Acute Abdomen Flashcards
9 life threatening abdominal pain
AAA
Abdominal aortic dissection
GI perf
Incarcerated hernia
Acute bowel obstruction
Mesenteric ischemia
Ectopic preg
Placental abruption
Splenic rupture
top 10 dx in pts with abdomen pain in ER
appendicitis
biliary tract disease
SBO
gyn disease
pancreatitis
renal colic
perforated ulcer
cancer
diverticular disease
non-spec abd pain
red flags in hx of acute abdominal pain
age over 65
alcoholism
immunocompromised
CVD
prior surgery
comorbidities
recent GI instrumentation
early preg
pain characteristics of acute abdominal pain
acute onset
sig pain at onset
pain followed by emesis
constant pain less than 2 days
physical exam of acute abdominal pain
rigid abdomen
signs of shock
involuntary guarding
referred pain:
gall bladder to ____
right subscapular area
referred pain
perforated duodenal ulcer to
shoulders
referred pain
ureteral obstruction to
testicles
referred pain
MI to where
epigastric area, jaw, neck, upper extremity
referred pain
GYN to where
lower back
def acute
less than 72 hours
progressive worsening
chronic def
unchanged for months - years
visceral or parietal pain
dull, achy, colicky
poorly localized
distention, ischemia
, inflammation or spasm of a hollow organ
visceral
visceral or parietal pain
sharp
well localized
peritoneal irritation, ischemia, infalmmation/stretching of parietal peritoneum
parietal
5 things that cause abrupt excrutiating pain
biliary colic
ureteral colic
myocardial infarction
perforated ulcer
ruptured aneurysm
6 things that cause gradual, steady pain
acute cholecystitis
acute cholangitis
acute hepatitis
appendicitis
acute salpingitis
diverticulitis
3 things that cause rapid onset of severe, constant pain
acute pancreatitis
mesenteric thrombosis, strangulated bowel
ectopic preg
3 things that cause intermittent, colicky pain, crescendo with free intervals
early pancreatitis (rare)
small bowel obstruction
inflammatory bowel disease
acute abdominal pain pertinent history (think OLDCAARTS)
sudden or gradual?
aggravating and alleviating factors?
quality - colicky, waxing/waning, dull/sharp
site - diffuse or particular quadrant
timing - hours or weeks
radiation - shoulder, flank, chest, perineum
assoc symptoms: fever, nausea vomiting diarrhea or constipation, dysuria, bloody stool, vaginal discharge, SOB
PMH: any cardiac risk factors
surgical hx: prior abdominal surgery ***
med hx: bleeding risk, pain meds, pepto?
social hx: menstrual, contraceptives, STI risk, alcohol use
physical exam with acute abdomen pain
appearance and level of comfort
movement or lack of movement in pt
skin color
vital signs
temp: fever or hypothermia?
resp rate - may be increased due to pain or compensatory due to metabolic acidosis
BP - hypotension due to sepsis, GI bleed
auscultation of heart/lungs: afib, pnuemonia
auscultation of bowel sounds: hypoactive or hyperactive
bruits: AAA
palpation!!!
restless pt who cannot sit still - whatcha thinking?
renal colic
lying perfectly still or supine - whatcha thinking?
peritonitis
if hypoactive or absent bowel sounds whatcha thinking
peritonitis, SBO
if hyperactive bowel sounds, whatcha thinking?
blood/inflammation of GI tract
if you hear bruits, you’re thinking
AAA
palpation with acute abdomen pain
what should you do for bones
chest wall, spine, pelvis
CVAT (costovertebral angle tenderness)
palpation with acute abdomen pain
abdominal exam
complete!
check for hernias
assess for hepatospenomegaly
specialized exams: rebound, Murphys
palpation with acute abdomen pain - men and women who have lower quadrant or hypogastric pain
testicular exam/pelvic ecam in all
acute abdomen physical exam
palpation of butt
rectal exam
initial dx of acute abdominal pain
CBC with diff
BMP/CMP
AST, ALT, Alk phoh total bilirubin
lipase/amylase
lactic acid
UA
urine preg in females
stool guaiac
imaging with acute abdomen (what three)
plain films
CT
ultrasound
when do you use plain films with acute abdomen pain
dilated bowel loops
air-fluid levels
free air
constipation
foreign body
when do you use CT WITHOUT CONTRAST with acute abdomen pain
renal stone, obstruction
when do you use CT WITH IV CONTRAST
ischemic bowel, diverticulitis, peritonitis, AAA
when do you use CT with ORAL contrast
really skinny adults and kiddos
when do you use US
gall bladder, free fluid, renal, ovarian, testicle
General tx of acute abdominal pain
IV fluids
anti-vomiting
analgesia
anti-pyretic
NPO
antibx when indicated
consults
monitor for signs of sepsis and shock, repeat exam and vitals frequently - look for fever, tachy, hypotension, AMS
5 dx that require urgent surgical referral
obstruction
perforation
peritonitis
ischemic bowel
dissection
increased tenderness and rigidity
pain is severe and out of proportion to exam
what do you do?
URGENT SURGERY
who may have vague, nonspecific, atypical presentation of acute abdominal pain
elderly
DM/immunocomp
causes of perforation of GI tract
spontaneous due to inflammatory changes (gallbladder, appendix)
bowel obstruction
trauma
instrumentation
clinical manifestations depend on what with perforation
organ affected and contents released:
air
stool
succus entericus - ENZYMES and MUCUS
who is perforations more common in
over 50 y/o
less than 10 y/o
perforation: diffuse or localized
diffuse pain AFTER localized tenderness
progression of perforation to peritonitis
pain may be relieved and then peritoniitis comes about!
5 things that describe peritonitis
occurs after perforation
high fever
may lead to sepsis/death
localized - contained to surrounding viscera or omentum
generalized = gross spillage into peritoneal cavity
how to tx abscess?
drainage
antibx
how do pts with peritonitis present
SICK
lie still to minimize discomfort
bloating/feeling of fullness
rebound tenderness, tenderness to percussion
pain with light palpation/bumps
HYPOACTIVE bowel sounds
N/V
Anorexia
low urine output
fever
cannot pass stool/gas
spontaneous bacterial peritonitis clinical presentation
SBP: ascites, liver cirrhosis, fever, AMS, abdominal pain +/- hypotension
IF super ascites - ridig abdomen may not be present
what do you do if you suspect spontaneous bacterial peritonitis
paracentesis
what do you NOT do with spontaneous bacterial peritonis
NO EXPLORATORY LAPAROTOMY
tx of spontaneous bacterial peritonitis
cefotaxime (antibx)
usually e.coli or klebsiella
clinical presentation of secondary bacterial peritonitis
possible perforation - peptic ulcer disease, appendicitis
ascites, fever, AMS, abdominal pain +/- hypotension
tx for secondary bacterial peritonitis
paracentesis WITH EXPLORATORY LAPAROTOMY (different spontaneous bacterial peritonitis)
tx of secondary bacterial peritonitis
cefotaxime
e. coli or klebsiella
what dx?
assoc with gallbladder inflammation that is usually related to gallstone disease
severe, constant pain in RUQ over 6 hours
radiates to epigastric and right shoulder
N/V, increase pain with fatty foo intake
guarding and RUQ pain withpalpation
+ Murphys sign
ill appearing, want to lie still
tachycardia
acute cholecystitis
+ Murphys
Acute cholecystitis
most common surgical emergency in elderly
acute cholecystitis
what will you see on labs with acute cholecystitis
leukocytosis with bands
elevated CRP
normal alkaline phosphate and transaminase
normal bilirubin
what would you do for imaging for acute cholecystitis and what will you see
RUQ US
gallbladder wall thickening
sonographic “Murphys sign”
gallstones or sludge
pericholecystic fluid
mgmt of acute cholecystitis
IV fluids
analgesia
NPO
antibx (ceftriaxone, cefuroxime)
non-opperative or opperative (another flashcard)
non-operative mgmt of acute cholecystitis
watch and wait - if lack of noticeable improvement within 1-2 days – need to do surgery
operative mgmt of acute cholecystitis with UNSTABLE pts
percutaneous drainage with radiologic guidance
do surgery when stable
presence of gallstones WITHIN the common bile duct
what dx?
acute choledocholithiasis
most common cause of acute choledocholithiasis
secondary - passage of stones from gallbladder to common bile duct
less common cause of acute choledocholithiasis
primary - formation of stones within common bile duct
clinical presentation of acute choledocholithiasis
biliary type pain (colicky)
RUQ pain that can radiate to epigastric region
N/V
Pain can be intermittent if transient blockage
labs elevated in acute choledocholithaisis
elevated bilirubin
elevated alk phos
elevated transaminases
elevated GTT
(diff than acute cholecystitis)
is gallbladder palpable in acute choledocholithiasis?
what sign
can - Courvoisier’s sign!
Courvoisier’s sign (palpable gallbladder) with what dx
acute choledocholithiasis
imaging for acute acholdocholithiaiss
US - looking for presence of stones in gallbladder/common bile duct
tx of acute choledocholithiasis for high risk pts?
consult surgery, GI
ERCP - remove stone followed by elective cholecystectomy
tx of acute choledocholithiaiss for low risk pts
cholecystectomy only
complications of acute choledocholithiasis
acute pancreatitis
acute cholangitis
what is acute cholangitis
ascending bacterial infection
is acute cholangitis an emergency
YES
causes of acute cholangitis
it is due to obstruction of biliary ducts
causes: biliary calculi, malig, benign stenosis
microbio of acute cholangitis
enterococci (most common)
e. coli
klebsiella
acute cholangitis presentation (not as serious even though still serious)
Charcot’s triad
fever/chills
RUQ/abdominal pain
jaundice
acute cholangitis presentation (SEVERE SEVERE)
charcot’s triad (fever/chills, RUQ/abdoinal pain, jaundice)
+
AMS
Hypotension
labs with acute cholangisits
leukocytosis (neutrophilia)
elevated alk phos, GGT, bilirubin, transaminases
if you suspect acute cholangitis and labs come back and show elevated amylase - what does this mean
pancreatic involvement!
imaging of acute cholangitis
US - common bile duct dilation or stones
EUS
ERCP
MRCO
in pregnant people with suspected acute cholangitis - what do you do
US first and then fetal shielding during ERCP if needed
acute cholangitis management
admit
NPO (in case surgery)
IV fluids
analgesia
consult GI/ID
monitor for sepsis (blood cultures x 2)
empiric antibx tx
biliary drainage
surgery for acute cholangitis
biliary drainage - ERCP (dx and tx)
antibx tx for acute cholangitis
empiric - ceftriaxone AND metro)
what dx?
abrupt onset RUQ abdominal pain
N/V
anorexia
fever/malaise
dark urine, pale stools
jaundice/scleral icterus
hepatomegaly
splenomegaly
hep A
labs with Hep A
elevated ALT > AST
elevated alk phos
elevated bilirubin
tx of hep A
symptomatic
fecal oral spread is common so counsel on hygiene
pt contagious for 28 days before and up to one week following onset of jaundice
acute inflammatory process of pancreas
pancreatitis
mild
moderate
severe
pancreatitis
mild: no organ failure or systemic complications
mod: transient organ failure (resolves within 48 hours)
severe: persistant organ failure can be more than one organ
gallstone pancreatitis clinical presentation
well localized pain with rapid onset
how does pancreatitis due to other causes (other than gallstone) present and what leads to pancreatitis (4)
less well localized with slower progression
alcohol, drugs (amiodarone, antivirals, diuretics, NSAIDS, antibx), severe hyperlipidemia, idiopathic
pancreatitis presentation
persistent, severe, boring acute epigastric or RUQ pain
radiates to back
pain may be relieved by leading forward
+/- dyspnea due to diaphragmatic inflammation
N/V
Bloating
pancreatitis physical exam
fever
tachypnea
hypotension
epigastric or diffuse tenderness
hypoactive bowel sounds
abdominal distention
scleral icterus/jaundice if due to choledocholithiasis
2 “signs” of pancreatitis and describe
Cullens sign - periumbilical region with superficial edema and bruising in the subcutaneous fatty tissue around umbilicus
Grey turner sign: along the flank - ecchymotic discoloration due to retroperitoneal bleeding from pancreatic necrosis
dx of pancreatitis (labs and imaging)
lipase elvated (3 times normal)
amylase elvated (3 times normal)
increased CRp
maybe leukocytosis
imaging:
US: enlarged pancreas, gallstones possible
CT with IV contrast: not as sensitive in early disease + diffuse enlargement, necrosis, stones
MRI: sensitive in early disease
which imaging is sensitive to pancreatitis in early disease
MRI -
pt must meet TWO of the following to meet pancreatitis dx?
acute onset of constant, severe epigastric pain radiating to back
elevation in serum lipase or amylase to 3 times greater the normal limit
characteristic findings of acute pancreatitis on imaging
IF pts meet first two criteria, no imaging needed to establish dx BUT helpful to rule out necrosis
pancreatitis mgmt
admit, ICU monitoring
NPO
IV fluids
NG tube
Foley catheter
Serial labs - amylase + electrolytes
Analgesia (opaites)
Consult GI for gallstone pancreatitis - ERCP
what dx?
assoc with GERD
risk factors:
NSAIDS use, H. pylori infection, smoking, excessive vomiting (people with gastroparesis, gastroenteritis, anorexia nervosa, bulimia nervosa)
PUD
can be atypical presentation in elderly
epigastric pain
pain radiates to midthoracic region
early satiety
dyspepsia
heartburn
pain with eating
shortness of breath, cough, (esp with lying flat)
N/V
Hematemsis
anorexia
melena
hematochezia with perf
PUD
PUD dx (labs)
CBC for Hgb/Hct
BMP for electrolytes
Hemoccult
PUD dx (imaging and consult)
kidney/ureter/bladder - check for free air
GI consult: endoscopy with biopsy
PUD tx
NSAIDS, H.pylori should be tx
if perforated - surgery!
what dx?
LUQ pain
+/- splenomegaly
fever
+/- left side pleural effusion
typ. results from endocarditis or seeding from another site
splenic abscess
typ results from endocarditis or seeding from another site
splenic abscess
dx of splenic abscess
CT scan with IV contrast
tx of splenic abscess
admit
NPO
IV fluids
antibx
consult with srugeon for splenectomy +/- ID consult
what dx?
splenic arterty or sub-branch occluded by embolus, clot or by infection
splenic infarct
risk factors for splenic infarct
hypercoagulable state (malig)
embolic disease (afib, infective endocarditis)
sickle cell disease
trauma
complication of mono
clinical presentation of splenic infarct
acute LUQ pain
+/- splenomegaly
fever
N/V
Elevated LDH
leukocytosis
dx of splenic infarct
CT scan with IV contrast
tx of splenic infarct
varies due to cause
uncomplicated - analgesia, monitor
complicated (abscessm sepsis, hemorrhage) - surgical eval for splenectomy
consult GI/surgery
atraumatic splenic rupture hx
neoplasms (leukemia, lymphoma)
infection (mono, CMV, HIV)
inflammatory disease (acute/chronic pancreatitis)
drugs (anticaog)
mechanical (preg)
idiopathic
classic presentation of splenic rupture
pain, fullness in LUQ
referred pain in left shoulder
pleuritic pain
early satiety
dx of splenic rupture - gold standard
US
other way to dx splenic rupture - not gold standard
CT with IV contrast
tx of splenic rupture
NPO
IVFluids
type and cross for transfusion??
immediate surgery - splenectomy
risk factors for what?
prior abdominal/pelvic surgery (adhesions)
abdominal wall/groin hernia
intestinal inflammation
neoplasm
prior irradiation
foreign body ingestion
intussusception/volvulus**
small bowel obstruction
the lead point of the bowel is pulled forward by normal peristalsis, telescoping or prolapsing the affected segment of the bowel into another segment of bowel
waht is this
intussusception
air filled loop of the sigmoid colon twists about its mesentery - what is this
volvulus
volvulus and intussusception - common or rare in adults
rare
N/V
Cramping abdominal pain, periumbilical
pain may become more focal if ischemia/necrosis
obstipation (inability to pass flatus or stool)
may be dehydrated
+/- fever if abscess/ischemia/necrosis
labs are variable dep on cause/timing
clinical presentation of what
small bowel obstruction
small bowel obstruction imaging
abdominal x ray
CT
what do you see on abdominal xray with small bowel obstruction
dilated loops of bowel with air-fluid levels
proximal bowel dilation with distal bowel collapse
what do you see on CT with small bowel obstuction
severity
masses, inflammatory changes
necrosis, perforation, ischemia
tx of small bowel obstruction
admit
NPO
IV fluids
anti-emetics
NG tube
consult surgery - GI
when is surgery warranted with small bowel obstruction
when it is not resolved with NG tube and bowel rest
surgical tx of small bowel obstruction and WHEN
immediate surgery - antibx for signs of complicated bowel obstruction
decreased or no perfusion to section of colon
occlusive process (arterial or venous)
embolic, thrombotic, athersclerosis
waht dx
acute mesenteric ischemia
risk factors for acute mesenteric ischemia
cardiac arrhythmias
advanced age
low cardiac output states
valvular heart disease
MI
malig
clinical presentation of acute mesenteric ischemia with arterial thrombosis/emboli
rapid onset, severe periumbilical pain out of proportion to physical exam
N/V common
possible forceful bowel evacuation
post-prandial pain (15-30 min)
+/- hematochezia
high mortality
acute mesenteric ischemia with venous thrombosis
more indolent course
lower assoc mortality
which is more assoc with mortality: arterial thromvosis/emboli and acute mesenteric ischemia OR venous thrombosis and acute mesenteric ischemia
arterial thrombosis/emboli and acute mesenteric ischemia
labs with acute mesenteric ischemia
hemoconcentration
increased lactate
increased LDH
MAYBE elevated serum amylase
d-dimer
dx of acute mesenteric ischemia
early signs/symptoms are non-specific
plain abdominal films: free air and signs of dead bowel
while trying to dx acute mesenteric ischemia and you see free air and/or signs of dead, bowel, what do you do?
what do you do if you do NOT see free air or signs of dead bowel
if you do - do laparotomy - embolectomy or colon resectioning
if you do NOT - abdominal CT angiography with IV contrast
acute mesenteric ischemia mgmt
admit
IV fluids
NPO
foley
empiric antibx (ceftriaxone + metro)
systemic anticoag
consult GI/surgery/cardio/vascular
most common abdominal emergency
appendicitis
blockage of appendix with stool, appendicolith, tumor with secondary infection can lead to what
appendicitis
is appendicitis easily missed?
yes - in pts under 12 y/o, up to 57% of cases are missed
if under 2 y/o, approx 100% of cases are missed
normal location for appendicitis pain
starts at periumbilical and moves to RLQ in approx 35% of patients
retroceccal appendix
what will you see
back/flank/testicular pain + psoas sign
+ psoas sign seen in what
retroceccal appendix
pelvic appendix - what will you see
suprapubic/rectal pain/dysuria/diarrhea more common
obturator sign
+ obturator sign seen in what
pelvic appendix
what is the psoas sign
hip extension
what is the obturator sign
rotation of right flexed hip
appendicitis - pt will complain of
N/V
anorexia
fever (later finding)
rebound tenderness/positive rovsing sign
MAYBE rigidity, voluntary guarding, pain on rectal exam - this all depends on duration of symptoms/location of appendix
labs of appendicitis
leukocytosis (bands) - extreme elevation? consider perforation
does a normal WBC rule out appendicitis
NOPE
what can UA show with appendicitis
pyruria, bacteria, hematuria if appendix is near bladder or ureter
where can pain present with appendicitis in third trimester of pregnancy
RUQ
due to displacement
is imaging needed for appendicitis
nope - not if clinical dx can be made
how to dx appendicitis if dx is UNCLEAR
what do you do in pregnant pts?
CT with contrast - shows inflammation, abscesses, fat stranding, fluid collection
MRI with contrast for pregnancy
appendicitis tx
admit
IV fluids
NPO
analgesia
antibx (Cefoxitin or cefazolin + metro)
surgery consult
inflammation generally considered to be due to microperforation of a diverticulum
diverticulitis
diverticulitis - prevalence ____ with age
increases
diverticultis pts usually have a hx of what
diverticulosis
diverticulitis pain description
deep, constant, steady
what can result from acute attack of diverticulitis
obstruction/paralytic ileus due to edema and compression of colon (inflammation)
clinical presentation of diverticulitis
N/V
change in bowel habits
urinary urgency, freq, dysuria
low grade fever
rebound/guarding
localized tenderness
left sided pain (tender mass) on rectal exam
diverticulitis - positive or negative stool guaiac
positive
diverticulitis - hyperactive/high pitched bowel sounds lead you to believe what
obstruction
diverticulitis - hypoactive/absent bowerl sounds lead you to believe what
peritonitis
UA will show what with diverticulitis
pyruria (PUS)
imaging for diverticulitis (preferred)
CT with contrast to see localized bowel thickening, colonic diverticula, abscesses, fistulas, dilated loops of bowel (bowel obstruction)
tx of uncomplicated diverticulitis
home with oral antibx (cipro + metro)
close follow up within 2 days with GI
tx of complicated diverticulitis - perforation, abscess, fistual, or obstruction
admit
iv fluids
NPO
IV antibx (type varies)
consult GI/surgery
most common complicatino of IBD
toxic megacolon
toxic megacolon can be complication of what diseases
IBD
volvulus
diverticulitis
obstructive colon cancer
secondary to C. diff
CMV in HIV pts
what dx?
severe, bloody diarrhea
toxic appearing pt
AMS
tachycardia
fever
postural hypotension
abdominal distension and tenderness
toxic megacolon
imaging for toxic megacolon
XRAY (abdomen)
transverse and right colon most dilated (up to 15 cm)
may or may not have air fluid levels
dx criteria for toxic megacolon
enlarged, dilated colon on xray
fever over 38C
HR over 120 bpm
neutrophilic leukocytosis over 10,500
Anemia (PLUS)
Dehydration
AMS
Electrolyte disturbance
Hypotension
tx for toxic megacolon
admit
IV fluids
NPO
NG tube placement
no anti-motility agents, opiods
broad spectrum IV antibx (amp, gentamycin, metro)
IV steroids (prednisolone or methylprenisolone)
surgery/GI consult
complications of toxic megacolon
perf
massive hemorrhage
progression of dilation
assoc with rectal bleeding, bright red, can be copious
anal pruritis, prolapse
acute perianal pain; “lump” due to thrombosis
what dx?
hemorrhoid
complications of hemorrhoid
prolapse
strangulated
gangrenous changes
phys exam for hemorrhoids
visual inspection
DRE
anoscopy
other endoscopic procedures
internal and external hemorrhoid mgmt
internal or external can be excised by surgeon
thrombosed hemorrhoid tx
incise overlying skin and evacuate small clot to provide immediate relief
symptomatic tx of hemorrhoids
increased fluid and fiber
severe in pain in anal area
fever uncommon unless cellulitis
areas of flatulence/indurated skin perianal area
no findings on digital rectal exam
what dx?
perianal abscess
tx of simple perianal abscess
can be drained in ER
anesthetize area, open wound, evacuate pus, irrigate well
no packing
sitz baths at home
when do you use antibx with perianal abscess
cellulitis, signs of systemic infection, DM, valvular heart disease, immunosuppression
for extensive non-superficial perianal abscesses, what do you do
Admit
CT or MRI to determine extension
drained
GI +/- surgeon
frequently long delay before medical attention
shape and size of object influences mgmt
anorectal or abdominal pain, blood per rectum, mucus discharge
what is this dx
rectal foreign body
physical exam of rectal foreign body
findings are variable
plain radiograph - flat and upright
CT scan if rectal foreign body is radio-opaque (WHITE)
tx of rectal foreign body
remove it - relax with IV sedation
OR
surgical removal - abdominal palpation allows for caudal pressure and stabilization; laparoscopy; colotomy with primary closure
following removal further evaluate with rigid proctoscopy or flexible sigmoidoscopy
5 causes of pelvic pain
ectopic preg
PID
ovarian torsion
ovarian cancer
postpartum endometritis
female pelvic pain workup
CBC with diff
BMP
Urinalysis
HCG (get quant if +)
Nucleic acid amp test (NAAT) for chlamydia and gonorrhea
Gram stain, cultures
Pelvic exam, check for cervical motion tenderness, erythema/edema
palpate ovaries for size, pain, masses
dx tests for female pelvic pain workup
US transvaginal:
suspected ovarian neoplasms, masses, torsion, ectopic preg
CT for further eval if needed following US
MRI in pregnant women
vaginal bleeding with pain, typically 6-8 weeks after last menses
can present with life-threatening hemorrhage if ruptured
what dx
ectopic preg
what do you monitor with ectopic preg
Hgb/Hct
dx of ectopic preg
transvaginal + HCG ultrasound
ectopic preg tx for stable pt
methotrexate
ectopic pregnancy methotrexate NOT used when
if high hCG concentration
fetal heart activity noted
large ectopic size
renal/liver disease
breastfeeding
ectopic pregnancy tx IF suspected tubal rupture/hemodynamically unstable
oophorectomy
who do you consult with ectopic pregnancy tx
GYN
85% of PID are related to STI - consider testing for what
HIV and syphillis
Will you have fever/chills with PID
yes
new vaginal discharge (mucupurulent/intermenstrual bleeding)
pelvic tenderness on palpation
cervical friability
presence of abundant WBCs on saline microscopy of vaginal fluid
what dx
PID
what dx tests for PID
ESR + CRP
Transvaginal US to evaluate for suspected abscess/pelvic free fluid
NAATs for C. trachomatis and N. gonorrhea
gram stain + cultures
when do you hospitalize your PID pt
severe clinical illness
unable to tolerate POs
complicated PID with abscess
preg or post-partum
PID mgmt (general)
IV fluids
pain control
anti-emetic
antibx
GYN consult
if you decide inpt tx for PID, how do you tx and what do you do?
cefoxitin + doxy
blood cultures x 2 if admitting
IV fluids
pain control
anti-emetic
consult GYN
outpt tx of PID
ceftriaxone + doxy
IV fluids
pain control
anti-emetic
consult GYN
what dx?
partial or complete rotation of ovary, often results in ischemia
most common GYN emergency
increased risk in preg
acute onset of pain, N/V and adnexal mass on exam
pain can radiate to back/flank/groin
+/- fever (marker of necrosis)
+/- abnormal genital tract bleeding
ovarian torsion
imaging of ovarian torsion
ultrasound with duplex for blood flow (transvaginal + transabdominal)
direct visualization during surgical eval
tx of pre-menopausal with viable ovary, no malignancy
laparoscopic detorsion
tx of post-menopausal with nonviable ovary or suspected malignancy
salpingo-oophorectomy
adnexal mass, abdominal distention
bloating, early satiety
weight loss
urinary uregency, frequency
acute presentation can be malignant effusion or SBO
what dx?
ovarian cancer
dx tests of ovarian cancer
US: transvaginal + transabdominal
Labs: tumor markers (CA 125)
tx tests of ovarian cancer
consult surgery
oncology/GYN
common cause of postpartum febrile mortality caused by infection of endometrium after delivery
what dx
postpartum endometritis
how will postpartum endometritis
fever/chills + uterine tenderness
foul smelling discharge (lochia)
uterus may be soft
+/- excessive uterine bleeding
tx of postpartum endometritis
admit
IV antibiotics (clindamycin IV + gentamycin IV)
consult GYN
what do you ALWAYS do in ALL pts with lower abdominal pain
a pelvic/rectal exam
significant abdominal pain should/should not be attributed to gastroenteritis
should not
in older pts with risk factors and abdominal pain exclude _____
AAA
is pain awakening the pt from sleep is/is not significant
is significant
does a lack of free air on chest xray rule out perforation
NO
anytime you have concern with surgical GI bleed - what do you order
type/cross
pts on chronic steroids or chronic opiate therapy can have what
masking of pain
older pts typically perceive pain more/less than younger pts
LESS
same with DM**
