Acute Abdomen Flashcards by Oliver Fischer

DDx RLQ Pain

Appendicitis, ruptured peptic ulcer, Diverticulitis, Chron’s, Ectopic pregnancy, ovarian cyst, ovarian torsion, endometriosis, psoas abscess

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DDx of RUQ pain

Cholecystitis, Choledocholithiasis, Hepatitis, Hepatic vein obstruction

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DDx for LUQ pain

Splenomegaly, splenic infarction, splenic rupture, PUD

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DDx for epigastric pain

Pancreatitis, Gastritis, PUD
Reflux esophagitis
Cholecystitis
Pericarditis

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DDx for LLQ Pain

Diverticulitis, Colon cancer, appendicitis, intestinal obstruction, IBD, ectopic, ovarian cyst, salpingitis, endometriousis, renal calculi

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Referred pain: Right shoulder

Diaphragm, gallbladder, liver capsule

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Referred pain: Right scapula

Gallbladder, biliary tree

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Referred pain: Groin or genitalia

Kidney, ureter, aorta or iliac artery

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Referred pain: Back-midline

Pancreas, duodenum, aorta

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Referred pain: Left shoulder

Diaphragm, spleen, tail of pancreas, stomach, splenic flexure

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Referred pain: Left scapula

Spleen, tail of pancreas

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Clinical associations with acute pancreatitis

Biliary tract stone disease
Ethanol
Trauma
Infection
HL, hyperparathyroid, drugs: Steroids, diuretics
Pregancy
Hyper

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Ranson’s criteria for acute pancreatitis: Admission

Age >55 years
WBC > 16,000
Glucose > 200 mg/dL
LDH >350 IU/L
SGOT (AST) > 250 IU/L

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Signs of acute appendicitis?

Fever, Guarding, rebound tenderness
Indirect tenderness (Rovsing's sign)
Psoas sign (95% specificity)

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Symptoms of acute appendicitis

RLQ pain (81% sensitive, 53% specific)
Nausea
Vomiting
Onset of pain before vomiting (100% Sensitive)
Anorexia (84% sensitive)

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Mortality rate according to ranson’s criteria

3 - 28%
5 or 6 - 40%
7 or 8 - 100%

Best way to assess patient’s pulmonary status and manage ventilation if labored breathing and pulse ox of 90%? What problems are you looking for?

Chest auscultation, ABG, CXR. Supplemental oxygen and pulse oximeter monitor. Problems: Pulmonary edema from overhydration, ARDS from pancreatitis, atelectasis, or PNA.

Ranson’s criteria after 48 hours

Hematocrit decrease = 10%
BUN increase 5 mg/dL
Ca2+ level < 60 mm Hg
Base deficit > 4 mEq/L
Fluid sequestration > 6 L

Indications for surgery on psuedocyst

Fails to improve by 6 weeks.

Mneumonic for DDx of acute abdominal Pain

‘BAD GUT PAIN’

B - Bowel obstruction (Large, Small)
A - Appendicitis, Adenitis (mesenteric), AAA leaking
D - Diverticulitis, Diabetic ketoacidosis
G - Gastroenteritis
Gall bladder disease/stones/
obstruction/infection
U - Urinary tract obstruction (stone)
infection (pyelo/cystitis)
T - Testicular Torsion
Toxin - Lead, black widow spider bite
P - Pneumonia/Pleurisy
Pancreatitis
Perforated bowel/ulcer
Porphyuria
A - Abdominal aneurysm
IN - Infarcted bowel
Infarcted myocardium (AMI)
Incarcerated hernia
Inflammatory bowel disease
S - Splenic rupture/infarction
Sickle cell pain crisis
sequestration crisis

DDx acute abdomen including gynecological problems.

“ECTOPIC”

E - Ectopic (This is your priority rule out always)
Endometriosis
C - Cyst rupture (corpus leutium cyst rupture)
T - Torsion of ovary or cyst
O - Ovulation: Mittelschmerz
P - Pelvic Inflammatory Disease,
salpingitis, tubo - ovarian abscess
I - Incomplete abortion
C - Cystitis/pyelonephritis

4 Main causes of an acute abdomen

Perforation
Obstruction
Inflammatory/Infection
Ischemia

When is surgery the answer?

Peritonitis
Abdominal pain/tenderness + signs of sepsis
Acute intestinal ischemia
Pneumoperitoneum

Diagnosis of obstruction?

CBC and lactate level
Supine and erict abdominal X-ray - look for dilated loops of bowel, absence of gas in rectum, bird’s beak sign of volvulus

Management of SBO

NPO, NG suction, IVF Gastrograffin contrast study until perforation has been ruled out Volvulus: Perform proctosigmoidoscopy with rigid instrument. Leave rectal tube in place. Perform sigmoid resection for recurrent cases. Abdominal hernias: Perform elective repair except umbilical in patients <2 and esophageal sliding hiatal hernia All other obstructions: Emergency surgery

Classic signs of appendicitis

Begins with ANOREXIA vague PERIUMBILICAL pain -> Sharp, severe, constant RLQ pain Tenderness, guarding, rebound found to right and below umbilicus

How do you diagnose acute appendicitis?

Look for fever and leukocytosis in the 10,000-15,000 range with neutrophilia and immature forms Ultrasound or CT if unclear history

Management of acute appendicitis

Administer IV before appendectomy | If appendix is perforated, continue IV until fever and WBC count have normalized.

How does acute pancreatitis present?

severe midepigastric abdominal pain and tenderness in an alcoholic or someone with gallstones

Best initial test for pancreatitis?

Amylase and lipase (lipase higher specificity)

Most accurate test for pancreatitis?

Abdominal CT - detect dilated common bile ducts and visualize intrahepatic ducts

Diagnostic tests for pancreatitits?

Amylase, lipase, Abdominal CT If dilation of CBD without a pancreatic head mass -> ERCP. Remove stones and dilate strictures Trypsinogen activation peptide - urinary test to determine severity of pancreatitis. Pancreatitis arises from the premature activation of trypsinogen while it is still within the pancreas instead of when it reaches the duodenum.

Treatment for Pancreatitis

No feeding Hydration Pain medications Prophylactitic ABX for 6-8 weeks - carbapenem or cefuroxime if severe acute pancreatitis, large fluid collections or necrosis. Low fat diet in chronic

Purpose of ranson's criteria

Operative criteria to see who needs pancreatic debridement. Replaced by CT scan

Treatment for necrotic pancreatitis

CT shows > 30% necrosis of pancreas, patient should: receive Abx such as imipenem and undergo CT-guided biopsy If biopsy shows infected, necrotic pancreatitis, patient should have surgical debridement of pancreas.

Diverticulosis

condition in which diverticula are present in the intestine without signs of inflammation. LLQ pain + GI Bleeding

Diagnostic testing for diverticulosis

Colonsocopy is most accurate | Abdominal CT scan is best diagnostic

Signs and symptoms of Diverticulitis

LLQ pain + Tenderness + Fever + Leukocytosis

Treatment for Diverticulitis

Abx - combine gram negative such as quinolone or cephalosporin with an agent against anaerobes such as metronidazole. Ciprofloxacin + Metronidazole is standard.