Abdominal Trauma and GI Emergencies

Question 1

What is the typical history of acute appendicitis?

Answer 1

History:
~RLQ Abdominal pain, anorexia, nausea/vomiting, +/- fever
Usually starts with visceral (vague, nonspecific, aching/cramping abdominal
pain)

~The pain migrates and/or becomes localized in the right lower quadrant (McBurney’s Point) and ends with somatic pain (sharp and localized) in the right lower quadrant

Question 2

What is typically seen in the PE of acute appendicitis?

Answer 2

Physical Exam:
~Initially may be vague, nonspecific abd pain
~RLQ abd pain (McBurney’s Point tenderness)
~Specialty tests (Mc Burney’s Point, Rovsing’s sign, Obturator and Psoas Signs)

Question 3

What type of imaging is done is pregnant patients, kids, and adults with acute appendicitis?

Answer 3

-Imaging-

Adults:
~Ct Abdomen and Pelvis with IV and oral contrast (in adults)
~96 % sensitive

Kids:
~Ultrasound of RLQ first (lower sensitivity than CT), if US negative need CT

Pregnant patients:
~MRI

Question 4

What can early appendicitis mimic?

Answer 4

**Early appendicitis can mimic gastroenteritis or viral illness
~Treat the patient not the lab
~Can have a normal CBC and still have
appendicitis
~Can have an abnormal UA and still have appendicitis

Question 5

80 percent of all foreign body ingestions occur in _______.

Answer 5

Children!

~Most (80 to 90 percent) pass without the need for intervention
~Only 10 to 20 percent require endoscopic removal,
~less than 1 percent require surgical intervention

Question 6

The ______ is the most frequent site of obstruction in the

gastrointestinal tract

Answer 6

Esophagus

Question 7

Where are the physiologic narrowings of the esophagus?

What are the structural or functional abnormalities?

Answer 7

Esophageal foreign bodies are often impacted at sites of physiologic or pathologic luminal narrowing

~Physiologic narrowing of the esophagus occurs at the upper esophageal sphincter, at the level of the aortic arch, and at the diaphragmatic hiatus.

~Structural or functional esophageal abnormalities that increase the risk of foreign body/food impaction in the esophagus include diverticula, webs, rings, strictures, achalasia, and tumors

~It is estimated that approximately half the individuals with esophageal food impactions have underlying eosinophilic esophagitis

Question 8

What are the sx/signs of ingested foreign bodies?

Answer 8

Symptoms/Signs:

Could be asymptomatic!
~The typical clinical presentation is the acute onset of dysphagia.

~Other symptoms of esophageal foreign body impaction include choking, refusal to eat, hypersalivation, retrosternal fullness, regurgitation of undigested food, wheezing, and blood-stained saliva.

~Drooling and inability to swallow liquids is indicative of an esophageal obstruction and requires emergent endoscopic evaluation.

~Fever, abdominal pain, repetitive vomiting after are a FB ingestion are concerning and warrant further workup

Question 9

Imaging is only performed in patients without signs or symptoms suggestive of an ______ ______.

Answer 9

~Imaging is only performed in patients without signs or symptoms suggestive of an esophageal obstruction (drooling and inability to swallow liquids) i.e. don’t delay EGD for imaging

Question 10

When should plain radiographs be ordered in a foreign body ingestion?

Answer 10

Plain Radiographs:
~Anteroposterior and lateral views from neck, chest, and abdomen

~In patients without a suspected esophageal obstruction and a history of ingestion of a radiopaque blunt foreign body or if the type of object is unknown

~Not all foreign bodies will be seen on radiographs

~Fish/chicken bones, wood, plastic, glass, thin metal objects, and food impactions are not readily seen on plain films

Question 11

When should a CT be ordered in an foreign body ingestion?

Answer 11

CT Scans for the following:
~Suspected perforation based on either clinical or radiographic findings
~Sharp or pointed foreign body ingestion
~In patients suspected of having ingested packets of narcotics or other drugs but with an unclear history.

Question 12

The approach to management of ingested foreign bodies is guided by the initial evaluation and depends on what 3 factors?

Answer 12

The approach to management is guided by the initial evaluation and depends upon the following:

~Presence and severity of symptoms
~Type of object ingested (size, shape, content)
~Location of the object as determined by imaging, if performed

Question 13

When should emergent endoscopy for ingested foreign bodies be done in less than 6 hours?

Answer 13

Emergent endoscopy (within 6 hrs):
~Complete esophageal obstruction as evidenced by drooling and an inability to handle oral secretions
~Disk batteries in the esophagus
~Sharp-pointed objects in the esophagus

Question 14

When should emergent endoscopy for ingested foreign bodies be done in less than 24 hours?

Answer 14

Urgent endoscopy (within 24 hours):
~All foreign bodies in the esophagus require removal within 24 hours.
~Because the risk of complications dramatically increases with time.

Note the exceptions if the object is already in the stomach!

Question 15

How are foreign bodies that enter the stomach treated? What are the exceptions?

Answer 15

~Most foreign bodies that enter the stomach will pass in four to six days

~Urgent endoscopy (within 24 hours) is indicated in patients with any one of the following:

~Sharp-pointed objected in the stomach or duodenum
~Objects >5 cm in length at or above the proximal duodenum
~High powered Magnets within endoscopic reach
~Blunt objects in the stomach that are >2 cm in diameter
~Disk batteries and cylindrical batteries
~Objects containing lead

Question 16

How are foreign bodies that are distal to the ligament of treitz treated? What are the exceptions?

Answer 16

Expectant Management (most patients)

~Asymptomatic patients with small, blunt objects can be managed expectantly
~Patients managed expectantly should undergo radiographic monitoring weekly.

~Patients should resume a normal diet and monitor their stools for evidence of the object

~Endoscopic or Surgical intervention:
When there are signs or symptoms suggesting inflammation or intestinal obstruction (fever, abdominal pain, or vomiting)

Question 17

What is the most popular type of hernia?

Answer 17

75% of all hernias are inguinal hernias
2/3 of all inguinal hernias are indirect
1/3 of all inguinal hernias are direct

Question 18

What is the most common type of ventral hernias?

What is the most common type of groin hernias?

Answer 18

Ventral hernias:
Epigastric
Umbilical

Groin Hernias:
Inguinal

Question 19

What is the difference between a direct and inguinal hernia?

Answer 19

~Direct inguinal hernia passes directly through a weakness in the transversalis fascia in the Hesselbach triangle

~Indirect inguinal hernia passes from the internal to the external inguinal ring through the patent process vaginalis, and then to the scrotum

Question 20

what are the three characterization of the contents of hernias

Answer 20

~Reducible = hernia sac itself is soft and easy to replace back through the hernia neck defect.

~Incarcerated = hernia sack is firm, often painful, and nonreducible by direct manual pressure, no signs of systemic illness

~Strangulated = hernia sack firm and very painful, usually with signs of systemic illness present (fever, nausea, vomiting) implies impairment of blood flow (arterial, venous, or both)

Question 21

How do strangulated hernias present?

Answer 21

~Presents as severe, exquisite pain at the hernia site
often with signs and symptoms of intestinal obstruction, toxic
~Appearance, and, possibly, skin changes overlying the hernia sac
~A strangulated hernia is an acute surgical emergency.

Question 22

How are reducible, strangulated, and incarcerated hernias treated?

Answer 22

If the hernia is strangulated…

~Consult general surgery immediately
~Administer broad-spectrum IV antibiotics fluid resuscitation and adequate narcotic analgesia obtain preoperative laboratory studies

~If hernia is incarcerated:
– Attempt to reduce, if unsuccessful consult surgery

~If hernia is reducible
–Outpatient surgery follow up

Question 23

What are the parameters of an AAA diagnosis?

Answer 23

~The diameter of the normal diameter of the abdominal aorta is approximately 2.0 cm (range 1.4 to 3.0 cm)
an AAA is diagnosed when the aortic diameter exceeds
3.0 cm.

Question 24

What is the classic triad of a symptomatically ruptured AAA?

Answer 24

Symptomatic and ruptured:
Patient looks bad, high morbidity and mortality
Classic Triad: Abdominal and/or flank pain, hypotension, and shock

Question 25

Most AAA have no ______.

Answer 25

Symptoms

Question 26

What is the difference in treatment of symptomatically stable vs unstable patients with AAAs?

Answer 26

Symptomatic:
Stable:
~CT abd/pelvis with IV contrast

Unstable:
If known hx of AAA:
~To OR without imaging
~If unknown but suspected, CT abd/pelvis
with IV contrast if possible

Question 27

When is conservative management undergone vs. a surgery for an AAA?

Answer 27

Conservative Management (watch and wait)
~For asymptomatic infrarenal AAA <5.5 cm

Elective AAA repair (open or endovascular):
For asymptomatic AAA >5.5 cm in good surgical candidates

~Rapidly expanding (>0.5 cm in six months or >1 cm per year) infrarenal AAA in well-documented serial studies.
~Patients with associated arterial disease such as coexisting iliac, femoral, or popliteal artery aneurysms, or symptomatic peripheral artery disease undergoing revascularization.

Question 28

What accounts for the majority of abdominal injuries seen in the Emergency Department?

Answer 28

~Blunt abdominal trauma (BAT) accounts for the majority of abdominal injuries seen in the Emergency Department

Question 29

How are hemodynamically stable injuries treated vs. hemodynamically unstable patients?

Answer 29

~If hemodynamically stable may be managed conservatively (non-operatively) with close observation by a general surgeon in the hospital.

~If hemodynamically unstable or continued bleeding require operative management

Question 30

What are the most commonly injured solid organs?

Answer 30

~Spleen and liver are the most commonly injured solid organs

Question 31

What is the top reason someone gets a laparotomy?

Answer 31

~Blunt abdominal trauma with hypotension with a positive fast scan or clinical evidence of intraperitoneal leading