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
Cholangitis
- clinical presentation
- Medical emergency
- Bacteria in duodenum ascends back into common bile duct, usu dt gallstone obstruction
- Charcot’s triad: abd pain, fever, jaundice (also hypotension, mental confusion)
- Can rapidly progress to septic shock, multiple organ failure
- Dx: +WBC and CRP (inflammation), elevated LFTS
- Tx: ERCP to remove stone, IV fluids, broad spectrum abx
Acute pancreatitis
- clinical presentatino
- Fever, anorexia, n, abd pain (severe and upper abdomen with radiation to back), no v/d
- Elevated WBC, slight elevation of LFTs
- Gross elevation of lipase and amylase
Acute pancreatitis
- common causes
- etoh
- gallstones
- elevated TG
What is the purpose of the Ranson Criteria?
Help predict mortality related to acute pancreatitis. Used to help determine whether pt should be discharged home
Mesenteric ischemia
- clinical presentation
- *Medical emergency, don’t let the gut die!!
- Ill appearing: diaphoretic, pain, severe distress (pain out of proportion to exam)
- Elevated vitals
- Abd: distended, TTP, rigidity, guarding, rebound tenderness
- Possible reduced unilateral pulses to LE
Mesenteric ischemia
- dx testing
- WBC elevation
- CTA: reveals stenosis
Peptic ulcer disease
- Clinical presentation
- Burning epigastric pain
- N/V
- Vomiting red blood
- Melanotic stool
- Anemia
- Perforation
- Gastric outlet obstruction
Peptic ulcer disease
- signs of perforation or hemorrhage
- PE and lab signs of blood loss (volume depletion, decreased H&H, etc.)
- Perf: Signs of free air in abdomen, usually hypotensive, worry for sepsis
Acute appendicitis
- presentation
- dx
- tx
- periumbilical pain that localizes to McBurney’s point
- leukocytosis
- Dx: CT is best, US if pregnant
- tx: surgery
Mallory-Weiss tear
- presentation
- Dx
- Tx
- Usu after bout of vomiting or retching
- Increased risk if portal HTN
- Usu middle-aged men who present with hematemesis, usually after vom or etoh
- Dx: endoscopy
- Tx: most stop bleeding spontaneously
Intussusception
- clinical presentation
- dx
- tx
- MC: 3 months ot 6 years
- M>F
- Sudden, intermittent, colicky abd pain. Episodes of pain usu spontaneously resolve
- Current jelly stool (late finding)
- Lethargy, v, diaphoresis. No melena, HA, fever, hematemesis
- Dx and Tx: air contrast enema
o Will have coiled spring appearance
o CI to air enema: perforation which needs surgical treatment
Incarcerated hernia
- clinical presentation
- Severe pain, usu acute onset
- n/v
- Inability to have a BM or bloody stool
- signs of infection
Incarcerated hernia
- tx
- surgery
- not sure if she wants more details than this
Dont’ forget
to read the required readings too!
workup for GI pain
- CBC
- CMP
- Lipase
- UA
- Preg test
- cardiac enzymes
- ECG
- Flat/upright abd x-rays
- KUB
- CT
- US
workup for Gi bleeding
- VITALS!!!!
- CBC
- PT/INR
- PTT
- BMP
- Stool guiac
- CTA/endoscopy
Workup for n/v/d without pain/bleeding
assess fluid volume
GI workup
- radiology
X-rays
- Upright and supine: air-fluid levels, free air
- KUB (upright chest, upright abdomen, and supine abdomen): gallstones, kidney stones, masses, perforations, obstruction
- Lateral decubitus: eval for free air (pneumoperitoneum) * usually left side down
Lab and/or radiologic w/u
- cholelithiasis
- US
- HIDA scan
- ERCP (also removes the stones)
- CBC: slight WBC elevation
Lab and/or radiologic w/u
- acute cholecystitis
- US: pericholecystic fluid (indicates acute not chronic)
- HIDA scan: failure of isotope to appear in GB in 4 hours is high suspicious
- Lipase
Lab and/or radiologic w/u
- Cholangitis
- ERCP (with intent to remove stone), secondary US and MRCP
- Elevated WBC
- Elevated CRP
- Elevated LFTs
- Elevated bilirubin
- *may look like hepatitis early on
Lab and/or radiologic w/u
- acute pancreatitis
- Elevated lipase (3X) and amylase
- Hyperglycemia or hypocalcemia
- Leukocytosis
- Elevated bilirubin, alk phos, LFTs
- US: gallstones and pancreatic edema
- CT: eval extent and complications
Lab and/or radiologic w/u
- chronic pancreatitis
ERCP is GS test
Lab and/or radiologic w/u
- appendicitis
- CT abdomen and pelvis W/contrast
- US: pregnant and children
Lab and/or radiologic w/u
- PUD
- Endoscopy
- Look for signs of blood loss
Lab and/or radiologic w/u
- bowel obstruction
- CT abd and pelvis w/contrast
- XR: AP supine (bowel loops), upright abd (air fluid levels), upright chest (free air)
Lab and/or radiologic w/u
- Intussusception
Air contrast enema: dx and tx
Lab and/or radiologic w/u
- Mesenteric ischemia
CTA of abdomen
Lab and/or radiologic w/u
- AAA
- US
- CT abd/pelvis
