Abdominal Pain Flashcards
What should your initial actions be for a patient presenting with abdominal pain?
- primary survey
- order UTP for young women
- Order blood products if hemodynamically unstable
- Bedside imaging if concern for pneumo- or hemoperitoneum
- Abx in setting of sepsis, peritonitis or perf
- provide analgesia
- immediate surgical consultation if hemodynamic instability or rigid abdomen
What aspect of the primary survey is usually of concern in the patient with abdominal pain?
circulation
What are the four things you should think about in a patient with abdominal pain and hemodynamic instability?
hemorrhage
sepsis
perforated viscus
necrotic bowel
What should immediately be done in a patient with abdominal pain and hemodynamic instability?
fluid resuscitation with 2 large bore IVs
Women of childbearing age with abdominal pain are presumed to have what until proven otherwise?
ectopic
What are the two best options for bedside imaging in abdominal pain?
portable upright or decubitus xray to identify pneumoperitoneum
US for hemoperitoneum
What is an important extra-abdominal etiology of critical abdominal pain?
ACS
Approximately 1in ___ pregnancies results in ectopics.
1 in 8
What is the current fatality rate for ectopic pregnancies?
only 0.05%
What percentage of ectopics are still misdiagnosed on the first patient encoutner?
40-50%
Overall, ectopic account for what percentage of pregnancy-related maternal deaths?
9%
What are the risk factors for ectopic pregnancy?
PID previous ectopic tubal surgery previous pelvic/abdominal surgery tubal pathology in utero DES IUD smoking infertility/inf treatment
What is the classic triad for ectopic presentation?
abdominal pain
delayed menses
vaginal bleeding
but this is not sensitive or specific!
What is the most common physical exam finding in ectopic?
tenderness on pelvic exam
True or false: most patients with an ectopic pregnancy have abnormal vital signs upon presentation to the ED.
false - most will have normal vital signs until they have experienced significant blood loss
Note: Paradoxic bradycardia can occur in ectopic pregnancy
What is the next management for an ectopic with hemodyamic instability?
call OB/GYN to take to the OR
What are the nextmanagement options for stable patients with ectopic in the first trimester of bleeding?
transvaginal ultrasound to look for IUP.
If you see an IUP, then a concurrent ectopic pregnancy is highly unlikely unless…
they received fertility treatments
What is the earliest sign of an IUP by transvaginal US?
double decidual sac sign
What is the discriminatory zone for B-hCG?
1500-2000 mIU/mL
meaning that if the B-hCG is this high, you should be able to visualize an IUP if it’s there
What are some US signs of an ectopic?
empty uterus
extraovarian mass
tubal ring sign
pelvic free fluid
For stable patients, diagnosing an ectopic in the absence of IUP is accomplished by what?
serial B-hCG levels (if doubling rate is not apprpriate, likely an ectopic)
What is the failure rate for methotrexate in single doses?
36% - necessiatating a second dose
What are the contraindications for MTX?
hemodynamic instability inability to return for FU breastfeeding immunodeficiency renal/liver/pulm disease PUD blood dyscrasias
What is the classic presentation for appendicitis?
vague epigastric/periumbilical pain n/v/anorexia abdominal tenderness migrating to localize in the RLQ fever leukocytosis
What are the useful exam findings for appendicitis?
RLQ pain and guarding: high sensitivity, but low specificity
abdominal rigidity has high specificity but low sensisitivity
psoas, obturator and rosving’s sign are relatively poor
Leukocytosis can be absent in 10-20% of patients with appendicitis, so what additional lab test can be used?
CRP
US is the preferred mode of imaging for appendicitis in children and pregnant patients. What are some US findings of acute appendicitis?
size greater than 6-7 mm and noncompressible
increased wall thickness
fecalith
increased vascularity on doppler flow
In all other patients, what is the preferred imaging study for evaluating the appendix?
CT (contrast is better than non-contrast)
For low risk pediatric and pregnant patients with an indeterminate US, what is an option to avoid CT?
Observation for serial exams or have them return to the ER in 12-24 hours for repeat exam
What is the treatment for acute appendicitis?
prompt appendectomy
unless there’s a perforation with a walled-off abscess, in which case IR drainage
What are some examples of appropriate ABx for appendicitis?
uncomplicated: amp-sulbactam, cefoxitin, or metronidazole+cipro
complicated: meropenem/imipenem, zosyn
What is the classic triad of a ruptured AAA?
abdominal pain
hypotension
pulsatile abd mass
What is the mortality rate of ruptured AAA even with surgical intervention?
50% eek
What should your initial action be when a patient has a known or suspected ruptured AAA?
Manage airway, breathing, but focus mostly on ciruclatory collapse
2 large fore IVs, but don’t just dump fluid into them because large volumes of crystalloid solution can cause further bleeding, so target a systolic BP between 90 and 100 mmHg
With a ruptured AAA and hemodynamic instability, what imaging should you use?
trick question - skip it and go to the OR
If they’re stable, what is the best imaging modality to identify a AAA?
ultrasound
CT and plain radiographs can also be used, but US is best
WHat is the treatment for a ruptured AAA?
surgery by vascular
What are the signs and symptoms of PID and TOA?
bilateral lower abdominal pain
purulent vag discharge
abnl vag bleeding
maybe fever, n/v, malaise
Describe the appropriate diagnostic testing for PID or TOA?
UA, CBC, LFTs, GC/Chlam testing (PCR or DNR probe) on cervical secretions or urine
pelvic US if TOA suspected
What are the risk factors for PID?
hx of STDs multiple partners IUD (?) adolescence early sexual debut recent instrumentation of uterine cavity
What are the potential complications of PID?
tuboovarian abscess
Fitz-High-Curtis syndrome
chronic pelvic pain
dyspareunia
infertility
ectopic pregnancy
What is the rationale for starting treatment in patients with potential PID in uncertain cases?
Because the potential complications are so high and life-affecting
Which women with PID require hospitalization?
Suspected TOA or Ftiz-high-Curtis
w/ intractable vomiting, sepsis, peritonitis
prepubertal children
women with IUD
pregnant women
nulliparous
with comorbidities like DM or AIDS
What is the spectrum of biliary disease?
Cholelithiasis (stones in the GB)
Choledocholithiasis (stones in the CBD)
Acute cholecystitis (inflammation of GB)
Cholangitis (inflammation of the bile ducts)
What is the classic presentation of biliary colic?
episodic RUQ pain associated with nausea and vomiting
pain may radiate to back, right flank or right scapula
What is the classic presentation for cholangitis?
charcot’s triad:
RUQ pain, fever, jaundice
What is the classic physical exam findings for acute cholecystitis?
murphy’s sign (cessation of inspiration on deep palpation over the gallbladder)
What will you find on labs for cholelithiasis/
not much:
normal WBC, bilirbin, amylase, lipase
maybe slightly elevated transaminases or alk phos
What will you find on labs for choledocholithiasis?
remember this is now a stone in the CBD without inflammation, so…
normal WBC, normal or slightly elevated transaminases, elevated bilirubin, elevated alk phos, normal amylase/lipase
What will you find on labs with acute cholelithiasis?
Remember this is inflammation now…
Normal or increased WBC
normal or increased transaminases
normal or slightly increased bilirubin
normal amylase/lipase
What will you find on labs in cholangitis?
Now it’s inflammation of the bile ducts:
normal or increased WBC
high transaminatses, bilirubin and alk phos
normal or slightly elevated amylase/lipase
What is the initial diagnostic study of choice for GB disease?
US
What findings will you see for stones on US?
echogenic material within the GB that cases posterior shadows
dilation of the CBD over 6 mm suggests stone in the duct
What US findings will you see in cholecystitis?
wall thickening (5mm or greater) stones pericholecystic fluid sonographic murphy's increased blood flow on doppler
What imaging test is indicated if the US is equivocal or negative for cholecystitis in the presence of a high clinical suspicion?
a HIDA scan
or CT if the HIDA is not available
What imaging study is best if you suspect choledocholithiasis?
ERCP (used to both diagnose and treat)
What is the treatment for biliary colic?
symptomatic control for acute biliary colic
definitive treatment is surgical removal, but can happen whenever
What is the management for choledocholithiasis/
surgical or endoscopic removal of the stone
What is the initial treatment for cholecystitis and cholangitis?
symptom control with fluids, antiemetics, analgesics in addition to broad-spec ABx like amp/sulbactam, a fluoroquiniolon or cephalosporin+metro
cholecystectomy is indicated, but may be delayed in the critically ill patient (in which case you should consider percutaneous decomrpession with cholecystostomy)
Which patients with biliary disease can go home and which should be admitted?
biliary colic can go home with outpatient surgery consult
everything else should be admitted
What are the most common causes of bowel obstruction?
adhesions
tumors
hernias
also strictures, intussuseption, vovulus, crohn’s, gallstone ileus
What is the classic presentation of an SBO?
abdominal pain, distension, diarrhea/obstipation, nausea, vomiting, inability to take oral intake
dehydration, electrolyte abnormalities, decreased UOP, tachycardia, azotemia, hypotention
What PE findings do you expect in an SBO?
abdominal distension hyperactive/hypoactive bowel sounds fever tachycardia peritoneal signs
What is the best diagnostic modality for an SBO?
start with plain radiograph
What would you see on a plain film?
air fluid levels
distended loops of bowel
maybe free air if perforated
What are the treatment priorities for bowel obstruction?
resuscitation and lyte replacement
ID severity and cause
GI decompression
symptoamtic treatment
determine whether or not surgery is needed
What kind of patient would you recommend an emergent surgical intervention/consult for?
if acutely ill with peritoneal signs
if free air on plain film
if evidence for strangulation
What is the classic history for a perforated viscus?
Sudden, severe abdominal pain, initially focal, followed by generalized peritonitis
What are the classic physical exam findings for a perforated viscus?
Board-like rigidity
involuntary guarding
significant diffuse rebound tenderness
may also have SIRS signs
What is the most sensitive and specific imaging modality for identifying a perforated viscus?
a CT scan
If a CT scan is the most sensitive and specific, why are we always getting plain films for perforated viscus?
Because you can get them a lot faster. Just make sure you sit them upright or in the left lateral decubitus position for at least 10 minutes so the free air will rise to the highest elevation in the body.
but note: 50% of patients with pneumoperitoneum on laparotomy may have a negative plain film
What are the treatment priorities for a perforated viscus?
resuscitation
appropriate ABx selection
immediate surgical consult
What is the classic presentation for mesenteric ischemia?
a patient over 50 yrs of age who presents with sudden abdominal pain associated with nausea, vomiting, diarrhea - initially severe and diffuse
OUT OF PROPORTION TO EXAMINATION (no guarding or rebound at first)
eventually no bowel sounds, wall rigidity, bloody diarrhea
What are the four main causes of mesenteric ischemia?
mesenteric artery embolus
mesentery artery thrombosis
mesenteric vein thrombosis
non-occlusive ischemia
Mesenteric artery embolus is the most common cause (50% of cases). What is the most common location?
superior mesenteric artery
Which cause carries the worse prognosis/
mesenteric artery thrombosis beecause the thrombus usually is at the origin of the SMA and this leads to an enormous amount of bowel necrosis.
they will usually not present with acute symptoms, but gradually worsening vague and insidious symptoms
Mesenteric vein thrombosis is more likely to be seen in relatively younger patients. In what other way is its presentation different from that of mesenteric artery embolism?
symptoms occur acutely or over time, but there is NO postprandial pain or food fear
What are some potential causes of non-occlusive mesenteric ischemia?
any condition associated with decreased cardiac output - shock, CHF, arrythmias, sepsis, hypotensive states, drugs inducing mesenteric vasoconstruction (digoxin, cocaine, alpha agonists, beta blockers)
Are laboratory tests useful in identifying mesenteric ischemia?
Not really helpful on their own
WBC usually elevated, hemoconcentratoin, high amylase and metabolic acidosis also common
elevated lactate is sensitive for ischemia, but low specificity. same for d-dimer
Which radiologic study is the best choice for diagnosing mesenteric ischemia and why?
Angiography - allows for both diagnosis and therapy
CT angiography has also become an alternative, but won’t allow for treatment
What is the treatment if the cause is mesenteric artery embolus?
embolectomy and bowel visualization to assess for signs of necrosis
percutaneou thrombolytics directly into the arty may be an option in non-operative candidates
trx if it’s a mesenteric artery thrombosis?
heparin right away
surgery
trx if it’s a mesenteric vein thrombosis?
if signs of infarction = surgery
otherwise thrombectomy with endarterectomy or distal bypass
then life-long anti-coagulation
trx if it’s non-occlusive mesenteric ischemia?
correct the underlying cause of low-flow state
papaverine can help treat the vasoconstriction of the vessels
What are the common presenting signs and symptoms of testicular torsion?
sudden, severe unilateral testicular pain, n/v, urgency, frequency, dysuria
exquisite tenderness and swelling of testicle, may sit higher within the scrotum with transverse lie, negative Prehn’s sign (pain not relieved by elevation of testicle), loss of cremasteric reflex
What is the initial management for testicular torsion?
IV placement, treat pain, nausea with IV medications, make NPO
if delay in surgery, attempt manual detorsion
What is the definitive management for testicular torsion?
surgical detorsion with orchiopexy
Why is testicular torsion such an emergent condition?
quickly leads to necrosis of the testicle and infertility
What is the general salvage timeline for testicular torsion?
best outcomes achieved if detorsion occurs within 6 hours
What are the common presenting signs and symptoms of ovarian torsion?
sudden unilateral lower abdominal pain initially visceral in character
n/v, radiation to groin
on pelvic exam, may have adnexal tenderness or adnexal mass
increased suscpicion if hx of ovarian cysts/mass, prior torsion or current pregnancy
What is the best imaging modality for diagnosis of an ovarian torsion?
US (absence of blood flow on doppler, although presence of doppler flow does not exclude the diagnosis)
CT can be used if kidney stone or appendicitis are high on the differential, but is nonspecific for ovarian torsion. What would you see on CT?
enlarged ovary or ovarian mass, thickened fallopian tube, free fluid/hemorrhage, deviation of the uterus to the affected side
What is the management for ovarian torsion?
IV, treat pain and nausea, make NPO
Surgical detorsion or removal if necrotic on surgical examination
if there is a mass or cyst, resect it but try to salvage any normal ovarian tissue in premenopausal patient.
oophoropexy is controversial
Describe the timeline for salvage of an ovary.
Best results if detorsed within 8 hours
