Abdominal General Surgery Flashcards
What is an Acute Abdomen?
severe abdominal pain lasting for ≤ 5 days
Periumbilical PAIN DDx
GI Etiologies
- Acute appendicitis
- Mesenteric ischemia
NON GI
- AAA
- Aortic dissection
Diffuse Abdominal PAIN DDx
GI Etiologies
- Bowel perforation
- Bowel obstruction
- Mesenteric ischemia
- Retroperitoneal hematoma
- Constipation
NON GI
- Diabetic ketoacidosis
- Sickle cell crisis
- Porphyria
- Cocaine use
- Opioid withdrawal
- Heavy metal poisoning
RLQ PAIN DDx
GI Etiologies
- Acute Appendicitis
- Colitis
- IBD
NON GI
- Ectopic pregnancy
- Ovarian torsion
- Testicular torsion
- PID
- Ureteric colic
Suprapubic PAIN DDx
GI Etiologies
- Diverticulitis
NON GI
- PID
- Ectopic Pregnancy
- Cycstitis
Epigastrium PAIN DDx
GI Etiologies
- Acute gastritis
- PUD
- GERD
- Acute pancreatitis
- Acute mesenteric ischemia
NON GI
- Myocardial infarction
- Pericarditis
- AAA
- Aortic dissection
LUQ PAIN DDx
GI Etiologies
- Gastric ulcer
- Splenic abscess
- Splenic laceration
- Splenic infarction
NON GI
- Lower lobe pneumonia
- Lower lobe pulmonary infarction
- Empyema
- Ureteric colic
- Pyelonephritis
LLQ PAIN DDx
GI Etiologies
- Diverticulitis
- Colitis
- IBD
NON GI
- Ectopic pregnancy
- Ovarian torsion
- Testicular torsion
- PID
- Ureteric colic
RUQ PAIN DDx
GI Etiologies
- Biliary colic
- Acute cholecystitis
- Ascending cholangitis
- Emphysematous cholecystitis
- Acute hepatitis
- Pyogenic liver abscess
NON GI
- Lower lobe pneumonia
- Lower lobe pulmonary infarction
- Empyema
- Ureteric colic
- Pyelonephritis
Cardiovascular causes of Acute Abdomen
- acute coronary syndrome
- acute mesenteric ishemia
- [impending] rupture of AAA
- Aortic Dissection
Acute Coronary Syndrome (acute abdomen)
Diagnostic findings
- ECG: nonspecific changes, ST-segment elevation/depression, T-wave inversions, Q waves
- Increased or normal troponin
- TTE: hypokinesis, regional wall motion abnormalities
Acute Coronary Syndrome (acute abdomen)
Clinical Features
- 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
Acute Mesenteric Ishemia
Clinical Presentation
- 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
Acute Mesenteric Ischemia
Dignostic Findings
- 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
[Impending] Rupture Of AAA
Clinical Findings
- 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
[Impending] Rupture of AAA
Diagnostic Findings
- 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
Aortic Dissection (acute abdomen)
Clinical Findings
- 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
Aortic Dissection (acute abdomen)
Diagnostic findings
- 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
Gastrointestinal causes of acute abdomen
- GI tract perforation
- Mechanical bowel obstruction
- acute appendicitis
- peptic ulcer disease
- diverticulitis
Gi tractperforation
clinical features
- 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
GI tract perforation
diagnostic finding
abdominal xray
pneumoperitoneum
Mechanical bowel obstruction
clinical findings
- 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
Mechanical bowel obstruction
diagnostic findings
- 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
Acute Appendicitis
clinical findings
- RLQ, epigastric, and/or periumbilical pain(migrating abdominal pain)
- Fever
- Nausea, anorexia
- Guarding, tenderness, and rebound tenderness in the RLQ
Acute appendicitis
diagnostic findings
- 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
Peptic ulcer disease
clinical findings
- 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
peptic ulcer disease
diagnostic findings
- 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.
Diverticulitis
clinical findings
- Fever
- LLQ pain
- Constipation
- Tender mass in LLQ
Diverticulitis
diagnostic findings
- Labs: ↑ WBC
- CT with IV and oral contrast: colonic diverticula with pericolic mesenteric fat stranding
Biliary and Pnacreastic causes of acute abdomen
- acute pancreatitis
- symptomatic cholelithiasis
- chledocholithiasis
- acute cholecystits
- acute cholangitis
Acute Pancreatitis
clinical findings
- 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
Acute pancreatitis
diagnostic findings
- ↑ Lipase, amylase
- Hypocalcemia (poor prognostic indicator)
- Abdominal ultrasound: pancreatic edema, peripancreatic fluid, gallstones
- Abdominal CT with IV contrast : pancreatic edema, peripancreatic fat stranding, gallstones
Symptomatic cholelithiasis
clinical findings
- Biliary colic: RUQ pain with radiation to the right shoulder
- Postprandial onset
- Nausea, vomiting
- Normal abdominal examination
Symptomatic cholelithiasis
diagnostic findings
- Labs: normal
- Abdominal ultrasound: gallstones with posterior acoustic shadow
Choledocholithiasis
clinical findings
- RUQ pain
- Features of obstructive jaundice
- Nausea, vomiting
- Normal abdominal examination
Choledocholithiasis
Diagnostic findings
- 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
Acute Cholecystitis
Clinical Findings
- 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)
Acute cholecysitis
diagnostic findings
- 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
Acute cholangitis
clinical findings
-
Charcot triad:
- RUQ pain,
- fever
- jaundice
- Reynold pentad
- above plus:
- hypotension
- altered mental status
Acute cholangitic
diagnostic findings
- 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
Genitourinary causes of acute abdomen
- Ruptured ectopic pregnancy
- ovarian torsion
- testicular torsion
- acute pyelonephritis
Ruptured Ectopic Pregancy
clinical features
- Sudden severe lower abdominal pain
- Vaginal bleeding or amenorrhea
- Lower abdominal guarding and tenderness
- Cervical motion tenderness, closed cervix
- Enlarged uterus
- Tachycardia, hypotension
Ruptured Ectopic Pregnancy
Diagnostic Findings
- ↑ 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
Ovarian Torsion
Clinical Findings
- Sudden onset unilateral lower abdominal or pelvic pain
- Nausea, vomiting
- Unilateral iliac fossa tenderness
Ovarian Torsion
Diagnostic Findings
- 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)
Testicular Torsion
Clinical Findings
- Severe lower quadrant and testicular pain
- Nausea and vomiting
- Abnormally elevated position of the testiswithin the scrotum
Testicular Torsion
Diagnostic finding
- Clinical diagnosis
- Doppler ultrasound: twisting of the spermatic cord; reduced perfusion of the affected testicle
Acute Pyelonephritis
Clinical Findings
- High fever, chills
- Flank pain with costovertebral angle tenderness (usually unilateral, may be bilateral)
- Dysuria, urinary frequency, urgency
Acute Pyelonephritic
Diagnostic FIndings
- 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
Upper vs Lower GI bleed
Location?
how common?
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%
Most Common Etiologies of GI Bleeding
Erosive/ Inflamatory
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)
Most Common Etiologies of GI Bleed
Vascular
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
Angiodysplasia
arteriovenous malformation
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%).
Most Common Etiologies GI Bleeding
Tumors
UPPER
- Esophageal cancer and/or gastric carcinoma
LOWER
- Colorectal cancer and/or anal cancer
- Colonic polyps
Most Common Etiologies GI Bleed
TRAUMATIC/IATROGENIC
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)
Most Common Etiologies GI Bleed
OTHER
Upper
- Portal hypertensive gastropathy
- Coagulopathies
Lower
- Anal fissures
Clinical Features GI Bleed
- 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
GI Bleed
Diagnostic Findings
- 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
Hemodynanamically Stable GI Bleed
UPPER
- Upper endoscopy
- If negative, perform a colonoscopy.
LOWER
- Colonoscopy
- If negative, perform an upper endoscopy.
Hemodynamically Unstable GI Bleed
- Nasogastric tube lavage
- Upper endoscopy (if negative, additional colonoscopy)
- In case of massive life-threatening bleeding: angiography or exploratory laparaotomy (LGIB)
Initial Management GI Bleed
- 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.
Gastrointestinal perforation
full-thickness loss of bowel wall integrity that results in perforation peritonitis.
Gastrointestinal Perforation Etiologies
-
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
GI Perforation
Clinical Features
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
GI Perforation
Diagnostic Findings
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
GI Perforation
Treatment
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
Spontaneous bacterial peritonitis
(primary Peritonitis)
- 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
Spontaneoud bacterial peritonitis
Risk factors
- cirrhosis and ascites
- Low ascitic fluid protein concentration (< 1.5 g/dL)
- Upper gastrointestinal bleeding
- Prior episodes of SBP
Spontanous Bacterial Peritonitis
Pathophys
- Bacterial translocation from the intestinal lumen to mesenteric lymph nodes →
- spread to systemic and portal circulation →
- colonization and subsequent infection of ascitic fluid
Spontanous Bacterial Peritonitis
Microbiology
- Monomicrobial
- Gram-negative enteric bacteria (e.g., Escherichia coli, Klebsiella spp.) are most common.
- Gram-positive bacteria (e.g., Streptococcus spp., Staphylococcus spp., Enterococcus spp.) are increasing in prevalence.
Spontanous Bacterial Peritonitis
Clinical features
- Diffuse abdominal pain/tenderness
- Fever and chills
- Worsening ascites
- New-onset or worsening encephalopathy
- NOTES
Spontanous Bactrial Peritonitis
Diagnotic Findings
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
Spontanous Bacterial Peritonitis
Antibiotic Treatment
- 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
Secondary Bacterial Peritonitis
inflammation of the peritoneum caused by bacterial infection from a surgically treatable intraabdominal source
usually surgical emergency
Secondary Bacterial Peritonitis
Etiology
- Perforation
- appendicitis, diverticulitis, pancreatitis, intraabdominal abscess
- Trauma
- surgery
Secondary Bacterial Peritonitis
Diagnosis
- 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
Contraindications for Laproscopic Surgery
- Hemodynamic instability/shock
- Acute intestinal obstruction with dilated bowel loops
- increased risk perforation
- Increased intracranial pressure
- Hypercarbia increases cerebral blood flow→ increased intracranial pressure.
