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Emergency Medicine > Abdominal pain > Flashcards

Abdominal pain Flashcards

1
Q
  • MC Older male, smoker, atherosclerosis
  • Sudden severe back or abd pain; HoTN; Pulsatile abdominal mass
  • Syncope, pain localized to flank, groin, hip or abdomen possible
  • Severe + abrupt ripping/tearing pain possible
  • Femoral pulsations nml
  • Retroperitoneal hemorrhage rarely present w/ external findings (Cullen’s, Grey-Turner’s, scrotal hematoma)

dx?

A

AAA

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2
Q

When would an AAA require emergent surgerical repair?

A

Symptomatic aneurysms and ≥ 5.0 cm

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3
Q
  • GI bleeding - small or life-threatening
  • H/o aortic grating at higher risk
  • Duodenum MC site
  • Hematemesis, melena, hematochezia
  • High output cardiac failure with ↓ arterial blood flow distal to fistula

dx?

A

Aortoenteric fistulas

AAA

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4
Q

how would a Rupture into retroperitoneum present?

AAA

A
  • Fibrosis → chronic contained rupture
  • Appear nml, may have pain for long time before dx is made
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5
Q

MC incorrect initial dx of AAA? How would this present?

A

renal colic - Back pain, intraabdominal process, testicular torsion , GI bleeding

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6
Q

w/u for AAA?
findings?

A

If dx unclear:

  1. Bedside abd US - >90% sensitivity
    - Aortic rupture/retroperitoneal bleed not reliably identified
  2. CT - delineates where aneurysm and any assoc rupture
  3. XR - calcified, bulging aortic contour (only in some)
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7
Q
  • mgmt AAA?
  • mgmt if small asx (3-5cm)? large (>5?)
A
  • Consult vascular surgeon if rupture / aortoenteric fistula
  • Fluids (for HoTN)
  • Target SBP: 90 mmHg
  • Transfuse PRBC if needed
  • Pain control while avoiding HoTN
  • Small asx (3-5cm): Refer to vascular surgeon
  • Large (>5cm): ↑ risk for spontaneous rupture; close f/u
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8
Q

types of nonaortic large-artery aneurysms

A
  1. popliteal
  2. SC
  3. femoral
  4. femoral pseudoaneurysms
  5. iliac
  6. splenic
  7. hepatic
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9
Q
  • Old, male, trauma, congenital disorders
  • MC peripheral aneurysm
  • Discomfort behind knee w/ swelling +/- DVT

dx?
mgmt?

A
  • popliteal aneurym
  • thrombolysis, ligation, arterial bypass, endovascular repair
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10
Q
  • RF: Arteriosclerosis, thoracic outlet obstruction
  • Pulsatile mass above/below clavicle
  • Dysphagia, hoarseness
  • Stridor
  • chest pain
  • UE fatigue / numbness & tingling
  • limb ischemic sx

dx?
mgmt?

A
  • subclavian aneurym
  • surgical repair
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11
Q
  • RF: Old, male, trauma, congenital disorders
  • Pulsatile mass +/- pain
  • Limb ischemic sx
  • peripheral embolic sx

dx?
mgmt?

A
  • femoral aneurym
  • thrombolysis, ligation, arterial bypass, endovascular repair
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12
Q
  • RF: Prior femoral artery cath, trauma, infection
  • Pulsatile mass +/- pain

dx?
mgmt?

A
  • Femoral pseudoaneurysm
  • surgical repair
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13
Q
  • RF: 40–60 y/o, HTN, fibrodysplasia,
  • arteriosclerosis; no gender preference
  • Flank pain
  • Hematuria
  • collecting system obstruction
  • shock if ruptured

dx?
mgmt?

A
  • renal aneurysm
  • surgical repair, Nephrectomy
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14
Q
  • RF: Old, female, HTN, congenital, arteriosclerosis, liver dz, multiparous; ↑ rupture w/ pregnancy
  • Rapid onset;
  • epigastric or LUQ pain first, then diffuse abd pain with rupture
  • shock

dx?
mgmt?

A
  • splenic aneurysms
  • surgical repair, splenectomy
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15
Q
  • RF: Infection, arteriosclerosis, trauma, vasculitis
  • Obstructive jaundice
  • hemobilia from rupture into CBD
  • RUQ pain
  • Peritonitis
  • Upper GI bleed

dx?
mgmt?

A
  • hepatic aneurysm
  • surgical ligation, embolization
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16
Q

Blood dissects between intimal and adventitial layers of aorta

A

Aortic Dissection

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17
Q

RF for Aortic Dissection

A
  • MC male, >50y, h/o HTN
  • Chronic cocaine use
  • h/o cardiac surgery
  • Young - CTD, congenital heart dz, pregnancy; Marfan’s syndrome
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18
Q
  • Acute CP
  • Most severe at onset
  • Radiates to back/scapula
  • Sharp, ripping, tearing pain
  • Syncope possible
  • Location dependent
  • Diastolic murmur of aortic insufficiency possible
  • HTN and tachycardia common; HoTN possible
  • ↓ pulsation in radial, femoral, or carotid arteries
  • Neurologic sequelae

dx?
how do anterior vs abd/back pain differ?

A

aortic dissection
Anterior - ascending aorta
abd/back - descending aorta

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19
Q

aortic dissection classification?

A

Stanford Classification

  • Type A - Ascending Aorta
  • Type B - descending Aorta
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20
Q

presentation of Progressed dissection

A
  • AV insufficiency
  • coronary artery occlusion - MI
  • carotid involvement - stroke sx
  • occlusion of vertebral blood supply - paraplegia
  • cardiac tamponade - shock and JVD
  • compression of recurrent laryngeal nerve - hoarseness
  • compression of superior cervical sympathetic ganglion - Horner’s syndrome.
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21
Q

w/u aortic dissection?
findings?

A
  1. D-Dimer
  2. CXR: MC - Abml aortic contour, widening mediastinum
    - Deviated trachea, mainstem bronchi, esophagus, apical capping, pleural effusion, displacement of aortic intimal calcifications
  3. Dx: CT w/ contrast; TEE
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22
Q

mgmt for aortic dissection

A
  • Vascular / thoracic surgeon
  • Fluids
  • Esmolol/labetalol - Goal HR: 60-70; SBP: 100-120
  • SBP >120: nitroprusside/nicardipine
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23
Q

3 types of pain

A
  1. Visceral: poorly localized; stretching of unmyelinated fibers of walls/capsules of organs
  2. Parietal: localized; irritation of myelinated fibers of parietal pleura covering peritoneum
    - tenderness & guarding → rigidity & rebound tenderness
  3. Referred: pain felt at a location distant to underlying cause
    - MC perceived on ipsilateral side
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24
Q

2 classifications/categories

A
  1. Intra-abdominal: organ infection/inflammation, peritonitis, bowel obstruction, vascular disorders
  2. Extra-abdominal: Cardiac, thoracic, GU, neuro, metabolic, hematologic, infectious, toxicities - MC: DKA, alc ketoacidosis, PNA, PE, Herpes Zoster
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25
Q

pertinent PMHx/SHx

A
  • steroids, abx (C. diff), NSAIDs (gastritis, ulcer/perforation)
  • CV/PAD dz, afib, HF (AAA, mesenteric ischemia, atypical MI)
  • Immunosupp
  • Previous abd surgery
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26
Q

pertinent social hx

A

heavy alc, opiates, smoking

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27
Q

gradual onset, think what dx?

A

inflammatory, infectious/obstructive

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27
Q

sudden, severe onset, think what dx?

A

ischemia, dissection, perforation

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28
Q

if abd pain is constant/worsening for >6 hrs, think what dx?

A

surgical cause

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29
Q

pain improves after meals - what dx?

A

PUD

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30
Q

pain worse after meals - what dx

A

biliary colic

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31
Q

pain improves when upright and worse when supine - what dx

A

pancreatitis

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32
Q

pain worse with sudden movements and improves with stillness - what dx?

A

peritonitis

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33
Q

Pain alleviated by constant movement - what dx?

A

renal colic

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34
Q

vomiting occurring after onset of pain = what cause?

A

surgical cause

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35
Q

bilious vomiting - what cause?

A

obstruction distal to pylorus

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36
Q

coffee-ground or hematemesis - what dx?

A

PUD, varices, aortoenteric fistula (aortic aneurysm repair)

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37
Q

loose/watery diarrhea - what dx/cause?

A

infectious or diverticulitis

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38
Q

mucoid diarrhea - what dx?

A

inflammatory or infectious

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39
Q

blood diarrhea - what dx?

A

mesenteric ischemia or infectious

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40
Q

small scant amounts of stool/diarrhea - what dx?

A

bowel obstruction

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41
Q

possible GU sx

A
  • Dysuria, hematuria - UTI, pyelonephritis, nephrolithiasis
  • Female: vaginal bleeding or discharge, recent changes in menstruation, dyspareunia - vaginitis, PID, tubo-ovarian abscess, Fitz-Hugh Curtis syndrome, pregnancy
  • Males: Penile discharge, scrotal pain/swelling, recent trauma - urethritis, testicular torsion, inguinal hernia
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42
Q

low temp w/ abd pain can be seen in what pt demographic?

A

infectious in elderly & neonates

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43
Q

> 50y
abd pain out of proportion to physical findings

dx?

A

Mesenteric ischemia

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44
Q

possible Auscultation findings

A
  • Absence - peritonitis, BO
  • hyperactive/high-pitched/tinkling - SBO
  • hyperactive/medium-pitch - blood/inflammation within GI tract
  • Bruit - AAA
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45
Q

goals of palpation

A

tenderness, guarding, masses, organomegaly, hernias

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46
Q

goal of light vs deep palpation? findings?

A

guarding
Voluntary vs involuntary
Involuntary → surgeon ASAP

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47
Q

peritoneal testings

A
  • Rebound tenderness, rigidity, referred tenderness, cough pain - peritonitis dx; Rebound tenderness alone not the best
  • Heel tap
  • Jumping
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48
Q

Carnett sign

A

sit-up test: abd wall pain
Place finger at max abd tenderness found
pain w/ palpation at semisitting position = (+) abd wall syndrome

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49
Q

what does murphy’s sign test for

A

cholecystitis

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50
Q

what does psoas sign test for

A

retrocecal appendicitis

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51
Q

what does obturator sign test for

A

appendicitis

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52
Q

what does rovsing sign test for

A

appendicitis

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53
Q

CVA percussion tests for what

A

pyelonephritis

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54
Q

when abd pain is in the lower 1/2 of abd, do what exam?

A

pelvic/testicular exam

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55
Q

what are you trying to assess for DRE?

A

tenderness, bleeding, masses

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56
Q

other PE findings other than abd exam

A
  • Heart & lungs - afib, PNA
  • MSK - hip infections/inflammation can radiate to lower abd
  • Skin - Cullen’s & Grey Turner’s - ruptured AAA or hemorrhagic pancreatitis
57
Q

what pt population may fail to show the same abd s/s?

A

Older pts, MC DM & immunocomp

  1. +/- tachycardia if hypovolemic
  2. ↓ pain perception, febrile or muscular response to infection/inflammation
  3. > 50y - Biliary dz, bowel obstruction, diverticulitis, CA, hernia
    - Less freq, but still high - Sigoid volvulus, diverticulitis, acute mesenteric ischemia, AAA
58
Q

what lab to order for ALL women of child-bearing age w/ abd pain +/- abnml vaginal bleeding

A

hCG (qualitative)
Blood count not specific/sensitive but MC ordered

59
Q

w/u for abd pain

A
  1. hCG
  2. plain abd radiography - low sensitivity
  3. US
  4. CT +/- contrast
60
Q

plain abd radiography would be helpful for what dx

A

obstruction, perforation, following identified stones in renal colic

61
Q

US may be helpful in what dx?

A
  1. cholelithiasis
  2. choledocholithiasis
  3. cholecystitis
  4. biliary duct dilatation
  5. pancreatic masses
  6. hydroureter or hydronephrosis
  7. intrauterine or ectopic pregnancies
  8. ovarian and tubal pathologies
  9. free intraperitoneal fluid
  10. suspected appendicitis
  11. AAA
62
Q

CT would be helpful in what dx

A
  1. mesenteric ischemia
  2. pancreatitis
  3. AAA
  4. appendicitis
  5. urolithiasis

IV contrast - lesions, inflammation; not needed for urolithiasis
PO contrast - bowel obstruction

63
Q

mgmt for unstable abd pain

A

resuscitation, dx clinically w/ emergent surgical consultation

64
Q

general mgmt for abd pain

A
  • Resuscitation - NS or LR, NPO
  • Analgesics - morphine, hydromorphone
  • Antiemetics - ondansetron/metoclopramide
  • Abx if indicated - gentamicin + metronidazole; pip-taz
65
Q

morphine/hydromorphone can be reversed with ?

A

naloxone 0.4 to 2 mg SC/IV

66
Q

using NSAIDs or ibuprofen as analgesics for abd pain would be more beneficial for which dx?

A

renal colic

67
Q

what acute abdominal or pelvic dx requiring immediate intervention

A
  • AAA
  • intrabdominal hemorrhage
  • perforated viscus
  • intestinal obstruction or infarction
  • ectopic preg
  • gyn emergencies
  • “Acute/surgical abdomen” - emergent surgery (pain, guarding, rebound)
68
Q

indications to admit for abd pain

A
  1. Toxic appearance
  2. unclear dx in elderly/immunocomp
  3. inability to reasonably exclude serious etiologies
  4. intractable pain or vomiting
  5. AMS
  6. inability to follow DC instructions

Serial examinations otherwise

69
Q

mgmt for nonspecific abd pain

A
  • DC and 12-24 f/u
  • return ASAP if incr pain, V, F, or failure of sx to resolve
70
Q

2 components that are key to ulcer development?

A
  1. Acid
  2. pepsin
71
Q

MCC of ulcers

A
  1. H pyloir
  2. NSAIDs
72
Q

acute or chronic gastric mucosal inflammation and has various causes

73
Q
  1. burning epigastric pain - sharp, dull, ache, “empty” or “hungry”
    - relieved by food, milk, or antacids
    - recurs as gastric contents empty; awakens pt night
    dx?
74
Q

Atypical PUD presentations MC in who? findings?

A

elderly: no pain, not relieved by food, N,V, anorexia, wt loss, and/or bleeding

75
Q

possible changes in pain seen in PUD?

A

Change in character = complication

  • Abrupt onset of severe pain = perforation w/ spillage of gastric/duodenal contents into peritoneal cavity
  • Back pain = pancreatitis from posterior perforation
  • N/V, early satiety, wt loss = gastric outlet obstruction, CA
  • Vomiting blood, melanotic stools +/- hemodynamic instability = bleeding complication
76
Q

PE finding indicative PUD complication

A
  • rigid abdomen - peritonitis in perforation
  • abd distention, succussion splash - gastric outlet obstruction
  • occult/gross rectal blood, blood in nasogastric aspirate - bleed
77
Q

DDx of epigastric pain

A
  1. GERD - pain, radiating to chest, belching
  2. Cholelithiasis/biliary colic - more severe RUQ, radiating around R abd w/ tenderness
  3. Pain radiating into back - pancreatitis
    - With mass - pseudocyst; Pulsatile - AAA
  4. Chronic pain, anorexia, wt loss +/- mass - CA
  5. MI - epigastric; considered esp DM & elderly
78
Q

w/u for PUD

A
  • CBC - nml r/o chronic GI bleeding (not acute tho)
  • Elevated liver enzyme - hepatitis
  • Elevated lipase - pancreatitis
  • Trops/ECG - MI
  • Upright XR - Free-air (perforation)
  • Abd US - cholecystitis, cholelithiasis , AAA
  • Dx: Upper GI endoscopy
79
Q

tx options for PUD

A
  1. PPIs - ↓ acid production (blocks H+ ion secretion; inhibitory effect on H. pylori)
  2. H2RAs - inhibit acid secretion, OTC
  3. Liquid antacids prn for pain relief; 1 hr after meals and at bedtime
  4. Tx H. pylori if indicated (not started in ED): PPI + clarithromycin + amoxicillin/metronidazole x 2 wks
80
Q

mgmt for uncomplicated, stable PUD

A

DC, PPI/H2RA with liquid antacid, PCP for further eval

81
Q

mgmt for PUD if “Alarm” features, stable enough or DC?

82
Q

mgmt for PUD complications?

A

consult, admit

  • Bleeding
  • Perforation - resuscitation, abx, immediate surgical consult
  • Gastric outlet obstruction - resuscitation, NG tube
83
Q

pt ed for suspected PUD pts?

A

Tell pt PUD is resumptive dx and f/u with gastroenterologist for definitive dx with endoscopy

84
Q

MCC of pancreatitis

A
  1. cholelithiasis
  2. alc abuse
85
Q

MCC of pancreatitis if no RF?

A

2/2 meds or severe hyperlipidemia if no RF - acetaminophen, carbamazepine, enalapril, estrogens, erythromycin, furosemide, HCTZ, opiates, steroids, tetracycline, and TMP-SMX

86
Q
  1. Midepigastric, constant, boring pain
    - Radiates to back
    - Supine worsens
  2. Assoc N/V/abd distention
  3. Low-grade F, tachycardia, HoTN
  4. Epigastric tenderness
  5. Peritonitis (late)
  6. Epigastric tenderness - More R/LUQ
  7. BS diminished & Abd distention - 2/2 ileus
  8. Severe dz: Refractory HoTN shock, renal failure, F, AMS, rsp failure

dx

A

Pancreatitis

87
Q

for Pancreatitis dx, 2 of the 3 clinical features can make the dx

A
  1. H&P
  2. lipase/amylase ≥2-3x ULN
  3. imaging consistent w/ pancreatic inflammation
88
Q

w/u for pancreatitis

A
  1. lipase/amylase (less specific)
  2. CBC - leukocytosis, anemia
  3. LFT - assoc biliary involvement
  4. Abd CT/US
89
Q

Why is CT preferred to dx pancreatitis instead of US?

A

US can be obscured by gas

90
Q

referred CP in pancreatitis - what possible dx?

A

IHD, pulm, hepatitis, cholecystitis, biliary colic, ascending cholngitis, renal colic, SBO, PUD/gastritis, acute aortic A/D

91
Q

mgmt for pancreatitis

A
  1. Aggressive fluids - crystalloids ; Pressors if HoTN and not responsive to fluids
  2. NPO if N/V
  3. Antiemetics - ondansetron, prochlorperazine
  4. IV analgesia - morphine
  5. O2 if < 95%
  6. MC need admission
92
Q

mgmt for Infected pseudocyst, abscess, infected peripancreatic fluid?

pancreatitis

A
  1. imipenem-cilastatin
  2. meropenem
  3. cipro + metronidazole
93
Q

mgmt for Severe systemic dz in pancreatitis

A
  • intubation, intensive monitoring, bladder cath, blood transfusion as needed
  • Correct symptomatic hypocalcemia
94
Q

mgmgt for hemorrhage/abscess drainage pancreatitis

A

laparotomy

95
Q

mgmt for gallstone pancreatitis

A

consult gastroenterology, ERCP, & sphincterotomy

96
Q

poor pronostic signs that require ICU admission:

A

Decr hgb, poor UO, persistent HoTN, hypoxia, acidosis, hypocalemia

97
Q

what type of pt may be DC with close f/u in pancreatitis?

A
  • Mild, no biliary tract dz, no systemic complications, tolerates PO intakes
  • Increase diet as tolerated once nausea is controlled
97
Q

MCC of cholecystitis

A
  • gallbladder or biliary duct by gallstones
  • MCC biliary tract emergency caused by gallstones: biliary colic, cholecystitis, gallstone pancreatitis, ascending cholangitis
98
Q

cholecystitis can be seen in all age, but MC in who?

A

DM & elderly

99
Q

T/F: pts presenting with gallstones are MC asx

100
Q

RF for choelcystitis

A

age, female, obesity, rapid wt loss, prolonged fasting, familial tendency, meds, asians, chronic liver dz, hemolytic disorders

101
Q

MCC of ascending cholangitis

A

CBD stone
life-threatening; Complete biliary obstruction w/ infection

102
Q
  • Epigastric or RUQ pain, constant
  • Intermittent or colicky
  • N/V
  • Referred to R shoulder or L upper back
  • After eating possible
  • Acute - lasts 1-5 hrs
  • Circadian pattern - MC 9pm-4am

dx?

A

Biliary colic

103
Q
  • Similar to biliary colic but lasts >5 hrs
  • F, chills, N, V, anorexia
  • h/o similar attacks or known gallstones
  • Sharp, localized RUQ

dx?

A

Acute cholecystitis

104
Q

midline pain, radiating to middle of back

dx?

Cholecystitis

A

Choledoncholithiasis

105
Q
  1. Jaundice, F, confusion, shock
  2. Focal RUQ pain, N
  3. **Charcot triad: Fever, jaundice, RUQ pain **

dx?

A

Ascending Cholangitis

106
Q

w/u for Cholecystitis

A
  1. WBC: leukocytosis w/ L shift - Acute cholecystitis, pancreatitis, cholangitis
  2. Serum bilirubin & alkaline phosphatase: nml/mild elevated - biliary colic, cholecystitis; Elevated - choledocholithiasis, ascending cholangitis
  3. Serum lipase/amylase
  4. Hepatobiliary US: stones small as 2 mm, signs of cholecystitis
    - thickened gallbladder wall (>3-5mm)
    - gallbladder distention (>4cm short-axis view)
    - pericholecystic fluid
    - CBD >5-7 mm = choledocholithiasis
  5. Intraabdominal dx → CT abd
  6. HIDA - very specific & sensitive; used if US fails
107
Q

heptabiliary US has Better predictive value with ?

A

sonographic Murphy’s sign and gallstones present

108
Q

general mgmt for Cholecystitis

A
  1. Fluids w/ crystalloids; Pressors if HoTN not responsive to fluids
  2. NPO
  3. ondansetron/prochlorperazine
  4. morphine, ketorolac
  5. Distended, actively vomiting, or unresponsive to antiemetics → NG tube low suction
109
Q

mgmt for Acute biliary obstruction

A

decompression via endoscopic sphincterotomy of ampulla of Vater

110
Q

mgmt for uncomplicated Suspected cholecystitis/cholangitis

A

ceftriaxone + flagyl

111
Q

mgmt for Ascending, sepsis, peritonitis Cholecystitis

A
  • triple therapy: ampicillin + gentamicin + clinda
  • Alt: metronidazole for clinda; 3rd gen cephalo/pip-taz, or FQ for ampicillin
112
Q

mgmt for Acute cholecystitis, gallstone pancreatitis, ascending cholangitis

A

surgery consult, admit

113
Q

mgmt for choledocholithiasis, gallstone pancr, ascending cholangitis

A

consult gastroenterology, ERCP + sphincterotomy

114
Q

mgmt for Signs of systemic toxicity/septic cholecystitis

A

ICU, surgery

115
Q

When to DC Uncomplicated biliary colic

A

relieved with supp within 4-6 hrs of onset and able to maintain oral hydration

  • DC, PO analgesics x 24-48 hrs, f/u with surgery/PCP
  • Return to ED if abd pain worsens, intractable vomiting, another significant attack before f/u
116
Q
  • Periumbilical/epigastric pain → RLQ (McBurney’s point)
  • Anorexia, N/V
  • Irritation of bladder and/or colon → dysuria, tenesmus, etc
  • “Bump” sign
  • Fever - late finding
  • Maneuvers depends on peritoneum irritation - rouvsing, psoas, obturator

dx?

A

Acute Appendicitis

117
Q

pt with suspected Acute Appendicitis does the jump test and pain suddenly decreases, what does this indicate

A

appendiceal perforation

118
Q

w/u for acute appendicitis?
What to use if you want to avoid radiation?

A
  • clinical dx
  • CBC, CRP - BOTH nml can be used as screening
  • UA - pyuria and hematuria in inflamed appendix irritating ureter
  • hCG
  • CT w/o contrast - 1st line: Pericecal inflammation, abscess, periappendiceal phlegmon or fluid collections
  • US - good too, but operator dependent
  • avoid radiation = MRI - avoid IV gadolinium in pregnant and renal dz
  • plain radiographs are NOT helpful!!
119
Q

high sensitivity s/s that indicate acute appendicitis

A
  • F, RLQ, pain before vomiting, absence of prior similar pain, pain migration
  • RL abd rigidity, (+) psoas sign
  • Consider if atraumatic R abd, periumbilical or flank pain w/ no h/o appendectomy
120
Q

mgmt for acute appendicitis

A
  1. surgical consult before imaging when dx is clear for appendectomy; transfer if no services
  2. NPO, IV access & fluids
  3. IV fentanyl, morphine
  4. Abx - pip/taz or Unasyn
121
Q
  • mgmt for unclear presentation of suspected appendicitis?
  • what pt demographics would benefit from this?
A
  1. admit to observe, serial exams, surgical consult
    - Safe for high-risk pts: kids, geriatric, pregnant, immunocomp
122
Q

when can appendicitis be DC?

A

DC & 12-hr f/u; avoid strong analgesics: Stable, nontoxic-appearing with adequate pain control who can tolerate oral hydration have no significant comorbidities, and are able to return in 12 hours

123
Q
  1. LLQ abd pain, F, leukocytosis
    - Higher F if generalized peritonitis or abscess
  2. Changes in bowel habits - D, C
  3. N/V, anorexia
  4. GU sx less common
  5. Redundant sigmoid colon, Asian, right-sided dz → suprapubic or RLQ pain
  6. Abd tenderness, obstruction, peritonitis
  7. Occult blood in stool possible

dx?
w/u?

A
  • Diverticulitis
  • clinical dx; no further eval if stable; imaging if no h/o dx or different presentation (CT w/ contrast, compression US, CBC, LFT, UA)
124
Q

mgmt for Diverticulitis

A
  • Ill-appearing, uncontrolled pain, V, peritoneal signs, systemic infection, comorbidities, immunosupp, complicated → admit & surgical consult
  • Uncomplicated, do not meet admission criteria - PO abx + liquid diet, Avoid dairy and red meat
  • Outpatient - f/u with gastroenterology for colonoscopy in 6 wks if they show improvement
  • Worsening during outpatient tx → admit
125
Q

abx for outpatient 4-7 d for diverticulitis

A
  1. Flagyl + FQ/Bactrim
  2. Alt: augmentin; moxifloxacin
126
Q

abx for moderate diverticulitis

A
  1. Flagyl + FQ (cipro, levaquin)
  2. Alt: rocephin; pip-taz
127
Q

abx for severe, life threatening diverticulitis

A
  1. pip-taz
  2. alt: aztreonam + flagyl
128
Q

what MC type of intestinal obstruction is self-limiting

A

Adynamic or paralytic ileus

129
Q

causes of SBO

A

adhesions d/t surgery, incarcerated hernias, inflammatory dz, IBS, congenital anomalies, FBs

130
Q

causes of LBO

A

CA, diverticulitis with stricture, sigmoid volvulus, fecal impaction

131
Q

what condition mimics LBO? who is at high risk for this?

A

Intestinal pseudoobstruction (Ogilvie syndrome)
elderly and bedridden on ACh or TCA

132
Q

Intussusception MC in who

133
Q

Sigmoid volvulus is MC in who?

A

elderly on ACh

134
Q

cecal volvulus is MC in who?

A

pregnant ppl

135
Q
  1. Crampy, intermittent, progressive abd pain or no BM or pass gas - if Partial, can pass gass
  2. Proximal - bilious V
  3. Distal - feculent V
  4. Localized pain + abd surgical scars, hernia, mass - possible reason
  5. Tympanitic to percussion
  6. Active, high-pitched BS if mechanical; Diminished BS with time
  7. DRE - impaction, CA, occult blood; Presence of stool does not r/o
  8. Pelvic exam

dx?

A

intestinal obstruction

136
Q
  • mild-mod pain
  • diffused pain
  • mild distention +/- tenderness, decr BS
  • dehydration
  • nml imaging

dx? mgmt?

A

ileus
observation, hydration

137
Q
  1. moderate to severe pain that can be localized
  2. mild distention, tenderness, high-pitched BS
  3. leukocytosis
  4. abnml imaging

dx? mgmt?

A
  • bowel obstruction
  • NG tube, surgery
138
Q

w/u for intestinal obstruction & volvulus

A
  1. Flat and upright abd radiographs and upright CXR - screens for obstruction, confirm severe constipation, or dx hollow viscus perforation with free air
  2. 1st line - CT w/ contrast: delineates partial vs complete obstruction, partial SBO vs ileus, and strangulated vs simple SBO
  3. CBC, lytes, BUN, CR, lactate, coags, type and cross-match
    - Leukocytosis >20k or left shift = abscess, gangrene, peritonitis
    - Elevated hct = dehydration
139
Q

mgmt for intestinal obstruction & volvulus

A
  1. Fluids with crystalloids, monitor for response, surgical consult
  2. Decompress bowel with NG tube esp if vomiting or distention
  3. Abx
    - Pip/taz; Ticarcillin-clavulanate; unasyn
    - Cefotaxime
    - Ceftriaxone + clinda or metronidazole or meropenum
  4. Dx unclear or adynamic ileus - IV fluids, observe
  5. Pseudoobstruction - colonoscopy only

Emergency Medicine (20 decks)

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