Abdominal pain reading quiz - Exam 2 Flashcards
What is the classic presentation of a pt with an AAA? What additional symptoms may he also have?
ruptured AAA is an older male smoker with atherosclerosis who presents with sudden severe back or abdominal pain, hypotension, and a pulsatile abdominal mass.
Patients may also present with syncope or pain that localizes to the flank, groin, hip, or abdomen.
How would the pt describe the pain sensation associated with AAA? What is their BP likely?
ripping or tearing pain that is severe and abrupt in onset.
usual hypotension due to blood loss but can be normal due to compensatory mechanisms
What will the femoral pulses feel like in AAA? What are the PE findings sometimes found on the abdomen?
Femoral pulsations are typically normal
Retroperitoneal hemorrhage may rarely present with external findings such as periumbilical ecchymosis (Cullen’s sign), flank ecchymo- sis (Grey–Turner’s sign)
What are the differences between Cullen’s sign and Grey-Turner sign?
Retroperitoneal hemorrhage may rarely present with external findings such as periumbilical ecchymosis (Cullen’s sign), flank ecchymo- sis (Grey–Turner’s sign)
What are pt with prior aortic grafting at an increased risk for? What will they present like?
Aortoenteric fistulas
may present as gastrointestinal bleeding with either a small sentinel bleed or a massive life-threatening hemorrhage
asymptomatic AAA larger than ____ need to be repaired due to _____
larger than 5 cm in diameter are at a greater risk for rupture.
_____ has >90% sensitivity for identifying AAA but CANNOT properly identify _____ or _______. ________ is used to identify and delineate anatomic details
Bedside abdominal ultrasound
aortic rupture or retroperitoneal bleed
CT
What are the steps of treating AAA in the emergency setting?
emergent vascular sx consult!!
IV access and start fluids to treat hypotension +/- packed RBC. Control pain
sx
What is the target systolic BP in AAA?
90
What size range can be safely referred to vascular sx?
small asymptomatic AAA (3.0 to 5.0 cm) is identified as an incidental finding, refer the patient to see a vascular surgeon.
Between what layers does an aortic dissection occur?
between the intimal and adventitial layers of the aorta
What is the classic presentation of aortic dissection?
classically presents with acute chest pain that is most severe at onset and radiates to the back
What is your typical aortic dissection pt?
male, older than 50, HTN
chronic cocaine use
prior cardiac sx
What type of murmur can be heard with aortic dissection?
A diastolic murmur of aortic insufficiency may be heard
What are some common chest xray findings that would point towards aortic dissection?
chest x-ray are an abnormal aortic contour and widening of the mediastinum
but also can be normal
What is the imaging modality of choice for aortic dissection?
CT scan with IV contrast
can also use TEE
What is the tx for aortic dissection?
- consult vascular or thoracic surgery!!
- stablize hemodynamically: IV fluids and blood transfusion as needed
- Manage HTN with esmolol or labetolol
+/- nitroprusside or nicardipine if extra BP meds are needed
What is the HR goal in aortic dissection? BP goal?
HR: 60-70 bpm
systolic BP: 100-120
What will a pt with peritonitis present like? What will their skin look like? What should you do next?
patients with peritonitis tend to lie still.
The skin should be evaluated for pallor, jaundice, or rash.
Tachycardia +/- fever
Look at virals: may also have hypovolemia due to blood loss/ volume depletion
How will elderly patients present differently in perionitis? Also holds true for _____ and ______
may not exhibit tachycardia or fever
often present with decreased pain perception
DM and Immunocompromised patients as well
______ is the most important aspect of the physical examination in abdominal pain. What should you be assessing?
palpation
tenderness
guarding
masses
organomegaly
hernies
rebound tenderness
______ is often regarded as the clinical criterion standard of peritonitis
Rebound tenderness
In patients with peritonitis, the combination of ______, ______ and, especially, ______ usually provides sufficient diagnostic confirma- tion
rigidity
referred tenderness
cough pain
What is the Carnett sign? How do you perform it?
sit-up test
After identification of the site of maximum
abdominal tenderness, the patient is asked to fold his or her arms across the chest and sit up halfway. The examiner maintains a finger on the tender area, and if palpation in the semisitting position produces the same or increased tenderness, the test is said to be positive for an abdominal wall syndrome.
______ should be considered in any patient older than 50 years with abdominal pain out of proportion to physical findings
Mesenteric ischemia
_____ is currently the preferred imaging method for mesenteric ischemia, pancreati- tis, aortic aneurysm, appendicitis, and urolithiasis. When is contrast NOT needed?
Computed tomography (CT)
not needed in urolithaisis
When is oral contrast helpful?
aids in the diagnosis of bowel obstruction
What are the steps to acute abdominal pain the ED setting?
- NS or LR fluids and NPO status
- Pain control with morphine/hydromorphone/fentanyl or NSAIDs
- Antiemetics (ondansetron or metoclopramide)
- Abx when appropriate: piperacillin-tazobactam or gentamicin plus metro
- Sx/gyn consult
What are the indications for admission for abdominal pain?
toxic appearance
unclear diagnosis in elderly
immunocompromised patients
inability to reasonably exclude serious etiologies
intractable pain or vomiting
altered mental status
inability to follow discharge or follow-up instructions.
What is a secondary alternative to admitting patients for acute abdominal pain?
Continued observation with serial examinations is an alternative. Many patients with nonspecific abdominal pain can be discharged safely with 12 to 24 hours of follow-up and instructions to return immediately for increased pain, vomiting, fever, or failure of symptoms to resolve.
When are NSAIDs a great choice for pain management in abdominal pain? Bad choice for ______?
great for renal colic
bad if concerned about peritonitis
great majority of ulcers are directly related to infection with _____ or _______
Helicobacter pylori
nonsteroidal anti-inflammatory drugs (NSAIDs) use
How will PUD present? What makes it better? What makes it worse?
with burning epigastric pain, though it may be described as sharp, dull, and an ache, or an “empty” or “hungry” feeling
It may be relieved by the ingestion of food, milk, or antacids
pain recurs when the stomach content empty, typically in the middle of the night
PUD with abrupt onset of pain, what are you thinking? With back pain?
Abrupt onset of severe pain is typical of perforation with spillage of gastric or duodenal contents into the peritoneal cavity
Back pain may represent pancreatitis from a posterior perforation
What will the vital signs be in PUD? PE?
typically normal
usually unremarkable +/- epigastric tenderness
Can a CBC with acute GI bleeding be normal?
YES!! acute bleeding can have normal CBC but chronic bleeding will be abnormal
What is the gold standard for dx of PUD?
visualization of an ulcer by upper GI endoscopy
What are the “alarm” features of GI cancer?
age >55 year
unexplained weight loss
early satiety or anorexia
persistent vomiting
dysphagia
anemia
abdominal mass
jaundice
What is the tx of PUD in the ED setting?
- PPI (ends in -prazole)
- H2 receptor antagonists (-tidine)
- triple therapy for H. pylori infection
- liquid antacid for breakthrough pain
- follow-up with GI/PCP for a definitive dx with EGD
What symptoms should a pt with PUD discharged home be on the look-out for?
worsening pain
increased vomiting
hematemesis or melena
weakness or syncope
fever
chest pain
What are the 2 MC causes of acute pancreatitis? Name 2 additional causes
Cholelithiasis and alcohol abuse
secondary to medications and severe hyperlipidemia
What is the most common symptom of pancreatitis? When is it worse? Name 3 additional findings?
midepigastric, constant, boring pain that radiates to the back
patient is supine
low grade fever, tachycardia and hypotension
What criteria makes the diagnosis of pancreatitis more likely?
(1) history and examination findings consistent with AP
(2) lipase or amylase levels at least two to three times the upper limit of normal
(3) imaging findings consistent with pancreatic inflammation
2 out of 3 makes the diagnosis
What is the preferred dx lab test in pancreatitis? What will a CBC show?
lipase
leukocytosis or anemia
What is the preferred imaging in pancreatitis? Why?
CT is preferred over US
US is often limited by bowel gas overlying the pancreas
What is the tx for pancreatitis in the ED setting?
- aggressive FLUIDS! +/- pressors if the fluid did not respond well with fluids alone
- NPO, antiemetics, pain meds (morphine)
- O2 to maintain pulse ox reading of 95%
- Concerned for infection, abscess, cyst: imipenem-cilastatin, meropenem,
or ciprofloxacin AND metronidazole 500 mg - Consult GI if concerned for gallstone pancreatitis for ERCP
What is the disposition for pancreatitis? What is the criteria for the pt to be sent home and monitored?
most require hospitalization
mild disease, no biliary tract disease, and no evidence of systemic complications may be managed as outpatients with close follow-up if they tolerate clear liquids and oral analgesics in the ED
How will biliary colic present? How long do symptoms usually last?
epigastric or right upper quadrant pain (right shoulder), may range from mild to severe, and, although classically described as intermittent or colicky, is often constant. sometimes get worse after eating, sometimes not
also have n/v
1 to 5 hours, followed by a gradual or sudden resolution of symptoms
How can you tell acute cholecystitis apart from biliary colic?
pain is present longer than 5 hours, usually pts have a hx of similar attacks or known hx of gallstones
What is choledocholithiasis? How will choledocholithiasis present?
choledocholithiasis is a condition where gallstones are present in the common bile duct
often presents with midline pain that radiates to the middle of the back.
______ is the most sensitive physical examination finding for the diagnosis of cholecystitis. Describe it.
Murphy’s sign
increased pain or inspiratory arrest during deep subcostal palpation of the right upper quadrant during deep inspiration.
What is cholangitis? How will patients present?
a life-threatening condition with high mortality, results from complete biliary obstruction with bacterial superinfection
jaundice, fever, confusion, and shock, focal RUQ pain
What is charcot triad? What is it associated with?
fever, jaundice, and right upper quadrant pain
cholangitis
What will labs of patients with biliary colic look like?
usually normal labs to mildly elevated
______ and _____ levels are usually elevated in cases of choledocholithiasis and ascending cholangiti
Serum bilirubin
alkaline phosphatase
What is in the initial diagnostic study of choice for patients with suspected biliary colic or cholecystitis?
Ultrasound of the hepatobiliary tract
What are 3 US findings that are consistent with cholecystitis?
a thickened gallbladder wall (>3 to 5 mm)
gallbladder distention (>4 cm in short-axis view)
pericholecystic fluid
Choledocholithiasis is suggested when the common bile duct diameter is greater than _____
5 to 7 mm
______ can be used in the ED AFTER an US scan if suspecting cholecystitis and US fails to establish dx
HIDA
What is the tx for biliary dz in the ED setting?
- aggressive fluids +/- pressors for hypotension not responding to fluids
2.NPO, antiemetics, pain medication (morphine, ketorolac)
- NG tube with low suction if actively vomiting
- obstruction -> need urgent decompression via endoscopic shincterotomy
- cholecystitis -> cefotaxime or ceftriaxone AND metro
cholangitis, sepsis, or obvious peritonitis -> ampicillin, gentamicin, clinda
- Sx consult
- everything except uncomplicated biliary colic is being admitted
What is the discharge criteria for uncomplicated biliary colic?
Patients with uncomplicated biliary colic whose symptoms abate with supportive therapy within 4 to 6 hours of onset can be discharged home if they are able to maintain oral hydration. Oral opioid analgesics may be prescribed for the next 24 to 48 hours for the common residual abdominal aching.
What is the “bump” sign? What does it indicate if the pain suddenly decreases?
where the patient notes an increase in the abdominal pain associated with bumps in the ride to the hospital
consider appendiceal perforation
What is McBurney’s point?
The classic point of maximal tenderness is in the right lower quadrant just below the middle of a line connecting the umbilicus and the right ante- rior superior iliac spine
What is Rovsing’ sign?
Patients may also have pain referred to the right lower quadrant when palpating the left lower quadrant
What is Psoas sign?
pain elicited by extending the right leg to the hip while lying in the left lateral decubitus position
What is Obturator sign?
pain elicited by passively flexing the right hip and knee and internally rotating the hip
What is the imaging of choice for appendicitis? _____ is the imaging of choice in children and pregnant patients for appendicitis.
CT
US
What 2 patient populations are at high risk for misdiagnoses of appendicitis?
pediatric patients and pregnant patients
What is the most common surgical emergency in pregnant?
acute appendicitis
What is the tx for acute appendicitis? What are the criteria to discharge vs admit?
- sx consult
- IV fluids, control pain with fentanyl or morphine, pre-sx abx: piperacillin/tazobactam or ampicillin/sulbactam
_________
Stable, nontoxic-appearing patients with adequate pain control who can tolerate oral hydration have no significant comorbidities, and are able to return for reevaluation in 12 hours may be considered for discharge and 12-hour follow-up
What is the classic presentation of diverticulitis?
steady, deep discomfort in the left lower abdominal pain, fever, and leukocytosis
pain can be constant or intermittent
occult blood may be present in the stool
What is the preferred imaging modality of choice for diverticulitis?
CT scan with IV and oral contrast
When should you admit someone with diverticulitis?
Ill-appearing patients, those with uncontrolled pain, vomiting, peritoneal signs, signs of systemic infection, comorbidities, or immunosuppression, and those with complicated diverticulitis
What is the tx for uncomplicated diverticulitis?
oral abx and liquid diet
outpt f/u with GI in 6 weeks for colonscopy to show improvement
What is first line tx for outpt diverticulitis?
Metro PLUS
cipro/levo/bactrim (pick 1)
alt:
augmentin
moxifloxacin
What is the first line tx for moderate inpt diverticulitis?
metro
PLUS
cipro/levo/aztreonam/ceftriaxone (pick 1)
ertapenem
pip/taz
moxifloxacin
What is first line treatment for severe diverticulitis?
imipenem
meropenem
pip/taz
alt: ampicillin PLUS metro PLUS cipro
______ volvulus is more common in the elderly taking anticholinergic medications while _____ volvulus is more common in gravid patients.
Sigmoid= elderly taking anticholinergic meds
cecal= gravid patients
What is the name for an intestinal pseudoobstruction?
Ogilvie syndrome
Who is at increased risk for Ogilvie syndrome?
The elderly and bedridden and patients taking anticholinergic medications or tricyclic antidepressants are at increased risk for pseudoobstruction.
What is the common complaint of intestinal obstruction?
crampy, intermittent, progressive abdominal pain and inability to have a bowel movement or to pass flatus are common presenting complaints
In an intestinal obstruction, the abdomen may be _______. What will it sound like?
tympanitic to percussion
active, high pitched bowel sounds in early obstruction and diminished/absent if obstruction has been present for many hours
What is the diagnostic procedure of choice for intestinal obstruction?
CT scanning using IV and oral contrast
When should you suspect abscess, gangrene, or peritonitis in the presence of intestinal obstruction?
if leukocytosis >20,000 or left shift is noted
What is the tx for intestinal obstruction in the ED setting?
- FLUIDS, monitoring and sx consultation
- Decompress the bowel with a nasogastric tube especially if vomiting or distension is present
- abx:
pip/taz
tircarcillin-clavulanate
amp/sulbactam
cefotaxime or ceftriaxone PLUS clinda or metra
meropenem
In patients with pseudoobstruction, ______ is both diagnostic and therapeutic. Surgery is not indicated.
colonoscopy
