Abdominal Pain Flashcards
Acute Appendicitis
etiology
symptoms
signs
diagnosis
Etiology
- pretty common: teenagers
- infection/inflammation of the appendix
Symptoms
- periumbilical nonspecific pain: later localizing to the RLQ
- nausea
- +/- fever
- anorexia
- McBurney’s Point: 1/3 distance between ASIS And umbilicus
- Rovsing’s Sign: pain in RLQ when you palpate LLQ
Diagnosis
- can be clinical with good hisotry
- Labs: can show elevated WBC in most
- CT Scan: for adults
- US: for kids
- MRI: pregnant
Acute Appendicitis
Treatment
(note on kids)
Kids: tricky to know
- ask them to jump aroudn: pain? proably true. no pain? probably ok
Pediatric Appendicitis SCore
- takes in account N/V, pain, fever, pain with coughing or jumping, RLQ tenderness,etc. to decide lieklihood
- score < 2-3 = not liekly
- score 4-6: possible: might wanna image
- score 7+: def have it
Treatment (once CT or US is done…)
antibiotics : broad spectrum
- ceftriaxone/cefazolin/cefoxitin + metronidazole
- unasyn
- pip/taz or cipro+ mentronidazole
surgery: take it out
- drain first if it is perforated, then a delayed surgery
Cholilithiasis
symptoms
Cholilithiasis: stone in the gallbladder
Symptoms
- biliary colic: the achy pain that comes and goes in the RUQ
- referred pain: back, scapula etc.
- N/V
- fatty food = issues
- heartburn
- bloating, farting, burping
Cholecystitis
Symptoms and Signs
calcuous chole v acaclulo.
what is happening patho.
Cholycystitis: inflammation/infection in the gallbladder
Symptoms
- RUQ & epigastric pain —> R scapula
- N/V
- fever/chills
- TTP RUQ/epigastric
- murphy’s sign
- jaundice (maybe)
Pathology
- most of the time, this inflammation is a result of a stone being stuck in the cystic duct (rarely its cancer or sludge)
- this creates a distended, angr GB that can actauly infarct and perforate!
rarely… acalculous cholecystitis
- due to severe sick pt (sepsis, trauam, burn, etc.)
- can be like stagnant bile that creates bloakcge/inflammation and infection
- treatment for acalculous: abx: cover for everything…
- then (if stable) remove via surgery o r(if unstable) put in percutaneous drain
Cholysistis and cholelithiasis & doco.
labs & imaging
Labs
cholilithiasis (stones): usually normal CBC
cholycystitis: elevate WBC on CBC
if there is bilary obstruction of teh common bile duct…
- Liver enyzmes (AST/ALT): elevated
- alk phosphate: elevated
- bilirubin: elevated
usually in cholithiasis and chlycysitis: no obstruction of the biliar tract
in cholidocolithiasis: there will be obstruction and thus
- elevated liver, bili and alk phosphate
Imaging
- US good noninvasive test: get first and see whats up
- CT can show thickening but not that great
- HIDA: radioactive tracer to see the flow (not necessary)
- plain radiographs not helpful
- MRI vi MRCP
Cholycystitis
Treatment
Treatment
- surgery or cholecysectomy : main treatment (laproscopically)
- sometimes it can be left in, if mild case or just biliary colic
- drain it? percut. drain if the pt. is too sick for surgery
- antibiotics: if fever or risk fo infection/perf.
Bowel Perforation
Causes
Symptoms
Diagnosis
Treatment
Causes
- trauma
- obstruction
- neoplams
- PUD (perf from dude)
- corrosive agents
- instruments
Symptoms
- pain that is worse over time and gets more severe in natrue
- rebound/garding of peritoneal (think infection in there!)
- fever
- tachycardia
- hypotension
Diagnosis
- check if there is free air: CXR can show free air
- ABD CT can localize
Treatment
- broad spectrum abx. + IV fluids
- surgery
Bowel Obstruction
Causes
Symptoms
Diagnosis
Treatment
Causes
adhesions and hernias!!!!*
Symptoms
- abd. pain & cramping = diffuse
- vomiting
- dirrhea early on : cleraing of anything distal to obstruction
- distension
- high pitched bowel sounds: trying to work through!!!
Diagnosis
- CT scan
- +/- US
- dont get obstruction series on xray
Treatment
- NPO, IV fluids
- NG tube to decompress
- surgery
Diverticulitis
background (diverticulosis, etc.)
symptoms
diagnosis
treatment
Divertiula : sac-like out pouches of teh colin wall - dx. = diverticulosis
diverticulitis: inflammation/infection of these diverticua
- this will be our 65+ crowd in the sigmoid colon
Symptoms
- LLQ pain and tenderness
- history of similar episodes
- nausea
- lowe-grade fever
Diagnosis
CT to see teh inflammation, and check for perforations
Treatment
- abx
- outpt. abx. = amox/clav. OR cipro+ metronidazole
- inpt. abx. = IV cephalosporins OR cipro/levo. + metronidazole
Outpt? if…
- uncompliated (no perforation and normal VS)
- mild/moderate symptoms
- able to keep meds down
- good follow up
inpt? if…
- compliated (abcess, perforation, etc.)
- cant do the above…
may need surgery
Acute Pancreatitis
causes
symptoms
Causes
- GALLSTONESSS
- Alcohol
- when the gallstone gets to the level of the sphincter of odi: it blocks not only the bile but also the pnacreatic secretions, leading to angry pancreas
- other causes (I GET(trauma) S(scorpion)M(mumps)A(autoimmune)S(streoids)H(hyperlipid)E(ercp)D(drugz))
Symptoms
- pain, acute severe epigastric abd.
- tenderness
- worse when flat
Diagnosis
- get labs: eleavted lipase 3x ULN
- eleavted ALT/AST too
- can get US: if youre worried about stones (increase liver enzymes and not alcohol induced)
- can get CT: but not needed if pt. is stable : good to see pancreas tho
Treatment
- hydrate and pain control
- no abx. see if GS
- no alcohol
- admit to observe, but low risk can go home
Chronic Pancreatitis
much different than acute
this is pancreas burn out due to repeated injuries
causes
- alcohol
- genetic
- autoimmune
Signs
- the lipase will often be low or normal: because shes not working (not elevated or angry, just tired)
- steatorrhea
- calcifications of teh pancreas on imaging
- DM signs
- chronic pain that is relapsing and remitting
Management
- are they sick looking? oder your labs and see if withdrawal–> admit to ICU or floor
- not that sick? contorl pain –> observe if N/V , if good –> D/C
Peptic Ulcer Disease
Etiology
- NSAIDS (think stomach)
- H Pylori (think duodenum)
- others but less likely
Symptoms
- ulcer pain: gnawing, buring, crampy and vague pain
- epigastric upper abd. pain
- food induced pain & full quickly + NSAID use = stoamch
- pain a few hours after eating + h. pylori = duodenum
Diagnosis
- EGD is needed to see the ulcers
- EGD also allows for biopsy for h. pylori testing (urease biopsy)
- can do a Urea breath test for H pylori also
Treatment
- PPI’s “prazoles” or H2 receptors “tidines”
- stop the NSAIDS, smoking, alcohol, etc.
if H. pylori —> treat with…
triple therapy : PPI + clairythromycin + amoxicillin
(PCN allergy = metronidazole)
quadruple thearpy : PPI + metronidazole + bsimuth + tetracycline
PUD Complications
Bleeding
Perforation
Bleeding
- higher risk in eldery and NSAID users if teh ulcer is on a vessel
Perforation
- sudden, severe abd. pain (can be unstable)
- mostly from duodenum
- evaluation: CXR: free air? & CT scan
- Treatement: stablize vitals, ABX. & IV PPI + surgical eval.
Mesenteric Ischemia
Acute
Chronic
Symptoms
Diagnosis
Acute
- occlusive: a thrombus or emobli (usually in SMA) stops the blood flow = severe pain acutely
- non-occlusive: low flow situation, lowe BP
Chronic
- vessel stenosis from atherosclerosis = episodic pain realated to eating (blood goes there when eating but its clogged, harder to get tehre = pain)
Symptoms (Acute)
- severe, sudden pain (rule out AAA)
- pain OUT OF PROPORTIon to your exam: you push and theyre fine but they explain more pain
Diagnosis
- EKG: check for a fib and thrown clots
- Lactate: will be elevated and rising if bowel is dying
- CTangio (see vessels)
- angiography: via IR
Treatment
- pain control!
- anticoag. = heparin
- IV fluids and maintain BP
- surgery evalualtion (open or percut. thrombus asipration + thrmobylysis)
AAA
Risk Factors
Size
Symptoms
AAA: Abdominal Aortic Anyuresum
Risk Factors
- men and older age
- SMOKING
- family history
- CVD
Size
- > 3 cm = AAA
- > 5cm = you need to consider repairing asap
- ruputre? high mortality
Symptoms
- sudden onset severe pain
- flank or abd. pain
- radiation to teh back
- pusitlie (maybe)
- hypotension (if its rutprue….)
Diagnosisi
US can be good if you can see
CT (if they’re satble)
- without contrast:see the anyurseum
- with contrast: can see the anyreusm better and see leak
Treatment
- call vascualr surgery ASAP
- control BP: esmolol to help
- treat shockif it happens with blood products
