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Emergency Medicine > Abdominal Pain pt 2 > Flashcards

Abdominal Pain pt 2 Flashcards

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1
Q

s/s of viral gastroenteritis

A
  • rapid onset of diarrhea (>3x/d or 200 g of stool/d) lasting <2 wks
  • stool is watery, without blood or mucus
  • N/V/Abd pain (nonbilious/nonbloody)
  • fever - MC in children
  • dehydration - dry mucosal membranes, reduced skin turgor; in infants - lack of tear production, sunken eyes, sunken fontanelle
  • abd exam - benign; hyperactive BS may be noted; (+/-) mild diffuse tenderness
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2
Q

w/u for viral gastroenteritits

A
  • POC glucose - if lethargic or unresponsive
  • BMP + Mg - to assess electrolytes and renal function if significant dehydration
  • Stool studies are not needed (if performed will be negative)
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3
Q

mgmt mild-moderate viral gastroenteritis

A

rehydration

  1. oral fluid challenge: NPO x 15 min, followed by slow 30 ml fluids, repeat oral rest x 15 min, repeat with 30 ml of fluid intake
    - goal 30-100 mL/kg over first 4 hr
  2. oral fluid: Pedialyte or Gatorade
    - soft drinks and fruit juices with high sugar content should be avoided due to risk of osmotic diarrhea
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4
Q

mgmt for moderate-severe viral gastroenteritis

A

IV NS or LR

  • Adults - 500 -1000 mL bolus
  • Children - 20 mL/kg
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5
Q

indication for antiemetic for viral gastroenteritis

A
  • only if pt fails oral fluid challenge but meets all other criteria to be DC
  • ondansetron (Zofran) ODT - SE of worsening diarrhea when utilized in viral gastroenteritis
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6
Q

indication for antidiarrheal in viral gastroenteritis

A

if diarrhea leads to dehydration
For adults only

  1. antimotility - loperamide (Imodium) and diphenoxylate with atropine (Lomotil)
    - avoid in pediatrics, IBD
  2. antisecretory - bismuth subsalicylate (Pepto-Bismol, Kaopectate)
    - avoid in pediatric (Reye Syndrome) and pregnancy (salicylate toxicity)
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7
Q

general mgmt for viral gastroenteritis

A
  1. rehydration
  2. +/- antiemetic and antidiarrheal
  3. probiotics
  4. BRAT diet, avoiding lactose, raw fruit, caffeine, and sorbitol-containing products - avoid dairy x 1 wk
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8
Q

admission criteria for viral gastroenteritis

A
  1. a toxic appearance
  2. severe dehydration - abnormal electrolytes/renal function
  3. persistent vomiting or diarrhea
  4. comorbid medical conditions - pregnancy, DM, immunocompromised
  5. very young or elderly
  6. sx lasting > 1wk
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9
Q

viral gastroenteritis - Discharge home if the following criteria is met

A
  1. VS stable
  2. Normal abdominal exam
  3. Successful oral fluid challenge
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10
Q

2 processes of bacterial gastroenteritis

A
  1. toxin-mediated (secretory) diarrhea
  2. invasive (inflammatory) diarrhea
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11
Q
  1. large amount of watery diarrhea or bloody mucopurulent diarrhea (dysentery)
  2. abd cramping/tenderness
  3. +/- fever

dx?
complication?

A
  • Bacterial gastroenteritis
  • hemolytic uremic syndrome (HUS)
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12
Q

what is hemolytic uremic syndrome (HUS)

A
  1. MC elderly and children < 10 y/o
  2. Assoc w/ enterohemorrhagic E. Coli (EHEC)
    - Hx of exposure to undercooked beef, contaminated drinking water, unpasteurized dairy or fecal contamination of raw fruits and vegetables
  3. hemolytic anemia, renal failure, and thrombocytopenia
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13
Q

w/u for bacterial gastroenteritis

A
  1. (+) FOB
  2. BMP - hypokalemia, acute renal injury
  3. CBC - only if HUS is suspected
  4. +/- Stool studies
  5. Plain film / CT abdomen
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14
Q

indications to order stool studies for bacterial gastroenteritis

A
  1. severely dehydrated or toxic patients
  2. (+) dysentery
  3. immunocompromised patients or prolonged diarrhea (>3 days)
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15
Q

what pathogens must be specified for stool studies

A

Salmonella, Shigella, and Campylobacter MC worldwide

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16
Q

3 labs of stool studies

A

fecal leukocytes, fecal lactoferrin², stool cultures

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17
Q

mgmt for bacterial gastroenteritis

A
  1. Fluids
  2. Replace glucose or K+ if indicated
  3. Abx - adults only
    - ciprofloxacin, azithromycin
    - Not recommended in children until a bacterial pathogen is identified
  4. Antidiarrheal
    - avoid antimotility agents (Imodium and Lomotil) - precipitate HUS in patients with underlying EHEC infections
    - Bismuth subsalicylate may be used if needed- CI in children
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18
Q

defining location that separates UGI bleed from LGI bleed

A

ligament of treitz

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19
Q

s/s of GI bleed

A
  1. hematemesis
  2. melena
  3. hematochezia
  4. Associated s/s indicating hypovolemia/shock
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20
Q

hematemesis is indicative of ?

A
  • bleeding proximal to the ligament of Treitz (UGI)
  • frank blood indicates moderate to severe bleeding
  • coffee-ground-like emesis - mild (limited) bleeding
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21
Q

melena is indicative of?

A
  • black, tarry stools - results from hgb being altered by digestive enzymes and intestinal bacteria
  • UGI bleed or a right sided colonic bleed
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22
Q

hematochezia is indicative of?

A
  1. maroon or bright red blood or blood clots per rectum
  2. can be seen with massive UGI bleeding
    - factors that suggest UGI source are signs of anemia and hx of UGI bleed
  3. MC LGI bleeding
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23
Q

pertinent hx for GI bleed

A
  1. Type of bleeding: hematemesis, hematochezia, melena
  2. Associated sx: pain; dizziness, syncope, confusion, diaphoresis, palpitations
  3. Pertinent hx: trauma; FBs; recent aortic or GI surgery, colonoscopy or EGD
  4. H/o similar sx
    - 60% with a h/o an UGI are bleeding from the same lesion
  5. Meds: NSAIDs, anticoagulants, and antiplatelet agents
  6. Social: alc - risk of alcoholic gastritis, chronic liver disease
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24
Q

what medications can simulate melena?
what food can simulate hematochezia?

A
  1. Iron or bismuth
  2. beets
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25
Q

hyperactive BS is indicative of what type of GI bleed?

A

UGI bleed
the presence of blood stimulates peristalsis

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26
Q

tenderness of abdomen with GI bleed is indicative of ?

A

inflammatory/infectious etiology or perforation

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27
Q

non-tender GI bleed is indicative of

A

a vascular etiology

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28
Q

ascites or hepatosplenomegaly with GI bleed, consider what condition?

A

consider coagulopathy due to liver disease

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29
Q

if LGI bleed is suspected, do what type of exam?

A

rectal

  • assess for laceration, trauma, fissure, external hemorrhoids, masses
  • Guaiac testing will confirm bleeding
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30
Q

if rectal exam is negative for blood and LGI bleed is suspected, do what exam next? (female)

A

Vaginal/urinary inspection

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31
Q

w/u for GI bleed

A
  1. Type and crossmatch
  2. CBC - monitored every 2-8 hours to assess severity of bleed
  3. CMP
  4. PT/INR
  5. EKG’s and cardiac enzymes - if MI risk
  6. NG tube - if suspected UGI
    - will not show bleeding distal to pylorus
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32
Q

CBC findings for GI bleed

A
  1. normocytic RBC = acute bleed
  2. microcytic RBC = chronic bleed
  3. initial hgb - will not reflect blood loss
    - >24 hours - decreased hgb due to amount of volume resuscitation
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33
Q

an elevated BUN:Cr ≥30 indicates what type of GI bleed?

A

acute UGI bleed

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34
Q

GI bleed - endoscopy can not be performed until INR is?

A

< 2.5

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35
Q

NG tube GI bleed - if lavage is (+) for clots or bright red blood perform ?

A

gentle gastric lavage with room temperature water

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36
Q

mgmt for Hemodynamically stable GI bleed

A

consult GI/Surgery for admission and scheduled endoscopy

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37
Q

mgmt for Hemodynamically unstable GI bleed

A
  • NPO
  • Supplemental oxygen via NC
  • Cardiac monitoring
  • 2 large bore IV sites
  • Fluids - IV NS/LR up to 2 L bolus
  • +/- Blood transfusion - 1 U FFP for every 4 U PRBC - no coag factors in PRBC
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38
Q

indications for Blood transfusion in GI bleed

A
  1. failure of perfusion and VS to respond to 2 L of NS/LR
  2. hgb < 7 grams/dL
  3. older pts and those with comorbidities who are unable to tolerate anemia transfuse at a hgb < 9 grams/dL
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39
Q

mgmt for GI bleed complicated by anticoagulation

A

INR > 2.0

  1. Hold anticoagulant/antiplatelet
  2. Reverse anticoagulation
    - consult anticoagulant prescribing provider
    - transfuse with FFP +/- reversal agent
  3. Reverse of Factor Xa inhibitor
    - andexanet alfa (Andexxa) - for rivaroxaban (Xarelto) or apixaban(Eliquis)
    - idarucizumab (Praxbind) - for dabigatran (Pradaxa)
  4. Reverse anticoagulation of warfarin
    - Vitamin K
    - Prothrombin complex concentrate infusions (Kcentra) if reversal agent for anticoagulant isn’t available; replaces Vit K dependent coagulation factors (Factors II, VII, IX, X) + Proteins C and S
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40
Q

additional mgmt for UGI bleed

A
  1. PPI - pantoprazole - bleeding from PUD
  2. Somatostatin analog - Octreotide - variceal bleeding, can be used as an adjunct in non-variceal bleeds
  3. Emergent consult to gastroenterology or general surgery for urgent endoscopy
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41
Q

disposition for UGI bleed

A

admitted to hospitalist with a consult to GI/general surgery

42
Q

additional mgmt for LGI bleed

A
  1. Consult gastroenterology/general surgery
  2. Consider upper endoscopy to r/o severe UGI bleed
  3. Discuss colonoscopy vs angiography - bowel prep if colonoscopy
43
Q

LGI bleed - DC home if all of the following are met

A
  1. hx of mild bleeding (from hemorrhoid or anal fissure)
  2. without BRBPR on DRE
  3. no melanotic stool
  4. hemodynamically stable
  5. no comorbidities

Rest will be admitted to hospitalist with a consult to GI/general surgery

44
Q

Hx: GERD
s/s: odynophagia, gastroesophageal reflux, dysphagia

UGI ddx?

A

Esophageal ulcers

45
Q

Hx: H. pylori infection, NSAIDs use, or smoking
s/s: associated abdominal pain

UGI ddx?

A

Peptic ulcer disease

46
Q

hx: liver disease or alcohol abuse
s/s: jaundice, ascites

UGI ddx?

A

Varices or portal hypertensive gastropathy

47
Q

Hx: forceful vomiting
s/s: vomiting, retching, or coughing prior to hematemesis

UGI ddx?

A

Mallory-Weiss Tear

48
Q

Hx: smoking, alcohol abuse, or H. pylori infection
s/s: dysphagia, early satiety, involuntary weight loss, cachexia

UGI ddx?

A

Malignancy

49
Q

Ulcer at the gastroenteric anastomosis
Hx: Roux en-Y gastric bypass

UGI ddx?

A

Marginal ulcers

50
Q

Hx: abdominal aortic aneurysm or an aortic graft

UGI ddx?

A

Aorto-enteric fistula

51
Q

Hx: renal disease, aortic stenosis, or hereditary hemorrhagic telangiectasia

UGI ddx?

A

Angiodysplasia

52
Q

complications of UGI bleed

A
  1. perforation: severe abd pain, with rebound tenderness or involuntary guarding
  2. anemia: worse outcomes in CAD, pulm disease; maintain a higher hgb in these pts to reduce sx of anemia
  3. volume overload: CHF, renal disease
  4. uncontrolled hemorrhage: worse in pts with coagulopathies, thrombocytopenia, significant hepatic dysfunction; transfuse FFP or platelets
  5. aspiration: high risk in dementia, hepatic encephalopathy; consider intubating early in course
53
Q

painless bleeding
90% will resolve spontaneously

LGI bleed ddx?

A

Diverticulosis

54
Q

abdominal pain/tenderness
diarrhea with blood or mucopurulent material
fever, weight loss, anemia

LGI bleed ddx?

A

Infectious or IBD

55
Q

hx of malignancy tx with radiation therapy

LGI bleed ddx?

A

Radiation-induced

56
Q

hx of straining on defecation or pregnancy
painless hematochezia

LGI bleed ddx?

A

Hemorrhoids

57
Q

hx of trauma

LGI bleed ddx?

A

anal fissures

58
Q

congenital defect
s/s occur during 1st year of life
associated abdominal pain resulting from ulcer formation in and around the diverticulum

LGI bleed ddx?

A

Meckel’s Diverticulum

59
Q

change is caliber of stool
change in bowel habits
weight loss

LGI bleed ddx?

A

CA

60
Q

painless bleeding, mostly in older pts

LGI bleed ddx?

A

Angiodysplasia

61
Q

pain out of proportion to exam

LGI bleed ddx?

A

Ischemic colitis/mesenteric ischemia

62
Q

Hx: abdominal aortic aneurysm or an aortic graft

LGI bleed ddx?

A

Aorto-enteric fistula

63
Q

Refer to gastroenterology with urgent referral if alarm sx are noted:

A
  1. > 50y w/ new-onset sx
  2. unexplained wt loss
  3. persistent vomiting
  4. dysphagia or odynophagia
  5. iron def anemia or GI bleeding
  6. abd mass or LAD
  7. Fhx of UGI bleed
64
Q

Nephrolithiasis MC in who?

A
  1. white
  2. male
  3. 20-50 y
65
Q

s/s of nephrolithiasis

A
  1. appears uncomfortable, unable to find position of comfort
  2. Sudden onset of fluctuating pain (renal colic)
  3. pain based upon location of stone
    - Proximal ureter: flank
    - Mid-ureter: lower quadrant of abdomen
    - Distal ureter: groin
  4. fever if complicated by infection
  5. N/V
  6. hematuria (85-90% pts)
  7. tachycardia, increased in BP, and diaphoresis
  8. urinary frequency, urgency and dysuria (stones as the UVJ)
  9. CVA tenderness
66
Q

patients older than 60 don’t usually present with their first kidney stone

consider what ddx?

A

AAA
r/o w/ beside US (if unstable) or CT (only if stable)

67
Q

presence of abdominal tenderness and often lacks hematuria

Nephrolithiasis ddx?

A

Appendicitis/Diverticulitis

68
Q

often associated with a fever

Nephrolithiasis ddx?

A

pyelonephritis

69
Q

often associated with metabolic acidosis; lacks hematuria

Nephrolithiasis ddx?

A

Mesenteric ischemia

70
Q

w/u for Nephrolithiasis

A
  1. UA
    - pyuria and bacteriuria = complicated pyelonephritis; C&S if evidence of infection is noted
  2. Hcg - childbearing females
  3. CBC
    - mild leukocytosis may be seen in uncomplicated cases
    - WBC ≥ 15,000/µL = pyelonephritis or systemic infection
  4. BMP - assess current renal function
  5. Non-contrasted CT of abdomen/pelvis
  6. Renal US - if CT is CI or h/o recurrent nephrolithiasis
  7. KUB XR: often used with US; 90% of stones are radiopaque
71
Q

indications for non-contrast CT for Nephrolithiasis

A
  1. first “renal colic” presentation, if dx is uncertain or if complicated by pyelonephritis
  2. Can still detect aortic aneurysm (even w/o contrast)
  3. Can detect stones >1 mm and hydronephrosis
72
Q

what imaging modality is preferred in pregnancy, pediatrics and hx of recent CT evaluations for Nephrolithiasis

A

US

73
Q

findings in US for Nephrolithiasis

A
  • signs of hydronephrosis, ureteral dilation and occasionally an abnormal radiographic density (indicative of a stone)
  • Less sensitive < CT for detecting stone; better for hydronephrosis/swelling
74
Q

renal Us is unreliable in stones ? mm in size

A

< 5 mm in size

75
Q

mgmt for Nephrolithiasis

A
  1. Analgesia - ketorolac (Toradol); Opiates
  2. Antiemetics - Zofran, phenergan, reglan
  3. Hydration - IV/PO fluids
  4. α-blocker therapy - tamsulosin (Flomax) 0.4 mg daily
    - increase expulsion rates of distal ureteral stones, decrease time to expulsion, and decrease need for analgesia during stone passage
76
Q

when to Admit for Nephrolithiasis

A
  1. Intractable pain or emesis
  2. Coexisting pyelonephritis
  3. Low probability of spontaneous stone passage - ≥6 mm or anatomic abnormal
  4. renal dysfunction - Elevated BUN or Cr., bilateral ureteral stones, oliguria or anuria
77
Q

Disposition for nephrolithiasis pts who do not require hospitalization

A
  1. Refer to a urologist within 24–48 hours
  2. Drink 2–3 L of fluid per day
  3. Strain urine for stone
78
Q

An infection of the upper urinary tract (renal parenchymal and pelvicalyceal system)

A

Pyelonephritis

79
Q

cystitis (dysuria, urgency, and frequency)
flank, abdominal, suprapubic pain
nausea, vomiting
+/- fever
CVA tenderness

dx?
w/u? findings?

A
  1. Pyelonephritis
  2. UA, Urine C&S, hCG
    - (+) leukocyte esterase and nitrite
    - leukocyte casts on microscopic

found in UA

80
Q

If Pyelonephritis pts meets admission criteria add what additional labs?

A
  1. BMP - look for signs of dehydration
  2. CBC - leukocytosis with left shift often indicates urosepsis
  3. Blood cultures
81
Q

vaginal discharge/dyspareunia, purulent cervicitis on exam

Pyelonephritis ddx?

A

PID

82
Q

tender prostate on exam

Pyelonephritis ddx?

A

prostatitis

83
Q

(+) specialized PE testing (McBurney), CT can rule out if needed

Pyelonephritis ddx?

A

appendicitis

84
Q

clinical presentation without abnormal urine

Pyelonephritis ddx?

A

diverticulitis

85
Q

(+) hcg, US can rule out dx

Pyelonephritis ddx?

A

ectopic

86
Q

general mgmt for Pyelonephritis

A
  1. IV fluids if vomiting or signs of dehydration
  2. antipyretics if febrile - tylenol or ibuprofen
  3. antiemetics if N/V - zofran
  4. analgesia for pain if needed - toradol or opiate
87
Q

Outpatient empiric antibiotic options for Pyelonephritis

A
  1. Ciprofloxacin or levofloxacin
  2. Initial dose of ceftriaxone
    - Alt: only if CI for FQ and no known resistance - Bactrim
88
Q

Inpatient parenteral empiric antibiotic options for Pyelonephritis

A
  1. Ciprofloxacin
  2. Ceftriaxone, cefotaxime, cefepime
  3. Gentamicin +/- ampicillin
  4. Piperacillin-tazobactam (Zosyn)
  5. Ertapenem, Imipenem, Meropenem

Choice depends on local resistance data

89
Q

admission criteria for Pyelonephritis

A
  1. Inability to maintain oral hydration or take medications
  2. Concern about compliance or follow-up
  3. Diagnostic uncertainty
  4. Severe illness with high fevers, severe pain, and marked debility
  5. Comorbid illness
  6. Failure of outpatient therapy
  7. Associated pregnancy or ureteral stone

DC home when admission criteria is not met: F/u in 1-2 days with PCP; Educate on increasing fluid intake to allow for frequent voiding

90
Q

Acute or chronic inflammation of the liver cells

A

Hepatitis

91
Q

causes of Hepatitis

A
  1. infection (viral)
  2. toxins (ETOH/acetaminophen)
  3. medication side effects
  4. autoimmune disorders
  5. ischemia
92
Q
  1. Fever
  2. RUQ pain and tenderness
  3. Nausea and vomiting
  4. Dark urine (bilirubinuria)
  5. (+/-) jaundice and scleral icterus
  6. Hepatomegaly
  7. Liver failure - Ascites, AMS, abnormal bleeding

dx?
w/u?
mgmt?

A
  1. Acute Hepatitis
  2. CMP, PT/INR & albumin, LDH, acetaminophen level, toxicology screen, acute hepatitis panel
  3. Supportive (fluids, pain, antiemetic); mainstay: tx underlying cause
93
Q

AST: ALT greater than 2.5

what type of hepatitis

A

alcoholic

AST: ALT < 1 = other causes of hepatocellular injury

94
Q

AST and ALT (>1000) = what types of hepatitis?

A

acetaminophen toxicity, acute viral hepatitis, acute liver failure from any cause

95
Q

acute hepatitis - if elevated Alk phos, GTT and serum bilirubin, assess for what other dx?

A

cholestasis

96
Q

acute hepatitis - PT/INR and albumin becomes prolonged within _____ hrs of liver dysfunction

A

24 hrs

97
Q

Admission criteria for acute hepatitis

A
  1. Elderly and pregnant women
  2. Patients who do not respond adequately to supportive care
  3. Bilirubin levels ≥20 mg/dL
  4. Prothrombin time 50% above normal
  5. (+) hypoglycemia or GI bleeding
  6. Ascites causing respiratory compromise

Return to ER if: poor oral intake, worsening vomiting, jaundice or abdominal pain

98
Q

mgmt for Unstable Dissecting/Rupture AAA

A
  1. Imaging: Bedside US
  2. Immediate vascular surgery consult if triad of abd/back pain, pulsatile abdominal mass, and HoTN
    - Never delay consultation for imaging
  3. Goal SBP 80-90
99
Q

mgmt for Stable Dissecting/Rupture AAA

A
  1. Imaging: CT abd/pelvis w/ IV contrast or CT Aortogram
  2. Rupture or impending rupture (rapidly changing dissection) - immediate consult
  3. Dissection w/o rupture - consult vascular and schedule urgent repair (< 24-72 h or ASAP by surgeon)
100
Q

mgmt for Hypertensive patients with suspected expanding aneurysm

A
  1. esmolol infusion
    - Goal SBP 120
    - HR < 60
  2. Add nitroprusside if BP remains uncontrolled

Emergency Medicine (20 decks)

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