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Emergency Medicine > Abdominal pain 2 > Flashcards

Abdominal pain 2 Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

The most important aspect of the evaluation of the patient with abdominal pain in the ED is __

A

history

*The next is serial exams to evaluate how the pain is changing during the ED course

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2
Q

risk factors for AAA

A
  1. Male
  2. over 60 years old
  3. Connective tissue d/o
  4. SMOKING, HTN, DM, hyperlipidemia
  5. Family History is one of the strongest predictors
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3
Q

AAA is Thinning of ___ of the aorta, resulting in decreased tensile wall strength

A

media

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4
Q

classic AAA rupture

A

male, older, with sudden back or abdominal pain, ripping/tearing; hypotensive

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5
Q

Keep a ruptured AAA in your mind when evaluating for:

A

back pain,
syncope, and
renal colic

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6
Q

AAA imaging studies

A

-CT is 100% accurate; but, if patient is unstable, ultrasound is preferred

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7
Q

common post surgical fevers

A

24 hours: atelectasis, necrotizing fasciitis
72 hours: Pneumonia, UTI
5 days: DVT
7-10 days: wound infections

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8
Q

melanoic stools indicate __

bright red stools indicate

A

upper GI bleed

lower GI bleed

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9
Q

Upper GIB is defined as originating proximal to the __. LGIB originates distally

A

ligament of Treitz- suspensory ligament of the duodenum

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10
Q

UGIB causes:

A 
PUD #1 45%
Erosive gastritis  23%
esophagitis 6%
varices, 10%
 Mallory-Weiss tears7%
duodenitis 6%
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11
Q

LGIB causes:

A 
Diverticular dz #1. 
Colitis, 
polyps, 
carcinoma, 
hemorrhoids.  
brisk UGIB.
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12
Q

source of hematemesis

A

usually source is proximal to the ascending colon

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13
Q

source of melena

A

usually from proxima/ UGI bleed

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14
Q

hematochezia source

A
  • suggests a distal colorectal lesion

- BUT – 10-15% of patients w/ this have UGI source – usually a rapid bleed

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15
Q

GI bleed fake outs for melena

A

charcoal

pepto-bismol*

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16
Q

GI bleed fake outs for hematoemesis

A 
Nosebleeds	
Dental bleeding
Tonsil bleeding
Red drinks
Red food
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17
Q

GI bleed fake outs for hematochezia

A

Partially digested red grapes
Red food (beets)
Vaginal bleeding
Gross hematuria

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18
Q

GI bleed fake outs for false + occult blood testing

A

Red meat, turnips, horseradish, vitamin C

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19
Q

how will GI bleeds change bowel patterns

A

go more frequently

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20
Q

exam for suspected GIB

A

Vital signs: may show hypotension, tachycardia, bradycardia
Skin changes:
cool clammy skin
stigmata of liver dz (petechiae, jaundice, spider angiomata)
ENT may reveal occult bleeding source
GI: tenderness, masses, organomegaly, ascites
Rectal exam for presence of blood

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21
Q

labs for GIB

A
  1. CBC
    - initial hematocrit may not reflect actual amount of blood loss
    - Consider rechecking - hemodilution? Rapid blood loss?
  2. Chem 7, LFT’s
  3. Coags: is patient on blood thinner? ASA?
  4. EKG prn
  5. Type and screen prn
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22
Q

imaging studies for GIB

A

Plain films have no value!!

  1. Upper Endoscopy for UGIB
  2. Colonoscopy for LGIB
  3. Angiography:
    - requires a brisk bleeding rate
  4. Tagged red cell study
    - can localize source of bleeding at a SLOW rate
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23
Q

tx of initial resuscitation of GIB

A
  1. Cardiac monitoring, oxygen, 2 large bore IV’s prn, IVF, blood
    - Transfuse is Hgb is less than 7 g/dL, or if symptomatic
  2. Consider Foley catheter, invasive hemodynamic monitoring if unstable
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24
Q

when do you transfuse someone

A

Hgb is less than 7 g/dL, or if symptomatic

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25
Q

tx of secondary resuscitation of GIB; medical

A

UGIB: get PPI

  1. PPI: bolus plus infusion
    - ie, Pantoprazole 80mg IV then 8mg/h IV
  2. If h/o esophageal varices
    - Octreotide 25-50mcg IV bolus plus infusion
  3. GI consult, medicine admit
  4. Erythromycin for UGIB?
  5. Prophylactic Abx for cirrhotic patients
    - Up to 20% of all cirrhotics have a bacterial infection; up to 50% develop inpatient
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26
Q

tx of secodnary intervention of GIB, surgical

A

NPO p MN

  • Endoscopy for UGI bleeding with sclerotherapy, electrocoagulation
  • Balloon tamponade for variceal bleeding

These patients are all admitted; you will help GI decide which test to order, based on your findings (upper vs lower

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27
Q

key predictors for bad outcomes in UGIB

A
  1. Older age
  2. Hemodynamic instability or orthostasis
  3. Co-morbid disease states
  4. Anti-coagulants
  5. Glasgow-Blatchford Bleeding Score (GBS) for UGIB - MDCalc
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28
Q

Dilated submucosal veins in lower esophagus

A

esophageal varices

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29
Q

presents:
Brisk painless bleeding
Can leading to hypovolemia, shock; requiring emergent endoscopy
hx of bing drinker

A

esophageal varices

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30
Q

ppl w/ esophegeal varices have H/O __-

A

portal HTN or cirrhosis in 50% of pts

*Mortality 30%; 70% recurrence in one year

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31
Q

cause of acute dysphagia

A
  • Food Impaction

- Esophageal Perforation

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32
Q

causes of chronic dysphagia

A
  • Poorly controlled GERD

- Esophagitis

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33
Q

causes of eosphgeal emergenices

A
  • Coin/ button battery ingestion
  • Sharp Objects
  • Swallowed FB
  • Narcotic packets
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34
Q

sx of dysphagia/ esophageal FB

A

FB sensation (vs aspiration?); CP; SOB?, throat pain; choking, coughing

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35
Q

PE for esophgeal FB/dysphagia

A
  • ability to swallow:
  • food vs fluids? secretions?
  • Look in OP; Listen for abnl lung sounds; Feel for neck masses/crepitance; Eval Abd for TTP
  • Imaging: CXR, consider CT prn
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36
Q

esophgeal food impaction: evaluate by

A

Ask about difficulty swallowing solids, liquids

  • Observe after drinking water
  • Esophageal abrasions
  • If can’t swallow water, need ED management

*Most patients with food impaction have underlying pathology

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37
Q

tx options for esophgeal food impaction

A
  • Glucagon relaxes LES
  • Carbonated beverages
  • GI consult/ Endoscopy

-Must evaluate after dislodgement
If able to take PO, can go home for GI follow up, with consult from ED

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38
Q

most common FB in adults

A

meat

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39
Q

workup for GERD

A
  • first consider your differential; are you sure it isn’t cardiac?
  • Belly labs if concerned for abd pathology
  • Trop/ EKG/ CXR prn
  • Rectal for GIB
  • may try GI Cocktail
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40
Q

what is in a GI cocktail

A

Viscous lidocaine, antacid, donnatal or dycyclomine

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41
Q

GERD TX

A
  1. Treat symptoms with PPI or H2 blocker
    - 2 weeks, ish; outpatient f/u
  2. Lifestyle modifications
    - Avoid lying down for 3 hours after a meal
    - Elevate HOB
    - Avoid acidic foods, caffeine, peppermint, chocolate, alcohol, cigarettes, NSAIDS
    - Weight loss
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42
Q

what are mallory weiss tears

A
  • Painless hematemesis from violent vomiting
  • Tear of the gastric mucosa from retching
  • Self limited
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43
Q

what are Boerhaave’s

A

painful, esophgeal perforation

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44
Q

what is the difference btwn oropharyngeal dysphagia and esophgeal dysphagia

A

Oropharyngeal dysphagia – Transfer dysphagia – difficult initiating swallowing

Esophageal dysphagia – Transport dyaphagia – difficult relaxing the LES

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45
Q

common pediatric FB aspirations

A

Pediatrics (over 80%)
- coins, toys, crayons, buttons, batteries, magnets

*Need high degree of suspicion; may not have been observed
V, choking, drooling, not wanting to eat

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46
Q

any person w/ hematemsis needs:

A
  1. Hematocrit
  2. soft belly?
  3. rectal exam
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47
Q

pediatric swallowed FB tend to get lodged where

A

in areas of anatomic narrowing: UES, LES

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48
Q

prisoners/psych pts tend to swallow

A

razor blades, tooth brushes, narc packets

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49
Q

imaging for swallowed FB

A
  1. XRay:
    - PA/LAT of neck/chest/abd
    - Plastic, wood, thin metal and bones are radioluscent
    - Can suggest free air or demonstrate esophageal air fluid levels, even if object is not visualized
  2. CT: If symptomatic or “concerning” Fb, and not visualized on XR:
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50
Q

Most FB swallowed will pass if they:

A

traverse the pylorus within 2-3 days.

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51
Q

F/U for FB swallowed

A

-Check the BMs for passage
-Follow up with PCP or GI in 24-48 hrs, for repeat XR and eval
BUT:
-10-20% need endoscopy;
- 1% need surgery

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52
Q

indications for urgen intervention/endoscopy of FB swallowed

A
  1. Sharp : open safety pins, needles, razor blades
  2. Big: over 5cm long or 2 cm wide
  3. Button batteries in esophagus
  4. Magnets
  5. Signs of airway compromise
  6. Signs of esophageal obstruction
  7. N/V/Abd Pain/ F
  8. In esophagus over 24 hours
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53
Q

special considerations for swallowed button batteries

A

must be removed immediately
burns/ perforation -can occur within 6 hours

*button batteries should be taken seriously; call consults
Try to determine more info about the battery

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54
Q

management of swallowed batteries

A
  • Batteries that do not need to be removed acutely
  • Pass the esophagus and asymptomatic
  • 24 hour follow up, call G
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55
Q

most common FB ingested by children

A

coins

56
Q

management of coin swallowed FB

A
  • If visualized in esophagus, and asymptomatic – observe for 24hrs
  • 30% will pass into stomach
  • Metal is not toxic and no sharp edges; usually pass after 1-3 weeks. Weekly Xrays w PCP
  • Always consider if a “coin” on XR is not actually a button battery
57
Q

cuases of PUD

A

H.pylori responsible for most; NSAIDs second

58
Q

predisposing factors of PUD

A

H Pylori infection, smoking, alcohol, NSAIDS, emotional stress

59
Q

complications of PUD

A

bleeding, perforation, obstruction

60
Q

Chronic illness manifest by recurrent ulceration in the stomach and duodenum

A

PUD

61
Q 
presentation: 
Dyspepsia
Upper abdominal pain
Food provoked symptoms
may be asymptomatic
A

PUD

62
Q

how cna you differentiate btwn gastric and duodenal ulcers

A

Gastric: Pain worse after eating

Duodenal: Pain occurs several hours after eating; improved with food or antacids

63
Q

Labs for PUD

A 
CBC (for Hematocrit)
\+/- belly labs
\+/- coags, T and S
Stool Hemoccult 
Cardiac labs prn
64
Q

imaging for PUD

A

XR: R/O perforation, o/w not helpful

Upper Endoscopy - gold standard and most common test. Usually outpatient.

65
Q

tx of PUD

A
  1. GI Cocktail
  2. PPI
    - Heals ulcers faster than H2 blocker
  3. Dietary/lifestyle changes
    - Smoking, NSAIDs, Alcohol, caffeine, obesity
66
Q

what PUD pts need urgent referral

A
  1. GI bleeding/anemia
  2. Unexplained weight loss
  3. Family h/o GI cancer
  4. Recurrent vomiting
67
Q

perforated ulcer presentation

A
  • Sudden onset of severe epigastric pain followed by peritonitis
  • tachy, guarded on exam
68
Q

labs and imaging for perforated ulcer

A

CBC, type and cross, lipase

Free air on x-ray or CT scan

69
Q

tx of perforated ulcer

A
  1. 2 large bore IV’s
  2. NGT
  3. Broad spectrum antibiotics – ie Zosyn
  4. Surgical consult
70
Q

cuases of perforated ulcer

A

PUD

Boeerhaves syndrome

71
Q

most common cause of pancreatitis

A

alcohol (#1) and cholelithiasis (#2)

Other causes include trauma, post operative, medications, hyperlipidemia

72
Q

Pathogenesis of pancreatitis is

A

auto digestion of the pancreas

73
Q

complications of pancreatitis

A

Causes significant systemic effects from overwhelming inflammatory response, can lead to SIRS, organ failure and death

74
Q

presentation:
Severe constant stabbing pain in the epigastrum or LUQ ; radiates to the back, flank, chest, or lower abdomen
Begins abruptly.
Nausea, vomiting, ileus are common

A

pancreatitis

75
Q

exam:
Low grade fever, hypotension, tachycardia are common
Abdominal exam
epigastric tenderness
-periumbillical blue
May have respiratory symptoms due to atelectasis, left pleural effusion

A

pancreatitis

76
Q

acute pancreatitis dx requires:

A

Require two of these three :

  1. Characteristic abdominal pain
  2. Serum Amylase/Lipase levels over 3x normal
  3. CT or US findings c/w pancreatitis
    - Usually rely on labs instead of imaging
77
Q

lab findings of pancreatitis

A
  1. CBC, UA, LFT’s, Chem 7, Lipase
  2. Lipase is the most specific test for pancreatitis.***
    - over 600 IU/L is highly predictive
    - Levels remain elevated for 6-7 days
    - Normal Lipase does not r/o pancreatitis
  3. Amylase - not specific
78
Q

imaging of pancreatitis

A

Don’t usually need them - your diagnosis is history and labs*

  1. CXR, abdominal films used to exclude other causes of pain
    - Sentinel loop, calcifications
  2. CT used for grading severity of disease.
    - Often normal in early dz
  3. US is useful for evaluation of biliary tract
79
Q

tx of pancreatitis

A
  1. IVF/ Fluid resuscitation - usually several liters
  2. Anti-emetics, Pain medication- Lots of both
  3. NPO
  4. Most patients require admission
    - Med bad if stable
    - ICU if requiring pressors/unstable hemodynamically
80
Q

pancreatitis dispo considerations

A

Sick or not sick?

  • Consider end organ damage
  • CV, respiratory or renal compromise
  • Apache II or Ransons criteria
81
Q

who w/ pancreatitis can go home

A
  • If Mild disease, w/o biliary tract disease, and able to tolerate PO, may go home with close follow up.
  • Clear liquid diet, pain/nausea meds.
82
Q

ICU admission criteria

A
  1. Encephalopathy
  2. Hypoxemia
  3. Tachycardia with hypotension
  4. HCT over 50 (dehydration)
  5. Oliguria
  6. Azotemia
83
Q

what is ranson’s criteria

A

Grading system for pancreatitis (on admission and 48 hrs later)

Prognostic 3 Positives = Severe Disease

ON ADMISSION

  • Age over 55
  • Blood sugar over 200 mg/dl
  • WBC over 16,000
  • AST over 250
  • LDH over 350 IU/dl
84
Q

tx of chronic pancreatitis

A
  1. Treatment includes pain management
  2. Low fat diet
  3. No ETOH
  4. CCK, pancreatic enzymes
85
Q

complications of chronic pancreatitis

A

Increased risk of pancreatic CA and malabsorption syndromes

86
Q

Most likely cause of rectal bleeding is

A

internal or external hemorrhoids

*May see blood on tp when wiping or red toilet water.

87
Q

work up of BRBPR/ hematochezia

A
  1. Check Hct; stool Guiac; vitals
  2. Minimum w/u includes anoscopy in ER****
  3. May require referral for flex sig or colonoscopy
88
Q

what is an anal fissure and hemorrhoid

A

Fissure: tear at rectal sphincter
Most common cause of rectal pain

Hemorrhoid: dilation of vascular bed
- May cause painless hematochezia

89
Q

how can you differentiate between internal and external hemorrhoids

A

Internal - above dentate line, painless

External - below dentate line, painful

90
Q

complications of external hemorrohoids

A

thrombosed hemorrhoid which requires draining

91
Q

hemorrhoid tx

A
  • Nonthrombosed - gently reduce

- Thrombosed - Excise and drain (if grape looking like)

92
Q

outpatient tx for nonthrombosed hemorrhoids

A
  1. Fiber
  2. Stool softeners
  3. Sitz baths
  4. hydrocortisone suppositories
  5. Topical NTG ointment .2% bid x6 weeks
  6. Single botox injection
  7. Surgery or GI for Sphincterotomy or banding if recurrent
93
Q

most common digestive compliant in US

A

constipation- The presence of hard stools which are difficult to pass

  • Do not overlook this in patients complaining of abdominal pain; can become surgical.
  • Diagnosis of exclusion
94
Q

common, acute, and chronic causes of constipation

A

Common causes: decreased fiber and water, lack of exercise

Acute causes: obstruction, medications, pregnancy

Chronic causes: neurologic dysfunction, hypothyroid, lead

95
Q

exam of constipation

A
  1. R/O organic causes such as obstruction, hernias, masses
  2. confirm no focal concerning abdominal tenderness
  3. Rectal exam; guaiac, and R/O fecal impaction, anal fissures
96
Q

labs and imaging for constipation

A

Labs: none required

X-ray of the abdomen show FOS

97
Q

tx for constipation

A
  1. exercise, 1.5 liters of water q day, 10 grams/day of fiber
  2. Medications:
    - metamucil, dulcolax, magnesium citrate, ?golytely; remove any triggers
  3. Fleets/ Soapsuds enemas
98
Q

what is fecal impaction

A
  • Bolus of stool sits in rectal vault only allows liquid stool to pass
  • Commonly misdiagnosed as an obstruction by providers who don’t perform a rectal exam
99
Q

tx of fecal impaction

A
  • manual disimpaction,
  • enemas,
  • may require sedation
100
Q

what are pilonial sinus/cyst

A

Recurring foreign body granulomatous reaction to ingrown hair

Usually painful; classic PEX

101
Q

tx for pilonial sinus/cyst

A

I and D; Abx +/-

-Refer to surgery for recurrent lesions

102
Q

anorectal abscess Originates from __ and spreads to ___

A

infected anal crypts and spreads to perianal and deep rectal spaces

103
Q

dx of anorectal abscess

A

*h/o aching dull pain that increases w/ BM

DX: History, rectal exam, CT

104
Q

tx of anorectal abscess

A
  1. drainage, frequently OR
105
Q

presents:
-Jaundice; abdominal, distention; peripheral edema; mental status changes
- Asterexis - “Liver flap”
h/o EtOH? IVDU?

A

cirrhosis/ ESLD

106
Q

complications of cirrhosis/ESLD

A
  1. Hepatic Encephalopathy
  2. Spontaneous bacterial Peritonitis
  3. Coagulopathy

*Acutely decompensating ESLD patients are admitted

107
Q

what is spontaneous bacterial peritonitis

A

-complication of cirrhosis
-Occurs yearly in 1/3 of patients with ascites
Ascites Plus:
1. Fever
2. Abdominal Pain
3. Mental Status Changes

108
Q

tx of spontaneous bacterial peritonitis

A
  • Parascentesis and culture

- empiric Abx treatment

109
Q

an ascitic fluid infection without evidence of a surgically treatable intra-abdominal source

A

spontaneous bacterial peritonitis

110
Q

w/u of hepatic encephalopathy

A
  • Check Ammonia level (may have AMS)

- Tx w Lactulose

111
Q

w/u and tx of coagulapathy

A
  1. Check PT/PTT; LFTs

2. Tx: Vit K PO or IV

112
Q

w/u of N/V +/- diarrhea

A
  1. Workup driven by your H & P
  2. Always consider life threatening conditions
  3. If concerning history, Labs may include CBC, BMP, Hepatic function panel, Upreg, UA, drug levels…et al. (not always indicated)
  4. Imaging: see above
113
Q

vomiting blood may be: __

vomiting w/ distention: ___

vomiting w/ HA: __

vomitning in Female

vomiting w/ DM

A

UGIB
varies

bowel obstruction

migraine
increased ICP

preg

gastroparesis, DKA

114
Q

1 cause of N/V in US is a

A

viral GE

115
Q

tx of N/V

A

Once you have ruled out pathology, may just need to treat symptoms and rehydrate

  1. NS IV 1-2 liter
  2. Antiemetics: Zofran, Reglan, Phenergan
  3. Peds – PO if possible
  4. Electrolyte repletion prn
  5. Dispo home if tolerating PO; clear liquid diet, introduce bland diet, toast, crackers, slowly
116
Q

what is cyclic vomiting syndrome

A

an idiopathic disorder characterized by recurrent, stereotypical bouts of vomiting with intervening periods of normal health, without organic cause identified

117
Q

tx of Cannabis Hyperemesis Syndrome

A

symptom management, then stop using MJ (for at least one month)
-r/o life threatening causes

118
Q

self diagnose of Cannabis Hyperemesis Syndrome

A
  • daily/cyclic vomiting

- frequent hot showers makes them feel better

119
Q

what is the official definition of diarrhea

A

“3 or more watery stools per day”

Acute diarrhea less than 3 wks
Chronic over 3 wks

120
Q

key questions to ask for diarrhea

A

Bloody? Fever? Pus? Pain? Travel?

121
Q

w/u of diarrhea

A

Most are viral/self limited

  1. IVF
  2. Check labs prn – such as severe dehydration
  3. Consider the need to stool for culture, WBC, O and P, C.dff, giardia if any red flags
122
Q

___ causes 50-80% of infectious diarrhea in the US

A

Norovirus

123
Q

diarrhea red flags

A

fever
abdominal pain
bloody stool

124
Q

what should you do a stool culture or C. diff assay w/ diarrhea

A 
Culture:
-blood or pus in stool 
 diarrhea over 3 days
-Immunocompromised
-Severely ill/dry’febrile
-Abdominal Pain

C.diff assay if
-recent antibiotic use

125
Q

diarrhea Culture looks for

A

salmonella, shigella, campylobacter,

*E. Coli 0157:H7, Vibrio are “special tests”

126
Q

when should you do an O and P for diarrhea

A
  1. diarrhea over7 days
  2. travel abroad
  3. Consumed untreated water

*O and P for giardia or cryptosporidium

127
Q

dispo of benign diarrhea

A

*if Abdomen is soft, VS are normal, no bleeding, no fevers, tolerating POs

  • Contact precautions
  • BRAT diet, Close follow up, return precautions
  • Abx if indicated for severe/prolonged diarrhea
  • Cipro 500mg bid x 3 d
  • Imodium OTC; Pepto bismol; Probiotic; Loperamide
128
Q

+ stool WBCs indicates

A

inflammatory disease

129
Q

___% of travelers to resource poor countries get diarrhea

A

40-60%

E. coli is most common

-self limited 3-4 days

130
Q

tx of mild diarrhea

A

(1-2 non bloody stools/day)

“Symptom management”
Loperamide and Pepto bismol

131
Q

tx of moderate diarrhea

A

Moderate (2-6 non bloody stools/day)

“Symptom management”
Loperamide and Pepto bismol

132
Q

tx of severe diarrhea

A

(over6 loose stools/day, or fever, or bloody stools)

  • Cipro 500mg bidx3d or Azithromycin 500mg qdx3d if pregnant or peds
  • Flagyl for giardia
  • Avoid antimotility agents (Lomotil)
133
Q

causes of C. diff

A

Commonly cause by broad spectrum abx
Quinolones, clindamycin, cephalosprins

Additional risks
recent hospitalization, elderly, severe illness

*Usually 5-10 days after Abx, but onset may be up to several weeks

134
Q

presentation of C. diff

A

Watery diarrhea is cardinal symptom; also have low grade fevers, abdominal cramping, leukocytosis

135
Q

dx and tx of c. diff

A

Dx: stool for c.diff to lab
Needs to be a loose stool

Tx:
metronidazole 500mg QID 10-14 d
Vancomycin 250mg PO QID 10-14 d.
Stool transplant!

136
Q

c. diff complications

A
  1. Pseudomembranous colitis

2. toxic megacolon

137
Q

what is Pseudomembranous colitis

A
  • complication of c. diff
  • Progression of symptoms to include increasing pain, severe leukocytosis, lactic acidosis, hypovolemia/hypoalbuminemia
  • Membrane like yellowish plaques overlay and replace necrotic intestinal mucosa

Emergency Medicine (22 decks)

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