Acute Abdomen Flashcards
Visceral pain
Poorly localized, dull, achy
From distention or spasm in hollow organs (crampy pain during intestinal obstruction)
Mid-epi = stomach, duodenum, hepatobiliary, pancreas
Mid-abd = jejunum, ileum
Lower abd = colon, internal repro organs
Parietal pain
Sharp, well-localized, somatic pain from irritation (usually by pus, bile, urine, GI secretions) of parietal peritoneum.
Examples of gradual, steady pain
Acute cholecystitis
Acute cholangitis
Hepatic abscess
Diverticulitis
Examples of abrupt, excruciating pain
Perforated ulcer
Ruptured aneurysm
Ureteral colic
Examples of intermittent, colicky pain
SBO
IBD
Biliary colic
Examples of rapid-onset severe constant pain
Acute pancreatitis Ectopic pregnancy Mesenteric ischemia Stangulated bowel Acute appendicitis
Kehr’s Sign
Pain referred to L shoulder due to irritation of left hemidiaphragm - seen with splenic rupture
Radiation to right shoulder/right scapula
Biliary tract pain
Radiation pattern of kidney pain
loin to groin
Pancreatic pain radiation
back
Most common cause of free air under diaphragm?
Perforated peptic ulcer (90%)
Could also be hollow viscus injury secondary to trauma, mesenteric ischemia (L hemidiaphragm) and large bowel perforation
Signs of perforated viscus
Scaphoid, tense abdomen
reduced BS (late)
Loss of liver dullness
Guarding or rigidity
Signs of peritonitis
Motionless
No BS (late)
Cough and rebound tenderness
Guarding or rigidity
Signs of inflamed mass or abscess
Tender mass (ab, rectal, pelvic)
Punch tenderness
Murphy’s, Psoas, Obturator signs
Signs of intestinal obstruction
Distention Visible peristalsis (late) Hyperperistalsis (early) or quiet abdomen (late) Diffuse pain without rebound tenderness Hernia or rectal mass (some)
Signs of paralytic ileus
Distention
Minimal BS
No localized tenderness
Signs of ischemic or strangulated bowel
Not distended (until late) BS variable Severe pain but little tenderness Rectal bleeding (some)
Signs of bleeding
Pallor Shock Distention Pulsatile (aneurysm) or tender (ectopic) mass Rectal bleeding (some)
Diagnosis for acute abdomen
CBC
lytes
Amylase, Lipase
ECG (rule out MI and as preop baseline cardio assessment)
LFTs for RUQ pain
b-hCG for all women of age
CXR and KUB (look for free air - easier to see in right side since stomach blocks the left)
CT-abd after the above is complete and dx still unclear (young male with clinical signs and symptoms of appendicitis won’t need CT)
Get contrast oral and IV when possible unless allergy or poor renal function. Non contrast will still give info
Splenic rupture patient giveaway
Elevated WBC in setting of trauma
Most common surgical emergency in pregnant woman?
Still appendicitis
Review: Signs that point to obstruction as source of abdominal pain
Vague/general
Colicky pain
Writhing around patient that finds no comfort
No fever
No leukocytosis
Can be gallstones, kidney stones, early SBO
Review: Signs that point to inflammation as source of abdominal pain
Still visceral pain
Constant pain
Writhing patient with no comfort
(+) fever
(+) WBC
Cholecystitis, cholangitis, diverticulitis, appendicitis
Review: Signs that point to perforation as source of abdominal pain
Still visceral
Sudden onset, constant pain
Frozen patient - hurts to move
Floridly peritoneal - fever, leukocytosis, guarding, rebound
XR shows free air under diaphragm
PUD
Cancer
Penetrating trauma
Review: Signs that point to ischemia as source of abdominal pain
Still visceral
Constant pain
Pain out of proportion to physical exam (no peritoneal signs)
PVD CAD CVA AFib Bloody BM
Can be Mesenteric ischemia or ischemic colitis
Review: Signs that point to distention as source of abdominal pain
Visceral
Referred pain. Diffuse, extremely vague
Can be constipation, bloating, Gyn
RUQ causes of abdominal pain
Lungs Diaphragm Liver Duodenum Gallbladder
U/S best in upper quadrants
Surgical: Perforated duodenal ulcer Acute cholecystitis Hepatic abscess Retrocecal appendix Appendicitis in pregnant woman
RLQ causes of abdominal pain
Kidneys/ureters
Colon-appendix
Gyn/testes
CT best in lower quadrants
Surgical:
Appendicitis
Cecal diverticulitis
Meckel’s diverticulitis intussusception
LLQ causes of abdominal pain
kidneys/ureters
Colon - diverticula
Gyn/testes
Surgical:
Sigmoid diverticulitis
Volvulus
LUQ causes of abdominal pain
Lungs
Diaphragm
Spleen
Surgical:
Splenic rupture
splenic abscess
Causes of diffuse abdominal pain
Bowel obstruction
Leaking aneurysm
Mesenteric ischemia
Causes of periumbilical abdominal pain
Early appendicits
Pain from SBO
Fitz-Hugh-Curtis
Perihepatitis associated with chlamydial infection of cervix
Suprapubic pain
Ectopic Ovarian torsion TOA Psoas abscess Incarcerated groin hernia
Important nonsurgical causes of abdominal pain
MI Mittelschmerz Poisoning (Pb, black widow) Zoster RLL pneumonia Endocrine (Addisonian crisis, DKA) Sickle cell crisis Porphyrias Psychological
