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Surgery Clerkship- Amboss Study Plan > Abdominal General Surgery > Flashcards

Abdominal General Surgery Flashcards

1
Q

What is an Acute Abdomen?

A

severe abdominal pain lasting for ≤ 5 days

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2
Q

Periumbilical PAIN DDx

A

GI Etiologies

  1. Acute appendicitis
  2. Mesenteric ischemia

NON GI

  1. AAA
  2. Aortic dissection
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3
Q

Diffuse Abdominal PAIN DDx

A

GI Etiologies

  1. Bowel perforation
  2. Bowel obstruction
  3. Mesenteric ischemia
  4. Retroperitoneal hematoma
  5. Constipation

NON GI

  1. Diabetic ketoacidosis
  2. Sickle cell crisis
  3. Porphyria
  4. Cocaine use
  5. Opioid withdrawal
  6. Heavy metal poisoning
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4
Q

RLQ PAIN DDx

A

GI Etiologies

  1. Acute Appendicitis
  2. Colitis
  3. IBD

NON GI

  1. Ectopic pregnancy
  2. Ovarian torsion
  3. Testicular torsion
  4. PID
  5. Ureteric colic
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5
Q

Suprapubic PAIN DDx

A

GI Etiologies

  1. Diverticulitis

NON GI

  1. PID
  2. Ectopic Pregnancy
  3. Cycstitis
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6
Q

Epigastrium PAIN DDx

A

GI Etiologies

  1. Acute gastritis
  2. PUD
  3. GERD
  4. Acute pancreatitis
  5. Acute mesenteric ischemia

NON GI

  1. Myocardial infarction
  2. Pericarditis
  3. AAA
  4. Aortic dissection
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7
Q

LUQ PAIN DDx

A

GI Etiologies

  1. Gastric ulcer
  2. Splenic abscess
  3. Splenic laceration
  4. Splenic infarction

NON GI

  1. Lower lobe pneumonia
  2. Lower lobe pulmonary infarction
  3. Empyema
  4. Ureteric colic
  5. Pyelonephritis
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8
Q

LLQ PAIN DDx

A

GI Etiologies

  1. Diverticulitis
  2. Colitis
  3. IBD

NON GI

  1. Ectopic pregnancy
  2. Ovarian torsion
  3. Testicular torsion
  4. PID
  5. Ureteric colic
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9
Q

RUQ PAIN DDx

A

GI Etiologies

  1. Biliary colic
  2. Acute cholecystitis
  3. Ascending cholangitis
  4. Emphysematous cholecystitis
  5. Acute hepatitis
  6. Pyogenic liver abscess

NON GI

  1. Lower lobe pneumonia
  2. Lower lobe pulmonary infarction
  3. Empyema
  4. Ureteric colic
  5. Pyelonephritis
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10
Q

Cardiovascular causes of Acute Abdomen

A
  1. acute coronary syndrome
  2. acute mesenteric ishemia
  3. [impending] rupture of AAA
  4. Aortic Dissection
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11
Q

Acute Coronary Syndrome (acute abdomen)

Diagnostic findings

A
  • ECG: nonspecific changes, ST-segment elevation/depression, T-wave inversions, Q waves
  • Increased or normal troponin
  • TTE: hypokinesis, regional wall motion abnormalities
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12
Q

Acute Coronary Syndrome (acute abdomen)

Clinical Features

A
  • Heavy, dull, pressure/squeezing sensation
  • Substernal or epigastric pain with radiation to left shoulder
  • Nausea, vomiting
  • Diaphoresis, anxiety
  • Dizziness, lightheadedness, syncope
  • Pain may improve with nitroglycerin.

STEMI, NSTEMI, Angaina

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13
Q

Acute Mesenteric Ishemia

Clinical Presentation

A
  • Age > 60 years, embolic risk factors (e.g., atrial fibrillation, thrombophilia), cardiovascular disease
  • Pain out of proportion to findings
  • Severe, diffuse abdominal pain and distention
  • Vomiting, diarrhea
  • Melena, hematochezia
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14
Q

Acute Mesenteric Ischemia

Dignostic Findings

A
  • Labs: lactic acidosis, hyperkalemia, leukocytosis
  • X-ray abdomen: normal (early stages), pneumatosis intestinalis (late stages)
  • CT angiography: mesenteric arterial narrowing or occlusion, thickening of bowel wall, nonenhancing segments of solid organs or of the bowel wall, pneumatosis intestinalis
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15
Q

[Impending] Rupture Of AAA

Clinical Findings

A
  • Age > 50 years
  • Sudden, severe central abdominal, chest, and/or back pain
  • Hypotension, shock
  • Pulsatile mass in the midline of the abdomen
  • Grey Turner sign ( flank ecchymosis)
  • Cullen sign
  • History of atherosclerosis, hypertension, and/or smoking
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16
Q

[Impending] Rupture of AAA

Diagnostic Findings

A
  • Imaging is only recommended in hemodynamically-stable patients with a low pretest probability of ruptured AAA.
  • Abdominal ultrasound: aortic dilatation, periaortic fluid, intraperitoneal free fluid
  • CT/MR angiography: retro- and intraperitoneal hemorrhage; localization of the ruptured/leaking site
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17
Q

Aortic Dissection (acute abdomen)

Clinical Findings

A
  • Sudden onset of severe, sharp tearing chest or abdominal pain that radiates to the back
  • Hypotension, syncope, neurological symptoms
  • Asymmetrical blood pressure, pulse deficit
  • New diastolic murmur (due to aortic regurgitation)
  • Symptoms of myocardial ischemia
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18
Q

Aortic Dissection (acute abdomen)

Diagnostic findings

A
  • Elevated D-dimer
  • ECG: nonspecific ST-segment changes
  • CXR: widening of the aorta
  • CT angiography of chest/abdomen/pelvis : intimal flap with false lumen
  • Transesophageal echocardiography (TEE): proximal aortic dissection, tamponade, aortic regurgitation
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19
Q

Gastrointestinal causes of acute abdomen

A
  1. GI tract perforation
  2. Mechanical bowel obstruction
  3. acute appendicitis
  4. peptic ulcer disease
  5. diverticulitis
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20
Q

Gi tractperforation

clinical features

A
  • Sudden onset of diffuse abdominal pain
  • Nausea, vomiting
  • Constipation/obstipation
  • Diffuse abdominal guarding, rigidity, and rebound tenderness
  • Absent bowel sounds
  • Loss of liver dullness on RUQ percussion
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21
Q

GI tract perforation

diagnostic finding

A

abdominal xray

pneumoperitoneum

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22
Q

Mechanical bowel obstruction

clinical findings

A
  • Colicky abdominal pain
  • Obstipation/bloating
  • Progressive nausea and vomiting (late finding)
  • Diffuse abdominal distention, tympanic abdomen, collapsed rectum on DRE
  • Tinkling bowel sounds
  • History of abdominal surgery
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23
Q

Mechanical bowel obstruction

diagnostic findings

A
  • X-ray abdomen
    • Dilated bowel loops proximal to the obstruction
    • Rectal air shadow absent
    • Multiple air-fluid levels
  • CT abdomen with IV and oral contrast
    • Similar findings as on x-ray
    • Transition point at site of obstruction
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24
Q

Acute Appendicitis

clinical findings

A
  • RLQ, epigastric, and/or periumbilical pain(migrating abdominal pain)
  • Fever
  • Nausea, anorexia
  • Guarding, tenderness, and rebound tenderness in the RLQ
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25
Q

Acute appendicitis

diagnostic findings

A
  • Neutrophilic leukocytosis
  • Abdominal CT scan with IV contrast : distended appendix with periappendiceal fat stranding
  • Abdominal ultrasonography : noncompressible, aperistaltic, distended appendix, probe tenderness in the RLQ, Target sign
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26
Q

Peptic ulcer disease

clinical findings

A
  • Epigastric pain
  • Duodenal ulcer: pain relieved with food; weight gain
  • Gastric ulcer: pain exacerbated by food; weight loss
  • Signs of GI bleed
  • History of NSAID intake
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27
Q

peptic ulcer disease

diagnostic findings

A
  • Anemia, positive FOBT (in cases of bleeding ulcer)
  • Urea breath test for H. pylori: positive in most cases of PUD
  • EGD: Mucosal erosions and/or ulcers are required for a definitive diagnosis.
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28
Q

Diverticulitis

clinical findings

A
  • Fever
  • LLQ pain
  • Constipation
  • Tender mass in LLQ
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29
Q

Diverticulitis

diagnostic findings

A
  • Labs: ↑ WBC
  • CT with IV and oral contrast: colonic diverticula with pericolic mesenteric fat stranding
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30
Q

Biliary and Pnacreastic causes of acute abdomen

A
  1. acute pancreatitis
  2. symptomatic cholelithiasis
  3. chledocholithiasis
  4. acute cholecystits
  5. acute cholangitis
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31
Q

Acute Pancreatitis

clinical findings

A
  • Severe epigastric pain that radiates to the back (circumferential pain)
  • Nausea, vomiting
  • Epigastric tenderness, guarding, rigidity
  • Hypoactive bowel sounds
  • Possibly fever
  • History of gallstones or alcohol use
32
Q

Acute pancreatitis

diagnostic findings

A
  • ↑ Lipase, amylase
  • Hypocalcemia (poor prognostic indicator)
  • Abdominal ultrasound: pancreatic edema, peripancreatic fluid, gallstones
  • Abdominal CT with IV contrast : pancreatic edema, peripancreatic fat stranding, gallstones
33
Q

Symptomatic cholelithiasis

clinical findings

A
  • Biliary colic: RUQ pain with radiation to the right shoulder
  • Postprandial onset
  • Nausea, vomiting
  • Normal abdominal examination
34
Q

Symptomatic cholelithiasis

diagnostic findings

A
  • Labs: normal
  • Abdominal ultrasound: gallstones with posterior acoustic shadow
35
Q

Choledocholithiasis

clinical findings

A
  • RUQ pain
  • Features of obstructive jaundice
  • Nausea, vomiting
  • Normal abdominal examination
36
Q

Choledocholithiasis

Diagnostic findings

A
  • Labs: ↑ ALP, AST, ALT, total bilirubin
  • Abdominal ultrasound
    • Dilated common bile duct (CBD)
    • Intrahepatic biliary dilatation
    • Echogenic structure within the CBD with shadowing
  • Endoscopic Ultra Sound (EUS): stone within the CBD
  • MRCP or ERCP: filling defect in the contrast-enhanced duct
37
Q

Acute Cholecystitis

Clinical Findings

A
  • Severe RUQ pain
  • Fever, chills
  • Nausea, vomiting
  • Right shoulder referred pain
  • Murphy sign (suddenly pausing during inspiration upon deep palpation of the right upper quadrant)
38
Q

Acute cholecysitis

diagnostic findings

A
  • Labs: ↑ WBC
  • Abdominal ultrasound:
    • sonographic Murphy sign ,
    • pericholecystic fluid collection,
    • gallbladder wall thickening, and/or edema (double-wall sign)
  • HIDA scan : nonvisualization of the gallbladder
39
Q

Acute cholangitis

clinical findings

A
  • Charcot triad:
    • RUQ pain,
    • fever
    • jaundice
  • Reynold pentad
    • above plus:
    • hypotension
    • altered mental status
40
Q

Acute cholangitic

diagnostic findings

A
  • Labs
    • ↑ WBC and CRP
    • ↑ ALP, ↑ AST, ↑ ALT,
    • ↑ GGT (Gamma-glutamyl transpeptidase)
    • ↑ Total bilirubin
    • Positive blood cultures
  • RUQ ultrasound:
    • biliary dilation and/or evidence of obstruction
    • thickening of bile duct walls
  • MRCP/ERCP : findings similar to those on ultrasound
41
Q

Genitourinary causes of acute abdomen

A
  1. Ruptured ectopic pregnancy
  2. ovarian torsion
  3. testicular torsion
  4. acute pyelonephritis
42
Q

Ruptured Ectopic Pregancy

clinical features

A
  • Sudden severe lower abdominal pain
  • Vaginal bleeding or amenorrhea
  • Lower abdominal guarding and tenderness
  • Cervical motion tenderness, closed cervix
  • Enlarged uterus
  • Tachycardia, hypotension
43
Q

Ruptured Ectopic Pregnancy

Diagnostic Findings

A
  • ↑ β-hCG
  • Transabdominal/transvaginal ultrasound
  • Free fluid within Morison pouch and/or pouch of Douglas
  • Empty uterine cavity, thickened endometrial lining
  • Adnexal mass
  • Tubal ring sign
44
Q

Ovarian Torsion

Clinical Findings

A
  • Sudden onset unilateral lower abdominal or pelvic pain
  • Nausea, vomiting
  • Unilateral iliac fossa tenderness
45
Q

Ovarian Torsion

Diagnostic Findings

A
  • Pelvic (or transvaginal) ultrasound with Doppler velocimetry: enlarged, edematous ovaries with decreased blood flow
  • Pelvic CT scan with IV contrast
    • Unilateral thickened ovarian tube, enlarged ipsilateral ovary, and decreased enhancement of ipsilateral ovary
    • Twisted vascular pedicle (whirlpool sign)
46
Q

Testicular Torsion

Clinical Findings

A
  • Severe lower quadrant and testicular pain
  • Nausea and vomiting
  • Abnormally elevated position of the testiswithin the scrotum
47
Q

Testicular Torsion

Diagnostic finding

A
  • Clinical diagnosis
  • Doppler ultrasound: twisting of the spermatic cord; reduced perfusion of the affected testicle
48
Q

Acute Pyelonephritis

Clinical Findings

A
  • High fever, chills
  • Flank pain with costovertebral angle tenderness (usually unilateral, may be bilateral)
  • Dysuria, urinary frequency, urgency
49
Q

Acute Pyelonephritic

Diagnostic FIndings

A
  • Labs
    • ↑ WBC, CRP, ESR
    • Positive urinalysis
    • Positive urine culture
  • Renal ultrasound: edema and focal hypoechogenic areas
  • CT pelvis with IV contrast: focal area(s) of hypoenhancement that extend to the cortical periphery
50
Q

Upper vs Lower GI bleed

Location?

how common?

A

Suspensory muscle of duodenum: Ligament of Treitz

A fold of peritoneum that attaches the duodenojejunal flexure to the retroperitoneum.

Upper-70-80%

Lower 20-30%

51
Q

Most Common Etiologies of GI Bleeding

Erosive/ Inflamatory

A

UPPER

  • Peptic ulcer disease (∼ 30% of cases)
  • Esophagitis
  • Erosive gastritis and/or duodenitis

LOWER

  • Diverticulosis (∼ 30% of cases)
  • Inflammatory bowel disease (IBD), i.e., ulcerative colitis and Crohn disease
  • Invasive or inflammatory diarrhea (bacterial gastroenteritis, due to e.g., Shigella, EHEC)
52
Q

Most Common Etiologies of GI Bleed

Vascular

A

UPPER

  • Esophageal varices or gastric varices
  • Gastric antral vascular ectasia
  • Dieulafoy lesion

LOWER

  • Hemorrhoids
  • Ischemia (e.g., ischemic colitis, mesenteric ischemia)
  • Arteriovenous malformation
  • Rectal varices

BOTH

  • Angiodysplasia
53
Q

Angiodysplasia

arteriovenous malformation

A

a common degenerative disorder of GI vessels (mostly venous)

  • Age > 60 years,
  • von Willebrand disease
  • aortic stenosis
  • end-stage renal disease
  • episodic bleeding (hematochezia) that ceases spontaneously in > 90% of cases
  • Diagnosis usually requires angiography.
  • Lesions are usually multiple tortuous dilated vessels
    • located in the right-sided colon (∼ 75%).
54
Q

Most Common Etiologies GI Bleeding

Tumors

A

UPPER

  • Esophageal cancer and/or gastric carcinoma

LOWER

  • Colorectal cancer and/or anal cancer
  • Colonic polyps
55
Q

Most Common Etiologies GI Bleed

TRAUMATIC/IATROGENIC

A

UPPER

  • Hiatal hernias
  • Mallory-Weiss syndrome
  • Boerhaave syndrome

LOWER

  • Lower abdominal trauma
  • Anorectal trauma (e.g., anorectal avulsion, impalement injuries)

Both

  • Following open or endoscopic surgery (e.g., anastomotic bleeding following a gastric bypass)
56
Q

Most Common Etiologies GI Bleed

OTHER

A

Upper

  • Portal hypertensive gastropathy
  • Coagulopathies

Lower

  • Anal fissures
57
Q

Clinical Features GI Bleed

A
  • Anemia
  • Acute hemorrhage: signs of circulatory insufficiency or hypovolemic shock
    • Tachycardia, hypotension (dizziness, collapse, shock)
  • Hematemesis (coffee-ground vomit)
  • Melena (Black, tarry stool)
  • Hematochezia(bright red (fresh) blood)
    • Colonic bleeding: maroon, jelly-like traces of blood in stools
    • Rectal bleeding: streaks of fresh blood on stools
58
Q

GI Bleed

Diagnostic Findings

A
  • Endoscopy
    • Used to identify the source of intestinal bleeding
  • Nasogastric tube lavage
    • Blood that is bright red or has a coffee-ground appearance indicates UGIB.
    • Negative in ∼15% of patients with UGIB.

Evaluate for small bowelbleeding.

  • Angiography
  • Surgery/exploratory laparotomy
59
Q

Hemodynanamically Stable GI Bleed

A

UPPER

  • Upper endoscopy
  • If negative, perform a colonoscopy.

LOWER

  • Colonoscopy
  • If negative, perform an upper endoscopy.
60
Q

Hemodynamically Unstable GI Bleed

A
  • Nasogastric tube lavage
  • Upper endoscopy (if negative, additional colonoscopy)
  • In case of massive life-threatening bleeding: angiography or exploratory laparaotomy (LGIB)
61
Q

Initial Management GI Bleed

A
  • Consider elective intubation in patients with altered mental or respiratory state and severe ongoing hematemesis.
  • Hemodynamic resuscitation
  • IV proton pump inhibitors (e.g., esomeprazole)
  • Management of anticoagulants

two large-caliber peripheral venous catheters should be inserted and preparations should be made for a possible blood transfusion.

62
Q

Gastrointestinal perforation

A

full-thickness loss of bowel wall integrity that results in perforation peritonitis.

63
Q

Gastrointestinal Perforation Etiologies

A
  • Peptic ulcer disease:
    • Most common cause of stomach and duodenal perforation (anterios wall>posterior)
  • IBD
  • Malignancy
  • Diverticulitis
  • Apendicitis
  • Bowel Obstruction
  • Ischemia
  • Trauma
  • Drug-induced (e.g., NSAIDs)

list not exclusive

64
Q

GI Perforation

Clinical Features

A

General signs and symptoms

  • Sudden onset of abdominal pain and abdominal distention
  • Fever, tachycardia, tachypnea, hypotension
  • Signs of peritonitis or shock

Perforated PUD:

  • Sudden onset of intense, stabbing pain,
  • Followed by diffuse abdominal pain and distention (beginning peritonitis)
  • History of recurrent epigastric pain, chronic use of NSAIDs
65
Q

GI Perforation

Diagnostic Findings

A

In some cases, clinical features alone are sufficient to warrant emergency explorative laparotomy.

Laboratory analysis

  • neutrophilic leukocytosis

Imaging

  • First line:
    • CT abdomen and pelvis with IV contrast (most sensitive)
  • Alternative imaging modalities
    • X-ray of the abdomen and chest: pneumoperitoneum
66
Q

GI Perforation

Treatment

A

Most Patients: Exploratory Laparotomy

Only localized peritonitis and no signs of sepsis possible NON-OP

  • NPO
  • IV Fluid Resusitation
  • IV PPI
  • IV broad-spectrum antibiotics
67
Q

Spontaneous bacterial peritonitis

(primary Peritonitis)

A
  • infection of the ascitic fluid in the absence of any focal intraabdominal, surgically treatable source of infection
  • most common bacterial infection in patients with cirrhosis
68
Q

Spontaneoud bacterial peritonitis

Risk factors

A
  • cirrhosis and ascites
  • Low ascitic fluid protein concentration (< 1.5 g/dL)
  • Upper gastrointestinal bleeding
  • Prior episodes of SBP
69
Q

Spontanous Bacterial Peritonitis

Pathophys

A
  1. Bacterial translocation from the intestinal lumen to mesenteric lymph nodes →
  2. spread to systemic and portal circulation →
  3. colonization and subsequent infection of ascitic fluid
70
Q

Spontanous Bacterial Peritonitis

Microbiology

A
  1. Monomicrobial
  2. Gram-negative enteric bacteria (e.g., Escherichia coli, Klebsiella spp.) are most common.
  3. Gram-positive bacteria (e.g., Streptococcus spp., Staphylococcus spp., Enterococcus spp.) are increasing in prevalence.
71
Q

Spontanous Bacterial Peritonitis

Clinical features

A
  • Diffuse abdominal pain/tenderness
  • Fever and chills
  • Worsening ascites
  • New-onset or worsening encephalopathy
  • NOTES
72
Q

Spontanous Bactrial Peritonitis

Diagnotic Findings

A

CBC: leukocytosis

Diagnostic paracentesis (ascitic fluid)

  • cirrhosis and ascites with:
    • fever; leukocytosis
    • abdominal pain/tenderness
  • neutrophil count of ≥ 250/mm3
  • serum-ascites albumin gradient (SAAG) > 1.1
73
Q

Spontanous Bacterial Peritonitis

Antibiotic Treatment

A
  • Community-acquired infection/no recent beta-lactam antibiotic exposure
    • First-line: 3rd-generation cephalosporin IV, preferably cefotaxime
    • Alternative: oral ofloxacin
  • Healthcare associated/ resistant pathogen/ recent beta-lactam exposure
    • low prevalence of multidrug-resistant pathogens: Piperacillin-tazobactam
    • consult ID

IV albumin supplementation

74
Q

Secondary Bacterial Peritonitis

A

inflammation of the peritoneum caused by bacterial infection from a surgically treatable intraabdominal source

usually surgical emergency

75
Q

Secondary Bacterial Peritonitis

Etiology

A
  • Perforation
  • appendicitis, diverticulitis, pancreatitis, intraabdominal abscess
  • Trauma
  • surgery
76
Q

Secondary Bacterial Peritonitis

Diagnosis

A
  • Peritoneal fluid analysis:
    • neutrophil count of ≥ 250/mm3
    • Bacterial culture and/or gram stain: positive
    • total protein > 1 g/dL, LDH > upper limit of normal for serum, glucose < 50 mg/dL
  • Imaging:
    • CT scan of the abdomen and pelvis
    • X-ray abdomen (upright): Free air
77
Q

Contraindications for Laproscopic Surgery

A
  • Hemodynamic instability/shock
  • Acute intestinal obstruction with dilated bowel loops
    • increased risk perforation
  • Increased intracranial pressure
    • Hypercarbia increases cerebral blood flow→ increased intracranial pressure.

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