Abdominal Pain Flashcards
1
Q
A woman w/abdominal pain should be considered to have ______________ until proven otherwise.
A
Ectopic pregnancy (order hCG)
2
Q
97% of ectopic pregnancies occur where?
A
Fallopian tubes
3
Q
What are top 3 r/f’s for ectopic pregnancy?
A
- history of salpingitis
- tubal surgery
- previous ectopic pregnancy
(others:) •Previous pelvic or abdominal surgery •Tubal Pathology •In utero diethylstilbestrol (DES) exposure •Intrauterine device use •Smoking •Infertility and infertility treatments
4
Q
You suspect ectopic preg. What should you start/order?
A
- Monitor
- 2 large bore IVs
- CBC, type and screen, and quantitative β-hCG
- Analgesic narcotics
- Consider transfusion
- FAST exam
- Consult OBGYN for surgery
5
Q
Hemodynamically unstable patients with a positive pregnancy test in the first trimester should be assumed to have an ___________________ until proven otherwise and should be immediately taken to the OR by OB/GYN for definitive diagnosis and treatment.
A
ectopic pregnancy
6
Q
The earliest sign of an IUP by transvaginal ultrasound is the double decidual sac sign , occurring at around ___ weeks after the last menstrual period (LMP).
A
4.5-5
7
Q
A fetal pole and embryonic cardiac activity are usually seen by __-__ weeks.
A
6-7
8
Q
The β-hCG is a glycoprotein hormone produced by trophoblasts that doubles approximately every __-__ hours in the first trimester.
A
48-72
9
Q
The discriminatory zone of β-hCG is the level at which an IUP should be visible by transvaginal ultrasonography, typically _____-_____ mIU/mL.
A
1500-2000
10
Q
Ultrasound signs of an ectopic include:
A
- an empty uterus
- extraovarian mass
- tubal ring sign
- pelvic free fluid
11
Q
Do you give Rhogam for ectopic pregs?
A
Yes (50)
12
Q
________________ (drug) is the most successful method to medically manage a patient with ectopic pregnancy and may preserve fertility better than surgical interventions.
A
Methotrexate (if HDS)
often need 2nd dose
13
Q
For those hemodynamically stable patients with inconclusive ultrasound findings where the diagnosis of ectopic pregnancy is in doubt, they may be managed how?
A
As an outpatient with serial US exams and β-hCG levels
14
Q
True or false? Ruptured ectopic pregnancies can be present at very low β-hCG levels.
A
True (discriminatory zone is just to see when you’d expect to see an IUP)
15
Q
When does incidence of appendicitis peak?
A
2nd & 3rd decades (can affect any age)
16
Q
Describe classic presentation of appendicitis.
A
- Vague epigastric or periumbilical pain.
- Nausea, vomiting and anorexia.
- Abdominal tenderness, migrating then localizing to the right lower quadrant.
- Fever
- Leukocytosis
17
Q
What s/sx are sensitive for appendicitis?
Specific?
A
- RLQ pain and guarding generally have a high sensitivity (81%), but poorly specific (53%).
- Rigidity is highly specific (83%) with a low sensitivity (27%).
18
Q
Besides WBC, what lab can support dx of appendicitis?
A
CRP
- UA should also be ordered (r/o UTI, hematuria, pregnancy)
19
Q
A normal appendix on ultrasound is typically less than __ mm and compressible.
A
6mm (> 6-7mm, consider appendicitis)
20
Q
Besides appendix length >6-7mm, what other findings support the diagnosis?
A
- increased wall thickness
- fecalith
- increased vascularity
(Doppler flow can be used to demonstrate the increased vascularity of an inflamed appendix)
21
Q
____________________ is the preferred imaging study for evaluating acute appendicitis in adult males and nonpregnant females.
A
CT (IV contrast recommended, but non-contrast still good; can use rectal contrast too)
(also more useful for discovering the alternatives on your differential diagnosis list, and diagnosing complications of appendicitis (perforation, abscess, etc.))
22
Q
In dx of appendicitis, when is MRI indicated?
A
MRI is typically reserved for pregnant patients with a nondiagnositic ultrasound.
23
Q
Should you use IV gadolinium when using MRI to dx appendicitis in pregnant women? Renal insufficiency?
A
- No, IV gadolinium, is potential teratogen.
- Similar to using IV contrast with CT, IV gadolinium cannot be used in patients with renal insufficiency.
24
Q
What would be a good lab panel to start with in those whom you suspect appendicitis?
A
- CBC
- BMP
- CRP
- UA
(get CT in male or non-preg female, otherwise US -> MRI)
25
What "score" can be used to r/o appendicitis?
Alvarado score
26
***Describe your approach to tx in a pt
- Appendectomy. Certain complicated cases like perforation with a walled off abscess will require drainage by IR.
- IV fluid resuscitation
- Pain control
- Antiemetics
- Once dx'd, NPO and IV abx should be started in the ED. Examples: ampicillin-sulbactam, or cefoxtin, or a combo of metronidazole and ciprofloxacin.
(- For complicated appendicitis (perforation, abscess, immunocompromise, etc.) a carbapenem, such as meropenem or imipenem, can be used or an extended spectrum penicillin with a beta-lactamase inhibitor, such as piperacillin/tazobactam)
27
True or false, an afebrile pt w/a nl WBC essentially r/o's appendicitis.
False (There is no single sign, symptom, or lab that completely rules out appendicitis)
28
In appendicitis, _______________________ and _______________have atypical presentations necessitating a high index of suspicion
extremes of age, pregnant pts
29
In females in whom you suspect appendicitis, list 3 gynecological dz's you should watch out for:
List 1 ddx unique to men:
- Ectopic pregnancy
- Ovarian torsion
- Tubo-ovarian abscess.
Torsion
30
Ruptured AAA is fatal unless treated surgically, and even with surgical intervention mortality is approximately __%.
50%
31
What is the classic triad of AAA?
* pain
* hypotension
* pulsatile abdominal mass
32
In AAA sx, a continuous abdominal bruit and a palpable abdominal thrill are suggestive of:
Aortovenous fistula
33
In AAA sx, heme-positive or grossly bloody stools can be indicative of:
Aortoenteric fistula
34
Describe the pain of AAA (type, onset, severity, locations, radiations)
Associated sx?
Pain
- Acute
- Severe
- Constant
- Located in the abdomen, back, or flank.
- Can radiate to the chest, thigh, inguinal region, or scrotum.
Can be a/w N/V, near-syncope, syncope, or AMS.
35
Describe the pain of an unruptured, incidentally discovered AAA. (onset, quality)
usually has a gradual onset and a dull quality.
36
What is the initial mgmt of AAA?
- ABCs
- 2 large-bore IVs
- No agreed upon tx (fluids can worsen it; just go to surgery)
- Contact vascular surgeons early
37
What systolic BP should you target in initial tx of AAA?
between 90 and 100 mm
38
What lab studies could you consider in AAA?
- CBC
- Coags
(detection of blood/renal failure:)
- UA
- Electrolytes
(r/o abd:)
- LFTs
- Lipase
39
What is the ideal study for detection of AAA?
US
40
If US non-diagnostic and pt HDS, what would you then perform?
CT (contrast preferred but not required; can worsen renal problems caused by hypovolemia!)
41
If US and CT not available, what other imaging modality may be used?
X-ray
| A curvilinear calcification of the aortic wall or a paravertebral soft tissue mass can be found.
42
How do you dx AAA in pts who are HDUS?
Hemodynamically unstable patients with signs and symptoms of ruptured AAA should be given presumptive diagnosis of ruptured aneurysm and treated as such.
43
If waiting for blood to become available, what blood type can you always use?
O-neg
44
In pt's over age __ with abdominal pain, you should include AAA in the ddx.
50
45
Describe s/sx of PID.
Typical presentation: bilateral lower abdominal pain, purulent vaginal discharge, or less frequently with abnormal vaginal bleeding
- Fever, nausea, vomiting and general malaise (all variable)
46
List r/f's for PID.
- H/o STDs
- Multiple sexual partners
- IUD use
- Adolescence (75% of PID cases occur between the ages of 15-25)
- Sexual intercourse at an early age
- Recent instrumentation of the uterine cavity
47
In PID, unilateral adnexal tenderness may represent what? (1)
Tubo-ovarian abscess
48
In PID, RUQ tenderness may represent what?
Fitz-Hugh Curtis (extension of infxn to perihepatic capsule -> violin string scar tissue formation)
49
List tests to order if you suspect PID.
- UA
- CBC w/diff
- LFTs (if Fitz-Hugh-Curtis suspected)
- Gonorrhea/chalmydia (NAAT); likely won't be back in time so do clinical dx based on sx
-
50
When PID suspected, when is pelvic US warranted?
If TOA is suspected or the diagnosis is unclear. It is particularly useful to rule out other diseases that may present with pelvic pain such as a ruptured ovarian cyst (free fluid in the pouch of Douglas) or ovarian torsion (absence of blood flow to one ovary on pelvic ultrasound with doppler).
51
Because of the potential complications of untreated PID and the prevalence of infection, the Center for Disease Control (CDC) has recommended initiating empiric therapy for all patients who meet minimal clinical criteria for PID. This minimum criterion includes:
History of lower abdominal or pelvic pain coupled with adnexal, uterine or cervical motion tenderness on exam, in a patient at risk for STDs with no other discernible cause for the illness identified.
52
List complications of PID
- chronic pelvic pain
- dyspareunia
- infertility
- ectopic pregnancy
- TOA
- Fitz-Hugh-Curtis syndrome
53
What should empiric PID abx tx's cover?
N gonorrhea, C trachomatis, Escherichia coli, and multiple anaerobic bacteria such as peptococcus, peptostreptococcus and bacteroides
54
What inpatient abx recommendations can you use for PID?
* Cefoxitin with Doxycycline OR
* Cefotetan with Doxycycline
* If the patient is allergic to cephalosporins, they may be treated with Clindamycin with Gentamycin.
* Alternatively they may be treated with Unasyn with Doxycycline. Doxycycline should always be given orally when possible, because it is caustic to vessels.
55
Describe the recommended outpt abx regimen for PID.
- Ceftriaxone IM OR Cefoxitin IM and Probenecid PO. Doxycycline for 14 days must also be prescribed.
- Adding Metronidazole for 14 days should be considered in women with more severe infection or history of uterine instrumentation within the preceding 3 weeks
56
What ar indications for PID women to be admitted?
- Suspected TOA
- Fitz-Hugh-Curtis syndrome
- intractable vomiting
- sepsis
- peritonitis
- prepubertal children
- women with an indwelling intrauterine device (IUD)
- pregnant patients (rare)
- to preserve fertility
57
Why should the nulliparous woman strongly be considered for inpt admission in PID?
Preserve fertility
58
Should you remove IUD in pts with PID?
Yes, s/p abx initiation
59
Describe d/c instructions for PID pts.
- Advise to avoid sexual contact
- Refer their partners for treatment
- Follow up in 72 hours, unless their symptoms worsen requiring earlier follow up.
- Refer for further STD testing including HIV, hepatitis, and syphilis.
60
True or false: PID is usually polymicrobial
True
61
Although rare, during what part of pregnancy is PID most commonly seen?
First 12 weeks
62
When should you resort to US for PID?
Patients with unilateral tenderness or mass, or if the diagnosis is unclear.
63
In what types of situations is acalculous cholecystitis more common (vs. calculous).
elderly, post-operative, or critically ill from other causes.
64
Describe the pain a/w biliary colic.
Intermittent or “colicky” pain that is burning, pressure-like, or heavy in nature
65
What is charcot's triad and what disease is it related to?
- Fever
- Jaundice
- RUQ pain
Cholangitis
66
True or false: most cases of biliary colic are self-limited.
True:
| Most episodes of uncomplicated biliary colic are self-limited and resolve within 4-6 hours with or without treatment.
67
Is Murphy's sign more sensitive or specific for acute cholecystitis?
sensitive
68
What is added to Charcot's triad to make the pentad?
hypotension and altered mental status
69
Describe the following labs might be in cholelithiasis (fyi, all labs might be nl)
- WBC
- AST/ALT
- Conjugated bili
- Alk phos
- amylase/lipase
cholelithiasis
- WBC: nl
- AST/ALT: nl/slightly ^
- Conjugated bili: nl
- Alk phos: nl/slightly ^
- amylase/lipase: nl
70
Describe the following labs might be in choledocholithiasis (fyi, all labs might be nl)
- WBC
- AST/ALT
- Conjugated bili
- Alk phos
- amylase/lipase
choledocholithiasis
- WBC: nl
- AST/ALT: nl/slightly ^
- Conjugated bili: ^
- Alk phos: ^
- amylase/lipase: nl
71
Describe the following labs might be in acute cholecystitis (fyi, all labs might be nl)
- WBC
- AST/ALT
- Conjugated bili
- Alk phos
- amylase/lipase
acute cholecystitis
- WBC: nl, ^, or v (if septic)
- AST/ALT: nl or slightly ^
- Conjugated bili: nl or slightly ^
- Alk phos: nl or slightly ^
- amylase/lipase: nl or slightly ^
72
Describe the following labs might be in cholangitis (fyi, all labs might be nl)
- WBC
- AST/ALT
- Conjugated bili
- Alk phos
- amylase/lipase
cholangitis
- WBC: nl, ^, or v (if septic)
- AST/ALT: ^
- Conjugated bili: ^
- Alk phos: ^
- amylase/lipase: nl or slightly ^
73
What is the initial diagnostic study of choice for evaluation of biliary tract diseases?
US
| less sensitive if the stone is outside the GB
74
What are the important signs on US that support acute cholecystitis?
- Presence of gallstones
- GB wall thickening (5mm or greater)
- Pericholecystic fluid
- Positive sonographic Murphy’s sign
75
When is HIDA scan indicated for the dx of acute cholecystitis?
If US is equivocal or negative for cholecystitis in the presence of a high clinical suspicion.
76
What is a HIDA scan?
HIDA = "hepatobiliary iminodiacetic acid scan"
A nuclear imaging procedure that utilizes a radioactive tracer, technetium-99m, to evaluate GB function.
- Get after equivocal US
77
Besides US & HIDA, what else can you use to dx biliary disease?
CT
In the setting of equivocal US results, CT can be considered as the next diagnostic step if HIDA scan is unavailable or if a broad differential to the patient’s abdominal pain is still being considered.
- X-rays have poor utility
78
If cholecocholithiasis is suspected, what is the next step in dx/tx?
ERCP
| - Dx & tx
79
What are some risks of ERCP?
- Pancreatitis (~5%)
- Perforation of the GI tract or ductal system
- Dye reactions
- Bleeding
Therefore, used more for tx than dx, especially as MRCP and endoscopic ultrasound become more widely used
80
Summarize the tests/procedures needed for dx of biliary tract disease.
- H&P
- Laboratory studies: CBC, LFT’s, pancreatic enzymes
- Imaging: US, HIDA, CT, ERCP
81
List r/f's for biliary disease
* Female gender
* Age > 40 years
* Family history
* Obesity
* Multiparity
* Rapid weight loss
* Sickle Cell or other hemolytic disorders (pigmented stones)
* Diabetes (increased risk of cholecystitis)
82
How are episodes of biliary colic usually treated?
Can be treated symptomatically with pain control (NSAIDS and/or narcotic pain medications), fluid resuscitation and antiemetics.
The definitive treatment for symptomatic cholelithiasis is surgical removal of the gallbladder (cholecystectomy).
83
How is choledocholithiasis treated?
ERCP or surgial stone removal
84
How is cholecystitis or cholangitis treated?
- Initially: symptom control with fluids, antiemetics and analgesics, + broad-spectrum parenteral abx (ampicillin/sulbactam, a FQ, or a third-generation cephalosporin +/- metronidazole given early)
- w/sepsis, likely need fluid resuscitation and BP support.
- *Prompt surgical consultation. Cholecystectomy is indicated in cholecystitis, but may be delayed, especially in the critically ill patient
85
What is the dispo for biliary cholic?
Those w/improving symptoms may be d/c'd home with outpatient referral to gen surg for consideration of an elective cholecystectomy.
86
What is the dispo for cholecocholithiasis?
Usually admission (high complication rate)
87
What is the dispo for acute cholecystitis/cholangitis?
Admit all pts to the hospital for IV antibiotics and possible surgery.
- If septic, ICU admission may be required.
88
True or false, lab tests can reliably distinguish cholelithiasis from acute cholecystitis.
False
89
If a pt has a RUQ pain with a fever, but no WBC and nl US findings, should you still consult surgery?
Yes
90
RUQ pain lasting more than __ hours should NOT be attributed to benign biliary colic regardless of the presence or absence of significant laboratory or imaging abnormalities. Persistent pain should prompt admission and further evaluation.
6 hours
91
Review some other things in the differential for RUQ abdominal pain.
Hepatitis
RLL PNA
Kidney stone/infection
ACS with atypical presentation
92
List the top 3 most common causes of bowel obstructions.
1. Adhesions
2. Tumors (esp. large bowel)
3. Hernias
Other causes include strictures, intussusception, volvulus, Crohn’s disease, and gallstones.
93
List some sx of SBO.
*Abd pain/distension
*N/V
Maybe diarrhea (partial)
No PO intake
*Inability to pass flatus
Feculent emesis
Lyte abnormalities (edema into peritoneum)
v urine output, tachycardia, azotemia, hypotension
94
What is the most extreme complication of a SBO?
Strangulation (surgical emergency)
This occurs when bowel wall edema compromises perfusion to the intestine and necrosis ensues. This will eventually lead to perforation, peritonitis and death if not intervened upon.
95
Describe the type of pain a/w simple SBO.
crampy and intermittent
96
What should you always ask pts w/ s/sx of SBO?
Any hx of abd surgeries?
97
What should you think if a pt with suspected SBO has never had abd surgeries?
“de novo small bowel obstruction”
| These are caused by tumor until proven otherwise and usually require a surgical intervention.
98
What types of sx might clue you in that strangulation of a SBO is occurring?
Fever, tachycardia and peritoneal signs
99
* Why should you do a GU exam in suspected SBO?
| * Why should you do a rectal exam?
Look for inguinal hernia as cause!
Look for signs of strangulation or malignancy as cause.
100
What type of x-ray imaging is needed in suspected SBO?
3 required
- upright chest film (looking for free air/perforation)
- upright abdominal film (looking for air fluid levels)
- supine abdominal film (looking for distended loops of bowel)
Above will reveal the diagnosis in up to 75% of cases.
101
What is needed to be seen on x-ray imaging for the dx of SBO to be made?
Multiple air-fluid levels along with distended loops of small bowel
- Absence of air in the colon or rectum suggests a complete obstruction while the presence of air in the colon suggests a partial obstruction.
102
More recently, _________________ has been replacing _________________ for *definitive diagnosis of SBO.
*CT
| small bowel follow-through
103
What is small-bowel follow-through?
AKA enteroclysis (the duodenum is instilled with air and contrast), sometimes used for SBO dx.
104
List some signs on CT of strangulation in SBO.
Bowel wall thickening, pneumatosis, and portal venous gas
105
Are labs required for dx of SBO?
No, not useful for dx, but are for dehydration status.
106
What labs should you order in SBO?
Chemistries, CBC, type and screen, and coags.
Lactic acid, liver function tests, lipase and UA are also of value in guiding diagnosis, resuscitation, and post-surgical care.
107
Review the goals of initial tx of SBO.
- Resuscitation and electrolyte replacement
- Identifying the severity and cause of the obstruction
- GI decompression
- Symptomatic treatment
- Determining whether or not surgical intervention is indicated
108
When can you use non-operative mgmt to treat SBO?
If there's no strangulation
109
*What does non-operative mgmt of SBO entail?
*Consists of GI decompression with n NG tube, IV fluid hydration, bowel rest, and symptomatic treatment.
- Also give pain meds
- Frequent re-assessments
- If not improving -> surgery
110
What are the dispo options for someone with SBO?
- OR
- ICU
- Floor
(d/c home not listed)
111
What is the mortality % of perforated viscus? (even w/surgery)
30-50%
112
Describe the typical pain presentation a/w perforated viscus.
Acute, sudden, sharp, then becomes generalized (peritonitis--> guarding, rebound, rigidity)
113
If suspected perforated viscus, recall other life-threatening pathologies to consider.
AAA
Aortic dissection
Mesenteric ischemia
114
What is the most sensitive and specific test for perforated viscus?
CT
- X-ray faster but often falsely negative
(Its numerous advantages include detecting extremely small volume pneumoperitoneum, retroperitoneal air, potential locations of the actual site or organ that has perforated and finally providing alternative diagnoses if no free intra-abdominal air is identified.)
115
While CT is still #1, US is becoming more sensitive in detecting perforated viscus. What signs should you look for on US?
The “ring down” artifact and enhancement of the peritoneal stripe over the liver can be used in experienced hands to achieve an almost 93 % sensitivity.
116
What lab studies are useful in perforated viscus?
```
These should be ordered with the goal of gathering information critical for the surgical control of the perforation site. Minimum:
- type and screen/cross
- initial hemoglobin/hematocrit
- platelets
- coagulation studies
Additional laboratories such as:
- WBC
- blood gas
- lactic acid
- renal and liver function
- lipase/amylase
- urinalysis are also of value in guiding diagnosis, resuscitation, and post-surgical care.
```
117
Recall: how do you r/o AAA/rupture when suspecting perforated viscous?
US (make sure no AAA or hemoperitoneum)
118
What tx is indicated for perforated viscus?
- 2 large bore IVs
- Monitoring equipment
- 2L wide-open crystalloids
- Abx (gram negative, gram positive, and anaerobic organisms. E.g., ciprofloxacin and metronidazole, piperacillin/tazobactam, or imipenem)
- Immediate surgical consultation
119
What are the dispo options for perforated viscus?
- OR
- ICU
- Interventional Radiology
120
What types of perforated viscus pts could be sent to IR + floor admission instead of gen surg?
Stable patients with abscesses secondary to colonic perforation that can be drained by interventional radiology, may be candidates for floor admission
121
Up to __% of patients with perforated viscus during laparotomy may demonstrate no pneumoperitoneum on plain x-rays
50%
| Conversely 10-14% of patients with pneumoperitoneum may have a non surgical cause of free air
122
Review some diseases that might be on your differential with mesenteric ischemia.
AAA, volvulus, perforated viscus, incarcerated hernia, appendicitis, biliary colic, and renal colic.
123
What are the presenting sx of mesenteric ischemia?
What is the classic age cutoff of presentation?
Sudden or gradual onset?
vague and variable signs and symptoms such as:
- poorly localized abdominal pain
- N/V/D
Patient older than 50 years of age
Sudden-onset
124
Why should mesenteric ischemia be considered first in all elderly pts with abd pain?
Delay in diagnosis can be disastrous.
If mesenteric ischemia is not considered early in the ED presentation, then the intestines will rapidly become gangrenous leading to multisystem organ failure, sepsis, and eventual death.
125
How common is mesenteric ischemia?
Rare
0.1% of hospital admissions and 1% of ED visits (may be rising incidence)
126
What are the initial actions to take in someone w/suspected mesenteric ischemia?
- Large bore IV access
- Fluid rescucitation
- Telemetry monitoring
- EKG (look for a-fib clot source)
- Surgical consult
- Correct vitals (e.g. O2)
127
What is a pathognomonic description of the pain in mesenteric ischemia?
abdominal pain that is out of proportion to examination (sudden, severe)
- The patient may be screaming in pain, but their abdomen is soft with no guarding or rebound.
128
While initially, pt's w/mesenteric ischemia may have severe pain but lack of physical findings, how does this pattern change over time?
As the disease progresses and the bowel infarcts and the patient will develop abdominal distension with guarding, rebound, and absence of bowel sounds.
+/- Rigidity
Bloody diarrhea and heme-positive stools are a late finding after bowel has infarcted.
129
*List the 4 etiologies of mesenteric ischemia.
- mesentery artery embolus
- mesentery artery thrombosis
- mesenteric vein thrombosis
- non-occlusive ischemia
130
What is the most common cause of the 4 etiologies of mesenteric ischemia?
Mesentery artery embolus (high mortality, ~70%)
131
What is the most common location for an arterial embolus to lodge in mesenteric ischemia?
SMA, due to its oblique angle from the aorta.
132
What are some r/f's for mesentery artery thrombosis (mortality at 90%)?
systemic atherosclerosis and old age
| - Celiac trunk most common area for this
133
Who are the types of pts who get mesentery artery thrombosis?
Most patients have a history of undiagnosed chronic mesenteric ischemia with vague and insidious symptoms such as weight loss, abdominal angina (abdominal pain after meals), diarrhea, and *fear of food.
- Difficult dx, often confused w/PUD
134
What demo of pts are more likely to get mesentery VEIN thrombosis (vs. artery)
Younger (e.g. factor V leiden, recent surgery, malignancy, cirrhosis)
135
What are some causes of NON-OCCLUSIVE mesenteric ischemia?
Cardiogenic shock (or any shock), CHF, arrhythmias, vasoconstrictive drugs (Digoxin, Cocaine, Alpha-agonists, Beta-blockers)
136
Mortality in all of the causes of mesenteric ischemia range from 50-90%, except for this cause, which is lower at 20-50%
Mesenteric vein thrombosis
137
What 2 labs have high sensitivity but low specificity for mesenteric ischemia?
lactate (elevated late in disease)
d-dimer
*overall, no good labs for mesenteric ischemia*
138
Are any x-rays indicated in dx/tx of mesenteric ischemia?
Abdominal xray series to help rule out free air from a perforated viscus.
139
*What is the gold standard for dx, and aiding in tx, of mesenteric ischemia?
Angiography
140
In dx of mesenteric ischemia, ___________________________ has rapidly become an alternative to angiography.
CT ANGIOGRAPHY (CTA) of the abdomen / pelvis
| sensitivity of 93% and specificity of 95%
141
In addition to the vascular findings of thrombus and emboli, CTA can also demonstrate more subtle signs of mesenteric ischemia such as: (review)
- circumferential thinking of the bowel wall
- bowel dilatation
- bowel wall attenuation
- mesenteric edema which may not be seen on angiography.
- Also helps r/o other dz's that angiography cannot (appendicitis, bowel obstruction)
142
Which test for mesenteric ischemia dx can also provide therapy?
Angiography
- CTA cannot provide therapy, but can help triage patients towards those who can undergo angiography and those who should go to the operating room immediately.
143
Are US and MRA useful in dx of mesenteric ischemia?
No, not really (obese pts, etc.)
144
Initial tx of mesenteric ischemia?
- 2 large bore IVs. Insertion of a triple lumen for CVP monitoring may be required to guide IV fluid treatment, especially in patients with a hx of CHF
- Start abx
- Stop vasoconstrictive meds
- Anticoagulant (e.g. heparin) if thrombus suspected
- Paperverine can be given to help vasodilate
- Surgery consult?
145
Tx of arterial embolus cause of mesenteric ischemia?
TOC: embolectomy and bowel visualization to assess for signs of necrosis
- Can give percutaneous thrombolytics into artery if non-operative candidate
146
Tx of arterial thrombosis cause of mesenteric ischemia?
Start heparin
- Operate to check bowel health
- For non-operative candidates, percutaneous transluminal angioplasty is done.
147
Tx of venous thrombosis cause of mesenteric ischemia?
If there are signs of infarction, then operative care is required. Otherwise thrombectomy with endarterectomy or distal bypass is the first choice of treatment.
- Anti-coagulants, often life-long
148
Tx of non-occlusive cause of mesenteric ischemia?
- Treat underlying cause
+/- Papaverine
- Operating room if signs of necrosis
149
Dispo of pts w/mesenteric ischemia?
- All patients are admitted, generally to an ICU for close monitoring due to the high mortality and ability for these patients to become sick rapidly.
150
If angiography is to be performed, who do you consult? (e.g. for mesenteric ischemia).
IR
151
What is actually twisted in testicular torsion?
Twisting of the testis and spermatic cord within the scrotum, with resulting in occlusion of venous return and and edema.
152
Normally the testicle is anchored within the scrotum by the _______________________, which surrounds the testicle and attaches posteriorly to the scrotal wall and epididymis.
tunica vaginalis
153
What is the appendix testes?
The appendix testes are embryonic remnants that have no known function and are located on the upper pole of the testicle. The appendix testes are prone to torsion as well, and the similar symptoms can be confused with torsion of the testicle.
154
True or false: in testicular torsion, always order an US to check for vascular blood flow.
False: Order an US to assess for the presence or absence of vascular flow IF THE DX IS UNCLEAR
155
When suspecting testicular torsion, what are the initial actions to take?
- Obtain vital signs and IV access.
- Perform a focused H&P
- IV pain control
- / + Order an US
- Consult urology early if torsion is suspected
- NPO (admission to OR likely)
156
Come up with a ddx for testicular torsion.
```
Testicular torsion
Torsion of the appendix testis
Epididymitis
Orchitis
Renal colic
Varicocele
Kidney stone
Appendicitis
Hernia
Hydrocele
Testicular trauma
```
157
Describe the classic presentation of testicular torsion.
Sudden, severe unilateral testicular pain, sometimes radiating into the abdomen, associated with N/V
+/- urgency, frequency, and dysuria
158
In testicular torsion, is the R or L testicle more often affected?
Left
159
What should you do if you see a pt that reported testicular pain that is intermittent.
Consult urology (spontaneous detorsion, but may have still had ischemia)
160
Describe the PE of someone with testicular torsion
- examine sitting and standing
- will see exquisite pain, swelling
- may sit higher than opposite testicle, transverse lie
161
*What is Prehn sign?
Prehn's sign describes the relief of pain with elevation of the testicle, and was once to be touted as a method to distinguish epididymitis from torsion since the pain associated with torsion is usually not relieved with elevation of the testicle (ie, positive Prehn's = epididymitis). However, this sign is not reliable in differentiating these two entities.
162
*What is the best (most accurate) way to diagnose testicular torsion on PE?
Loss of the cremasteric reflex to be the most accurate sign of testicular torsion.
- This reflex is elicited by stroking the ipsilateral thigh which leads to reflex elevation of the ipsilateral testicle by greater than 0.5cm.
163
What labs are useful in testicular torsion?
None really, UA + G/C if suspecting epididymitis
164
When dx is unclear of testicular torsion and US must be ordered, what on US indicates evidence of torsion?
Enlarged and hypoechoic testicle, with decreased blood flow
- Complete absence of Doppler flow confirms the diagnosis of torsion, but is a relatively late finding
- Always compare to opposite testicle
165
At what ages are testicular torsion, torsion of testicular appendage and epididymitis most common?
- Testicular torsion: Bimodal, 1st year of life (including prenatal period) and at puberty
- Torsion of testicular appendage: 7-14 years
- Epididymitis: adult
166
What are the presenting features of the pain of testicular torsion, torsion of testicular appendage and epididymitis?
- Testicular torsion: Entire testicle, onset over hours
- Torsion of testicular appendage: Upper pole of testicle, onset over hours to day
- Epididymitis: Epididymis, onset over days
167
What are the associated sx of testicular torsion, torsion of testicular appendage and epididymitis?
- Testicular torsion: Nausea
- Torsion of testicular appendage: None
- Epididymitis: Fever, dysuria
168
What are the physical exam signs of testicular torsion, torsion of testicular appendage and epididymitis?
- Testicular torsion: Cremasteric reflex absent. Diffusely swollen tender testicle.
- Torsion of testicular appendage: Cremasteric reflex present
- Epididymitis: Cremasteric reflex present. Epididymal tenderness with or without testicular tenderness
169
*What are the tx's of testicular torsion, torsion of testicular appendage and epididymitis?
- Testicular torsion: *Surgical detorsion and bilateral orchiopexy
- Torsion of testicular appendage: Supportive
- Epididymitis: Abx
170
If outcome is untreated, what are the sequelae of testicular torsion, torsion of testicular appendage and epididymitis?
- Testicular torsion: Testicular infarction, decreased fertility
- Torsion of testicular appendage: Infarction and resorption of appendage, no effect on fertility
- Epididymitis: Possible scarring, possible impaired fertility
171
What is the definitive dx for testicular torsion?
Surgery
172
If surgical detorsion is not an option, what should you do (for testicular torsion)?
manual detorsion (painful, likely use IV sedation/analgesia)
173
Describe how to do manual testicular detorsion.
Have the patient lie supine, and stand facing towards the patient's head. To manually detorse the testicle, grasp it gently and rotate it away from midline, as if you are opening a book (a minority will twist in the opposite direction). Most torsions involve one or more complete (360°) rotations. Therefore, you may need to make two or three complete rotations of the testicle. When the maneuver is successful, patients report dramatic pain relief within minutes.
174
Consider torsion in any patient with testicular trauma who still has pain __-__ hours after an injury.
1-2
175
Initial actions to take in suspected Ovarian torsion?
* Obtain vital signs and IV access.
* Perform a focused history and physical examination
* Order an ultrasound to assess for the presence or absence of vascular flow.
* Consult gynecology early if torsion is suspected.
* Treat pain
* Make NPO for surgery
176
DDX when suspecting ovarian torsion?
* Ovarian torsion
* Ovarian cyst
* Tubo-ovarian abscess
* Ectopic pregnancy
* Appendicitis
* Kidney stone
177
At what age does ovarian torsion commonly occur?
It is most common in the reproductive years, but can occur at any age.
178
Classic presentation of ovarian torsion?
- Sudden-onset of unilateral lower abdominal pain (initially vague)
- may be accompanied by N/V.
- It may radiate to the groin or flank.
- Sometimes the patient will describe several episodes of pain over the course of hours, days, or even weeks, if the ovary has been torsing intermittently
- Low-grade fever
179
Why should current pregnancy increase your suspicion of ovarian torsion?
Corpus luteum cyst
180
The most dangerous condition in the differential for adnexal (ovarian) torsion is __________________.
ectopic pregnancy
181
In the ddx of ovarian torsion, what can UA help dx? (2) CBC? (1)
None
- A urinalysis may reveal blood consistent with nephrolithiasis, or it may show nitrites and leukocyte esterase more consistent with a UTI.
- A markedly elevated serum WBC count may favor tubo-ovarian abscess over torsion.
182
_______________ is the diagnostic modality of choice for detecting ovarian torsion.
Ultrasound
| - It is important to note that the presence of Doppler blood flow does not exclude the diagnosis of torsion
183
Why would you ever order a CT with suspected torsion?
If strongly considering appendicitis or kidney stone as an alternate dx, CT may be helpful in ruling in or ruling out these conditions.
184
How is the definitive dx of ovarian torsion made?
Intraoperatively
185
What condition are the sx of ovarian torsion probably most similar to overall?
Kidney stone
