Acute Abdomen Flashcards
How to differentiate between peritoneal and visceral pain
Visceral: crampy, not localized
Peritoneal: localized pain
Risk factors for severe GI bleeding
- Etoh: esophageal varices
- Gastritis: perforated ulcer
- Bowel obstruction, etc. → perforation
- Hemorrhoids
- History of GI bleed
- Aortoenteric fistula (Hx of AAA)
- Hx diverticulosis
- NSAID use
- Oral anticoagulation
- Liver dz
- Abd surgery
Cirrhosis PE findings
- Diffuse abd pain and swelling, ascites
- Hypoactive and distant bowel sounds
- Bilateral LE edema
- Telangiectasias, caput medusa
- Asterixis
- Weak, fatigue, ill feeling
Cirrhosis Lab w/u
- CBC: reduced platelets and RBC
- CMP:
o AST/ALT will not be sig increased, BUN and Cr WNL
o Decreased albumin, elevation of bilirubin - PT and PTT: can be effected?
Triad of sx associated tis AAA
- severe abd/flank pain
- hypotension
- pulsatile mass
Non-contrast XR
- pneumoperitoneum
- Double wall sign (can see both sides of the bowel clearly)
- Falciform ligament sign
- Air over the liver (should look like a solid organ, not like air)
- Lateral decubitus (XR or CT): air between liver and wall
Non-contrast XR
- small bowel obstruction
- Stacked coins
- Dilated loops of bowel
- “string of pearl” sign: small pockets of gas in fluid in the bowel
Non-contrast XR
- large bowel obstruction
Colonic distention proximal to the obstruction, distal collapse
Non-contrast XR
- intussusception
air fluid
target sign US
Non-contrast XR
- Volvulus
- small bowel: corkscrew configuration
- cecal: distended loop of large bowel with axis from RLQ to LUQ, haustra usually preserved
- sigmoid: dilated colon with loss of haustra, “coffee bean sign” with axis towards LLQ
Non-constrast XR
- toxic megacolon
- dilated colon
- haustra usu less visible
Acute diverticulitis
- clinical presentation
- Case study: BRBPR, LLQ pain, urgency before BM
- Abd pain, fever, leukocytosis, gradual onset LLQ pain, constant (not colicky) pain
- n/v/d/c and urinary sx can occur (sits next to bladder)
Acute diverticulitis
- tx
Bowel rest and abx (metro + quinolone, metro + Bactrim, augmentin)
Ischemic colitis
- clinical presentation
- Abd pain
- New onset diarrhea, Hematochezia, TTP
- May not be severely ill-appearing
- Have to CT to differentiate from diverticulitis
- Fever, tachycardia, TTP, positive blood on DRE
- Elevated WBC count?
- Dx: colonoscopy w/o bowel prep, XR “thumbprinting”
Ischemic colitis
- treatment
IV fluid
bowel rest
abx
Sx if severe
Acute cholecystitis
- clinical presentation
- Severe pain, RUQ but can start mid-epigastric. May also refer to right shoulder. Constant for >6 hours (vs. intermittent biliary colic)
- RUQ TTP, + Murphy’s sign, guarding, rebound
- Anorexia, malaise, n/v, fever
- Signs of inflammation (leukocytosis, fever, etc.) and mild elevation of LFTs
- US: stones, gallbladder wall thickening, pericholecystic fluid (acute sign, vs. chronic)
Biliary colic
- clinical presentation
- Gallbladder neck is impacted by a gallstone
- No inflammatory response
- Pain (sudden, dull, colicky) d/t contraction of gallbladder against occluded neck. Usually RUQ, radiation to epigastrum or back
- Pain usu precipitated by consumption of fatty food
- Often n/v
- Might pass stone, if it gets stuck in common bile duct: pancreatitis.
- Need an US
What w/u is needed to differentiate biliary colic from acute cholecystitis
- US Inc. in cholecystitis: - alk phos - bilirubin - LFTs slightly elevated
Choledocholithiasis
- clinical presentation
- Cholecystitis but the stone is stuck in the duct and causing an obstruction
- Severe epigastric pain, n/v, no blood, ill appearing, TTP in epigastric region, guarding and rebounding, no distention
- Mild elevation of AST, ALT, alk phos (NOT bilirubin), elevated WBC
- US: will show the stone
