Acute Abdomen, Appendix, Biliary Tree Flashcards
acute abdomen
-pain so severe pt seeks medical attention
-most dont require surgery
signs of peritoneal irritation
-extreme tenderness to percussion and palpation, rebound tenderness, involuntary/voluntary guarding, motion pain
-pt is motionless in bed with knees flexed
-surgical condition -> control the source
-give IV antibiotics
-sharp, severe, localized
herpes zoster
-pain proceeds vesicular eruption/rash
-you can take out the appendix and then dermatomal rash appears after!!
diaphragmatic irritation
-lower lobe pneumonia
-left shoulder referred pain -> Kehr’s sign (typically from splenic rupture)
mesenteric adenitis
-URI 1-2 weeks before RLQ pain
-lymphocytosis - viral PNA
-enlargement of lymph nodes in the mesentary- RLQ near the terminal ileum has greatest concentration of lymph nodes
conditions that mask abdominal pain
-steroids
-DM
-paraplegia
tabes dorsalis
-syphilis nerve pain
-T10 dermatome
-right/left lower quad pain
appendicitis
-females have higher neg appendix finding
-visceral pain
-RLQ pain- starts at belly button
-McBurney’s, psoas sign, obturator sign, rebound tenderness, Rovsings
-anorexia!!
-mass affect -> shift to left due to phlegmon or perforation
-leukocytosis, bands, left shift
-do a rectal and vaginal exam -> tender along R wall
-dx
-PE!!!
-x-ray - not really useful
-may see ball (fecalith -> poop stone) if do CT
-U/A abnormal- if irritation of ureter
-tx- laparoscopic procedure
-better to take out suspected appendicitis in women bc adhesions on tubes
-interval appendectomy if burst
-hydration
-antibiotics
-fowler position
different appendicitis incisions
-Rocky-Davis = transverse, done during open appendectomy
-McBurney incision = oblique incision, following the external oblique muscles -> laparoscopic
-through the vagina - less adhesions and no scarring
-follow the taenia coli on the cecum to find the appendix
-fat stranding
-inflammation extending up distal cecum
-fat in that area
US for appendicitis
-most accurate
-thickened wall
-fluid around it
-distended
interval appendectomy
-appendicle phlegmon
-delayed sx with a lot of inflammation
-cant operate on it due to contacted omentum -> allows leakage of stool in abdomen
-give moxifloxacin IV -> send home PO -> inflammation goes down -> pt comes back to get appendectomy
-appendix phlegmon = inflammation of colon, appendix, mesentery, omentum
complicated appendicitis tx flow chart
physical exam
-inspection, auscultation, percussion, palpation
-child/histrionic female- use stethoscope to palpate
-have pt localize pain by using one finger to point
-HCG ON EVERY PT
other causes for abdominal pain
-addisonian crisis
-DKA
-CMV in an AIDS pt
-Fitz-hugh-curtis syndrome- chlamydia/gonorrhea ascends and causes RUQ pain -> projections pull on liver capsule
-uremic pt
-heavy metal toxicity
-snake bite, venom
-mittelschmerz- ovulation pain- mimics appendicitis
labs to order with abdominal pain
-lipase - pancreas, ovarian cysts
-high amylase - mumps, twisted ovaries
-lactic acid - high with ischemia
-CBC- left shift -> inflammatory response
-Elevated bilirubin & Alk Phos- choledocholithiasis and cholangitis
-beta HCG
-U/A
-U/S
-CT abdomen and pelvis
diverticulitis
-fever
-LLQ
-change in bowel habits
mesenteric ischemia
-abdominal pain out of proportion to PE
-do mesenteric angiogram
-jejunum- folate
-ileum- b12
-ligamentum teres to transverse colon will die
LLQ colon cancer
-LLQ pain
-change in bowel habits (pencil thin stool)
-weight loss
-apple core sign
AAA
-hypotension
-pulsatile abdominal mass
-OR for emergent laparotomy
perforation
-any suspicions of perforation -> WATER SOLUBLE CONTRAST FOR CT
-do not use barium
-IV contrast- fluids and N-acetylcysteine to protect kidneys
-sudden onset and constant pain
-air under diaphragm
-fever, leuks, tachy
-motionless pt
-peptic ulcer, penetrating trauma, final outcome of ischemia & obstruction
gallbladder
-stores bile
-fatty food presence -> CCK -> gal bladder contracts -> makes more bile
-if pt eats a fatty meal -> Fat goes through stomach -> CCK stimulation -> gallbladder contraction -> if RUQ pain = obstructed and dilation
-robin’s egg blue- WNL
-dark green- disease
-abnormal bile function = cant absorb/digest fat soluble vitamin - Vitamin K!!
gallstones
-mostly cholesterol (75%) -> dont light on scan
-majority asymptomatic
-calcium bilirubinate is less common -> pigment
-cholelithiasis- stone in gallbladder
-typically lodge in cystic duct or hartmann’s pouch (infundibulum)
-bile to lecithin ratio!!!! -> if there is overload of bile pigment/load -> stones develop
-dx- U/S- GOLD STANDARD
-ERCP/MRCP= dx and tx -> remove stones via stenting -> good for ductal visualization
-HIDA = physiologic functioning
-PTC (percutaneous transhepatic cholangiogram) = never on cirrhosis, ascites, coagulopathic pt = inject contrast into bile ducts -> x ray -> invasive and painful
-tx- symptomatic pts cholecystectomy (laparoscopically)
-if very sick (shock) -> tube cholecystostomy
-dont tx asymptomatic
biliary colic
-gallbladder/gallstone attack- stone trying to pass
-colic pain due to gallstone temporarily blocking cystic duct
-acute inflammation ABSENT
-RUQ, epigastric, episodic pain
-pain will wake you up from sleep
-Dx- US
-bloodwork is normal
-Tx- only for symptomatic -> laparoscopy
-elective cholecystectomy
-shock wave lithotripsy, dissolution agents - RARE
risks for gallstone development
-obesity/pregnancy → increases abd pressure and causes stasis
-5 F’s → female (>40), fat, fertile, flatulent
-hereditary spherocytosis, sickle cell ds → continuous HEMOLYSIS → increased bile → stones
-crohn’s ds
-backwash ileitis due to UC
-gastric surgery
-NPO→ stasis of bile → sludge
-diabetes mellitus → increased risk bc dont feel pain
-drugs - hormones, TPN
-rapid weight loss
acute cholecystitis
-RUQ pain
-murphy’s sign
-fever
-rigidity
-tachy
-right shoulder radiation (Boas sign)- chronic
-acute inflammation of gallbladder PRESENT
-inflammation and infection of the gallbladder due to obstruction of the CYSTIC DUCT by gallstones
-If chills present → d/t E coli/klebsiella
-dx- US:
-thickening of GB wall
-dilation of CYSTIC DUCT
-pericholecystic fluid collection
-WBCs, LFTs
-HIDA if US is unequivocal
-TX: abx (gram -) and cholecystectomy within 72hrs (laparoscopically!!)
-Boas sign → most likely chronic cholecystitis
-exclamation point
-cystic duct blockage
-acute cholecystitis
-stones are seen with no shadowing -> dense
-bursted gallbladder or abscess
-blood culture for e coli and klebsiella
choledocholithiasis
-gallstones in COMMON bile duct
-biliary colic
-obstructive jaundice
-cholangitis- infection of bile duct -> sepsis and fever
-pancreatitis- due to obstruction of pancreatic duct
-secondary biliary cirrhosis- d/t obstruction
-S&S:
-if of obstruction: pain, jaundice, cholestasis (elevated Bili and alk phos!)
-if of Secondary infxn (cholangitis): sepsis and fever
-!!!dilated bile ducts and hepatic duct
-dx- high alk phos and bilirubin, LFTs, lipase
-dilated bile ducts or filling defects in bile duct -> US, CT, MRCP, ERCP
-tx with endoscopic sphincterotomy (ERCP)! and stone extraction
-stent and take out stone
-if fails do surgery
-even if asymptomatic you treat
gallstone diseases
-cholelithiasis- no tx
-cholecystitis- treat
cholelithiasis vs choledocholithiasis vs cholecystitis
-cholelithiasis = presence of abnormal concretions (gallstones) in gallbladder
-choledocholithiasis = gallstones in the common bile duct
-cholecystitis = inflammation of gallbladder w/ gallstones in the cystic duct
cholangiocarcinoma
-klatskin tumor occurs at the confluence of the right and left hepatic bile ducts
bile duct neoplasms
-intrinsic = primary bile duct origin (biliary)
-ampullary
-gallbladder
-extrinsic = confluence of common bile duct and pancreas (pancreatic)
-periampullary carcinoma
-contiguous malignant process
-s/sx → cholestasis, jaundice, wt loss, abd mass
-imaging shows obstructed, dilated bile ducts, +/- mass
-tissue sampling to confirm dx
-non tender palpable RUQ mass = couvsiours sign
-Dx with bx- radiological guided aspiration or ERCP
-Tx → ERCP/stent but usually not bc veins of luschka spreads mets to liver
-surgical resection if resectable
-palliative care
-also must feed pt adequately bc the deposition of bile salts in skin → itch
-Itching from deposition of bile salts on skin → Cancer
-cure- may not be possible
-supportive- itch, pain, nutrition, bowel obstruction
cholecystectomy
-right hepatic artery is susceptible to injury
-find the hepatoduodenal artery -> if this is cut -> PRINGLE MANEUVER
-pringle maneuver- pinch cystic artery, 2 clips placed on vascular end and 1 on other end
-if pt is hypotensive, oliguric, tachy -> back to OR due to bleed
triangle of Calot’s (cystohepatic triangle)
-UPPER: liver
-LOWER: cystic duct,
-MEDIAL: bile duct
-WITHIN: cystic artery and Lund’s node
-Node inflamed/enlarged in acute cholecystitis (pain)
-May be palpable w/ cancer (painless)
-NOTE Recall: Lund’s Node = Calot’s Node
calot triangle
courvoisier’s sign
-painless
-obstructive jaundice
-palpable distended, non-tender gallbladder
-enlarged
-seen with tumors at head of pancreas (MC adenocarcinoma) or duodenum, biliary tumor -> QUIZ
-whipple procedure
whipple procedure
-for courvoisier’s gallbladder
-head of pancreas (adenocarcinoma) cancer
-iatrogenic injury to spleen
mirizzi syndrome
-Common hepatic duct obstruction caused by compression from cholcystitis
-mechanical obstruction
-cholcystitis + choldococystitis
-Jaundice, increased alk phos and transaminase elevated
-Sx of obstructed jaundice
-pain
-can lead to cholangitis
-Post chole complication → Baby GB left behind, can lodge and compress common hepatic duct
RUQ pain, pericholecystic fluid, Murphy’s sign
-ALP, GGT, and direct bilirubin are elevated
-CBD dilation proximal to the cystic duct and normal ducts distal
-tx- cholecystectomy, NOT ERCP
gallstone ileus
-causes bowel obstruction
-gallbladder forms fistula to duodenum
-large stones travels from gallbladder to duodenum through the fistula
-travels through intestines to ileocecal valve where it lodges and causes mechanical gallstone obstruction and SBO → intraluminal obstruction
-inflamed gallbladder fall against duodenum -> fistula -> large stones goes and gets stuck at ileocecal valve
-mechanical obstruction caused by stone inside the bowel
-pneumobilia
hepatoduodenal ligament
