Abdominal Pain

Question 1

Remarks on abdominal pain

Answer 1

More adult patients visit the ED for “stomach and abdominal pain, cramps, or spasms” than for any other chief complaint

Question 2

Remarks on patients with peritonitis

Answer 2

Patients with peritonitis generally prefer to remain immobile

Rebound tenderness is often regarded as the sine qua on for peritonitis.
However, the combination of rigidity, referred tenderness, and pain with coughing usually provides sufficient diagnostic confirmation for peritonitis such that little additional information is gained by eliciting the unnecessary pain of rebound.
Also, more than 1/3 of patients with surgically proven appendicitis do not have rebound tenderness

Question 3

Shock that develops rapidly after the onset of acute abdominal pain is usually the consequence of

Answer 3

intra-abdominal hemorrhage

A bedside US should be performed rapidly in an attempt to expedite identification of emergent causes of abdominal pain in the patient with hemodynamic collapse.

The presence of an abdominal aortic aneurysm and intra-abdominal hemorrhage can be quickly discovered.

Question 4

Remarks on guarding

Answer 4

Voluntary guarding (contraction of the abdominal musculature in anticipation of or in response to palpation) can be diminished by asking patients to flex the knees

Question 5

Evaluate the abdominal aorta, particularly in patients > ______ years of age

Answer 5

50

Question 6

Remarks on analgesia

Answer 6

Do not withhold analgesia from patients with acute undifferentiated abdominal pain.

Question 7

Remarks on a surgical abdomen

Answer 7

If the clinical impression suggests that the need for surgery is obvious, surgical consultation should be initiated immediately. It is not necessary to wait for diagnostic imaging before surgical consultation.

Question 8

Remarks on abdominal xrays

Answer 8

1. Radiographic evidence of small bowel obstruction may be seen 6 to 12 hours before symptoms develop. However, signs may be absent in up to half of patients with developing small bowel obstruction.
2. Although an upright chest film is better to detect free air than an abdominal film, the sensitivity for small amounts of free air is only about 30%.
3. The use of plain abdominal radiographs should be limited to screening for obstruction, sigmoid volvolus, perforation, or severe constipation.

Question 9

Remarks on radiation does of CT

Answer 9

The radiation dose of abdominal CT is about 10 millisievert (mSv), about 10x that of plain abdominal radiographs.

Question 10

Noncontrast CT in appendicitis

Answer 10

Noncontrast abdominaopelvic CT has about 97% specificity for the diagnosis of acute appendicitis, with the possible exception of patients with a low BMI (<25 kg/m2)

Question 11

Remarks on IV contrast CT

Answer 11

1. It can identify small and large bowel obstruction and the transition point.
2. It is the initial test of choice for suspected abdominal aortic aneurysm rupture or mesenteric ischemia

Question 12

Instructions for patients with unclear diagnosis at discharge

Answer 12

Patients with an unclear diagnosis at discharge, even if the CT scan is “negative” (or whom response to treatment is a concern), should be asked to return to the ED or their primary care physician for reevaluation within 12 hours.

Question 13

Leading cause of pregnancy-related maternal death in the first trimester

Answer 13

Hemorrhage from an ectopic gestation
despite improved diagnostic and treatment modalities
Obtain a qualitative or quantitative urine or serum pregnancy test in women of childbearing age with acute abdominal pain who have not had a hysterectomy.

Question 14

A gestational sac is typically visible if the patient’s serum B-HCG is ____

Answer 14

> 1,500 mIU/mL
“discriminatory zone”
either inside or outside the uterus

Question 15

Most common surgical entity in elderly patients with abdominal pain

Answer 15

Cholecystitis
Followed by
SBO
Perforated viscus
Appendicitis
LBO

Question 16

Remarks on abdominal pain in the elderly.

Answer 16

1. Any acute abdominal pain is important in an elderly patient.
2. No single test can distinguish among patients who should be admitted and who can be safely discharged
3. A liberal imaging/admission/observation policy is strongly advocated when the diagnosis is in doubt or follow-up is uncertain.

Question 17

Epiploic (omental) appendages are most commonly found where?

Answer 17

sigmoid colon and cecum
each person has ~50 to 100 epiploic appendages

Question 18

Normal bowel function returns _____ days postoperatively

Answer 18

2 to 3 days

Question 19

Features of mechanical obstruction

Answer 19

1. High-pitched bowel sounds
2. Air fluid-levels
3. Thickened valvulae conniventes
4. Little air in the distal bowel

Question 20

Intra-abdominal hypertension is defined as

Answer 20

Persistent intra-abdominal pressure above 12 mm Hg.
Abdominal compartment syndrome occurs as increased intra-abdominal pressure, often above 20 mm Hg, causes associated organ dysfunction.

Question 21

Abdominal compartment syndrome is most often seen in

Answer 21

criticalaly ill septic, trauma, burn, and postoperative patients who receive aggressive fluid resuscitation.

Question 22

Abdominal compartment syndrome is confirmed by assesing intra-abdominal pressure, which is most often measured via

Answer 22

Urinary bladder pressure monitoring

Question 23

Management of abdominal compartment syndrome

Answer 23

Medical:
- identification and treatment of contributing factors
- evacuating intraluminal contents
- improving abdominal wall compliance
- optimizing fluid administration and perfusion

Surgical decompression is required in patients with severe or refractory abdominal compartment syndrome

Question 24

Features of mesenteric arterial occlusion

Answer 24

1. Pain out of proportion to physical findings; n/v
2. concomitant atrial fibrillation

Question 25

Remarks on leaking AAA

Answer 25

1. Only 50% are hypotensive at presentation
2. Normal pulses do not exclude diagnosis
3. Bedside US is 100% sensitive