Acute Abdomen

Question 1

Challenge of Diagnosis

Answer 1

History confounded by stoicism, alterations in pain perception, memory deficits, communication problems, or mental status changes
Physical exam unreliable: 80% no rigidity, 50% afebrile
Check potential hernia sites
Less abdominal inflammatory response
Ancillary testing unreliable
CT & US must be used liberally

Question 2

Biliary Tract Disease

Answer 2

Most common cause of surgery in the elderly

“Biliary colic” replaced by vague abdominal complaints

Question 3

Diagnosis of Biliary Tract Disease in the Elderly

Answer 3

15% no epigastric or RUQ pain
5% no pain at all
40% normal WBC
10% afebrile
90% ultrasound diagnostic

Question 4

Appendicitis

Answer 4

Etiology: gallstones
Pain is usually absent
Pain when present is vague, PE unremarkable

Question 5

Signs of Appendicitis

Answer 5

Non-specific
Tachycardia
Hypotension
Tachypnea
Confusion

Question 6

Symptoms of Acute Diverticulitis

Answer 6

LLQ pain
Tenderness
Moderate abdominal distension
Moderate temperature elevation

Question 7

Diagnosis of Acute Diverticulitis

Answer 7

CT scan

Question 8

PUD

Answer 8

1/3 pain absent
Pain: vague, poorly localized
Symptoms: systemic & related to blood loss

Question 9

Typical Presentation of AAA Rupture

Answer 9

Hypotension
Abdominal pain
Back pain

Question 10

Key Finding of AAA

Answer 10

Enlarged, tender aorta

Question 11

Beware of ______ in the Elderly

Answer 11

Renal colic symptoms
Labeling hypotension as vagal
Atypical location of abdominal pain

Question 12

Diagnosis of AAA

Answer 12

Ultrasound

CT with contrast in stable patient

Question 13

Ischemic Bowel Presentation

Answer 13

Severe, visceral pain out of proportion with physical exam findings in a patient with risk factors

Question 14

Treatment for Ischemic Bowel

Answer 14

Early angiography

Question 15

Cause of Ischemic Bowel

Answer 15

SMA embolus
SMA thrombosis
Venous thrombosis
Non-occlusive

Question 16

Risk Factors for Ischemic Bowel

Answer 16

A. fib
Recent MI
CAD
Low flow states
Hypercoaguable states
Low cardiac output (CHF, sepsis, digoxin, hypovolemia)

Question 17

Causes of Mechanical Obstruction

Answer 17

Adhesions
Hernias
Appendicitis
Malignancy
Volvulus
Diverticulitis
AAA

Question 18

Abdominal Pain in the Elderly

Answer 18

Difficult & dangerous disease
Investigate & manage aggressively
Maintain a high level of suspicion