Abdominal Pain - Exam 2 Flashcards
______ results from stretching of the unmyelinated fibers of the walls/capsules of the organs
Visceral- poorly localized pain
______ results from irritation of the myelinated fibers of the parietal pleura covering the peritoneum. How do these symptoms progress?
Parietal- localized pain
symptoms progress from tenderness and guarding to rigidity and rebound tenderness
What are the MC extra-abdominal sites of abdominal pain?
DKA
Alcoholic ketoacidosis
Pneumonia
PE
Herpes Zoster
______ pt have a less severe or atypical presentation of abdominal pain. What etiologies should you include?
older pts
ischemic heart disease, vasculopathies, coagulopathies
If the pt is female, ____ needs to be assessed
pregnancy status
consider etiologies related to sex organs
abd pain with maximal intensity at onset is red flag for _____, _____ or ______
ischemia, dissection or perforation
abd pain with a gradual onset, should be thinking _____, ____ or ______ etiologies
inflammatory, infectious or obstructive etiologies
if abd pain is constant or worsening over 6 hours, ______ etiology is more likely
surgical
pain improves with meals think ______
pain worsens with meals think _____
improves after meals = PUD
worse after meals = biliary colic
pain improves when upright and worse with supine = _______
pain worse with sudden movements and improves with stillness = _______
pancreatitis
peritonities
rapid onset of severe constant pain should think _______, _____ or ______
acute pancreatitis
mesenteric thrombosis, strangulated bowel
ectopic pregnancy
Gradual steady pain should think ???
acute cholecystitis, cholangitis, hepatitis
appedicitis
acute salpingitis
intermittent colicky pain, crescendo with free intervals
small bowel obstruction
IBD
what order of vomiting and pain would increase suspicion of surgical etiology?
vomiting occurring AFTER the onset of pain is more likely to be a surgical etiology
Pain then vomiting = surgery
What does loose/watery diarrhea make you think?
infectious or diverticulitis
What does mucoid diarrhea make you think? Bloody? small scant amounts?
infectious or inflammatory
bloody: mesenteric ischemia or infectious
small scant amounts: bowel obstruction
What does the auscultation of the abdomen tell you? Give absence, periodic high pitched, hyperactive medium pitch, bruit
absence - peritonitis or bowel obstruction
periodic high-pitched - bowel obstruction
hyperactive medium pitch - blood or inflammation within the GI tract
bruit - abdominal aortic aneurysm
When is a pelvic/testicular exam indicated?
Indicated when the pain is located in the lower ½ of the abdomen
When is a rectal exam indicated?
indicated if concern for GI bleed or rectal mass leading to obstruction
What are the non-contrasted CT indications?
nephrolithiasis
trauma
hemoperitoneum
bowel obstruction
what are the ORAL IV contrast CT indications?
Indications:
BMI <23
GI abscess
appendicitis
diverticulitis
perforation
fistula
What are the indications for IV contrast? What are the CIs?
bowel obstruction/perforation, stable AAA
serum creatinine >1.5 or GRF<60 (unless life threatening situations)
caution with metformin use
When is an abdominal angiography indicated?
indicated in mesenteric ischemia and massive lower GI bleed
What do you need to order if there is any concerned for bleeding?
order type and crossmatch
What should you do if vital signs are abnormal in abdominal pain?
need to order continuous cardiac monitoring
What is the basic overview of managing pts with abdominal pain? What if the pt has normal BP?
NPO and fluids!!
Rapid infusion - 1 L bolus over 10-20 minutes (adults) if hypotensive or signs of dehydration are present
Rate of 75-125 ml/h rate if normotensive
antiemetics: ondansetron and metoclopramide
What is the SE of metoclopramide? What can you do to combat this?
consider co-administration with diphenhydramine 25-50 mg to avoid SE (above)
slow push to avoid extrapyramidal SE
What are the pain management goals in abdominal pain? What agents are preferred?
improve pain to a tolerable level (not to eliminate pain)
improve patient cooperation with exam (eliminate voluntary guarding)
morphine, fentanyl and ketorolac
What pain management agent is a good choice for renal colic? When should it be avoided?
ketorolac is GREAT for renal colic
but avoid NSAIDs if any concern for peritonitis
When are empiric abx indicated in abdominal pain? What are the options?
suspected sepsis and peritonitis
Option1: piperacillin-tazobactam (Zosyn)
If PCN allergy -> Option 2: gentamicin plus metronidazole (Flagyl) IV
When should you admit a pt with abdominal pain?
admit high risk pts:
Geriatric
immunocompromised
unable to communicate
cognitively impaired
Ill appearing
intractable pain or vomiting
unable to comply with discharge or f/u instructions
lack of social support
What are the indications to discharge someone with 12 hour f/u? What needs to be included in their discharge instructions?
Patients with normal CT and unclear dx
If discharged, clear written and verbal instructions about diagnosis, diet to follow, medications, what to watch for and where and when to return/follow up
What are symptoms that warrant return to ED in abdominal pain?
increased/different pain
fever
vomiting
syncope
bleeding
rapid onset of diarrhea (3 or more/d or 200 g of stool/d) lasting <2 wks
nausea, vomiting (nonbilious/nonbloody) and/or abdominal pain
fever
signs of dehydration
What am I?
What will the abdominal exam reveal?
viral gastroenteritis
abdominal exam is usually benign
_____ and ____ need to be ordered in viral gastroenteritis to assess electrolytes and renal function
BMP + Mg
magnesium needs to be added on
What is the management of mild/moderate viral gastroenteritis? What is the goal?
oral fluid challenge:
oral rest x 15 minutes, followed by slow 30 ml fluid intake, repeat oral rest x 15 minutes, repeat with 30 ml of fluid intake
goal 30-100 mL/kg over first 4 hours
probiotics and BRAT diet
What are the preferred fluids in viral gastroenteritis treatment? Why?
Pedialyte or Gatorade
soft drinks and fruit juices with high sugar content should be avoided due to risk of osmotic diarrhea
What is the treatment in moderate/severe viral gastroenteritis?
IV NS or LR
Adults - 500 -1000 mL bolus
Children - 20 mL/kg
probiotics and BRAT diet
When are antiemetics used in viral gastroenteritis? What is the associated pt education?
utilize only if pt fails oral fluid challenge but meets all other criteria to be discharged
if given ondansetron in viral gastroenteritis it will make diarrhea worse!
When are antidiarrheal medication used in viral gastroenteritis? Who is eligible? What are the options?
Recommended if diarrhea leads to dehydration
ADULTS only!
-loperamide (Imodium)
-diphenoxylate with atropine (Lomotil)
-bismuth subsalicylate
What drug class are loperamide (Imodium) and diphenoxylate with atropine (Lomotil). What 2 populations can you not use these in?
antimotility agents
avoid in pediatrics, IBD
What is the drug class for bismuth subsalicylate? What 2 pt populations can you not use these in?
antisecretory
avoid in pediatric (Reye Syndrome) and pregnancy (salicylate toxicity)
What is the pt education with regards to diet following viral gastroenteritis?
BRAT diet
Avoid lactose, raw fruit, caffeine, and sorbitol-containing products
Avoid dairy products for 1 week after improvement of symptoms
What is the discharge home criteria in viral gastroenteritis?
VS stable
Normal abdominal exam
Successful oral fluid challenge
What are the admission criteria in viral gastroenteritis?
a toxic appearance
severe dehydration: abnormal electrolytes/renal function
persistent vomiting or diarrhea
comorbid medical conditions: pregnancy, DM, immunocompromised
very young or elderly
symptoms lasting > 1wk
What are the 2 pathophysiologic processes that lead to bacterial gastroenteritis?
toxin-mediated (secretory) diarrhea
invasive (inflammatory) diarrhea
large amount of watery diarrhea or bloody mucopurulent diarrhea
abdominal cramping/tenderness
+/- fever
What am I?
What is the major complication?
bacterial gastroenteritis
hemolytic uremic syndrome
What 2 pt populations are hemolytic uremic syndrome MC in? What bacteria is it associated with? How will the pt present?
elderly and children under 10
Associated with enterohemorrhagic E. Coli (EHEC)
anemia, thrombocytopenia, s/s of renal failure
What are common ways to become exposed to enterohemorrhagic E. Coli (EHEC)
Hx of exposure to undercooked beef, contaminated drinking water, unpasteurized dairy or fecal contamination of raw fruits and vegetables
What is the underlying cause of HUS?
HUS from E. coli infections results when bacterial toxins cross from the intestines into the bloodstream and damage the very small blood vessels. This results in the glomeruli becoming clogged with platelets and damaged RBC’s preventing adequate renal filtration
What diagnostics test should you order in bacterial gastroenteritis?
(+) Fecal occult blood
BMP - hypokalemia, acute renal injury
CBC (only if HUS is suspected)
Stool studies
When are stool studies indicated if you suspect bacterial gastroenteritis?
Indicated in:
severely dehydrated or toxic patients,
(+) dysentery
immunocompromised patients
prolonged diarrhea (>3 days)
What 3 pathogens need to make sure are being tested for in stool cultures?
Salmonella, Shigella, and Campylobacter MC worldwide
What is the tx for bacterial gastroenteritis?
same fluid management as viral gastroenteritis
replace glucose or K if indicated
empiric abx in adults only!! - Cipro or azithromycin
When are abx recommended in kiddos with bacterial gastroenteritis?
Antibiotics are not recommended in children until a bacterial pathogen is identified
What medication class should be avoided in bacterial gastroenteritis? Which one can you use?
AVOID antimotility agents (Imodium and Lomotil)
can use bismuth subsalicylate if needed
**What defines the difference between upper and lower GI bleed?
Ligament of Treitz
hematemesis
melana
hematochezia
hypovolemia
shock
pain
dizziness, syncope, confusion, diaphoresis, palpitations
What am I?
How can you tell if the hematemesis is mild or moderate/severe?
GI bleeding
frank blood indicates moderate to severe bleeding
coffee-ground-like emesis - mild (limited) bleeding
What is important to note in the hx when working a pt up for a GI bleed?
any hx of similar symptoms?
any recent sx (includes colonscopy or EGD) or trauma?
60% of patients with a history of an upper GI bleed are bleeding from the same lesion
____ or ____ can simulate melena. _____ can stimulate hematochezia
Iron or bismuth can simulate melena
beets -> hematochezia
What type of GI bleed does hyperactive bowel sounds suggest? What does tenderness suggest?
suggests UPPER GI bleed
tenderness is indicative of an inflammatory/infectious etiology or perforation
What does a non-tender abdomen in a GI bleed tell you about the etiology?
likely vascular in nature
What does ascites or hepatosplenomegaly in the presence of GI bleeding indicate?
consider coagulopathy due to liver disease
Need to do _____ exam if concerned about lower GI bleed. What will confirm it?
rectal exam
assess for laceration, trauma, fissure, external hemorrhoids, masses
Guaiac testing will confirm bleeding
what does a normocytic RBC on the CBC tell you? microcytic?
likely can acute GI bleed
microcytic RBC= chronic bleed
What does a CMP tell you in the presence of a GI bleed?
an elevated BUN:Cr ≥30 indicates acute UGI bleed
An endoscopy can not be performed until the INR is at what level?
less than 2.5
_______ is most sensitive for confirming an UPPER GI bleed
visual inspection of gastric content
NG tube with gentle lavage
What is the tx for GI bleed on a pt who is hemodynamically stable?
consult GI/Surgery for admission and scheduled endoscopy
What is the tx for a GI bleed on a pt who is hemodynamically unstable?
NPO
Supplemental oxygen via NC
Cardiac monitoring
2 large bore IV sites
Fluid resuscitation: NS/LR up to 2L bolus
blood transfusion
What is the ration of blood products used in a blood transfusion for a GI bleed? Why?
Transfuse PRBC with 1 unit of FFP for every 4 units of PRBC
PRBC doesn’t contain coagulation factors
What are the indications for blood transfusion in a hemodynamically unstable GI bleed pt?
failure of perfusion and VS to respond to 2 L of NS/LR
most patients with a hgb <7 grams/dL
older patients and those with comorbidities who are unable to tolerate anemia transfuse at a hgb <9 grams/dL
What is the management of a GI bleed for a pt who is on a blood thinner?
INR >2.0
Hold anticoagulant/antiplatelet
reversal anticoag agent in life threatening conditions
transfuse with FFP
What is the reversal agent for rivaroxaban (Xarelto) or apixaban(Eliquis)?
andexanet alfa (Andexxa)
What is the reversal agent for dabigatran (Pradaxa)?
idarucizumab (Praxbind)
What is the reversal agent for warfarin?
administer Vitamin K
Prothrombin complex concentrate infusions (Kcentra)
replaces Vit K dependent coagulation factors (Factors II, VII, IX, X) plus Proteins C and S
What are some additional tx options for an upper GI bleed due to PUD? Due to variceal bleeding?
PPI IV bolus and infusion if bleed from PUD
Octreotide bolus and infusion: Preferred for variceal bleeding
emergent consult to GI for EGD
What is the additional management for LGI bleed?
consult GI or general sx to discuss colonscopy vs angiography
What are the discharge criteria in a GI bleed? What about everyone else?
hx of mild bleeding (from hemorrhoid or anal fissure)
without BRBPR on DRE
no melanotic stool
hemodynamically stable
no comorbidities
everyone else: admitted with consult to GI/general sx
What are the complications of an upper GI bleed?
perforation
anemia
volume overload: in CHF and renal dz
uncontrolled hemorrhage
aspiration
What is the classic presentation of PUD? What makes it better? worse?
Burning epigastric pain is the “classic” presentation
Pain may also be sharp, dull, an ache, or an “empty” or “hungry” feeling
Pain is relieved by ingestion of milk, food, or antacids
Pain is worse when stomach is empty, may wake patient up at night
What is the atypical presentation of PUD in the elderly?
no pain, epigastric pain not relieved by eating, nausea, vomiting, anorexia, weight loss, and bleeding
What are the complications of PUD?
perforations
gastric outlet obstruction: N/V due to scarring or edema
bleeding ulcer
What does abdominal distension and a succussion splash make you think?
Gastric outlet obstruction associated with PUD
What is the tx for PUD?
stop NSAIDs!!
PPI and H2RA (-prazole and -tidine)
liquid antiacids for prn pain relief
What are the GI alarm symptoms?
What is the disposition for PUD with perforation?
consult general surgery and start broad-spectrum antibiotics
What is the disposition for PUD with gastric outlet obstruction?
place NG tube and consult GI
What is the epidemiology of nephrolithiasis?
white, male, 20-50 years old
Often patient appears uncomfortable, unable to find position of comfort
Sudden onset of fluctuating pain
N/V
hematuria
tachycardia, increased in BP, and diaphoresis
urinary frequency, urgency and dysuria
What am I?
When would the pt have a fever?
______ is present in 85-90% of patients
nephrolithiasis
fever if kidney stones are infected
hematuria
Where are sites of pain that are common to nephrolithiasis? What does the site of pain depend on?
Proximal ureter: flank
Mid-ureter: lower quadrant of the abdomen
Distal ureter: groin
Location varies based upon location of stone
if a pt is older than 60 and presents with a kidney stone, what is one question you should ask?
any hx of previous kidney stones?
aka older than 60, this should NOT be there first kidney stone
An UA of a pt with a kidney stone also has pyuria and bacteriuria present, what should you be thinking?
indicates complicated pyelonephritis
What will the CBC of a pt with nephrolithiasis reveal? What if WBC is ≥ 15,000/µL?
mild leukocytosis may be seen in uncomplicated cases
WBC ≥ 15,000/µL is indicative of pyelonephritis or systemic infection
What imaging is indicated in nephrolithiasis if this is the FIRST presentation of symptoms?
Non-contrasted CT of the abdomen/pelvis
aka do NOT need to get a CT every time if the pt has had multiple kidney stones in the past
_____ is indicated if hx positive for recurrent nephrolithiasis. It is also preferred in ______
renal US
US also preferred in pregnancy
What will the US show in a pt with kidney stones? When is an US not reliable?
US can show signs of hydronephrosis, ureteral dilation and occasionally an abnormal radiographic density (indicative of a stone)
unreliable in stones < 5 mm in size
_____ is often used in conjunction with US in nephrolithiasis
KUB xray
What is the tx for nephrolithiasis?
ketorolac (Toradol) IM/IV or opiates
Zofran, Phenergan, Reglan
IV/PO fluids
tamsulosin (Flomax) 0.4 mg daily
What is the drug class for tamsulosin? What is the MOA?
α-blocker therapy
increase expulsion rates of distal ureteral stones, decrease time to expulsion, and decrease need for analgesia during stone passage
aka helps to pass stone and to decrease pain
What is the disposition for a kidney stone?
admit and call urology if intractable pain/emesis
coexisting pyelonephritis
stone measuring 6+mm
anatomic abnormalities make it less likely to pass stone
renal dysfunction
What is the f/u for a kidney stone pt who does NOT require admission? Pt education?
Refer to a urologist within 24–48 hours
Patient education:
Drink 2–3 L of fluid per day
Strain urine for stone
What is pyelonephritis?
An infection of the upper urinary tract (renal parenchymal and pelvicalyceal system)
cystitis (dysuria, urgency, and frequency)
flank, abdominal, suprapubic pain
nausea, vomiting
+/- fever
CVA tenderness
What am I?
What dx test should you order?
What will it show?
pyelonephritis
UA
(+) leukocyte esterase and nitrite
leukocyte casts on microscopic
What is the management for pyelonephritis?
IV fluids if vomiting or signs of dehydration
antipyretics if febrile: tylenol or ibuprofen
antiemetics if N/V: zofran
analgesia for pain if needed: toradol or opiate
abx
What is the outpt empiric abx options for pyelonephritis? What is the alternative option?
cipro/levo PLUS initial ceftriaxone IV
bactrim
What are the admission criteria in pyelo?
When should pyelo pts discharged home f/u with PCP? What is the pt education?
F/u in 1-2 days with PCP
Educate on increasing fluid intake to allow for frequent voiding
What are the etiologies of hepatitis?
infection (viral)
toxins (ETOH/acetaminophen)
medication side effects
autoimmune disorders
ischemia
Fever
RUQ pain and tenderness
Nausea and vomiting
Dark urine (bilirubinuria)
(+/-) jaundice and scleral icterus
Hepatomegaly
Ascites, altered mental status, abnormal bleeding
What am I?
What labs should you order?
acute hepatitis
CMP, PT/INR, albumin, LDH
What will the AST/ALT levels be in alcoholic hepatitis?
AST: ALT greater than 2.5 = alcoholic hepatitis
What will the AST/ALT levels be in all other causes of hepatocellular injury?
AST: ALT < 1 = other causes of hepatocellular injury
What will the AST, ALT levels look like in acetaminophen toxicity, acute viral hepatitis, acute liver failure from any cause?
AST and ALT (>1000)
What 3 labs should you order in also concerned for cholestasis?
Elevated Alk phos
GTT
serum bilirubin
____ is elevated in acute liver injury
LDH
What is the tx for acute hepatitis?
supportive care: pain management, fluid and antiemetic medication
identify and tx underlying cause
What are the admission criteria for acute hepatitis?
Elderly and pregnant women
Patients who do not respond adequately to supportive care
Bilirubin levels ≥20 mg/dL
Prothrombin time 50% above normal
(+) hypoglycemia or GI bleeding
Ascites causing respiratory compromise
When do acute hepatitis pts that are discharged home need to return to ER?
poor oral intake
worsening vomiting
jaundice
abdominal pain
What layer is weakened in AAA? Increased _____ wall stress
weakened medial layer
increases intimal wall stress
Where is the MC location for an AAA? What is considered AAA? What is normal?
MC location is the infrarenal aorta
Defined as an aorta ≥3.0 cm in diameter
normal is 2cm
What are risk factors for AAA? **Which one is the most important?
Age >60 years old
Male
Chronic hypertension
**Smoking - is the most important environmental risk factor
Chronic cocaine or amphetamine use
Connective tissue disorders:
Marfan’s syndrome, Ehlers-Danlos syndrome
Sudden onset of severe ripping or tearing pain located in the abdomen and/or back
What am I?
What will the pt’s BP be? Pulses?
dissection or rupture of AAA
If rupture occurs hypertension will be present
pulses are usually normal, can sometimes have diminished femoral/LE pulses
What is the standard management for dissecting/rupture AAA?
2 large bore IVs
cardiac monitoring
O2 if needed
pain control
labs
What is the management for an unstable dissected/ruptured AAA? **What is a super important note to remember?
CONSULT vascular sx!!!
bedside US
IV fluids to keep SBP 80-90 and mentation intact while waiting on sx
Never delay consultation for imaging if hypotension or acute end-organ perfusion deficit is evident
What is the triad that instantly equals EMERGENT vascular sx consult?
abdominal/back pain
a pulsatile abdominal mass
hypotension
What is the management for stable dissecting/ruptured AAA?
CT abdomen/pelvis with IV contrast or CT Aortogram
immediate consult with vascular sx and schedule URGENT repair (24-72 hours)
What is the goal BP in dissecting/ruptured AAA?
IV fluids to keep SBP 80-90 mmHg and mentation intact while waiting on surgery
What is the management for a hypertensive AAA with suspected expanding aneurysm? What is the target SBP and HR?
esmolol infusion (half-life, 9 minutes, add nitroprusside infusion is BP remains not at target
SBP of 120 mm Hg and HR < 60 bpm
What is the recommended f/u for asymptotic AAA? Give both ≥ 5 cm and 3-5 cm?
≥ 5 cm - outpatient follow up with vascular surgery within 2-3 days
3-5 cm - less likely to rupture - f/u with PCP or vascular surgeon
