Abdomen Flashcards
location of visceral pain and often accompanied with
vague and midline →nausea, pallor, diaphoresis
arises from the walls of hollow viscera and solid organs → due to abnormal stretching/distention, ischemia or inflammation
visceral pain
pain that is sharp in quality and is well localized
somatic pain
arises from the parietal peritoneum, mesneteric roots, and anterior abdominal wall due to chemical or bacterial inflammation
somatic pain
pain due to fibers from different organs returning to CNS overlapping with pathways from cutaneous sites which had similar embryologic origin
referred pain
Diaphragmatic irritation that refers pain to the shoulder via C4 due to splenic rupture/abscess, renal calculi, ruptured ectopic
Kehr’s Sign
pulsatile and well localized pain
burns, lacterations, fractures, infection, inflammations
somatic pain
aching and cramping, nonpulsatile, poorly localized pain or referred to distant locations
angina, hepatic distention, bowel distention, hypermobility, pancreatitis
visceral pain
spontaneous, burning, lancinating or shooting pain → may be distal or proximal to site of injury
complex regional pain syndrome, sciatica
neuropathic pain
stomach, 1st and 2nd parts of duodenum, liver, gallbladder, pancreas
epigastric area
3rd and 4th parts of duodenum, jejunum, ileumm, cecum, appendix, ascending colon, first two thirds of transverse colon
periumbilical area
last one third of transverse colon, descending colon, sigmoid, sectum, intraperitoneal GU organs
suprapubic area
two big history points to hit in patient with abdominal pain
social hx. (IVDA, Smoke, EtOH, GU, STD, pregnancy hx)
surgical hx.
respiratory arrest on inspiration during palpatino of RUQ [cholecystitis]
Murphy’s Sign
pain referred to RLQ on palpation of LLQ [appendicitis]
Rovsing Sign
Pain with internal rotation of flexed hip
Obturator Sign
Pain with hyperextension of hip
Psoas Sign
patients coming to ED for abdominal pain should be…
NPO
where are pediatrics most likely to have foreign body entrapment in their esophagus?
upper esophageal sphincter
where are adults most likely to have foreign body entrapment in their esophagus?
lower esophageal sphincter
sign that esophageal foreign body has > 80% chance of passing
if it reaches the stomach
MC cause of esophageal foreign body in adults
mechanical dysfunction
diameters of object that will not pass through the esophagus
> 2.5 cm wide and > 6 cm long
MC common GI foreign bodies in pediatrics
food boluses and other object (coins, toy, button battery, magnet)
how will esophageal foreign body present in an adult?
foreign body sensation → mild/severe pain
can’t swallow/handle secretions, drooling, spitting, vomiting
issue with foreign bodies in pediatrics patients
asymptomatic or can’t communicate
Worse cause scenario for foreign esophageal body in pediatric patient
In UES → tracheal impingement → stridor, respiratory compromise, death
sodium hydroxide is generated by current produced by the battery → 20 mm button batteries have higher capacitance and generate more current compared to other disc batteries
liquefaction necrosis
How can you differentiate button batteries from coins?
X-ray will show “double contour” of button battery
Time line for button battery:
liquefaction necrosis
perforation
LN → as early as 2 hours
Perforation → 6 hours
methods to remove button battery
endoscopy
Foley catheter removal
Magill forceps removal
Even though a button battery is removed, what can continue to cause injury in the body?
residual alkali
weakened tissues
You supect patient has foregin body in esophagus that you can’t see on X-ray, what should you order next?
CT
Giving this will supposedly help move esophageal foreign body
Glucagon
How do you usually remove esophageal foreign body? What if that foreign body is a magnet?
endoscopy
magnet → open exploratory laparotomy
which esophageal FB may pass alone?
distal smooth solitary FB
MC cause of esophageal perforation
iatrogenic (endoscopy and dilation)
Boerhaave Syndrome, Mallory-Weiss tear, trauma, FB, infection, ingestion
why does esophageal perforation have high mortality?
gastric contents leaking into mediastinum and pleural space, etc
acute, severe, diffuse , unrelenting chest/neck/abdominal pain that radiates to back/shoulder
Esophageal perforation
What is Mackler’s Triad? Indicates?
Vomiting, chest pain, SubQ emphysema
Esophageal rupture
Hallmark sign for esophageal rupture
Subcutaneous emphysema → will appear usually after 1 hour of onset
raspy, crunchy sound heard over precordium with each heartbeat
Hammon crunch
signs of esophageal rupture
tachycardia
tachypnea
NO HEMATEMESIS
What makes the pain worse with esophageal rupture?
swallowing or laying supine
Chest X-ray indicators for pneumomediastinum
SubQ emphysema mediastinal air fluid levels pleural effusion free air under the diaphragm pneumothorax
You see pneumomediastinum on CXR, what do you order next?
contrast esophagogram (+ water soluble agent) CT Chest with contrast
3 antibiotic options for esophageal rupture
piperacillin-tazobactam (Zosyn)
ceftriaxone + metronidazole (flagyl)
clindamycin
Esophageal rupture is a ____
emergency surgical consult
suspensatory muscle of duodenum, thin muscle connecting junction between duodenum, jejunum, and duodenojujenal flexure to connective tissue surrounding superior mesenteric artery and coeliac artery
Ligament of Treitz
MC location of GI bleed
Upper GI Bleed → proximal to ligament of treitz
PUD, erosive gastritis/esophagitis, esophageal/gastric varices, Mallory-Weiss tear, alcoholic, ASA/NSAID use
MC cause of lower GI bleed
diverticular disease, anal fissue, AVM, colitis (ischemic or infetious), polyps, malignancy, anticoagulant/NSAID, hemorrhoids
Signs of Upper GI Bleed
hematemesis, coffee ground emesis, melena
why is hematochezia worrisome in Upper GI bleed?
indicates rapid transit through intestines
subcutaneous emphysema with history of vomiting → presenting with retrosternal CP
Boerhaave’s Syndrome
where does Boerhaave’s most likely occur?
lower 1/3 esophagus → posterolateral distal esophagusepigastric
severe vomiting then painless hematemesis → 90% are self-limiting
Mallory Weis tear
Who are Mallory Weis tears MC in
patient with Cirrhosis
Describe the type of tear in in Mallory Weis
incomplete → only mucosa and submucosa tear
These are the result of portal HTN due to cirrhosis or banding
esophageal varices
Signs of shock
tachycardia/hypotension
poor perfusion
AMS
How do you determine if red/black stool is due to blood or other cause?
Hemoccult test
Maroon stool indicates
LGIB from right side or small bowel
Bright red stool indicates
LGIB from the left side
Painless bleeding occurs with…
diverticular bleed
anticoag use
internal hemorrhoids
Fever + diarrhea + severe/crampy pain + GI bleed
UC, Crohns, C. diff
management for upper GI bleed
protonix
octreotide
balloon tamponade
this inhibits flucagon release and other hormones → reduces GI motility and gastric emptying → decreases splanchnic blood flow and portal venous pressure
Octreotide
who is the Balloon Tamponade for UGIB contraindicated in?
Mallory Weis tear
when is endoscopy for UGIB contraindicated?
perforated stomach, esophagus, instestine
Methods to find LGIB
colonoscopy
tagged RBC scan
angiography (SMA → IMC → celiac a.)
severe and sudden epigastric pain → slight movement worsens the pain → diaphoresis, pale, rebound, tachycardia, guarding, rigidity, hypotension
perforated ulcer
CXR of perforated ulcer reveals
free abdominal air → elevating the diaphragm
Treatment for perforated ulcer
open laparotomy with washout and repair
gallstones obstruct cystic duct for prolonged period of time → inflammation of gallbladder wall results
acute cholecystitis
Acute cholecystitis develops in 20% of patients with ____ if left untreated
biliary colic
6 F’s of acute cholecystitis
Female Fat Forty Fertile Family history Fair
pain begins in epigastric region and localizes to RUQ
acute cholecystitis
Acute cholecystitis may present with ____
positive Murphy’s Sign
1 diagnostic test for acute cholecystitis
Ultrasound of RUQ → pericholecystic fluid, gallbladder wall thickening (>4 mm) → best if NPO 8 hours prior
2 diagnostic test for acute cholecystits
HIDA scan
What should you order to assess complications of cholecystitis nonspecific to US?
CT abdomen/pelvis with contrast
Antibiotics for acute cholecystits
piperacillin-tazobactam (zosyn)
ampicillin - sulbactam
meropenem
antibiotic used in severe life-threatening cases of cholecystitis
imipenem - cilastatin (primaxin)
MC cause of cholangitis
choledocholithiasis
stone in cystic or common hepatic duct → obstruction
Charcot Triad
fever
RUQ pain
jaundice
malignant obstruction of gallbladder will have higher levels of what
bilirubin
antibiotics for cholangitis
piperacillin
ceftazadime
ampicillin
metronidazole
diagnostic procedure for cholangitis
MRCP → Magnetic resonance cholangiopancreatography
initial treatment for sever cholangitis
endoscopic or perQ biliary drainage and decompression
acute inflammation of pancreas where pancreatic enzymes digest the gland → obstruction of pancreatic/bile duct or direct toxicity to pancreatic cells → inflammation resulting in increased pancreatic enzyme activation
pancreatitis
MC cause of pancreatitis
cholelithiasis
ecchymosis/discoloration of umbilicus
Cullen’s Sign
ecchymosis/discoloration of flanks
Grey Turner Sign
which is more specific for pancreatitis - lipase of amylase?
elevated lipase (2-3x normal)
Used to predict risk of mortality in pancreatitis
Randon Criteria
antibiotics for severe pancreatitis
Cipro + flagyl
meropenem
imipenden-cilastatin
which pancreattis cases get admitted
new onset → look for pseudocyst, abscess, mass, hepatits, EtOH withdrawal, gallstone
MC cause of spontaneous bacterial peritonitis
patient on peritoneal dialysis (PD)
MC organism with bacterial peritonitis
3/4 due to anaerobic Gram (-) → E. coli
How do you diagnose spontaneous bacterial peritonitis?
paracentesis
Antibiotic treatment for spontaneous bacterial peritonitis
cefotaxime
oral ofloaxacin
fluoroquinolone
MC cause of infectious diarrhea
norovirus
Treatment for infectious diarrhea
IV fluid
electrolyte replacement
antiemetic
+/- antibiotics (cipro + flagyl)
cause of C. dif
antibiotic use > 3 months
How do you diagnose C. Difficile?
stool culture + PCR
What must you do with your C. dif patients?
place on contact precautions → highly contagious
if C. dif colitis patient is healthy and stable what do you discharge them with?
metronidazole
Treatment for C. dif patients who need hospitalization → severe disease, fever, pain, immunocompromised
ORAL vancomycin
C. diff coliits with yelowish plaques of exudate replace necrotic intestinal mucosa
pseudomembranous colitis
Treatment for pseudomembranous colitis
metronidazole AND Oral Vanc
RLQ pain + N/V + rarely constipation + rectal sparing
Crohns
periumbilical/LLQ pain + constipation + commonly have bloody stool + always involves rectum
ulcerative colitis
extraintestinal manifestations of Inflammatory Bowel
arthritis
uveitis
liver disease
Crohn’s patients typically have
perianal disease
why do you avoid antibiotics in UC/CD cases?
increased risk of antibiotic associated colitis
inflammation of diverticular from fecalith
diverticulitis
Where will patients with diverticulitis have abdominal pain?
LLQ is classic
best imaging for diverticulitis
CT Abdomen/pelvis with contrast
Outpatient antibiotic treatment for diverticulitis
Cipro + metronidazole (1st choice)
TMP-SMX + metronidazole
amoxicillin/clavuanic acid
MC type of bowel obstruction
ileus
MC cause of small bowel obstruction
adhesions
bilious vomiting may indicate
proximal bowel obstruction
feculent vomiting may indicate
distal bowel obstruction
what may small bowel obstruction progress to
bowel strangulation
1 cause of larger bowel obstruction
cancer
large bowel obstruction in children - consider?
intussusception
diagnostic test for bowel obstruction
CT abdomen/pelvis with oral and IV contrast
How do you differentiate complete vs partial obstruction?
loop of small bowel > 2.5 cm dilated proximal to distinct transition zone of collapsed bowel < 1 cm
treatment for small bowel obstruction
NG tube to decompress + supportive treatment
MC cause of mesenteric ischemia
embolic
mural thrombi after MI, thrombus due to mitral stenosis/Afib, vegetative endocarditis, septic emboli, AAA rescetion
risk factors for mesenteric ischemia
age artherosclerosis arrhythmias hypovolemia CHF recent MI valve disease intra-abdominal malignancy IBD mesentary artery stenosis cocaine use smoking
Patient presents with disproportionate pain than what found on exam
acute mesenteric ischemia
two lab values used to order with mesenteric ischemia
Troponin Lactic acid (sepsis vs volume depletion)
1 diagnostic study for mesenteric ischemia in ED
CT/CTA with and without contrast
You just diagnose Mesenteric Ischemia → next step
emergency consult with surgery
Vasodilator administered to mesenteric ischemia
papaverine
main therapy for mesenteric vein thorbus
heparin
MC cause of inlammation of veriform appenix (acute appendicitis)
obstruction from facalith
line between umbilicus and ASIS
McBurney Point Tenderness
Patient presents with RLQ pain that suddenly goes away and is no longer tender
perforation
Female with RLQ or LLQ pain → top of Ddx?
ectopic pregnancy
appendicitis on CT will show…
appendiceal diameter > 6-8 mm, wall thickening >3mm, periappendiceal fat stranding, wall enhancement
Antibiotics for appendicitis
piperacillin-tazobactam
PCN allery → carbapenem
forcal dilation of aorta causing weakness to integrity of vessel
abdominal aortic aneurysm
separation of layers within aortic wall → disruption of intima into media → false lumen
aortic dissection
Type A vs Type B aortic dissection
management?
A → ascedning aorta → surgery
B → beyond L subclavian → BP control
hypertensive, agitated, diaphoretic, anxious, tamponade, etc →
aortic dissection
diagnostic test for aortic dissection
CT angio chest/abdomen/pelvis with contrast
Goal BP for aortic dissection
systolic → 90 - 100/60-80
diameter for AAA
> 3 cm
Triad for AAA
abdominal pain
hypotension
syncope
medication for managing AAA BP and tachycardia exacerbations
BB
morphine sulfate
