Abdominal Pain in the ED Flashcards
Belly pain in the ED should start with
- ABCDE
- large bore IV
- cardiac monitoring
- IV fluids
- NPO
- symptom mangament (zofran, analgesics)
when to worry?
- Extremes of age
- abnormal vital signs
- sudden onset of severe abdominal pain
what are three main types of abdominal pain
Visceral peritoneal pain
- inflammation/stretching of visceral peritoneum
- dull, poorly localized
Parietal peritoneal pain
- inflammation of the parietal peritoneum
- localized and distinct
referred pain
- pain felt away from the source
- i.e gallbladder pain referred to the right shoulder
- Sharp = risk of perforation
- larger = risk of ischemia, aspiration, tracheal encroachment
- button batteries= risk of erosion/perf (thermal burn, alkaline injury, fistula formation)
Presentation
- ped, cognitivie impairment, mental health hx, incarcerated
- drooling/refusing P/O
- dysphagia
- tracheal involvement = Stridor/dyspnea
Esophageal Obstruction
diagnosis of esophageal obstruction
plain films
- button battery = “stacked sign”, flat FB shows circle in coronal plane
- typically “O” on cOronal = in esOphagus
If not radio-opage
- CT soft tissue neck
- exploratory EGD
- gastrograffin swallow study
Management of Esophageal obstruction
Emergent EGD
- button battery- erosioin starts in 15 min, can perf within a few hours
- sharp
- airway compromise
- aspiration risk
Output Xray 24 hours
- no emergent indication, no pain, tolerating PO
Boerhaaves syndrome
- effort rupture: ++ vomiting, abdominal trauma, defecating
Iatrogenic
- EGD
Presentation
- Hx of ETOHism, bulimia, recent EGD
- severe retrosternal/upper abdomen pain
- odynophagia
Esophageal perforation
Diagnosis of esophageal perforation
- CXR- mediastinal or free peritoneal air
- CT
- gastrograffin esophagram
management of esophageal perforation?
- NPO
- IVF
- Broad spectrum abx
- surgery: primary repair, stent, diversion
Esophageal varices
- enlarged veins d/t portal hypertension
- risk factors = ETOH use, liver disease
Peptic ulcer disease
- gastric or duodenal
- risk factors= h.pylori, NSAIDs, high dose steroids, smoking, ETOH
- complications= deep ulceration causing UGIB or perforation
Presentation
- hematemesis (red or coffee grounds)
- melena
- tachycardia, hypotension, LH/syncope, shock
- PUD: abdominal rigidity
Upper GI bleed
diagnosis of upper GI bleed?
- Decreased h/h, increased BUN
- hemooccult or melena on DRE
- PUD: xray= free air, if stable- CT= air, defect
Variceal bleed
- clinical
- EGD
Management of Upper GI bleed?
- IV x 2
- type and crossmatch blood
- +/- blood transfusion
- prophylactic abx
- bleeding/perforated ulcer: PPI, surgery cautery/omental patching
- Variceal bleed: octreoctide, intubate, GI or EGD/banding
- Post op adhesion
- hernias
- IBD
- tumors
Presentation
- abdominal distention
- diffuse crampy pain
- n/v
- inability to pass gas or stool
- dehydration
Small bowel obstruction
diagnosis of SBO?
X-ray
- obstruction series, air-fluid levels
CT
- can determine grade
management of SBO?
- IVF
- NPO
- NG tube
Partial SBO: medical admit
high grade SBO= surgical consult
closed loop SBO= surgical emergency
- protrusion of viscous through abdominal wall defect
- risk factors: increased intra-abdominal pressure (pregnancy, ascites, obesity) surgical incision sites
- reducible
- incarcerated
- strangulated
Presentation
- severely painful, tender, non-reducible mass
- sbo presentation (N/V, inability to pass gas/stool)
- hematochezia
- if strangulated–> gangren–>perforation–> peritonitis–> septic shock
Incarcerated and strangulated hernia
Diagnosis of hernia?
Clinical= redness, severe tenderness at hernia
labs: Leukocytosis, elevated lactate
X-ray: SBO signs
+CT
managment of incarcerated hernia
- IV, Pain/nausea management, NPO, IVF
- uncertain duration of incarceration? = don’t reduce
- incarcerated = surgical consult
- strangulated= IV abx, surgical emergency
- median age 22, but can occur at any age
- most common gen surg problem in pregnancy
Presentation
- visceral pain–migrates to McBurney’s
- anorexia
- N/V
- resisting movement
Appendicitis
diagnosis of appendicitis?
- Rosving sign: pain to RLQ with palpation of LLQ
- obturator sign: pain with internal rotation of R hip
- iliospoas sign: RLQ pain with passive extension of R hip
- labs: +/- leukocytosis, up 30% with normal WBC
- imaging: +CTAP most sensitive, +US= children, pregnant patients, MRI= pregnancy
management of appendicitis?
- IV, NPO, IVF, pain/nausea control, abx if per
- surgical consult- appendectomy, drain/wash out if complicated (abscess or perf)
- inflammation/infection of out-pocketing of the colon
- risk factors= constipation/low fiber diets, increased intraluminal pressures
- complications: abscess, perforation
Presentation
- LLQ pain/ tenderness
- diarrhea
- N/V
- +/- fever
- hematochezia
- hx of diverticulosis on colonoscopy
Acute diverticulitis
diagnosis of acute diverticulitis?
- labs (+/- leukocytosis)
- imaging: CTAP, shared decision making if forego CTP, prior episode with exact same sxs, not sick
management of acute diverticulitis?
- IV, NPO, IVF, pain/nausea control
- Uncomplicated = discharge home (bowel rest- clear liquid diet) abx (cipro and flagyl or augmentin)
- complicated= IV abx, admit/OR (perforation= surgery, abscess = IR drainage)
- Perforation through the wall of hollow organs (small intestine, colon)
- PUD
- Complicated apendectomy
- complicated diverticu
- complicated SBO
Presentation
- sick
- abdominal distention
- septic shock
Rupture hollow viscus
diagnosis of rupture hollow viscus?
labs
- leukocytosis
- elevated lactate (sepsis)
Xray
- pneumoperitoneum (air cresent- under diaphragm on upright, rigler sign- double wall sign)
- CT
Managment of rupture hollow viscus
IV, NPO, IVF, pain/nausea control, IV abx
sugery
- average size < 2 cm diameter
- aneruysmal = >3 diameter
- higher rupture risk > 5cm diameter
- risk factors: age, atherosclerosis, HTN, connective tissue disorders, family hx
Presentation
- Classic triad: abdominal or flank pain, hypotension, pulsatile abd mass
- LH/ syncope
- tachycardia and hypotension
- hemorrhagic shock
- pain is severe, ripping or tearing
- retroperitoneal hemorrhage (cullen sing, grey-turner sign)
Ruptured abdominal aortic aneurysm
diagnosis of Ruptured abdominal aortic aneurysm
- POCUS esp in the setting of known AAA
- aorta > 5.5cm diameter with shock
- CT if stable
- labs: decreased h/h, elevated lactate
management of AAA?
ABCDE
- emergency surgery, vascular
septic ureteral stones
- dont miss AAA
- typically 20s to 50s
- 75% calcium- increased intake, immobilization, hyperparathyroidism
- 10-15% magnesium phosphate, “struvite”
- staghorn calculi- very prone to infection, abx penetration poor
- 10% uric acid
presentation of
- colicky pain, follows trajectory of ureter
- if septic + sick sxs
- pacing, vomiting, extremely painful
- hang up uteropelvic and uterovesicular junctions
Septic ureteral stones
diagnosis of septal ureteral stones?
- clinical clues
- UA: blood, infection
- CBC/cmpt
- CT Renal stone protocol (no contrast)
- US- pregnancy, may miss smaller stones
management of Ureteral stones?
- IV, NPO, IVF, pain/nausea control (septic stone = urine culture, blood cultures, IV abx)
- emergency urologic surgery (obstructing stone+ infection, staghorn infection+)
- urology consult (renal dysfunction on labs, obstructing stone or staghorn, > 6mm)
- admit (intractable pain or vomiting)
- home (no infection, baseline renal function, pain and nausea managed PO)
- severe hepatocellular injury in pt with normal liver or well-compensated liver disease
- toxin induced (acetaminophen) or viral (Hep B)
- Presentation: AMS, abdominal pain, generalized weakness, anorexia, jaundice, N/V/D, RUQ tenderness
- dx: Elevated LFTs (very high AST and ALT), prolonged INR, +/- elevated ammonia, APAP level
fulminant hepatic failure/ acetaminophen OD
management of acetaminophen OD?
- +/- activated charcoal if within 4 hours
- N=aceytlcysteine (NAC = antidote) prevents APAP metabolites from futher damaging liver cells (almost 100% effective if given within 8 hours post ingestion)
Rumack matthew nomogram
- acute, single ingestion
- known time of ingestion
- above the nomogram line= treat with NAC to decrease hepatotoxicity
- ICU, +/- care at liver transplant facility
- ascites fluid infection without apparent intra-abdominal treatable source
- associated with large volume ascies
- up to 30% cirrhotic pts
- presentation: large volume ascites, fever, diffuse abdominal pain/ttp/ peritoneal signs, AMS
Spontaneous bacterial peritonitis
diagnosis of spontaneous bacterial peritonitis?
- basic labs
- paracentesis with fluid analysis
- 60% of patients will be culture negative, abx still indicated
management of spontaneous bacterial peritonitis
- abx for typical enteric flora
- consider albumin infusion
- large volume paracentesis => 5 L fluid taken off
- ICU admission
