Acute Abdomen and Referred Pain, C35 P203-209 Flashcards
What is an “acute
abdomen”?
P203
Acute abdominal pain so severe that the patient seeks medical attention (Note: Not the same as a “surgical abdomen,” because most cases of acute abdominal pain do not require surgical treatment)
What are peritoneal signs?
P203
Signs of peritoneal irritation: extreme tenderness, percussion tenderness, rebound tenderness, voluntary guarding, motion pain, involuntary guarding/ rigidity (late)
Define the following terms:
Rebound tenderness
P203
Pain upon releasing the palpating hand
pushing on the abdomen
Define the following terms:
Motion pain
P203
Abdominal pain upon moving, pelvic
rocking, moving of stretcher, or heel
strike
Define the following terms:
Voluntary guarding
P203
Abdominal muscle contraction with
palpation of the abdomen
Define the following terms:
Involuntary guarding
P203
Rigid abdomen as the muscles “guard”
involuntarily
Define the following terms:
Colic
P203
Intermittent severe pain (usually because
of intermittent contraction of a hollow
viscus against an obstruction)
What conditions can mask
abdominal pain?
P203
Steroids, diabetes, paraplegia
What is the most common
cause of acute abdominal
surgery in the United
States?
Acute appendicitis (7% of the population
will develop it sometime during their
lives)
What important questions should be asked when obtaining the history of a patient with an acute abdomen? P204
“Have you had this pain before?”
“On a scale from 1 to 10, how would you
rank this pain?”
“Fevers/chills?”
“Duration?” (comes and goes vs. constant)
“Quality?” (sharp vs. dull)
“Does anything make the pain better or
worse?”
“Migration?”
“Point of maximal pain?”
“Urinary symptoms?”
“Nausea, vomiting, or diarrhea?”
“Anorexia?”
“Constipation?”
“Last bowel movement?”
“Any change in bowel habits?”
“Any relation to eating?”
“Last menses?”
“Last meal?”
“Vaginal discharge?”
“Melena?”
“Hematochezia?”
“Hematemesis?”
“Medications?”
“Allergies?”
“Past medical history?”
“Past surgical history?”
“Family history?”
“Tobacco/EtOH/drugs?”What should the acute
abdomen physical exam
include?
P204
Inspection (e.g., surgical scars,
distention)
Auscultation (e.g., bowel sounds, bruits)
Palpation (e.g., tenderness, R/O hernia,
CVAT, rectal, pelvic exam, rebound,
voluntary guard, motion tenderness)
Percussion (e.g., liver size, spleen size)
What is the best way to have
a patient localize abdominal
pain?
P204
“Point with one finger to where the pain
is worse”
What is the classic position
of a patient with peritonitis?
P204
Motionless (often with knees flexed)
What is the classic position
of a patient with a kidney
stone?
P205
Cannot stay still, restless, writhing in pain
What is the best way to
examine a scared child or
histrionic adult’s abdomen?
P205
Use stethoscope to palpate abdomen
What lab tests are used to
evaluate the patient with an
acute abdomen?
P205
CBC with differential, chem-10,
amylase, type and screen, urinalysis,
LFTs
What is a “left shift” on CBC
differential?
P205
Sign of inflammatory response:
Immature neutrophils (bands)
Note: Many call >80% of WBCs as
neutrophils a “left shift”
What lab test should every woman of childbearing age with an acute abdomen receive? P205
Human chorionic gonadotropin (-hCG)
to rule out pregnancy/ectopic pregnancy
Which x-rays are used to
evaluate the patient with an
acute abdomen?
P205
Upright chest x-ray, upright abdominal
film, supine abdominal x-ray (if patient
cannot stand, left lateral decubitus
abdominal film)
How is free air ruled out if
the patient cannot stand?
P205
Left lateral decubitus—free air collects
over the liver and does not get confused
with the gastric bubble
What diagnosis must be
considered in every patient
with an acute abdomen?
P205
Appendicitis!
What are the differential
diagnoses by quadrant?
RUQ
P205
Cholecystitis, hepatitis, PUD, perforated
ulcer, pancreatitis, liver tumors, gastritis,
hepatic abscess, choledocholithiasis,
cholangitis, pyelonephritis, nephrolithiasis,
appendicitis (especially during
pregnancy); thoracic causes (e.g.,
pleurisy/pneumonia), PE, pericarditis,
MI (especially inferior MI)
What are the differential
diagnoses by quadrant?
LUQ
P206
PUD, perforated ulcer, gastritis, splenic
injury, abscess, reflux, dissecting aortic
aneurysm, thoracic causes, pyelonephritis,
nephrolithiasis, hiatal hernia (strangulated
paraesophageal hernia), Boerhaave’s
syndrome, Mallory-Weiss tear, splenic
artery aneurysm, colon disease
What are the differential
diagnoses by quadrant?
LLQ
P206
Diverticulitis, sigmoid volvulus, perforated colon, colon cancer, urinary tract infection, small bowel obstruction, inflammatory bowel disease, nephrolithiasis, pyelonephritis, fluid accumulation from aneurysm or perforation, referred hip pain, gynecologic causes, appendicitis (rare)
What are the differential
diagnoses by quadrant?
RLQ
P206
Appendicitis! And same as LLQ;
also mesenteric lymphadenitis, cecal
diverticulitis, Meckel’s diverticulum,
intussusception
What is the differential
diagnosis of epigastric pain?
P206
PUD, gastritis, MI, pancreatitis, biliary
colic, gastric volvulus, Mallory-Weiss
What is the differential
diagnosis of gynecologic pain?
P206
Ovarian cyst, ovarian torsion, PID, mittelschmerz, tubo-ovarian abscess (TOA), uterine fibroid, necrotic fibroid, pregnancy, ectopic pregnancy, endometriosis, cancer of the cervix/ uterus/ovary, endometrioma, gynecologic tumor, torsion of cyst or fallopian tube
What is the differential
diagnosis of thoracic causes
of abdominal pain?
P206
MI (especially inferior), pneumonia,
dissecting aorta, aortic aneurysm,
empyema, esophageal rupture/tear, PTX,
esophageal foreign body
What is the differential
diagnosis of scrotal causes
of lower abdominal pain?
P206
Testicular torsion, epididymitis, orchitis,
inguinal hernia, referred pain from
nephrolithiasis or appendicitis
What are nonsurgical causes
of abdominal pain?
P207
Gastroenteritis, DKA, sickle cell crisis, rectus sheath hematoma, acute porphyria, PID, kidney stone, pyelonephritis, hepatitis, pancreatitis, pneumonia, MI, C. difficile colitis
What is the unique differential
diagnosis for the patient with
AIDS and abdominal pain?
P207
In addition to all common abdominal
conditions:
CMV (most Common)
Kaposi’s sarcoma
Lymphoma
TB
MAI (Mycobacterium Avium
Intracellulare)What are the possible causes
of suprapubic pain?
P207
Cystitis, colonic pain, gynecologic causes
and, of course, appendicitis
What causes pain limited to
specific dermatomes?
P207
Early zoster before vesicles erupt
What is referred pain?
P207
Pain felt at a site distant from a disease
process; caused by the convergence of
multiple pain afferents in the posterior
horn of the spinal cord
What is gastroenteritis?
P207
Viral or bacterial infection of the GI tract,
usually with vomiting and diarrhea, pain
(usually after vomiting), nonsurgical
What is classically stated to
be the “great imitator”?
P207
Constipation
Name the classic locations of referred pain:
Cholecystitis
P207
Right subscapular pain (also epigastric)
Name the classic locations of referred pain:
Appendicitis
P207
Early: periumbilical
Rarely: testicular pain
Name the classic locations of referred pain: Diaphragmatic irritation (from spleen, perforated ulcer, or abscess) P207
Shoulder pain ( + Kehr’s sign on the left)
Name the classic locations of referred pain:
Pancreatitis/cancer
P207
Back pain
Name the classic locations of referred pain:
Rectal disease
P208
Pain in the small of the back
Name the classic locations of referred pain:
Nephrolithiasis
P208
Testicular pain/flank pain
Name the classic locations of referred pain:
Rectal pain
P208
Midline small of back pain
Name the classic locations of referred pain:
Small bowel
P208
Periumbilical pain
Name the classic locations of referred pain:
Uterine pain
P208
Midline small of back pain
Give the classic diagnosis for the following cases:
“Abdominal pain out of
proportion to exam”
P208
Rule out mesenteric ischemia
Give the classic diagnosis for the following cases:
Hypotension and
pulsatile abdominal mass
P208
Ruptured AAA; go to the O.R.
Give the classic diagnosis for the following cases:
Fever, LLQ pain, and
change in bowel habits
P208
Diverticulitis
Give the test of choice for the following conditions:
Cholelithiasis
P208
Ultrasound (U/S)
Give the test of choice for the following conditions:
Bile duct obstruction
P208
U/S
Give the test of choice for the following conditions:
Mesenteric ischemia
P208
Mesenteric A-gram
Give the test of choice for the following conditions:
Ruptured abdominal
aortic aneurysm
P208
NONE—emergent laparotomy
Give the test of choice for the following conditions:
AAA
P208
Abdominal CT scan or U/S
Give the test of choice for the following conditions:
Abdominal abscess
P208
Abdominal CT scan
Give the test of choice for the following conditions:
Severe diverticulitis
P208
Abdominal CT scan
What is the most common
cause of RUQ pain?
P208
Cholelithiasis
What is the most common
cause of surgical RLQ pain?
P208
Acute appendicitis
What is the most common
cause of GI tract LLQ pain?
P209
Diverticulitis
Classically, what endocrine
problems can cause abdominal pain?
P209
- Addisonian crisis
2. DKA (Diabetic KetoAcidosis)
