Abdominal pain 2 Flashcards
The most important aspect of the evaluation of the patient with abdominal pain in the ED is __
history
*The next is serial exams to evaluate how the pain is changing during the ED course
risk factors for AAA
- Male
- over 60 years old
- Connective tissue d/o
- SMOKING, HTN, DM, hyperlipidemia
- Family History is one of the strongest predictors
AAA is Thinning of ___ of the aorta, resulting in decreased tensile wall strength
media
classic AAA rupture
male, older, with sudden back or abdominal pain, ripping/tearing; hypotensive
Keep a ruptured AAA in your mind when evaluating for:
back pain,
syncope, and
renal colic
AAA imaging studies
-CT is 100% accurate; but, if patient is unstable, ultrasound is preferred
common post surgical fevers
24 hours: atelectasis, necrotizing fasciitis
72 hours: Pneumonia, UTI
5 days: DVT
7-10 days: wound infections
melanoic stools indicate __
bright red stools indicate
upper GI bleed
lower GI bleed
Upper GIB is defined as originating proximal to the __. LGIB originates distally
ligament of Treitz- suspensory ligament of the duodenum
UGIB causes:
PUD #1 45% Erosive gastritis 23% esophagitis 6% varices, 10% Mallory-Weiss tears7% duodenitis 6%
LGIB causes:
Diverticular dz #1. Colitis, polyps, carcinoma, hemorrhoids. brisk UGIB.
source of hematemesis
usually source is proximal to the ascending colon
source of melena
usually from proxima/ UGI bleed
hematochezia source
- suggests a distal colorectal lesion
- BUT – 10-15% of patients w/ this have UGI source – usually a rapid bleed
GI bleed fake outs for melena
charcoal
pepto-bismol*
GI bleed fake outs for hematoemesis
Nosebleeds Dental bleeding Tonsil bleeding Red drinks Red food
GI bleed fake outs for hematochezia
Partially digested red grapes
Red food (beets)
Vaginal bleeding
Gross hematuria
GI bleed fake outs for false + occult blood testing
Red meat, turnips, horseradish, vitamin C
how will GI bleeds change bowel patterns
go more frequently
exam for suspected GIB
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
labs for GIB
- CBC
- initial hematocrit may not reflect actual amount of blood loss
- Consider rechecking - hemodilution? Rapid blood loss? - Chem 7, LFT’s
- Coags: is patient on blood thinner? ASA?
- EKG prn
- Type and screen prn
imaging studies for GIB
Plain films have no value!!
- Upper Endoscopy for UGIB
- Colonoscopy for LGIB
- Angiography:
- requires a brisk bleeding rate - Tagged red cell study
- can localize source of bleeding at a SLOW rate
tx of initial resuscitation of GIB
- Cardiac monitoring, oxygen, 2 large bore IV’s prn, IVF, blood
- Transfuse is Hgb is less than 7 g/dL, or if symptomatic - Consider Foley catheter, invasive hemodynamic monitoring if unstable
when do you transfuse someone
Hgb is less than 7 g/dL, or if symptomatic
tx of secondary resuscitation of GIB; medical
UGIB: get PPI
- PPI: bolus plus infusion
- ie, Pantoprazole 80mg IV then 8mg/h IV - If h/o esophageal varices
- Octreotide 25-50mcg IV bolus plus infusion - GI consult, medicine admit
- Erythromycin for UGIB?
- Prophylactic Abx for cirrhotic patients
- Up to 20% of all cirrhotics have a bacterial infection; up to 50% develop inpatient
tx of secodnary intervention of GIB, surgical
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
key predictors for bad outcomes in UGIB
- Older age
- Hemodynamic instability or orthostasis
- Co-morbid disease states
- Anti-coagulants
- Glasgow-Blatchford Bleeding Score (GBS) for UGIB - MDCalc
Dilated submucosal veins in lower esophagus
esophageal varices
presents:
Brisk painless bleeding
Can leading to hypovolemia, shock; requiring emergent endoscopy
hx of bing drinker
esophageal varices
ppl w/ esophegeal varices have H/O __-
portal HTN or cirrhosis in 50% of pts
*Mortality 30%; 70% recurrence in one year
cause of acute dysphagia
- Food Impaction
- Esophageal Perforation
causes of chronic dysphagia
- Poorly controlled GERD
- Esophagitis
causes of eosphgeal emergenices
- Coin/ button battery ingestion
- Sharp Objects
- Swallowed FB
- Narcotic packets
sx of dysphagia/ esophageal FB
FB sensation (vs aspiration?); CP; SOB?, throat pain; choking, coughing
PE for esophgeal FB/dysphagia
- 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
esophgeal food impaction: evaluate by
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
tx options for esophgeal food impaction
- 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
most common FB in adults
meat
workup for GERD
- 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
what is in a GI cocktail
Viscous lidocaine, antacid, donnatal or dycyclomine
GERD TX
- Treat symptoms with PPI or H2 blocker
- 2 weeks, ish; outpatient f/u - Lifestyle modifications
- Avoid lying down for 3 hours after a meal
- Elevate HOB
- Avoid acidic foods, caffeine, peppermint, chocolate, alcohol, cigarettes, NSAIDS
- Weight loss
what are mallory weiss tears
- Painless hematemesis from violent vomiting
- Tear of the gastric mucosa from retching
- Self limited
what are Boerhaave’s
painful, esophgeal perforation
what is the difference btwn oropharyngeal dysphagia and esophgeal dysphagia
Oropharyngeal dysphagia – Transfer dysphagia – difficult initiating swallowing
Esophageal dysphagia – Transport dyaphagia – difficult relaxing the LES
common pediatric FB aspirations
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
any person w/ hematemsis needs:
- Hematocrit
- soft belly?
- rectal exam
pediatric swallowed FB tend to get lodged where
in areas of anatomic narrowing: UES, LES
prisoners/psych pts tend to swallow
razor blades, tooth brushes, narc packets
imaging for swallowed FB
- 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 - CT: If symptomatic or “concerning” Fb, and not visualized on XR:
Most FB swallowed will pass if they:
traverse the pylorus within 2-3 days.
F/U for FB swallowed
-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
indications for urgen intervention/endoscopy of FB swallowed
- Sharp : open safety pins, needles, razor blades
- Big: over 5cm long or 2 cm wide
- Button batteries in esophagus
- Magnets
- Signs of airway compromise
- Signs of esophageal obstruction
- N/V/Abd Pain/ F
- In esophagus over 24 hours
special considerations for swallowed button batteries
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
management of swallowed batteries
- Batteries that do not need to be removed acutely
- Pass the esophagus and asymptomatic
- 24 hour follow up, call G
most common FB ingested by children
coins
management of coin swallowed FB
- 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
cuases of PUD
H.pylori responsible for most; NSAIDs second
predisposing factors of PUD
H Pylori infection, smoking, alcohol, NSAIDS, emotional stress
complications of PUD
bleeding, perforation, obstruction
Chronic illness manifest by recurrent ulceration in the stomach and duodenum
PUD
presentation: Dyspepsia Upper abdominal pain Food provoked symptoms may be asymptomatic
PUD
how cna you differentiate btwn gastric and duodenal ulcers
Gastric: Pain worse after eating
Duodenal: Pain occurs several hours after eating; improved with food or antacids
Labs for PUD
CBC (for Hematocrit) \+/- belly labs \+/- coags, T and S Stool Hemoccult Cardiac labs prn
imaging for PUD
XR: R/O perforation, o/w not helpful
Upper Endoscopy - gold standard and most common test. Usually outpatient.
tx of PUD
- GI Cocktail
- PPI
- Heals ulcers faster than H2 blocker - Dietary/lifestyle changes
- Smoking, NSAIDs, Alcohol, caffeine, obesity
what PUD pts need urgent referral
- GI bleeding/anemia
- Unexplained weight loss
- Family h/o GI cancer
- Recurrent vomiting
perforated ulcer presentation
- Sudden onset of severe epigastric pain followed by peritonitis
- tachy, guarded on exam
labs and imaging for perforated ulcer
CBC, type and cross, lipase
Free air on x-ray or CT scan
tx of perforated ulcer
- 2 large bore IV’s
- NGT
- Broad spectrum antibiotics – ie Zosyn
- Surgical consult
cuases of perforated ulcer
PUD
Boeerhaves syndrome
most common cause of pancreatitis
alcohol (#1) and cholelithiasis (#2)
Other causes include trauma, post operative, medications, hyperlipidemia
Pathogenesis of pancreatitis is
auto digestion of the pancreas
complications of pancreatitis
Causes significant systemic effects from overwhelming inflammatory response, can lead to SIRS, organ failure and death
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
pancreatitis
exam:
Low grade fever, hypotension, tachycardia are common
Abdominal exam
epigastric tenderness
-periumbillical blue
May have respiratory symptoms due to atelectasis, left pleural effusion
pancreatitis
acute pancreatitis dx requires:
Require two of these three :
- Characteristic abdominal pain
- Serum Amylase/Lipase levels over 3x normal
- CT or US findings c/w pancreatitis
- Usually rely on labs instead of imaging
lab findings of pancreatitis
- CBC, UA, LFT’s, Chem 7, Lipase
- 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 - Amylase - not specific
imaging of pancreatitis
Don’t usually need them - your diagnosis is history and labs*
- CXR, abdominal films used to exclude other causes of pain
- Sentinel loop, calcifications - CT used for grading severity of disease.
- Often normal in early dz - US is useful for evaluation of biliary tract
tx of pancreatitis
- IVF/ Fluid resuscitation - usually several liters
- Anti-emetics, Pain medication- Lots of both
- NPO
- Most patients require admission
- Med bad if stable
- ICU if requiring pressors/unstable hemodynamically
pancreatitis dispo considerations
Sick or not sick?
- Consider end organ damage
- CV, respiratory or renal compromise
- Apache II or Ransons criteria
who w/ pancreatitis can go home
- 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.
ICU admission criteria
- Encephalopathy
- Hypoxemia
- Tachycardia with hypotension
- HCT over 50 (dehydration)
- Oliguria
- Azotemia
what is ranson’s criteria
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
tx of chronic pancreatitis
- Treatment includes pain management
- Low fat diet
- No ETOH
- CCK, pancreatic enzymes
complications of chronic pancreatitis
Increased risk of pancreatic CA and malabsorption syndromes
Most likely cause of rectal bleeding is
internal or external hemorrhoids
*May see blood on tp when wiping or red toilet water.
work up of BRBPR/ hematochezia
- Check Hct; stool Guiac; vitals
- Minimum w/u includes anoscopy in ER****
- May require referral for flex sig or colonoscopy
what is an anal fissure and hemorrhoid
Fissure: tear at rectal sphincter
Most common cause of rectal pain
Hemorrhoid: dilation of vascular bed
- May cause painless hematochezia
how can you differentiate between internal and external hemorrhoids
Internal - above dentate line, painless
External - below dentate line, painful
complications of external hemorrohoids
thrombosed hemorrhoid which requires draining
hemorrhoid tx
- Nonthrombosed - gently reduce
- Thrombosed - Excise and drain (if grape looking like)
outpatient tx for nonthrombosed hemorrhoids
- Fiber
- Stool softeners
- Sitz baths
- hydrocortisone suppositories
- Topical NTG ointment .2% bid x6 weeks
- Single botox injection
- Surgery or GI for Sphincterotomy or banding if recurrent
most common digestive compliant in US
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
common, acute, and chronic causes of constipation
Common causes: decreased fiber and water, lack of exercise
Acute causes: obstruction, medications, pregnancy
Chronic causes: neurologic dysfunction, hypothyroid, lead
exam of constipation
- R/O organic causes such as obstruction, hernias, masses
- confirm no focal concerning abdominal tenderness
- Rectal exam; guaiac, and R/O fecal impaction, anal fissures
labs and imaging for constipation
Labs: none required
X-ray of the abdomen show FOS
tx for constipation
- exercise, 1.5 liters of water q day, 10 grams/day of fiber
- Medications:
- metamucil, dulcolax, magnesium citrate, ?golytely; remove any triggers - Fleets/ Soapsuds enemas
what is fecal impaction
- 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
tx of fecal impaction
- manual disimpaction,
- enemas,
- may require sedation
what are pilonial sinus/cyst
Recurring foreign body granulomatous reaction to ingrown hair
Usually painful; classic PEX
tx for pilonial sinus/cyst
I and D; Abx +/-
-Refer to surgery for recurrent lesions
anorectal abscess Originates from __ and spreads to ___
infected anal crypts and spreads to perianal and deep rectal spaces
dx of anorectal abscess
*h/o aching dull pain that increases w/ BM
DX: History, rectal exam, CT
tx of anorectal abscess
- drainage, frequently OR
presents:
-Jaundice; abdominal, distention; peripheral edema; mental status changes
- Asterexis - “Liver flap”
h/o EtOH? IVDU?
cirrhosis/ ESLD
complications of cirrhosis/ESLD
- Hepatic Encephalopathy
- Spontaneous bacterial Peritonitis
- Coagulopathy
*Acutely decompensating ESLD patients are admitted
what is spontaneous bacterial peritonitis
-complication of cirrhosis
-Occurs yearly in 1/3 of patients with ascites
Ascites Plus:
1. Fever
2. Abdominal Pain
3. Mental Status Changes
tx of spontaneous bacterial peritonitis
- Parascentesis and culture
- empiric Abx treatment
an ascitic fluid infection without evidence of a surgically treatable intra-abdominal source
spontaneous bacterial peritonitis
w/u of hepatic encephalopathy
- Check Ammonia level (may have AMS)
- Tx w Lactulose
w/u and tx of coagulapathy
- Check PT/PTT; LFTs
2. Tx: Vit K PO or IV
w/u of N/V +/- diarrhea
- Workup driven by your H & P
- Always consider life threatening conditions
- If concerning history, Labs may include CBC, BMP, Hepatic function panel, Upreg, UA, drug levels…et al. (not always indicated)
- Imaging: see above
vomiting blood may be: __
vomiting w/ distention: ___
vomiting w/ HA: __
vomitning in Female
vomiting w/ DM
UGIB
varies
bowel obstruction
migraine
increased ICP
preg
gastroparesis, DKA
1 cause of N/V in US is a
viral GE
tx of N/V
Once you have ruled out pathology, may just need to treat symptoms and rehydrate
- NS IV 1-2 liter
- Antiemetics: Zofran, Reglan, Phenergan
- Peds – PO if possible
- Electrolyte repletion prn
- Dispo home if tolerating PO; clear liquid diet, introduce bland diet, toast, crackers, slowly
what is cyclic vomiting syndrome
an idiopathic disorder characterized by recurrent, stereotypical bouts of vomiting with intervening periods of normal health, without organic cause identified
tx of Cannabis Hyperemesis Syndrome
symptom management, then stop using MJ (for at least one month)
-r/o life threatening causes
self diagnose of Cannabis Hyperemesis Syndrome
- daily/cyclic vomiting
- frequent hot showers makes them feel better
what is the official definition of diarrhea
“3 or more watery stools per day”
Acute diarrhea less than 3 wks
Chronic over 3 wks
key questions to ask for diarrhea
Bloody? Fever? Pus? Pain? Travel?
w/u of diarrhea
Most are viral/self limited
- IVF
- Check labs prn – such as severe dehydration
- Consider the need to stool for culture, WBC, O and P, C.dff, giardia if any red flags
___ causes 50-80% of infectious diarrhea in the US
Norovirus
diarrhea red flags
fever
abdominal pain
bloody stool
what should you do a stool culture or C. diff assay w/ diarrhea
Culture: -blood or pus in stool diarrhea over 3 days -Immunocompromised -Severely ill/dry’febrile -Abdominal Pain
C.diff assay if
-recent antibiotic use
diarrhea Culture looks for
salmonella, shigella, campylobacter,
*E. Coli 0157:H7, Vibrio are “special tests”
when should you do an O and P for diarrhea
- diarrhea over7 days
- travel abroad
- Consumed untreated water
*O and P for giardia or cryptosporidium
dispo of benign diarrhea
*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
+ stool WBCs indicates
inflammatory disease
___% of travelers to resource poor countries get diarrhea
40-60%
E. coli is most common
-self limited 3-4 days
tx of mild diarrhea
(1-2 non bloody stools/day)
“Symptom management”
Loperamide and Pepto bismol
tx of moderate diarrhea
Moderate (2-6 non bloody stools/day)
“Symptom management”
Loperamide and Pepto bismol
tx of severe diarrhea
(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)
causes of C. diff
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
presentation of C. diff
Watery diarrhea is cardinal symptom; also have low grade fevers, abdominal cramping, leukocytosis
dx and tx of c. diff
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!
c. diff complications
- Pseudomembranous colitis
2. toxic megacolon
what is Pseudomembranous colitis
- 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
