Abdominal Pain Flashcards
what is the number 1 complaint in the ED
acute abdominal pain
*accounts for 10% of all ED visits
ED approach to acute abdominal pain ddx
- is pt critically ill? (rapid onset? abnormal VS?)
- constellation of sx that fit a known disease pattern?
- special conditions or risk factors that would make it difficult to identify the critical illness or known disease process?
- is surgical consult required?
what type of abdominal pain presentations require surgery consult?
- Acute abdomen,
- a pulsatile abdominal mass,
- shock,
- hemodynamic instability,
- rigid abdomen,
- GI bleeding
different approaches to abdominal pain ddx
- out –> in (skin–> fat–> fascia–> muscle–> peritoneum)
- by region
- by symptomology and time course
- risk factors, special populations
GI causes of acute abdominal pain
- Appendicitis
- Biliary tract disease
- SBO/LBO
- Pancreatitis
- Diverticulitis
- IBD
- IBS
- PUD
- Perforated viscus
GU causes of acute abdominal pain
- Acute scrotum
- Renal colic, nephrolithiasis
- Urinary retention
Gyn causes of acute abdominal pain
- Ectopic pregnancy
- PID
- Ruptured ovarian cyst
- Ovarian torsion/abscess
vascular causes of acute abdominal pain
- AAA
- Mesenteric ischemia
- Ischemic colitis
extra-abdominal causes of acute abdominal pain
- Cardiac
- Pneumonia
- Hernias
- Abdominal wall strain
- Infections
- Poisonings
- Metabolic
ddx of abdominal pain in the periumbilical region
- IBD
- bowel obstruction or ischemia
- appendicitis
- AAA
- IBS, DKA
- gastroenteritis
ddx of abdominal pain in the epigastric region
- MI
- PUD
- pancreatitis
- biliary disease
common causes of abdominal pain in people less than 60 y/o
- Abdominal pain, nonspecific
- Appendicitis, acute
- Urologic
- Intestinal obstruction
- Biliary Disease
- Trauma, abdominal
- PUD, perforated viscus
common causes of abdominal pain in people older than 60 y/o
- Biliary Disease
- Intestinal obstruction
- Abdominal pain, nonspecific
- Diverticulitis
- Appendicitis
- PUD, perforated viscus
- Malignancy
life-threatening conditions that present with abdominal pain
- Abdominal aortic aneurysm*
- Thoracoabdominal aortic dissection*
- Mesenteric ischemia
- Perforation of gastrointestinal tract
- peptic ulcer, bowel, esophagus, or appendix - Acute bowel obstruction
- Volvulus
- Splenic rupture
- Incarcerated hernia
- Ectopic pregnancy*
- Placental abruption
- Myocardial infarction
types of abdominal pain
- visceral pain
- parietal (somatic) pain
- referred pain
- misleading pain
describe visceral pain
- Usually dull, achy, poorly localized, protracted
- Direct irritation of the inner layer (visceral peritoneum) of HOLLOW VISCERA and CAPSULES OF SOLID ORGANS. (Distension, inflammation, or ischemia)
describe parietal (somatic) pain
-Usually steady, sharp, better localized
- Peritoneal pain signs: guarding, rebound, rigidity
- Direct irritation of PARIETAL PERITONEUM of the abdominal wall by gastric juice, pus, bile, urine, succus entericus, feces
visercal pain–> localized peritonitis–> pertonitis
describe referred abdominal pain
ex?
- Pain felt at a location distant from the diseased organ/primary stimulus
ex. AAA to lower back, gallbladder to shoulder, Ureter to groin, pancreatitis to back, perforated ulcer to RLQ
describe misleading abdominal pain
ex?
Abdominal pain from “extra-abdominal” source
Examples: Intrathoracic diseaseto upper abdomen, uremia
describe why abdominal pain in the elderly is more concerning
- Have more serious illness and disease is more advanced at time of diagnosis
- Tend to underreport symptoms
- Surgical emergencies are more common
- Don’t mount the same immune response
*Fever is not a reliable marker
- Usually sicker than they look
- Low threshold for a bigger workup and to admit
elderly w/ abdominal pain
ED approach to the patient with abdominal pain
- general survey and VS
- H and PE
- diagnostic workup (labs/images)
- reexamine
- diposition/admit
how to take a history for abdominal pain
OPPQRST
- onset
- provacative/palliative factors
- quality of pain
- region and radiation
- severity of pain
- temporal factors
key associated GI sx
- N/V
- Anorexia
- Diarrhea, constipation, obstipation
- Acholic stool, hematochezia, melena, BRBPR
- Dyspepsia, dysphagia
- Time and content of last meal
- Time and character of last BM
key associated GU sx
- Time and character of LMP or irregular bleeding
- Dark urine, hematuria
bluish flank discoloration
Grey turner’s sign
-seen in acute pancreatitis or AAA hemorrhage
bluish periumbilical discoloration
Cullen’s sign
-seen in acute pancreatitis, ectopic pregnancy, or AAA hemorrhage
visible dilated abdominal venous vasculature
caput medusa
- in patients suffering from cirrhosis of the liver.
high-pitched/tinkling or hypeactive BS–
decreased or absent BS–
high-pitched/tinkling or hypeactive BS– obstruction
decreased or absent BS– ileus, narcotic use, mesenteric ischcemia, LBO
guarding is ___,
rigidity is __
Voluntary
involuntary contraction of abdomen wall
Rigidity, referred tenderness, rebound tenderness–> pain w/ release NOT pushing down
peritoneal irritation
when are rectal exams useful?
- . if patient is hypotensive and suspect bleed
- Anal lesions, tenderness, masses
- Detection of grossly bloody or melanotic stools, Guaiac for occult blood
- Fecal impaction
what labs MUST you get with abdominal pain
CBC, BMP, LFTs, Lipase/Amylase, UA, urine pregnancy
*could also get coags, cardiac enzymes, venous lactate, ABG
when would the following imaging studies best be indicated? plain film US CT A/P Angiography (CTA) ECG
- plain film– suspect obstruction or perforation
- US- RUQ, hernias
- CT A/P- study of choice except for stones**
- Angiography (CTA)- mesenteric ischemia, AAA (if they have time)
- ECG- all pts w/ upper abdominal pain
supplemental studies
- UGI:
- HIDA:
- MRCP:
- ERCP:
- UGI: can help resolve SBO
- HIDA: used to diagnose problems of the liver, gallbladder and bile ducts
- MRCP: looks at ducts
- ERCP: through mouth into duodenum and takes out stones in BD
what antibiotics would you use for actue abdomen
Broad Spectrum, coverage for Gram-negative rods, anaerobes, and enterococci
- One of the most common surgical emergencies
- Most common age group is 10-30 years of age
- Misdiagnosis remains as a leading cause of malpractice suits
appendicitis
causes of appendicitis
- Obstruction by lymphoid hyperplasia or fecalith (most common cause)
- Tumor (carcinoid - most common tumor)
- Infection (parasitic)
clinical presentation:
- Poorly localized periumbilical pain initially ⟹ migrates and localizes to RLQ pain
- Visceral pain that progresses to parietal pain
- Anorexia, nausea, +/- vomiting, low-grade temp
- Onset of pain before GI symptoms
- Low-grade temp, mildly uncomfortable ⟹ fever, ill-appearing
- Periumbilical tenderness ⟹ RLQ tenderness and guarding
appendicitis
*McBurney’s point tenderness (pathognomonic)
how does pain present w/ perforated appendicitis and pregnancy?
- Pain free interval and peritoneal signs/sx suggest perforation
- Pain may be displaced from RLQ to RUQ in pregnancy
special maneuvers for appendicitis
- Rovsing’s sign - RLQ tenderness with LLQ palpation (Rovsing’s= Referred pain)
- Psoas sign - pain with RLE active hip extension
- Obturator sign - pain with RLE passive hip flexion and internal/external rotation
(A positive psoas sign or obturator test → an inflammatory process adjacent to these respective structures)
labs suggestive of appendicits
- Leukocytosis range 10-20,000 usually with left shift (over 75% neutrophils)
- UA may be normal or have few RBC and WBC 2ndary to local inflammation
imaging findings of appendicitis
CT A/P + IV contrast** and Ultrasound (US)- in pregnancy and children
-Typical CT findings: edematous, dilated appendix (over 6mm)– thickened enhanced walll of appendix– with periappendiceal fat stranding (representing inflammation)
- US is operator dependent and visualizes only one area, reserved for pregnancy and children
- abcess, pheglmon, free air= perforated appendix
management of appendicitis
- surgical consult and admission
- preop management: hydration w/ IVF, NPO, IV analgesics, IV abx
- Definitive tx is appendectomy (laparoscopic or open technique)
what people w/ RLQ pain can go home?
RLQ pain or tenderness with normal labs and imaging, clinically stable, pain well controlled on PO meds, able to return if symptoms get worse, and plan OK’d with surgery
risk factors for biliary tract disease
Female, Fertile, Forty, Fluffy, Fair
-Primarily related to gallstone disease and complications from gallstone obstruction
pathophysiology of biliary tract disease
Obstruction or impaired gallbladder contraction → cholestasis → inflammation → infection
*gallstones remain asymptomatic in 80% of cases
what is:
- choleithiasis:
- biliary colic:
- Cholecystitis:
- Choledocholithiasis:
- Cholangitis:
- choleithiasis: GB stones
- biliary colic: Intermittent obstruction of the biliary tree by stones (can go home)
- Cholecystitis: GB wall inflammation often caused by GS blocking cystic duct
- Choledocholithiasis: CBD obstruction from stone
- Cholangitis: ascending biliary tract infection of CBD due to CBD obstruction
describe the difference btwn acute, chronic, acalculous, and emphysematous cholecystitis
- Acute- obstructed cystic duct most common
- Chronic– thickening of GB wall (2/2 fibrosis), NO infection
- Acalculous- (no evidence of GS or cystic duct obstruction) geriatrics, critically ill, trauma, TPN, postpartum
- Emphysematous (gas w/in GB wall) high risk of gangrene, perforation, mortality
tx of choledocholithiasis
remove w/ ERCP
what is charots triad and Reynold pentad
Charcot’s triad: fever, RUQ abdominal pain, and jaundice
Reynolds pentad: Charcot’s triad + AMS and shock
*suggest cholangitis-Ascending biliary tract infection of common bile duct due to CBD obstruction
clinical presentation:
- Acute RUQ pain (pts often say epigstric pain) occasionally referred to the R scapula or epigastrium
- Crampy, colicky pain vs moderate to severe, unremitting pain
- Postprandial pain (triggered by fatty foods)
- Anorexia, nausea, vomiting, +/- fever
biliary tract disease
-No fever w/ what type of biliary tract disease
cholelithiasis
Dark urine, light stools, jaundice/pruritus suggest what biliary tract disease
CBD obstruction (cholecystitis, cholangitis)
Jaundice, fever, shock, AMS suggests what biliary tract disease
cholangitis
what labs should you order w/ biliary tract disease and what would expect them to be?
CBC - normal or elevated WBC
C/(B)MP- normal or elevated LFTs, ALP, T. bili
Lipase- elevated Lipase (GS pancreatitis)
what imaging studies could you get for biliary tract disease?
- US Abdomen diagnostic study of choice*
- CT A/P if GS pancreatitis or CBD stone obstruction is suspected.*
- HIDA (Biliary Radionuclide Scanning) = functional evaluation of the GB, sensitive/specific for acute cholecystitis
- Acalculous cholecysitis, biliary leak
- Good for post-op and worry about biliary leak - ERCP diagnostic and therapeutic for CBD stones
- MRCP diagnostic only, evaluates biliary tree and pancreatic ducts
what labs are associated w/ Cholelithiasis
Biliary Colic
Normal
what labs are associated w/
cholecystitis
↑ WBC*
↑ AST/ALT (mild)
↑ ALP (mild)
Normal T. bili*
what labs are associated w/ choledoncholithiasis
↑ AST/ALT, ↑ T.bili*
↑ Lipase (GS pancreatitis)
what labs are associated w/ cholangitis
↑ WBC (very high), bacteremia
↑ AST/ALT, ↑ T.bili*
US findings:
Gallstones, dilated gallbladder, dilated cystic duct. No GB wall thickening*
Cholelithiasis
Biliary Colic
US findings:
Pericholecystic fluid, distended GB, GB wall thickening, intra/extrahepatic ductal dilatation, +/- gallstones
Cholecystitis
US findings:
Dilated CBD over 6mm*, stone in common bile ducts, distended gallbladder
choledocholithasis
US findings:
Dilated, obstructed intrahepatic biliary ducts, dilated CBD, gallstones
Cholangitis
management of biliary tract disease
- pain control- IV fentanyl or diluadid (avoid morphine- causes constriction of sphincter of oddi)
- IV abx- broad spectrum to cover Gram +, -, and anaerobes
- IVF, IV antiemetics
- surgery consult +/- admit to hospital
- Cholecystectomy (laparoscopic vs open)
- ERCP for choledocholithiasis, cholangitis
- HIDA for acalculous cholecystitis
what is:
Diverticula
diverticulosis
Diverticulitis
Diverticula: small herniations through the wall of the colon.
Diverticulosis: multiple diverticula
Diverticulitis: inflamed or infected diverticula
Usually involves the sigmoid colon
-Common in Western cultures
Incidence increases with age
-15% to 25% of patients will develop
-2/3 of patients have uncomplicated disease (treat with high fiber diet)
diverticular disease
what is the pathophysiology of:
diverticulosis
diverticulitis
Diverticulosis:
↑ intraluminal pressures in the colon + weakening of the colon wall → diverticula
Diverticulitis:
Thickened fecal material → erosion of the diverticular wall → inflammation and microperforation → diverticulitis
complications of diverticulitis
macroperforation, abscess, fistula, peritonitis, sepsis
clinical presentation:
-Intermittent or constant LLQ abdominal pain, FEVER, +/- diarrhea, constipation, n/v, anorexia
-LLQ tenderness, tender palpable mass
RLQ or suprapubic pain → redundant sigmoid colon
-Peritonitis (rebound and guarding) → perforation
diverticulitis
*dverticulosis is typically asymptomatic
what labs should you order for diverticular disease
CBC – Leukocytosis
BMP, LFTs, Lipase, UA pregnancy test
To r/o other causes, assess hydration status
what imaging could you order for diverticular disease and what would you see
CT A/P +IV and/or PO contrast (Gastrografin)
- Inflammation, colonic diverticula, bowel wall thickening
- Phlegmon, pericolic fluid collections (abscess)
- Contained microperforation, free air
- PO done more w/ inpatient (3 hr study)
*Barium will cause peritonitis if there is a perforation
CT reveals:
Multiple outpouchings seen from sigmoid colon, surrounded by fat stranding with local inflammation affecting an adjacent small bowel loop.
diverticulitis
management of uncomplicated diverticular disease
- Bowel rest (liquid diet)
- PO Abx x 7-14 days
- Levo/Flagyl or Augmentin
- Colonoscopy after episode subsided
- Outpatient f/u with surgery if recurrent episodes
management of complicated diverticular disease
-Admit
-Bowel rest (liquid diet)
-NPO if obstructed (fistula, abscess)
-IV Abx (broad spectrum)
-Abscess – IR/CT guided drainage
-Perforation – Surgical consult
OR for exploration
describe what a mechanical obstruction, simple obstruction and strangulated obstruction
- Mechanical Obstruction: implies a physical barrier, may be complete or partial. (generally requires definitive intervention)
- Simple obstruction: Blockage of intestinal lumen only, usually one point of blockage
- Strangulated obstruction: Blockage of lumen and blood supply, usually two points of blockage (closed loop)
what is adynamic ileus (paralytic ileus)
Neurogenic failure of peristalsis → Decreased bowel motility and muscular tone
more common, usually self-limited–> surgical interventino uncommon
what is Intestinal pseudo-obstruction (Ogilvie syndrome):
- Colonic dilatation without evidence of a mechanical obstruction
- more common in elderly than young pts
what is the number 1 cause of SBO
adhesions
-if no hx of surgery, increased concern about mass/CA
causes of SBO
- Hernias (groin, abdominal wall, internal)
- Intussusception (Neoplasm is #1 cause in adults)
- IBD
- Foreign bodies
- Large Bowel Obstruction
- adhesions
causes of LBO
- Neoplasm (#1)
- Almost never caused by hernia or surgical adhesions - Fecal impaction
- Diverticulitis
- Volvulus (cecal, sigmoid)
- Stricture
- Pseudo-obstruction
causes of ileus (mechanical obstruction)
- Opiates*
- Manipulation of the bowel during surgery*
- Spinal cord trauma
- Ischemic bowel
clinical presentation:
- INTERMITTENT, poorly localized, crampy abdominal pain
- N/V, abdominal distension, decreased bowel movements and/or flatus
- The more proximal the obstruction, the mores severe the symptoms
- Abdominal distension and diffuse tenderness
- Abnormal bowel sounds
intestinal obstruction
High pitched/tinkling bowel sounds, peristaltic rushes → SBO
Diminished or absent bowel sounds → Ileus
peritoneal signs (+ bed bump sign, + cough sign) indicate:
perforation/ischemia
intestinal obstruction
labs for intestinal obstructions
-CBC, BMP, venous lactate
- Normal in early obstruction
- Leukocytosis with a left shift
- ↑H/H, ↑BUN and Cr, abnormal lytes (vomiting, dehydration)
- ↑ venous lactate (strangulation)
imaging for intestinal obstructions
- abdominal plain film (KUB and upright abdominal films)
- CT A/P w/ PO and IV contrast (Complete vs partial obstruction, strangulated vs simple)
- upper GI series w/ SB follow through
abdominal plain film reveals:
Dilated loops of bowel, air-fluid levels, constipation, free air
Ileus: dilated, fluid filled loops of bowel
intestinal obstruction
*gas may not be present in cases of a closed-loop obstruction
abdominal CT A/P with PO and IV contrast shows:
- Pneumatosis intestinalis (gas in the bowel wall), portal venous gas, circumferential wall thickening, fat stranding–> ___
- Pneumoperitoneum → ____
- “whirl sign” →___
- small air bubbles along cecum wall–> __
(intestinal obstruction)
strangulated bowel
perforation
volvulus
Pneumatosis intestinalis
Hugely dilated sigmoid that almost fills the entire abdomen.
Note the “coffee bean sign” also known as “bent tire tube sign”, extending from the pelvis to the diaphragm.
Complete loss of haustral pattern
sigmoid volvulus
management of intestinal obstruction
- Admit to hospital, consult Surgery
- IVF, IV pain control, NPO
- NG tube to intermittent suction (if vomiting)
- Can save someone from going to the OR - IV Abx (broad spectrum)
intestinal obstruction surgical emergencies
Closed-loop obstruction, bowel necrosis, or cecal volvulus
- Ileus: NPO, NGT if vomiting, d/c narcotics, ambulate
- Sigmoid volvulus: GI consult for endoscopic detorsion
a protrusion of any viscus from its surrounding tissue walls (i.e. through a fascial defect in abdominal wall)
hernia
anatomical types of hernias
- groin (most common 75%)
- inguinal (indirect more common than direct)
- femoral- more prone to strangulation and incarceration;more common in women - anterior abdominal wall hernia- Incisional, ventral, umbilical, epigastric, etc.
what is the difference btwn an indirect and direct hernia
direct- near the opening of the inguinal canal
-abdominal cavity → through the posterior inguinal canal wall → inguinal canal
indirect- at the opening of the inguinal canal
-abdominal cavity → through internal inguinal ring → inguinal canal → into the scrotum
types of hernias
- Reducible: hernia contents can be displaced back to their usual position
- Hernia sac is soft - Incarcerated: non-reducible by direct pressure
- hernia sac is firm, contents should not be tense
- Incarcerated tissue may be bowel, omentum, or other abdominal contents - Strangulated: incarcerated with resulting ischemia
- Hernia sac is hard, tender, indurated, red/purple skin changes
- Surgical emergency
clinical presentation:
- First symptom is usually a lump or swelling at hernia site
- Increase size in lump or swelling during exertion (straining or lifting)
- May be painful/tender
hernia
signs and sx of strangulated hernia
abdominal pain/tenderness N/V fever -Severe, exquisite pain at the hernia site, - skin changes overlying the hernia sac \+/- signs of intestinal obstruction, - peritoneal signs, -sepsis
labs to order for hernias
Normal unless strangulated bowel is present (↑WBC, ↑VL)
imaging for hernias
*Imaging not always necessary
- US will identify hernia, Doppler useful to exclude strangulation
- Decreased BP in strangulation - CT A/P if concerned about incarceration and/or strangulation
- Strangulated loops of bowel w/ signs of obstruction (dilated loops of bowel), ischemia
CT findings show:
Ventral hernia containing loops of small bowel and omentum.
Bowel wall thickening, mesenteric gas and pneumatosis, mesenteric fat stranding suggestive of strangulated hernia with bowel ischemia.
Dilation of the proximal loops of bowel and collapse of the distal loops
strangulated hernia w/ bowel ischemia
management of hernias
reducible if possible== may be reduced manually under sedation in trandelenburg position
*surgical repair for definitive tx
how to manage an incarcerated hernia
Try to reduce 1-2 times, then observe the patient in the ED for a period of time for serial abdominal examinations
If unable to reduce → consult Surgery
how to manage a strangulated hernia
- Surgical consult for emergent repair
- Do not try to reduce if you suspect strangulation
- May need bowel resection if ischemic bowel is present from strangulation
- IVF, NPO, IV abx, IV pain control
what is the difference btwn mesenteric ischemia and ischemic colitis
MI-Often leads to bowel necrosis (ischemic colitis does not)
Usually involves the SMA → SMALL BOWEL
IC-Variant of mesenteric ischemia
Usually involves the IMA → COLON (splenic flexture)
s/sx:
Sudden onset of severe abd pain out of proportion to exam, soft abdomen?, ill appearing
mesenteric ischemia
s/sx:
LLQ pain and tenderness, mild/crampy abd pain, bloody diarrhea
ischemic colitis
tx of mesenteric ischemia and ischemic colitis
MI: Surgical emergency, admit, treat shock
IC: Sigmoidoscopy
Usually transient, 20% need surgical intervention
Small bowel intestinal ischemia 2ndary to occlusion of mesenteric vessel(s)
mesenteric ischemia
*SMA is the most common
causes of mesenteric ischemia
Embolic arterial occlusion »_space; thrombotic arterial occlusion »_space; thrombotic venous occlusion
Small bowel has a ___hour viability window after ischemia
2-3
risk factors for mesenteric ischemia
age over 60 Afib CHF hemodialysis hypercoagulable states
clinical presentation:
-Sudden onset of severe, diffuse, mid to lower abdominal pain
-Postprandial pain, gradual onset → thrombotic arterial occlusion
+/- Nausea, vomiting, diarrhea, bloody stool
- Pain out of proportion to exam
- Abdominal distension, absent BS, peritoneal signs, ill appearing
mesenteric ischemia
labs for mesenteric ischemia
- CBC, BMP, venous lactate, ABG, coags
- ↑↑WBC, ARF, ↑lactate, metabolic acidosis
imaging studies for mesenteric ischemia
- Angiography (CTA or MRA) is diagnostic study of choice
- CT A/P + IV contrast to identify additional findings
- Bowel wall thickening, pneumatosis intestinalis, organ infarction
management of mesenteric ischemia
- Immediate Surgical consult
-OR for exploratory surgery
2 Admit to hospital, stabilize patient
-IVF, IV pain control, IV Abx - Often there is a poor prognosis - survival of 50% if diagnosed within 24 hours
risk factors for AAA
- M:F 4:1
- age over 65
90% are infrarenal
Infrarenal aortic diameter
Normal: __
Aneurysmal: __
Need repair: __
Normal: 2 cm
Aneurysmal: over 3cm
Need repair: over 5cm
clinical presentation:
- Severe, abrupt onset of abdominal or back pain, hypotension, syncope, AMS (lack of cerebral profusion)→ Leaking or ruptured
- signs of shock, unstable hypotension
- Palpable midline abdominal pulsation or mass
- Tender –> leaking or ruptured
AAA
*most AAA are asymptomatic
what should you do with someone who presents w/ suspected AAA
get plain film and take to OR
Periumbilical ecchymosis (Cullen sign) or flank ecchymosis (Grey Turner sign)
sign for AAA
*massive hemorrhage
labs for AAA
CBC, BMP, Type and Cross, coags, VL
PRBC, Platelets, FFP
imaging for AAA
- plain film (CXR, AbXR)– calcifed and buling aortic contour
- abdominal US- over 90% sensitive (good for those who are unstable and cannot have CT)
- CT A/P wwo IV contrast- Anatomic details of the aneurysm and associated hemorrhage
management of AAA
- ALL PATIENTS with the clinical triad of abdominal and/or back pain, a pulsatile abdominal mass, and hypotension → emergent eval by a Vascular surgeon
- IV access (2 large-bore IV’s), cardiac monitoring, supplemental O2
- IVF, +/- blood products, control of VS
- target HR 60-80, targe BP 100-120 (permissive hypotension) - surgical repair
5 W’s of post surgical complications
- Wind- atelectasis or pneumonia
- Water- urinary tract infection
- Wound- infection
- Walking- DVT
- Wonder drugs- drug fever, thrombophlebitis, C.diff colitis
When do these top 10 causes of post-op fever occur?
- Atelectasis
- transfusion rxn
- PNA
- UTI
- infection
- Skin/soft tissue infection
- thrombophlebitis
- DVT and PE
- Intra-abdominal abscess or peritonitis
- Pseudomembranous colitis
first 24 hrs: atelectasis or transfusion rxn
3-7 days: pneumonia
2-5 days: UTI
5-10 days: Skin/soft tissue infection**
less than 3 days: thrombophlebitis
4-6 days: DVT
4-21 days: intra-abdominal abscess or peritonitis**
anytime: pseudomembranous colitis or PE***
If you are worried about an abscess and you are only a couple days out, r/o other things –> it takes a while to show up on scan
common post surgical abdominal pain, GI compliants
- Intestinal obstruction
- Adhesions (few weeks to develop)
- Ileus - Intraabdominal abscess
- Anastomotic leaks
- Bowel injury
post surgical wound complications
- Hematomas – pain, pressure, swelling of the wound, bloody wound drainage
- Call their surgeon - Seromas – painless swelling below the wound
- Infection – increasing pain, erythema, swelling, drainage, tenderness at incision site, systemic s/sx of infection
- Smells funny, have surgeon look at - Wound dehiscence – wound ruptures along a surgical suture.
cholecystectomy surgical complications
Bile leak, bowel injury, pancreatitis, retained CBD stones, abscess
laparoscopic surgery complications
- Atelectasis, ptx, GI tract injuries, bowel injury
- Get CT of abdomen to r/o bowel perforation and free air
colonoscopy surgery complications
Hemorrhage, perforation, retroperitoneal abscess, volvulus
10 most common causes of post-op fever
- Atelectasis
- transfusion rxn
- PNA
- UTI
- infection
- Skin/soft tissue infection
- thrombophlebitis
- DVT and PE
- Intra-abdominal abscess or peritonitis
- Pseudomembranous colitis
