Abdominal Pain and Acute Abdominal Disorders Flashcards
characteristics of visceral pain
- slow onset
- poorly localized
- dull discomfort
characteristics of somatic pain
- sudden
- sharp
- well localized
- lateralizing
it may be necessary to wait as long as ____ minutes to establish absence of peristalsis
2-3
Carnett sign
flex stomach to determine if pain is located in the abdominal wall or intraabdominally
if pain when flexed carnett is positive and pain is abdominal wall pain
murphy’s sign
patient takes a slow, deep breath in and there is an abrupt cessation in inspiration by deep palpation of the RUQ
what is murphy’s sign indicative of?
cholecystitis
rovsing sign
RLQ pain elicited by pressure applied on the lower left quadrant
what is rovsing sign indicative of?
appendicitis
psoas sign
patient flexed the thigh against the resistance of the examiner’s hand
what is psoas sign indicative of?
appendicitis
obturator sign
patient’s thigh is flexed to a right angle and gently rotated, first internally and then externally
what is obturator sign indicative of?
- appendicitis
- diverticulitis
- PID
management of abdominal pain
- stabilize
- NPO
- IV hydration
- analgesics
- antiemetics
- consult
indications for admission of abdominal pain
- toxic appearance
- unclear diagnosis
- inability to exclude serious etiology
- intractable pain or vomiting
- altered mental status
- inability to follow discharge or F/U instructions
volvulus
torsion of a segment of the bowel
types of volvulus
- MC sigmoid
- cecal
t/f some volvulus may reduce spontaneousley
true
pathophys of sigmoid volvulus
air filled loop of the sigmoid colon twists about its mesentery
risk factors for sigmoid volvulus
- long, redundant sigmoid colon w/ a narrow mesenteric attachment
- chronic fecal overloading from constipation
clinical presentation of sigmoid volvulus
insidious onset of slowly progressive abdominal pain, nausea, abdominal distention, and constipation
vomiting in volvulus usually occurs…
several hours after onset
PE of sigmoid volvulus
- abdominal distention and tympany
- tenderness to palpation
diagnosis of sigmoid volvulus
abdominal CT showing whirl patterns and birds beak
imaging used for volvulus when there isnt access to CT
radiographs
management of sigmoid volvulus
- reduce volvulus
- IV fluids
- endoscopic detorsion with rigid sigmoidoscope
- surgical exploration with gangrene
cecal volvulus
torsion of a mobile cecum and ascending colon
in cecal volvulus, rotation occurs around the…
ileocolic blood vessels
risk factors for cecal volvulus
- pregnancy
- tumors
- exertion
- violent coughing
- infections
- weakness of colon muscle
clinical findings of cecal volvulus
gradual onset of steady abdominal pain with episodic cramping due to peristalsis
PE of cecal volvulus
- distended and tympanic abdomen
- tenderness to palpation
- fever
- hypotension
diagnosis of cecal volvulus
- initially, a plain radiograph will be done
- CT is first line and confirmatory
results of plain radiography of cecal volvulus
- coffee bean sign
- comma sign
results of CT with cecal volvulus
whirlwind sign
results of barium GI series for cecal volvulus
birds beak
t/f cecal volvulus can not be detorsed endoscopically
true
management of cecal volvulus stable without bowel compromise
open surgical detorsion, then iliocecal resection
management of cecal volvulus hemodynamically unstable without bowel compromise
cecopexy after detorsion
t/f you should detorse when the patient has bowel compromise
false
management of cecal volvulus stable with bowel compromise
ileocolic resection and anatamosis
management of cecal volvulus unstable with bowel compromise
resection of compromised bowel
MC cause of intestinal obstruction between 6 months and 3 years
intussesception
intussusception
portion of the bowel is telescoped into another segment
MC type of intussusception
ileocolic
as the intussusception develops, the mesentery is dragged into the bowel, leading to…
development of venous and lymphatic congestion with resulting edema
clinical presentation of intussusception
- severe pain in a perviously healthy child
- currant jelly stool
- sausage shaped mass in the right side of the abdomen
diagnosis of intussusception
US
what do you see on US for intussusception?
bullseye
whirlwind
one more thing? snails shell? idk
confirm diagnosis of intussusception
barium enema
t/f the barium enema is curative as well as diagnostic for intussusception
true
management of intussusception
- nonoperative reduction
- surgical consult if severe
nonoperative reduction
hydrostatic or pneumatic pressure by enema
fluoroscopy
- type of medical imaging that shows a continuous xray image on monitor
- can be pneumatic or hydrostatic
sonographic
uses US and hydrostatic technique to provide retrograde pressure
what type of intussusception management has higher success rates?
pneumatic
MC abdominal surgical emergency
appendicitis
etiology of appendicitis
fecalith causing obstruction leading to increased intraluminal pressure
clinical presentation of appendicitis
- vague, colicky, abdominal pain
- RLQ
PE of appendicitis
- localized tenderness with guarding in RLQ
- mcburneys point tenderness
- rovsing sign
- psoas sign
- obturator sign
- heel slap sign
McBurney’s point tenderness
tenderness to palpation in the mid-point of the right lower quadrant (RLQ) which can indicate appendicitis
diagnosis of appendicitis
CT
(US in pregnant or child)
management of appendicitis
- laparoscopic appendectomy
- hydrate with IV fluids
- antibiotics (cefotixin or cefotetan for surgical. metro+rocephin if non surgical.
etiology of toxic megacolon
lethal complication of inflammatory bowel disease or infectious colitis
toxic megacolon is a nonobstructive colonic dilation of at least …… + …….
6cm and systemic toxicity
what inflammatory bowel disease is toxic megacolon related to?
chrons
hallmark of toxic megacolon
- severe inflammation extending into the smooth muscle layer
- paralyzing the colonic smooth muscle and leading to dilation
clinical findings of toxic megacolon
- s/s of colitis resistant to therapy
- severe bloody diarrhea
- malaise
- abdominal pain and distention
PE of toxic megacolon
- altered mental status
- fever
- tachycardia
- lower abdominal pain and tenderness
diagnosis of toxic megacolon
CT
criteria for toxic megacolon diagnosis
- radiographic evidence
- at least 3 of the following (fever, HR>120, elevated neutrophils, and anemia)
- at least one of the following (dehydration, altered mental status, electrolyte disturbances, hypotension)
what part of the colon is most dilated in toxic megacolon?
transverse or right
treatment of toxic megacolon
- complete bowel rest
- NG tube
- IV fluids
- IV steroids
- surgical consult
Acute mesenteric ischemia
sudden onset of small intestine hypoperfusion
MC artery affected by acute mesenteric ischemia
superior mesenteric artery
clinical features of acute mesenteric ischemia
abdominal pain out of proportion to PE
PE of acute mesenteric ischemia
- abdominal distention
- absent bowel sounds
- occult blood in stool
- feculent odor to breath
labs for acute mesenteric ischemia
metabolic acidosis
imaging for acute mesenteric ischemia
- CT/MRI performed first
- definitive mesenteric arteriography
what does the mesenteric arteriography show in acute mesenteric ischemia ?
- narrowing/spasming of mesenteric arteries
- reduced filling
- irregularity of arterial branches
treatment of acute mesenteric ischemia
- pain control
- hemodynamic support
- anticoagulation
- vasodialtor
Upper GI bleed
originating proximal to the ligament of treitz
MC cause of upper GI bleed
PUD
lower GI bleed
Distal to the ligament of Treitz
MC cause of lower GI bleed
diverticulosis
what do each of the following indicate?
* hematemesis
* melena
* hematochezia
- hematemesis: source is proximal to the right colon
- melena: upper GI bleed
- hematochezia: coming from the colon/rectum
emergency stabilization of GI bleed
- ABCs
- fluids
- NG tube
hernia
protrusion, bulge, or projection of an organ or part of an organ through the body wall that normally contains it
how are hernias typically classified?
location or etiology
cause of umbilical hernia
increased intra-abdominal pressure
risk factors for umbilical hernias
- multiple pregnancies
- ascites
- obesity
- large intra-abdominal tumor
indications for emergent repair for an umbilical hernia
incarceration and strangulation
treatment of umbilical hernia
- surgical repair
- open repair
- mesh laparoscopic
incisional hernia
herniation through a previous surgical wound
risks for incisional hernia
- poor surgical technique
- obesity
- age
- post-op wound infection
t/f hernias can cause bowel obstruction
true
concerning clinical features for strangulation
- firm, incarcerated hernia
- severe tenderness on exam
- redness and other discoloration of the overlying skin
if the patient…. then the symptoms can be controlled by an abdominal binder
- doesn’t require emergency surgery
- unwilling to undergo surgery
- poor surgical risk
