Abdominal Emergencies Flashcards
Case 1: • Paramedics arrive with a 65 year old man complaining of sudden severe left flank and epigastric pain • PMH: None • No medications, NKDA • SH: Smokes 1ppd x 30 years Exam: • VS: BP82/40 P110 RR16 T37.2°F • HEENT: Normal • Heart: Regular rhythm, tachycardic • Lungs: Clear all fields • Abdomen: Non-distended, + bowel sounds, soft, slightly tender in epigastrium • Guaiac negative brown stool Extremities: Diminished dorsalis pedis pulses, capillary refill time 3 sec • Skin: Clammy, cool • Neurologic: A+O x 3, anxious, moves all extremities, GCS 15 (1) DDx? (2) Initial steps in management for this patient (during first 5 minutes of ED arrival)? (3) Which lab studies are indicated based on your clinical suspicion? (4) Which radiographic studies are indicated based on your clinical suspicion?
(1) AAA, perforated peptic ulcer, acute pancreatitis, incarcerated hernia, nephrolitiasis, gastritis (2) Place 2 large bore IVs–14 or 16 gauge, hook up cardiac monitoring, supplemental O2 (3) CBC, BMP, coags, type and screen x 6u of blood (4) FAST and/or CT
Most common site for AAA
intrarenal
True aneurysm =
dilation of all 3 layers of the aorta
Normal abdominal aorta diameter:
≤ 2cm
Other health conditions associated with increased risk of AAA
Trauma Infection Connective tissue disease Arteritis
Size of dilation at which it is considered an abdominal aneurysm:
3cm or larger
Major risk factors for AAA
Atherosclerosis Peripheral Vascular Disease First degree relative with AAA
First degree relative with AAA increases risk by _____.
10x
Clinical presentation of unruptured AAA:
Asymptomatic. or… Gradual onset of vague, dull, constant abdominal pain
Risk of rupturing aneurysm via palpation during exam:
None
Abdominal bruit common in patients with AAA?
Not super common–10 to 30% will have one
Classic triad for AAA presentation:
Abdominal pain
Hypotension
Syncope
Common presenting signs of AAA:
Abdominal Pain
Hypotension
Syncope
Back pain
Flank pain
Size of AAA at which rupture become EXTREMELY likely:
Over 5.5 cm
Most common site of AAA rupture leakage and associated symptoms?
Outcome if leak is intraperitoneal?
Most common site = retroperitoneal and is associated with severe back and flank pain.
If leak is intraperitoneal then death is imminent
Role of plain films in AAA management:
Supine and lateral abdomen plain films can identify calcifications in the abdominal wall and there may be non-specific shadowings of the psoas muscle or kidney
Visualization of retroperitoneum with abdominal US:
You cannot visualize the retroperitoneum with US
Role of angiography in emergent evaluation of AAA:
None
Role of MRI in emergent evaluation of AAA:
None
Surigical mortality rate in ruptured and elective AAA repairs:
Ruptured: 50%
Elective: 5%
Treatment of AAA:
- Vascular surgery consult ASAP
- Traditional laparotomy
- Endovascular repair
Explain how open AAA repair vs endovascular repair is done:
Open: aneurysm is opened, a graft is placed, the aneurysm is then closed over the graft.
Endovascular: stent is placed within the aneurysm via the femoral artery.
Case 2
A 75 year old female presents with sudden onset of diffuse abdominal pain that woke her from sleep. She is in obvious pain, tearful
PMH: atrial fibrillation
Meds: coumadin (ran out a week ago)
NKDA
Exam:
VS: BP 146/90 HR 118 RR 24 T 37.0°F SaO2 98%
Heart: irregularly irregular, tachycardic
Lungs: CTA
Abdomen: non-distended, soft, non- tender, no palpable masses
Guaiac positive, brown stool
Extremities: no edema, moves all extremities, dorsalis pedis pulses intact
Diagnostic Adjuncts
Abdominal plain film: Non-specific bowel gas pattern, no free air
CT Abdomen/pelvis: Ischemia of small bowel, filling defect in proximal superior mesenteric artery
- Diagnosis?
- Next steps in management?
- Acute Mesenteric Ischemia
- Although we pretty much know that this is AMI, we could perform the gold standard diagnostic test and order an angiogram. Treatment would include heparin, glucagon, intra-arterial papverince, and laparotomy to remove the embolus, bypass the occlusion, and remove any dead bowel.
Treatment of non-occlusive acute mesenteric ischemia
fewer good options, since this is caused by other underlying conditions in the patient.
However you should attempt to:
- Remove the affending stimulus
- Correct the underlying conditions
- Acheive vasodilation, anticoagulation, mesenteric regional blockade, and intra-arterial papaverine.
**Laparotomy is only necessary if dead bowel is suspected.
Treatment of mesenteric venous thrombosis:
Heparin
IV thrombolytics and thrombectomy occasionally used.
Mortality rates for:
- Arterial AMI:
- Acute venous thrombosis AMI:
- AMI from chronic venous thrombosis:
- Non-occlusive ischemia:
- 70-100%
- 30-40%
- 20%
- 70-80%
Case 3:
A 56 year old male presents with 3 days of epigastric abdominal pain and vomiting dark blood approximately 1 hour PTA
PMH: Arthritis
Medications: Naproxen
NKDA
• Social: Smokes 1 ppd x 20 years, occasional alcohol use
Physical exam:
VS: BP 100/55 HR 122 R 18 T 37.5°F
General: Middle aged male appears uncomfortable
Heart: Regular, tachycardic
Lungs: CTA
Abdomen: Non-distended, soft, + BS, epigastric tenderness, no rebound or
guarding, guaiac negative stool
Extremities: Cool and clammy
- Diagnosis:
- Next steps in management:
- Upper GI bleed–likely from a perforated peptic ulcer based on naproxen use.
- Establish 2 large bore IVs and start crystalloid resuscitation with normal saline solution. Type and cross x 4-6 units of blood, and perform NG lavage only after stabilizing the patient
Number 1 cause of upper GI bleeding:
PUD
Possible etiologies of upper GI bleeding:
PUD
Gastric erosions
Variceal bleeding
Mallory Weiss
Esophagitis
Duodenitis
Aortoenteric fistula (rare)
Renal Disease
Most common presenting sign of perforated peptic ulcer:
Melena
% cases of hematochezia caused by UGIB:
10%
Tricky part of heme-testing stool in PUD upper GI bleeding cases:
Early on these tests are often negative
Preferred solution to use when performing NG lavage in upper GI bleeding:
Most people use tap water at room temp
Main relative contraindication to NG lavage:
prior gastric bypass surgery
Common electrolyte abnormality seen in UGIB:
elevated BUN
Who are the typical consults for upper and lower GI bleeds:
UGIB: GI
LGIB: Surgery
Which GI bleeding patients are admitted and which are D/Ced?
Pretty much all are admitted, unless:
Cause is hemorrhoids or fissue
the patient is stable and has a negative w/u (Hb, NG lavage, no active rectal bleeding)
Which GI bleeder patients are taken to ICU vs the floor:
ICU: hemodynamically unstable, active bleeding, severe anemia, coagulopathy, need for urgery endoscopy, blood transfusion needed.
Floor: hematemesis that quickly clears in stable patient, stable vital signs.
Treatment for upper Gi bleeds:
Octreotide / Somatostatin
PPI
Sengstaken-Blakemore Tube for intractable hemorrhage
Endoscopy (mainstay)
What increases the risk of rebleeding and mortality in upper GI bleeds:
Hb < 11
Shock or hypotension on presentation
Tachycardia > 110-120 per minute
Age > 60
Coagulopathy
Co-morbidities like cancer
Most common causes of LGIB:
Diverticulosis
Angiodysplasia
Cancer
Rectal Disease
Ischemic colitis
IBD
(Brisk upper GI bleed)
Management of LGIB:
- Resuscitate
- Perform diagnostic maneuvers:
- Anoscopy
- Colonoscopy
- Nuclear RBC tagging
- Angiography
- Treatment with:
- Embolization
- Intra-arterial vasopressin
- Surgery
