Abdominal Emergencies

Question 1

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?

Answer 1

(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

Question 2

Most common site for AAA

Answer 2

intrarenal

Question 3

True aneurysm =

Answer 3

dilation of all 3 layers of the aorta

Question 4

Normal abdominal aorta diameter:

Answer 4

≤ 2cm

Question 5

Other health conditions associated with increased risk of AAA

Answer 5

Trauma Infection Connective tissue disease Arteritis

Question 6

Size of dilation at which it is considered an abdominal aneurysm:

Answer 6

3cm or larger

Question 7

Major risk factors for AAA

Answer 7

Atherosclerosis Peripheral Vascular Disease First degree relative with AAA

Question 8

First degree relative with AAA increases risk by _____.

Answer 8

10x

Question 9

Clinical presentation of unruptured AAA:

Answer 9

Asymptomatic. or… Gradual onset of vague, dull, constant abdominal pain

Question 10

Risk of rupturing aneurysm via palpation during exam:

Answer 10

None

Question 11

Abdominal bruit common in patients with AAA?

Answer 11

Not super common–10 to 30% will have one

Question 12

Classic triad for AAA presentation:

Answer 12

Abdominal pain

Hypotension

Syncope

Question 13

Common presenting signs of AAA:

Answer 13

Abdominal Pain

Hypotension

Syncope

Back pain

Flank pain

Question 14

Size of AAA at which rupture become EXTREMELY likely:

Answer 14

Over 5.5 cm

Question 15

Most common site of AAA rupture leakage and associated symptoms?

Outcome if leak is intraperitoneal?

Answer 15

Most common site = retroperitoneal and is associated with severe back and flank pain.

If leak is intraperitoneal then death is imminent

Question 16

Role of plain films in AAA management:

Answer 16

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

Question 17

Visualization of retroperitoneum with abdominal US:

Answer 17

You cannot visualize the retroperitoneum with US

Question 18

Role of angiography in emergent evaluation of AAA:

Answer 18

None

Question 19

Role of MRI in emergent evaluation of AAA:

Answer 19

None

Question 20

Surigical mortality rate in ruptured and elective AAA repairs:

Answer 20

Ruptured: 50%

Elective: 5%

Question 21

Treatment of AAA:

Answer 21

1. Vascular surgery consult ASAP
2. Traditional laparotomy
3. Endovascular repair

Question 22

Explain how open AAA repair vs endovascular repair is done:

Answer 22

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.

Question 23

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

1. Diagnosis?
2. Next steps in management?

Answer 23

1. Acute Mesenteric Ischemia
2. 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.

Question 24

Treatment of non-occlusive acute mesenteric ischemia

Answer 24

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.

Question 25

Treatment of mesenteric venous thrombosis:

Answer 25

Heparin IV thrombolytics and thrombectomy occasionally used.

Question 26

Mortality rates for: 1. Arterial AMI: 2. Acute venous thrombosis AMI: 3. AMI from chronic venous thrombosis: 4. Non-occlusive ischemia:

Answer 26

1. 70-100% 2. 30-40% 3. 20% 4. 70-80%

Question 27

**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 1. Diagnosis: 2. Next steps in management:

Answer 27

1. Upper GI bleed--likely from a perforated peptic ulcer based on naproxen use. 2. 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

Question 28

Number 1 cause of upper GI bleeding:

Answer 28

PUD

Question 29

Possible etiologies of upper GI bleeding:

Answer 29

PUD Gastric erosions Variceal bleeding Mallory Weiss Esophagitis Duodenitis Aortoenteric fistula (rare) Renal Disease

Question 30

Most common presenting sign of perforated peptic ulcer:

Answer 30

Melena

Question 31

% cases of hematochezia caused by UGIB:

Answer 31

10%

Question 32

Tricky part of heme-testing stool in PUD upper GI bleeding cases:

Answer 32

Early on these tests are often negative

Question 33

Preferred solution to use when performing NG lavage in upper GI bleeding:

Answer 33

Most people use tap water at room temp

Question 34

Main relative contraindication to NG lavage:

Answer 34

prior gastric bypass surgery

Question 35

Common electrolyte abnormality seen in UGIB:

Answer 35

elevated BUN

Question 36

Who are the typical consults for upper and lower GI bleeds:

Answer 36

UGIB: GI LGIB: Surgery

Question 37

Which GI bleeding patients are admitted and which are D/Ced?

Answer 37

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)

Question 38

Which GI bleeder patients are taken to ICU vs the floor:

Answer 38

**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.

Question 39

Treatment for upper Gi bleeds:

Answer 39

Octreotide / Somatostatin PPI Sengstaken-Blakemore Tube for intractable hemorrhage Endoscopy (mainstay)

Question 40

What increases the risk of rebleeding and mortality in upper GI bleeds:

Answer 40

Hb \< 11 Shock or hypotension on presentation Tachycardia \> 110-120 per minute Age \> 60 Coagulopathy Co-morbidities like cancer

Question 41

Most common causes of LGIB:

Answer 41

Diverticulosis Angiodysplasia Cancer Rectal Disease Ischemic colitis IBD (Brisk upper GI bleed)

Question 42

Management of LGIB:

Answer 42

1. Resuscitate 2. Perform diagnostic maneuvers: * Anoscopy * Colonoscopy * Nuclear RBC tagging * Angiography 3. Treatment with: * Embolization * Intra-arterial vasopressin * Surgery