), and radioopaque foreign bodies
-Ultrasound
-Initial study of choice for pregnancy women, suspected AAA (unstable at bedside), gallbladder disease, pediatric appendicitis.
-CT is the study of choice for undifferentiated abdominal pain in patients not expected to have biliary or reproductive disease
-MRI
-Consider in pediatric appendicitis, pregnancy appendicitis
acute abdominal pain management
-Antiemetics for nausea vomiting
-In a pinch: Isopropyl alcohol swabs
-Ondansetron (Zofran) is generally first line
-Metoclopramide (Reglan) with -Benadryl to decrease dystonia risk
-Haloperidol (Haldol) is good for intractable N/V in gastroparesis, cannabinoid hyperemesis syndrome, and acute on chronic abdominal pain
-Topical capsacin : For cannabinoid hyperemesis syndrome or gastroparesis (applied to abdomen)
-Pain control
-Typically patients are kept NPO until sure there is no surgical intervention
-Acetaminophen
-Opioids: morphine, hydromorphone, fentanyl
-Ketorolac (Toradol) is an NSAID, used for renal colic, but not generally due to contraindications if patient goes for surgery
-“GI Cocktail”
-Antacid such as Maalox or Mylanta, viscous lidocaine, and H2 block famotidine
-Treatment for likely dyspepsia and gastritis
abdominal pain the ER
-After a thorough workup, the large majority of discharged patients with abdominal pain of unknown origin are found to have a benign condition and discharged.
-In a retrospective study of discharged ED patients with abdominal pain, only 7.9% re-presented with abdominal pain, and 76% of these patients were once again given the same diagnosis of non-specific abdominal pain
acute abdomen
-Acute abdomen = urgent attention and treatment
-Often due to: infection, inflammation, ischemia, obstruction, free air
-ILL-APPEARING
-Peritoneal signs: rigid abdomen, guarding, rebound, absent bowel sounds
-Diagnosing a patient with a full-blown acute abdomen is easy!!!
-It’s the early presentations that are hard to detect
CL is a 71M hx HLD, squamous cell CA of tonsil diagnosed 11/12/18, admitted 11/20-11/30/18 from ENT clinic for oncology workup and PEG tube placement on 11/26, BIBEMS from home for severe abdominal pain on attempted use of PEG tube. The last time it was used normally was yesterday morning (12/1). Around 4pm today, a helper at home tried to push water and then tube feed through the tube, but it caused excruciating pain. Patient also endorses nausea but no vomiting. Has been passing gas but has not had a bowel movement in a few days. Currently has LUQ abdominal pain that is non-radiating and severe. +Nausea without emesis.
What do you want to do based off the information so far?
Moved to monitored area, 2 large bore IV placed, fluids given, pain control given
Physical exam:
General: Cachetic, NAD, A&Ox3
HEENT: Normocephalic, non-icteric sclera, normal ROM of neck/supple
CV: RRR, normal heart sounds without murmur
Pulm: Crackles in LLL, diminished on right side. Effort normal, no distress, no stridor, no wheezing.
Abdomen: Generalized tenderness. Rigidity. Guarding. Rebound. PEG tube in place. No surrounding erythema/induration around site. No distension.
Skin: Warm and dry without noted rash. Extremities without edema
-PERFORATED VISCUS
perforated viscus
-causes: inflammation, ulceration, trauma, obstruction
-leads to peritonitis -> life threatening
-anywhere from stomach to the rectum
-Extremely dangerous!
-Peritoneum does not like air
-Peritoneum does not like gut microbes -> sepsis
-Typical presentation:
-!!Abrupt, severe pain
-↑ HR, ↓ BP, ± fever
-Exam: Distress w/ peritoneal signs
-!Rigidity
-!Pain to light palpation
-!Involuntary guarding
-sepsis/shock
-ill appearing
-early -> focal tenderness
-late -> Peritoneal signs, laying still (shake the bed, jump), difuse tenderness and rigidity, rebound and guarding
causes of perforated viscus
-perforated peptic ulcer -MC
-NSAIDs, smoking, ETOH use, gastritis
-hematemesis, melena, hematochezia
-local inflammation
-appendicitis, diverticulitis!!!!, crohns, etc.
-post-instrumentation
-colonoscopy, postop, PEG, foreign body
-bowel perforation/ischemia
-prior abdominal surgery, SBO, cancer
perforated viscus: labs
-Labs will not dx
-Pre operative labs
-Urine hcg
-Lactic acid level
-xray:
-Peritoneal air under diaphragm in upright CXR
-Lateral decubitus -> free air between liver edge and wall
-False neg -> If minimal air, might miss it
-Limitations -> doesnt tell us WHERE
-CT abdomen pelvis
-Both sensitive & specific for free air
-Can localize the perforation
-Evaluates for other cause of pain
-Limitations -> Requires pt to be stable
-Limitations -> Needs IV contrast and if time permits, water soluble PO contrast
left lateral decubitis
-perforated viscus
