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Gastrointestinal > Acute Abdomen And Surigcal Indications > Flashcards

Acute Abdomen And Surigcal Indications Flashcards

1
Q

What does the term “surgical abdomen” mean?

A

Progressively worsening pain of acute onset

Almost always signals an immediate surgical intervention

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2
Q

Ileus

A

A paralyzed portion of the small bowel that doesnt move with peristalsis
- is a common cause of abdominal pain

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3
Q

What are the most common causes of abdominal pain?

A

Distension of a hollow viscus

Mucosal ulcerations From PUD/gastric cancer

Altered motility from IBD/IBS/ diverticulitis

Metabolic disturbance from diabetic ketoacidosis, porphyria, lead poisoning

Nerve injuries (compression/herpes/etc.)

Muscle wall disease (trauma/myositis/hematoma)

Referred pain from pneumonia/inferior STEMI and pulmonary infarction

Psychopathology (especially younger women)

Peritoneal irritation from infections/chemical/systemic inflammatory process

Obstruction via gastric outlet/small bowel/large bowel/biliary tract/urinary tract obstructions

Vascular insufficiency

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4
Q

When a patient has Pain out of proportion compared to your abdominal exam findings, what does this usually mean?

A

Vascular compromise

- make sure to check for infarcts

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5
Q

Why is the bare area of the liver important?

A

It is not covered by peritoneum and therefore has no peritoneal innervation
- growths and damage here isnt felt well, so often damage here is hidden

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6
Q

Murphy sign

A

Associated with acute cholesistitis

Patient will hold breath and wince in pain when physician palpates the right upper quadrant
- will also grapes right upper quadrant

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7
Q

McBurney sign

A

Associated with acute appendicitis

depicts serious stabbing pain in the right lower quadrant at mcburney point especially upon palpation

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8
Q

Rovsing sign

A

Associated with appendicitis

Show’s pain in the right lower quadrant while physician palpates the left quadrant

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9
Q

Grey-turners sign

A

Associated with hemorrhageic pancreatitis/retroperitoneal bleeding

Shows bruising of the ipsilateral flank

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10
Q

CVA tenderness

A

Seen in pyelonephritis, hydronephrosis or kidney stones

Shows pain in the back kidney area upon palpation

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11
Q

Obturator sign

A

Pain in the obturator canal upon medial rotation and flexion of the hip

**Signals Retroperitoneal appendicitis (tip of the appendix)

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12
Q

Rigid abdomen

A

“Board-like” abdomen that is seen commonly seen In perforated ulcers/bowels or abdominal cancers

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13
Q

What does rebound vs guarding pain usually mean?

A

Rebound pain = implies visceral inflammation/pain
- this layer is more sensitive to stretch/elasticity

Guarding pain = implies parietal inflammation/pain

  • this layer is more sensitive to generalize touch and pain
  • pain gets worsens with pressure and changes to the peritoneum

both are peritoneal signs

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14
Q

How is parietal peritoneum innervated?

A

Somatic efferent and afferent nerves
- irritation to the parietal innervated causes the corresponding segmental areas of skin and muscles reflexively (guarding)

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15
Q

How is the visceral peritoneum

A

Innervated by visceral afferent nerves

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16
Q

Where can referred abdominal pain come from?

A

Appendicitis = pelvic pain and right shoulder pain

Cystitis = pelvic pain and flank pain

UTIs = pelvic pain

Gynecological issues

Pancreatitis = LUQ and epigastric pain

Diverticulitis = LLQ pain (“left-sided appendicitis”)

Ectopic pregnancy

Lower lobe pulmonary pneumonia = diffuse abdominal pain

Inferior MIs = heart burn/RUQ pain

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17
Q

Kehrs sign

A

Can mean acute cholecystitis

Pain is referred to the back/tip of the right shoulder

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18
Q

What can suggest rebound tenderness without having to actually touch the patient?

A

Patient feels sharp increase in pain when coughing

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19
Q

What is the “chandelier sign?”

A

Presents in patient with pelvic inflammatory disease or ectopic pregnancies

Upon biannual pelvic exam (two fingers are used to feel the anatomy of the pelvis) the patient experiences sooo much pain that they mimic reaching up to grab a ceiling mounted chandelier

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20
Q

Signs for small bowel obstruction

A

Patient has intermittent pain with feels of comfort in between pain bouts
- if pain is constant, means strangulation/infarction of the bowel has occurred

Almost always presents with vomiting

Abdomen is distended with high pitched hyperactive bowel sounds

tenderness to palpation is generally not impressive or note worthy

21
Q

Differences between celiac trunk/SMA/IMA diseases and infarcts

A

Celiac = N/V and bloating symptoms

SMA = pain after eating and weight loss

IMA = constipation and blood loss

all will show POOP w/out abdominal signs if infarct is present

22
Q

What are quick facts that can signal a ruptured abdominal aortic aneurysm (AAA)?

A

Elderly patient

Syncope with intense radiating back pain

Pulsatile mass is palpable

  • *best tests to confirm are abdominal and pelvic CT with and without contrast or cross table X-ray**
  • DONT use contrast if renal insufficiency is present
23
Q

What is the most common small bowel and large bowl obstruction causes?

A

Small bowel = Fitzhugh-Curtis syndrome
- adhesions caused by past STDs (especially chlamydia) or post-surgical processes

Large bowel = cancer/metastasis

hernias are the second most common cause of small bowel and especially in the elderly

24
Q

What is the most common volvulus?

A

Sigmoid volvulus
- makes up 75-80% of all volvulus cases

the next most common is cecal volvulus which occurs more often in males in 50-60s ANS makes up 15% of volvulus

**tx for cecal volvulus = ALWAYS SURGERY ; sigmoid volvulus = colonoscopy initially and then surgery

25
Presentation of necrotic volvulus
Shows with hypotension, fever and high WBC counts - also vomiting and constipation Also presents with acute/subacute onset of colicky pain That often persists between spasms *abdominal distention is late fining and is poor prognosis*
26
What is a petersens hernia?
An internal hernia that occurs after gastric bypass surgery where the small bowel herniates and gets obstructed in the bypass area - common in elderly
27
How does constipation usually present differently from surgical issues?
There will be NO peritoneal signs with constipation - there is a palpable mass, however unless there is severe radiating pain or peritoneal signs, it is never a surgical indication
28
What does acute abdominal pain that is localized with lower peritoneal signs usually imply?
Pelvic diseases or possible pregnancy (normal or ectopic)
29
What is the #1 most common cause for acute left lower quadrant pain without a palpable mass or Pain out of proportion?
Diverticulitis disease *palpable mass and POOP could be volvulus or ischemic tissue*
30
What are predisposing factors for volvulus
Elderly Use of anti-cholinergic medications Sedentary lifestyle Chronic constipation and low fiber diets
31
How does chronic appendicitis appear in the elderly
*almost always has 100% with abdominal pain* Pain is often poorly localized - 35% have typical pain patterns - 85% have RLQ tenderness on palpation - <50% have guarding/rebounding - 75% have elevated WBCs - fever is only seen in roughly 25%
32
Risk factors for appendicitis
Male sex Elderly Economic status (poor have high rates) Diet (high carbs and low fiber) Genetics (first degree relative = 10x high risk) Season (summer months are more common due to higher incidences of viral epidemics and bacterial/ameba gastroenteritis) Breast feeding (children who are extended breast feeding have Lower incidence rates)
33
Diagnosis of acute appendicitis
Acute pain around McBurney point (McBurney sign) WBC is elevated in 75% of cases Ultrasound shows non-collapsible, swollen appendix (>6mm) - this doesnt always work though ***CT scans are gold standard to confirm*** **xrays and MRIs DONT WORK**
34
Acute cholecystitis symptoms
Sudden onset RUQ pain - can radiate to the right shoulder/scapula (kehrs sign) - often presents 2-3 hrs after eating a meal - pain progressively gets worse overtime Fever and jaundice Biliary colic *labs can be normal (but usually mild AST/ALT elevation and WBC increase)* **80% will also have gallstones**
35
Charcots triad and reynold’s pentad
Charcots triad - Common in cholidocholethiasis and cholangitis - Contains the following 3 symptoms: 1) RUQ pain 2) Jaundice 3) Fever Reynold pentad - common in only cholangitis ONLY * Has all of charcots PLUS* - AMS - hypotension
36
Imaging for cholelithiasis/ choledocholithiasis
Ultrasound - 75% sensitive if the bile duct is dilated >8 mm - 50% sensitive if no dilation CT scanning - 75% sensitive (same as CT) MRCP - Most sensitive noninvasive 90%** - also doesn’t use ionizing radiation - essentially extreme MRI for just the gallbladder - Takes forever to do though ERCP - Most sensitive invasive 99% and usually the gold standard as long there is heavy clinical evidence backing the decision** - deserves consideration if non-invasive shows nothing but is still invasive so need to weigh considerations - requires endoscopy into the gallbladder - is diagnostic and therapeutic however since if cholelithiasis Is found, can perform sphincterotomy of the sphincter of oddi at the same time (since your already in there)
37
Gastritis/PUD signs
*There is usually NO peritoneal signs* Generalized epigastric pain Common Causes - stress - NSAIDs - Alcohol - H. Pylori infection
38
When can you say ab pain is psychological
While it is common, need to diagnosis via EXCLUSION - NEVER say 1st differential is psychologic pain Usually presents with inconsistent physician findings (POOP) with ruling out ischemic disorders **usually has chronic (>1 year) non progressive ab pain that comes and goes** ***tied heavily to depression, psychosis disorders, anxiety disorders and somatic symptom disorders***
39
What is porphyria
Dark red-purple urine - can be poisoning, septic shock or hemorrhages in the urinary tract - * also can be triggered via extensive alcohol binge, hormone therapies, and some medication (especially chemotherapy) - ** also can be diabetic ketoacidosis so need to known this
40
What is pneumobilia?
Is the presence of gas in the biliary system **Typically is a cause of post operative surgeries on the gallbladder Found on imagining usually incidentally, however can present with unspecified epigastric pain, N/V, fever and jaundice
41
What is the most common cause of constipation?
Idiopathic causes
42
what are the most common etiologies of acute localized abdominal pain?
1) infections or chemical irritations 2) Capsular distention - usually liver or spleen only 3) nerve injuries
43
Lloyds sign
Referred pain from kidney stones Pain is in the back and groin
44
what are examples of patient presentation that can clue you into possible GI differential diagnoses?
Feverish, pale, diaphoretic - infection - bowel infarction/necrosis(usually POOP also) - peritonitis (will also lay still) Laying still - peritonitis Restless and walks around/refuse to lay down - obstruction in the GI tract
45
Sister Mary Joseph node
Is a red buldging area from the umbilicus that is painful upon palpation - usually signals metastatic GI cancer
46
how does sounds of the abdomen signify possible diagnoses?
Rushes/tinkles = obstructions NO sound = infection/ileus Bruits = rushing sounds “whoosh”
47
How does interpretation of MCV in blood tests signify certain diagnoses?
MCV low = iron-deficiency (microcytic anemia) | MCV high = folic acid/B12 deficiencies Macrocytic anemia
48
Treatment of ulcers in the GI tract
- PPIs - H2 blockers - Multiple antibiotics (H. Pylori infections especially)
49
what is “colicky pain”
Pain that comes and goes Very common in cholelithiasis - if in cholelithiasis = worsens with fatty food

Gastrointestinal (71 decks)

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