acute abdomen, appendix, biliary tree

Question 1

facute abdomen

Answer 1

-pain so severe pt seeks medical attention
-most dont require surgery

Question 2

signs of peritoneal irritation

Answer 2

-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

Question 3

herpes zoster

Answer 3

-pain proceeds vesicular eruption/rash
-you can take out the appendix and then dermatomal rash appears after!!

Question 4

diaphragmatic irritation

Answer 4

-lower lobe pneumonia
-left shoulder referred pain -> Kehr’s sign (typically from splenic rupture)

Question 5

mesenteric adenitis

Answer 5

-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

Question 6

conditions that mask abdominal pain

Answer 6

-steroids
-DM
-paraplegia

Question 7

tabes dorsalis

Answer 7

-syphilis nerve pain
-T10 dermatome
-right/left lower quad pain

Question 8

appendicitis

Answer 8

-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

Question 9

different appendicitis incisions

Answer 9

-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

Question 10

US for appendicitis

Answer 10

-most accurate
-thickened wall
-fluid around it
-distended

Question 11

interval appendectomy

Answer 11

-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

Question 12

physical exam

Answer 12

-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

Question 13

other causes for abdominal pain

Answer 13

-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

Question 14

labs to order with abdominal pain

Answer 14

-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

Question 15

diverticulitis

Answer 15

-fever
-LLQ
-change in bowel habits

Question 16

mesenteric ischemia

Answer 16

-abdominal pain out of proportion to PE
-do mesenteric angiogram
-jejunum- folate
-ileum- b12
-ligamentum teres to transverse colon will die

Question 17

LLQ colon cancer

Answer 17

-LLQ pain
-change in bowel habits (pencil thin stool)
-weight loss
-apple core sign

Question 18

AAA

Answer 18

-hypotension
-pulsatile abdominal mass
-OR for emergent laparotomy

Question 19

perforation

Answer 19

-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

Question 20

gallbladder

Answer 20

-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!!

Question 21

gallstones

Answer 21

-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

Question 22

biliary colic

Answer 22

-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

Question 23

risks for gallstone development

Answer 23

-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

Question 24

acute cholecystitis

Answer 24

-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
-TX: abx (gram -) and cholecystectomy within 72hrs (laparoscopically!!)
-Boas sign → most likely chronic cholecystitis

Question 25

choledocholithiasis

Answer 25

-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
-dilated bile ducts or filling defects in bile duct -> US, CT, ERCP
-tx with endoscopic sphincterotomy (ERCP)! and stone extraction
-stent and take out stone
-if fails do surgery
-even if asymptomatic you treat

Question 26

gallstone diseases

Answer 26

-cholelithiasis- no tx
-cholecystitis- treat

Question 27

cholelithiasis vs choledocholithiasis vs cholecystitis

Answer 27

-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

Question 28

(ascending) cholangitis

Answer 28

-SURGICAL EMERGENCY
-bacterial or sclerosing (PSC)
-bacterial infection of GB d/t obstruction in common bile duct
-2ndry to choledocholithiasis
-Charcot’s triad → RUQ pain, fever, jaundice (bacterial)
-Reynolds Pentad’s → above + AMS & hypotension (Ascending)
-Occurs in presence of pus in biliary ducts
-Elevated bilirubin & Alk Phos
-TX: IV abx , tube chole to drain fluid out of GB -> ERCP for stenting and tx

Question 29

ascending cholangitis

Answer 29

-SURGICAL EMERGENCY
-Reynolds Pentad’s → RUQ pain, fever, jaundice + AMS & hypotension (Ascending)

Question 30

primary sclerosing cholangitis

Answer 30

-long term progressive ds of the liver and gallbladder characterized by inflammation and scarring of the bile ducts, which normally allow bile to drain from gallbladder
-pANCA is diagnostic marker (not specific to this tho)- antibody
-males, >50% have IBD
-results in multiple bile duct strictures
-predisposed to liver failure, cholangiocarcinoma

Question 31

cholangiocarcinoma

Answer 31

-klatskin tumor occurs at the confluence of the right and left hepatic bile ducts

Question 32

bile duct neoplasms

Answer 32

-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

Question 33

cholecystectomy

Answer 33

-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

Question 34

triangle of Calot’s (cystohepatic triangle)

Answer 34

-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

Question 35

chronic cholecystitis

Answer 35

-chronic, repeated attacks of cholecystitis
-BOA’s sign = RUQ pain radiating to tip of right scapula
-Rokitansky-aschoff bodies!!

Question 36

painful obstructive jaundice

Answer 36

-biliary tract problem
-stone from gallbladder go into cystic duct into the common bile duct -> get impacted at ampulla of vater (where it empty into SB)

Question 37

courvoisier’s sign

Answer 37

-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

Question 38

whipple procedure

Answer 38

-for courvoisier’s gallbladder
-head of pancreas (adenocarcinoma) cancer
-iatrogenic injury to spleen

Question 39

chronic acalculous cholecystitis

Answer 39

-long term NPO patient
-GB not contracting = stasis
-severe inflammatory disorder in absence of calculi
-usually hospitalized pt already ill
-complication of salmonellosis
-sludge blocks the gallbladder
-tx- do tube cholecystostomy

Question 40

mirizzi syndrome

Answer 40

-Common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum (hartmann’s pouch) of the gallbladder
-mechanical obstruction
-causes compression of common bile duct
-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

Question 41

gallstone ileus

Answer 41

-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

Question 42

different color stones

Answer 42

-black stones- calcium salt stones from hemolysis or cirrhosis -> sterile gallbladder
-brown stones- calcium apatite from dysmotility of biliary system and bile ducts
-can sometimes be bacterial
-pts with ascending cholangitis with choledocholithiasis
-infected gallbladder
-yellow stones- cholesterol gallstone
-assoc with bacterial infection
-E. coli or klebsiella
-Approximately 10-20% of gallstones; calcium bilirubinate

Question 43

abdominal pain: obstruction, inflammation, perforation, ischemia

Answer 43

-obstruction:
-colicky
-if there is peristalsis it will cresendo and decrescendo
-can progress to constant pain due to distention
-no fever, no leuko
-cholelithiasis, nephrolithiasis, SBO
-inflammation:
-fever, leukocytosis (infection)
-constant pain
-cholecystitis, appendicitis, diverticulitis
-perforation:
-sudden onset and constant pain
-air under diaphragm
-fever, leuks, tachy
-motionless pt
-peptic ulcer, penetrating trauma, final outcome of ischemia & obstruction
-ischemia:
-POOP- pain out of proportion to PE
-pt is moving uncomfortable
-leuks, fever, high lactate
-bloody diarrhea after full infarct -> too late
-embolism, acute mesenteric ischemia, nonvascular=volvulus

Question 44

jaundice

Answer 44

-cancer
-mirizzi syndrome
-choledocholithiasis
-cholangitis

Question 45

spleen infarction

Answer 45

-sickle cell pts
-autosplenectomy bc its not used
-spleen function = opsonization of encapsulated bacteria
-strep pneumonia, Hemophilus, Neisseria meningitis

Question 46

retroperitoneal hematoma

Answer 46

-pt with groin catheter (possible cardiac catheterization)
-hypotensive, tachy
-hematoma disections up into retroperitoneal space
-you can feel it in a skinny pt
-dx- CT

Question 47

pneumobilia

Answer 47

-infection in the bowel
-air in the liver
-bacteria produces gases
-rigler triad- SBO, pneumobilia, aberrant gallstone (outside the gallbladder) -> indicates gallstone ileus

Question 48

causes of bowel obstructions

Answer 48

-adhesions- prior surgery- MCC of SBO
-herniation- young pts
-intussusception- young pts
-cancer- older pts

Question 49

transition point

Answer 49

-adhesions
-dumbbell appearance
-distended bowel prior to it
-tx laparoscopic

Question 50

types of pain

Answer 50

-Visceral Pain - Dull, Crampy, Deep, Aching
-Parietal Pain - Sharp, Severe, Persistant
-Epigastric - Foregut
-Periumbilical - Midgut
-Lower Abdominal - Hindgut

Question 51

visceral stimulation

Answer 51

-Stretching and Contraction
-Traction, Compression, Torsion
-Stretch Alone
-Certain Chemicals
-distention
-peristalsis

Question 52

strictures and other obstructions to bile flow

Answer 52

-Lumen (stone, blood, foreign body)
-Bile duct (post-operative, benign, malignant)
-Extrinsic compression (benign, malignant)

Question 53

imaging for biliary disease

Answer 53

-Ultrasound: Good for gallbladder, calculi, bile duct visualization (esp in liver); not expensive, generally readily available
-CT scan: Generally good for visualizing bile ducts and other intraabdominal organs, staging of tumors. Expensive
-ERCP/MRCP: Excellent for ductal visualization, including pancreas, therapeutic (removal of stones in bile duct, placement of stents for palliation; invasive; very operator dependent
-HIDA scan: Nuclear medicine study. Helpful if suspect gallbladder dysfunction (esp acute cholecystitis) when other imaging equivocal. Many false negatives (and positives). Cannot be used if significant jaundice.
-Oral cholecystogram: Oral contrast taken up by gallbladder. Rarely used these days -> for small free floating stones -> give meds
-PTC (percutaneous transhepatic cholangiogram): Performed by interventional radiologist. Invasive. Occasionally employed when ERCP unable to be performed and non-surgical intervention required
-insert needle for dye in liver
-EUS: Ultrasound system attached to endoscope

Question 54

complications of gallstones and cholecystitis

Answer 54

-Compression of bile duct (Mirizzi’s syndrome)
-Mucocele, empyema, emphysematous cholecystitis (air in gallbladder wall) -> gallstone ileus
-Gangrene, perforation, bile peritonitis
-Cholecyst-enteric fistula (air in gallbladder lumen)
-Gallstone ileus (small bowel obstruction)
-Porcelain gallbladder (calcified gallbladder wall)
-Carcinoma (rare)
-Choledocholithiasis (about 10%)

Question 55

gallbladder polyps

Answer 55

-Asymptomatic, benign. No treatment necessary
-Concern if large, irregular shape

Question 56

other causes of cholangiopathy

Answer 56

-Primary sclerosing cholangitis
-Autoimmune
-AIDS cholangiopathy
-Cryptosporidiosis
-CMV
-Cholangiocarcinoma
-Chemotherapy (hepatic artery infusion)
-Biliary papillomatosis