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Emergency Medicine > Abdominal Pain > Flashcards

Abdominal Pain Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

what is the number 1 complaint in the ED

A

acute abdominal pain

*accounts for 10% of all ED visits

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2
Q

ED approach to acute abdominal pain ddx

A
  1. is pt critically ill? (rapid onset? abnormal VS?)
  2. constellation of sx that fit a known disease pattern?
  3. special conditions or risk factors that would make it difficult to identify the critical illness or known disease process?
  4. is surgical consult required?
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3
Q

what type of abdominal pain presentations require surgery consult?

A
  1. Acute abdomen,
  2. a pulsatile abdominal mass,
  3. shock,
  4. hemodynamic instability,
  5. rigid abdomen,
  6. GI bleeding
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4
Q

different approaches to abdominal pain ddx

A
  1. out –> in (skin–> fat–> fascia–> muscle–> peritoneum)
  2. by region
  3. by symptomology and time course
  4. risk factors, special populations
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5
Q

GI causes of acute abdominal pain

A
  1. Appendicitis
  2. Biliary tract disease
  3. SBO/LBO
  4. Pancreatitis
  5. Diverticulitis
  6. IBD
  7. IBS
  8. PUD
  9. Perforated viscus
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6
Q

GU causes of acute abdominal pain

A
  1. Acute scrotum
  2. Renal colic, nephrolithiasis
  3. Urinary retention
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7
Q

Gyn causes of acute abdominal pain

A
  1. Ectopic pregnancy
  2. PID
  3. Ruptured ovarian cyst
  4. Ovarian torsion/abscess
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8
Q

vascular causes of acute abdominal pain

A
  1. AAA
  2. Mesenteric ischemia
  3. Ischemic colitis
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9
Q

extra-abdominal causes of acute abdominal pain

A
  1. Cardiac
  2. Pneumonia
  3. Hernias
  4. Abdominal wall strain
  5. Infections
  6. Poisonings
  7. Metabolic
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10
Q

ddx of abdominal pain in the periumbilical region

A
  1. IBD
  2. bowel obstruction or ischemia
  3. appendicitis
  4. AAA
  5. IBS, DKA
  6. gastroenteritis
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11
Q

ddx of abdominal pain in the epigastric region

A
  1. MI
  2. PUD
  3. pancreatitis
  4. biliary disease
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12
Q

common causes of abdominal pain in people less than 60 y/o

A
  1. Abdominal pain, nonspecific
  2. Appendicitis, acute
  3. Urologic
  4. Intestinal obstruction
  5. Biliary Disease
  6. Trauma, abdominal
  7. PUD, perforated viscus
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13
Q

common causes of abdominal pain in people older than 60 y/o

A
  1. Biliary Disease
  2. Intestinal obstruction
  3. Abdominal pain, nonspecific
  4. Diverticulitis
  5. Appendicitis
  6. PUD, perforated viscus
  7. Malignancy
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14
Q

life-threatening conditions that present with abdominal pain

A
  1. Abdominal aortic aneurysm*
  2. Thoracoabdominal aortic dissection*
  3. Mesenteric ischemia
  4. Perforation of gastrointestinal tract
    - peptic ulcer, bowel, esophagus, or appendix
  5. Acute bowel obstruction
  6. Volvulus
  7. Splenic rupture
  8. Incarcerated hernia
  9. Ectopic pregnancy*
  10. Placental abruption
  11. Myocardial infarction
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15
Q

types of abdominal pain

A
  1. visceral pain
  2. parietal (somatic) pain
  3. referred pain
  4. misleading pain
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16
Q

describe visceral pain

A
  • 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)
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17
Q

describe parietal (somatic) pain

A

-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

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18
Q

describe referred abdominal pain

ex?

A
  • 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
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19
Q

describe misleading abdominal pain

ex?

A

Abdominal pain from “extra-abdominal” source

Examples: Intrathoracic diseaseto upper abdomen, uremia

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20
Q

describe why abdominal pain in the elderly is more concerning

A
  1. Have more serious illness and disease is more advanced at time of diagnosis
  2. Tend to underreport symptoms
  3. Surgical emergencies are more common
  4. Don’t mount the same immune response

*Fever is not a reliable marker

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21
Q
  • Usually sicker than they look

- Low threshold for a bigger workup and to admit

A

elderly w/ abdominal pain

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22
Q

ED approach to the patient with abdominal pain

A
  1. general survey and VS
  2. H and PE
  3. diagnostic workup (labs/images)
  4. reexamine
  5. diposition/admit
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23
Q

how to take a history for abdominal pain

A

OPPQRST

  1. onset
  2. provacative/palliative factors
  3. quality of pain
  4. region and radiation
  5. severity of pain
  6. temporal factors
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24
Q

key associated GI sx

A
  1. N/V
  2. Anorexia
  3. Diarrhea, constipation, obstipation
  4. Acholic stool, hematochezia, melena, BRBPR
  5. Dyspepsia, dysphagia
  6. Time and content of last meal
  7. Time and character of last BM
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25
Q

key associated GU sx

A
  • Time and character of LMP or irregular bleeding

- Dark urine, hematuria

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26
Q

bluish flank discoloration

A

Grey turner’s sign

-seen in acute pancreatitis or AAA hemorrhage

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27
Q

bluish periumbilical discoloration

A

Cullen’s sign

-seen in acute pancreatitis, ectopic pregnancy, or AAA hemorrhage

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28
Q

visible dilated abdominal venous vasculature

A

caput medusa

  • in patients suffering from cirrhosis of the liver.
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29
Q

high-pitched/tinkling or hypeactive BS–

decreased or absent BS–

A

high-pitched/tinkling or hypeactive BS– obstruction

decreased or absent BS– ileus, narcotic use, mesenteric ischcemia, LBO

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30
Q

guarding is ___,

rigidity is __

A

Voluntary

involuntary contraction of abdomen wall

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31
Q

Rigidity, referred tenderness, rebound tenderness–> pain w/ release NOT pushing down

A

peritoneal irritation

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32
Q

when are rectal exams useful?

A
  1. . if patient is hypotensive and suspect bleed
  2. Anal lesions, tenderness, masses
  3. Detection of grossly bloody or melanotic stools, Guaiac for occult blood
  4. Fecal impaction
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33
Q

what labs MUST you get with abdominal pain

A

CBC, BMP, LFTs, Lipase/Amylase, UA, urine pregnancy

*could also get coags, cardiac enzymes, venous lactate, ABG

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34
Q 
when would the following imaging studies best be indicated?
plain film
US
CT A/P
Angiography (CTA)
ECG
A
  1. plain film– suspect obstruction or perforation
  2. US- RUQ, hernias
  3. CT A/P- study of choice except for stones**
  4. Angiography (CTA)- mesenteric ischemia, AAA (if they have time)
  5. ECG- all pts w/ upper abdominal pain
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35
Q

supplemental studies

  • UGI:
  • HIDA:
  • MRCP:
  • ERCP:
A
  • 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
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36
Q

what antibiotics would you use for actue abdomen

A

Broad Spectrum, coverage for Gram-negative rods, anaerobes, and enterococci

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37
Q
  • 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
A

appendicitis

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38
Q

causes of appendicitis

A
  1. Obstruction by lymphoid hyperplasia or fecalith (most common cause)
  2. Tumor (carcinoid - most common tumor)
  3. Infection (parasitic)
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39
Q

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
A

appendicitis

*McBurney’s point tenderness (pathognomonic)

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40
Q

how does pain present w/ perforated appendicitis and pregnancy?

A
  • Pain free interval and peritoneal signs/sx suggest perforation
  • Pain may be displaced from RLQ to RUQ in pregnancy
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41
Q

special maneuvers for appendicitis

A
  1. Rovsing’s sign - RLQ tenderness with LLQ palpation (Rovsing’s= Referred pain)
  2. Psoas sign - pain with RLE active hip extension
  3. 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)

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42
Q

labs suggestive of appendicits

A
  1. Leukocytosis range 10-20,000 usually with left shift (over 75% neutrophils)
  2. UA may be normal or have few RBC and WBC 2ndary to local inflammation
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43
Q

imaging findings of appendicitis

A

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
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44
Q

management of appendicitis

A
  1. surgical consult and admission
  2. preop management: hydration w/ IVF, NPO, IV analgesics, IV abx
  3. Definitive tx is appendectomy (laparoscopic or open technique)
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45
Q

what people w/ RLQ pain can go home?

A

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

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46
Q

risk factors for biliary tract disease

A

Female, Fertile, Forty, Fluffy, Fair

-Primarily related to gallstone disease and complications from gallstone obstruction

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47
Q

pathophysiology of biliary tract disease

A

Obstruction or impaired gallbladder contraction → cholestasis → inflammation → infection

*gallstones remain asymptomatic in 80% of cases

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48
Q

what is:

  • choleithiasis:
  • biliary colic:
  • Cholecystitis:
  • Choledocholithiasis:
  • Cholangitis:
A
  • 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
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49
Q

describe the difference btwn acute, chronic, acalculous, and emphysematous cholecystitis

A
  • 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
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50
Q

tx of choledocholithiasis

A

remove w/ ERCP

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51
Q

what is charots triad and Reynold pentad

A

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

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52
Q

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
A

biliary tract disease

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53
Q

-No fever w/ what type of biliary tract disease

A

cholelithiasis

54
Q

Dark urine, light stools, jaundice/pruritus suggest what biliary tract disease

A

CBD obstruction (cholecystitis, cholangitis)

55
Q

Jaundice, fever, shock, AMS suggests what biliary tract disease

A

cholangitis

56
Q

what labs should you order w/ biliary tract disease and what would expect them to be?

A

CBC - normal or elevated WBC
C/(B)MP- normal or elevated LFTs, ALP, T. bili
Lipase- elevated Lipase (GS pancreatitis)

57
Q

what imaging studies could you get for biliary tract disease?

A
  1. US Abdomen diagnostic study of choice*
  2. CT A/P if GS pancreatitis or CBD stone obstruction is suspected.*
  3. 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
  4. ERCP diagnostic and therapeutic for CBD stones
  5. MRCP diagnostic only, evaluates biliary tree and pancreatic ducts
58
Q

what labs are associated w/ Cholelithiasis

Biliary Colic

A

Normal

59
Q

what labs are associated w/

cholecystitis

A

↑ WBC*
↑ AST/ALT (mild)
↑ ALP (mild)
Normal T. bili*

60
Q

what labs are associated w/ choledoncholithiasis

A

↑ AST/ALT, ↑ T.bili*

↑ Lipase (GS pancreatitis)

61
Q

what labs are associated w/ cholangitis

A

↑ WBC (very high), bacteremia

↑ AST/ALT, ↑ T.bili*

62
Q

US findings:

Gallstones, dilated gallbladder, dilated cystic duct. No GB wall thickening*

A

Cholelithiasis

Biliary Colic

63
Q

US findings:

Pericholecystic fluid, distended GB, GB wall thickening, intra/extrahepatic ductal dilatation, +/- gallstones

A

Cholecystitis

64
Q

US findings:

Dilated CBD over 6mm*, stone in common bile ducts, distended gallbladder

A

choledocholithasis

65
Q

US findings:

Dilated, obstructed intrahepatic biliary ducts, dilated CBD, gallstones

A

Cholangitis

66
Q

management of biliary tract disease

A
  1. pain control- IV fentanyl or diluadid (avoid morphine- causes constriction of sphincter of oddi)
  2. IV abx- broad spectrum to cover Gram +, -, and anaerobes
  3. IVF, IV antiemetics
  4. surgery consult +/- admit to hospital
    - Cholecystectomy (laparoscopic vs open)
    - ERCP for choledocholithiasis, cholangitis
    - HIDA for acalculous cholecystitis
67
Q

what is:
Diverticula
diverticulosis
Diverticulitis

A

Diverticula: small herniations through the wall of the colon.
Diverticulosis: multiple diverticula
Diverticulitis: inflamed or infected diverticula
Usually involves the sigmoid colon

68
Q

-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)

A

diverticular disease

69
Q

what is the pathophysiology of:
diverticulosis

diverticulitis

A

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

70
Q

complications of diverticulitis

A

macroperforation, abscess, fistula, peritonitis, sepsis

71
Q

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

A

diverticulitis

*dverticulosis is typically asymptomatic

72
Q

what labs should you order for diverticular disease

A

CBC – Leukocytosis
BMP, LFTs, Lipase, UA pregnancy test
To r/o other causes, assess hydration status

73
Q

what imaging could you order for diverticular disease and what would you see

A

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

74
Q

CT reveals:

Multiple outpouchings seen from sigmoid colon, surrounded by fat stranding with local inflammation affecting an adjacent small bowel loop.

A

diverticulitis

75
Q

management of uncomplicated diverticular disease

A
  • 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
76
Q

management of complicated diverticular disease

A

-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

77
Q

describe what a mechanical obstruction, simple obstruction and strangulated obstruction

A
  • 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)
78
Q

what is adynamic ileus (paralytic ileus)

A

Neurogenic failure of peristalsis → Decreased bowel motility and muscular tone
more common, usually self-limited–> surgical interventino uncommon

79
Q

what is Intestinal pseudo-obstruction (Ogilvie syndrome):

A
  • Colonic dilatation without evidence of a mechanical obstruction
  • more common in elderly than young pts
80
Q

what is the number 1 cause of SBO

A

adhesions

-if no hx of surgery, increased concern about mass/CA

81
Q

causes of SBO

A
  1. Hernias (groin, abdominal wall, internal)
  2. Intussusception (Neoplasm is #1 cause in adults)
  3. IBD
  4. Foreign bodies
  5. Large Bowel Obstruction
  6. adhesions
82
Q

causes of LBO

A
  1. Neoplasm (#1)
    - Almost never caused by hernia or surgical adhesions
  2. Fecal impaction
  3. Diverticulitis
  4. Volvulus (cecal, sigmoid)
  5. Stricture
  6. Pseudo-obstruction
83
Q

causes of ileus (mechanical obstruction)

A
  1. Opiates*
  2. Manipulation of the bowel during surgery*
  3. Spinal cord trauma
  4. Ischemic bowel
84
Q

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
A

intestinal obstruction

High pitched/tinkling bowel sounds, peristaltic rushes → SBO
Diminished or absent bowel sounds → Ileus

85
Q

peritoneal signs (+ bed bump sign, + cough sign) indicate:

A

perforation/ischemia

intestinal obstruction

86
Q

labs for intestinal obstructions

A

-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)
87
Q

imaging for intestinal obstructions

A
  1. abdominal plain film (KUB and upright abdominal films)
  2. CT A/P w/ PO and IV contrast (Complete vs partial obstruction, strangulated vs simple)
  3. upper GI series w/ SB follow through
88
Q

abdominal plain film reveals:
Dilated loops of bowel, air-fluid levels, constipation, free air
Ileus: dilated, fluid filled loops of bowel

A

intestinal obstruction

*gas may not be present in cases of a closed-loop obstruction

89
Q

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–> __
A

(intestinal obstruction)

strangulated bowel

perforation

volvulus

Pneumatosis intestinalis

90
Q

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

A

sigmoid volvulus

91
Q

management of intestinal obstruction

A
  1. Admit to hospital, consult Surgery
  2. IVF, IV pain control, NPO
  3. NG tube to intermittent suction (if vomiting)
    - Can save someone from going to the OR
  4. IV Abx (broad spectrum)
92
Q

intestinal obstruction surgical emergencies

A

Closed-loop obstruction, bowel necrosis, or cecal volvulus

  • Ileus: NPO, NGT if vomiting, d/c narcotics, ambulate
  • Sigmoid volvulus: GI consult for endoscopic detorsion
93
Q

a protrusion of any viscus from its surrounding tissue walls (i.e. through a fascial defect in abdominal wall)

A

hernia

94
Q

anatomical types of hernias

A
  1. groin (most common 75%)
    - inguinal (indirect more common than direct)
    - femoral- more prone to strangulation and incarceration;more common in women
  2. anterior abdominal wall hernia- Incisional, ventral, umbilical, epigastric, etc.
95
Q

what is the difference btwn an indirect and direct hernia

A

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

96
Q

types of hernias

A
  1. Reducible: hernia contents can be displaced back to their usual position
    - Hernia sac is soft
  2. 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
  3. Strangulated: incarcerated with resulting ischemia
    - Hernia sac is hard, tender, indurated, red/purple skin changes
    - Surgical emergency
97
Q

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
A

hernia

98
Q

signs and sx of strangulated hernia

A 
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
99
Q

labs to order for hernias

A

Normal unless strangulated bowel is present (↑WBC, ↑VL)

100
Q

imaging for hernias

A

*Imaging not always necessary

  1. US will identify hernia, Doppler useful to exclude strangulation
    - Decreased BP in strangulation
  2. CT A/P if concerned about incarceration and/or strangulation
    - Strangulated loops of bowel w/ signs of obstruction (dilated loops of bowel), ischemia
101
Q

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

A

strangulated hernia w/ bowel ischemia

102
Q

management of hernias

A

reducible if possible== may be reduced manually under sedation in trandelenburg position

*surgical repair for definitive tx

103
Q

how to manage an incarcerated hernia

A

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

104
Q

how to manage a strangulated hernia

A
  1. Surgical consult for emergent repair
  2. Do not try to reduce if you suspect strangulation
  3. May need bowel resection if ischemic bowel is present from strangulation
  4. IVF, NPO, IV abx, IV pain control
105
Q

what is the difference btwn mesenteric ischemia and ischemic colitis

A

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)

106
Q

s/sx:

Sudden onset of severe abd pain out of proportion to exam, soft abdomen?, ill appearing

A

mesenteric ischemia

107
Q

s/sx:

LLQ pain and tenderness, mild/crampy abd pain, bloody diarrhea

A

ischemic colitis

108
Q

tx of mesenteric ischemia and ischemic colitis

A

MI: Surgical emergency, admit, treat shock

IC: Sigmoidoscopy
Usually transient, 20% need surgical intervention

109
Q

Small bowel intestinal ischemia 2ndary to occlusion of mesenteric vessel(s)

A

mesenteric ischemia

*SMA is the most common

110
Q

causes of mesenteric ischemia

A

Embolic arterial occlusion &raquo_space; thrombotic arterial occlusion &raquo_space; thrombotic venous occlusion

111
Q

Small bowel has a ___hour viability window after ischemia

A

2-3

112
Q

risk factors for mesenteric ischemia

A 
age over 60
Afib
CHF
hemodialysis
hypercoagulable states
113
Q

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
A

mesenteric ischemia

114
Q

labs for mesenteric ischemia

A
  • CBC, BMP, venous lactate, ABG, coags

- ↑↑WBC, ARF, ↑lactate, metabolic acidosis

115
Q

imaging studies for mesenteric ischemia

A
  1. Angiography (CTA or MRA) is diagnostic study of choice
  2. CT A/P + IV contrast to identify additional findings
    - Bowel wall thickening, pneumatosis intestinalis, organ infarction
116
Q

management of mesenteric ischemia

A
  1. Immediate Surgical consult
    -OR for exploratory surgery
    2 Admit to hospital, stabilize patient
    -IVF, IV pain control, IV Abx
  2. Often there is a poor prognosis - survival of 50% if diagnosed within 24 hours
117
Q

risk factors for AAA

A
  1. M:F 4:1
  2. age over 65

90% are infrarenal

118
Q

Infrarenal aortic diameter
Normal: __
Aneurysmal: __
Need repair: __

A

Normal: 2 cm
Aneurysmal: over 3cm
Need repair: over 5cm

119
Q

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
A

AAA

*most AAA are asymptomatic

120
Q

what should you do with someone who presents w/ suspected AAA

A

get plain film and take to OR

121
Q

Periumbilical ecchymosis (Cullen sign) or flank ecchymosis (Grey Turner sign)

A

sign for AAA

*massive hemorrhage

122
Q

labs for AAA

A

CBC, BMP, Type and Cross, coags, VL

PRBC, Platelets, FFP

123
Q

imaging for AAA

A
  1. plain film (CXR, AbXR)– calcifed and buling aortic contour
  2. abdominal US- over 90% sensitive (good for those who are unstable and cannot have CT)
  3. CT A/P wwo IV contrast- Anatomic details of the aneurysm and associated hemorrhage
124
Q

management of AAA

A
  1. ALL PATIENTS with the clinical triad of abdominal and/or back pain, a pulsatile abdominal mass, and hypotension → emergent eval by a Vascular surgeon
  2. IV access (2 large-bore IV’s), cardiac monitoring, supplemental O2
  3. IVF, +/- blood products, control of VS
    - target HR 60-80, targe BP 100-120 (permissive hypotension)
  4. surgical repair
125
Q

5 W’s of post surgical complications

A
  1. Wind- atelectasis or pneumonia
  2. Water- urinary tract infection
  3. Wound- infection
  4. Walking- DVT
  5. Wonder drugs- drug fever, thrombophlebitis, C.diff colitis
126
Q

When do these top 10 causes of post-op fever occur?

  1. Atelectasis
  2. transfusion rxn
  3. PNA
  4. UTI
  5. infection
  6. Skin/soft tissue infection
  7. thrombophlebitis
  8. DVT and PE
  9. Intra-abdominal abscess or peritonitis
  10. Pseudomembranous colitis
A

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

127
Q

common post surgical abdominal pain, GI compliants

A
  1. Intestinal obstruction
    - Adhesions (few weeks to develop)
    - Ileus
  2. Intraabdominal abscess
  3. Anastomotic leaks
  4. Bowel injury
128
Q

post surgical wound complications

A
  1. Hematomas – pain, pressure, swelling of the wound, bloody wound drainage
    - Call their surgeon
  2. Seromas – painless swelling below the wound
  3. Infection – increasing pain, erythema, swelling, drainage, tenderness at incision site, systemic s/sx of infection
    - Smells funny, have surgeon look at
  4. Wound dehiscence – wound ruptures along a surgical suture.
129
Q

cholecystectomy surgical complications

A

Bile leak, bowel injury, pancreatitis, retained CBD stones, abscess

130
Q

laparoscopic surgery complications

A
  • Atelectasis, ptx, GI tract injuries, bowel injury

- Get CT of abdomen to r/o bowel perforation and free air

131
Q

colonoscopy surgery complications

A

Hemorrhage, perforation, retroperitoneal abscess, volvulus

132
Q

10 most common causes of post-op fever

A
  1. Atelectasis
  2. transfusion rxn
  3. PNA
  4. UTI
  5. infection
  6. Skin/soft tissue infection
  7. thrombophlebitis
  8. DVT and PE
  9. Intra-abdominal abscess or peritonitis
  10. Pseudomembranous colitis

Emergency Medicine (22 decks)

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