Acute Abdomen - Exam 4 Flashcards
What information do you really need to obtain from the patient when evaluating an acute abdomen?
What is an important distinction to make clear when evaluating an AA (acute abdomen)?
is it visceral or somatic?
slow-onset, poorly localized, dull discomfort (visceral= organ pain)
sudden, sharp, well-localized, lateralizing pain (somatic/parietal, peritoneal irritation)
What needs to be included as part of your PE work up for AA? What needs to be included as part of the abdominal exam?
abdominal exam
orthostatic vital signs
HEENT
heart and lung
need to include FOB!! and look at testicular/pelvic exam
How long should you listen to the abdomen for peristalsis?
at least 2-3 minutes especially in those who have not eaten
What is the Carnett sign? Give a brief interpretation
A very simple test that can identify whether pain in the abdomen is arising from overlying muscle or underlying peritoneal cavity.
Ask to tense the abdominal wall with neck flexion (protecting the abdominal viscera and cavity from the pressure of the examiner’s hands), and the abdomen is then reexamined
If the patient’s discomfort worsens, it suggests a disorder of the abdominal wall. If it lessens, an intra-abdominal process is more likely
What is the Murphy’s sign? What does it indicate?
Murphy’s Sign - AKA “inspiratory arrest”
As the patient takes a slow, deep breath, the examiner elicits an abrupt cessation in inspiration by deep palpation of the right upper quadrant. This finding is suggestive of cholecystitis
Good indicator for Gallbladder inflammation
What is the Rovsing sign? What does it indicate?
Rovsing - AKA “indirect tenderness”
Right lower quadrant pain elicited by pressure applied on the left lower quadrant
Appendicitis
What is the Psoas sign? What does it indicate?
The patient flexes the thigh against the resistance of the examiner’s hand.
appendicitis
What is the obturator sign? What 3 things does it indicate?
The patient’s thigh is flexed to a right angle and gently rotated, first internally and then externally.
appendicitis
diverticulitis
PID
What is the management for an AA?
What is volvus? What does it lead to? What are the 2 main types? Which one is MC
Torsion of a segment of the bowel, an air segment of colon twists about its mesentery
bowel obstruction
sigmoid and cecal volvulus
sigmoid is MC
What is the MC pt with a volvus? What do they often have a history of?
older adults with a mean age of 70 years at presentation
Patients often institutionalized and debilitated due to underlying neurologic or psychiatric disease and have a history of constipation
What are the risk factors for volvulus?
Anatomic features that may predispose include a long, redundant sigmoid colon with a narrow mesenteric attachment
Chronic fecal overloading from constipation may cause elongation and dilation of sigmoid colon
-Insidious onset of slowly progressive abdominal pain, nausea, abdominal distention, and constipation
- Vomiting usually occurs several days after onset of pain
-Usually ends up continuous and severe, often with colicky component during peristalsis
What am I?
What will be ABSENT in early stages?
Volvulus
Fever, tachycardia, hypotension
______ establishes diagnosis of volvulus (can be cecal or sigmoid). What 2 findings are common
abdominal CT
“whirl” pattern
“Bird-beak” appearance
What is common to find on xray for a pt with volvulus?
Findings include presence of a U-shaped, distended sigmoid colon (“bent inner tube”)
What is this? What dx is it associated with?
whirl pattern on CT
volvulus
What is the management for a sigmoid volvulus? What is the reoccurrence risk? What is the tx?
IV fluids
Endoscopic detorsion with rigid sigmoidoscope
High risk of recurrence
elective sigmoid colectomy performed with primary anastomosis after detorsion
What is the LEAST common type of volvulus? What does it result from? Where does rotation occur around?
cecal volvulus
Results from non fixation of the right colon
Rotation occurs around the ileocolic blood vessels
What are the risk factors for cecal volvulus?
pregnancy, tumors, exertion, violent coughing, colon muscle weakness, infections
-Most present with gradual onset of steady abdominal pain accompanied by episodic cramping pain due to peristalsis
-N/V and obstipation
-Duration of symptoms can last from hours to day
-Diffusely distended and tympanitic with tenderness to palpation
-Fever and or hypotension with peritonitis
What am I?
What is common to see on xray?
Volvulus: Cecal
“Coffee bean sign”
“Comma Sign”
What is the first line imaging for cecal volvulus? What will the report show?
CT : 1st line and confirmatory: locates level of obstruction and can assess bowel damage
“Whirlwind” sign: indicating rotation of mesentery
What is this? What dx is it associated with?
“coffee bean” sign
cecal volvulus
______ can be seen on rectal barium for a volvulus dx
“birds beak”
What is the tx for STABLE cecal volvulus without bowel compromise?
Open Surgical Detorsion, then ileocecal resection #1
What is the tx for Hemodynamically Unstable without bowel compromise or debilitated cecal volvulus?
Cecopexy after detorsion
Anchors to abdominal wall which reduces mobility of cecum
What is the tx for stable WITH with bowel compromise cecal volvulus?
Ileocolic resection or right colectomy
Ileocolonic anastomosis
What is the tx for UNSTABLE with bowel compromise cecal volvulus?
Resection of compromised bowel in its volvulized position followed by an end ileostomy
Can a cecal volvulus be detorsed endoscopically?
NO! needs to be opened up
What is intussusception? What is the MC cause?
Portion of the bowel is telescoped into another segment. One segment becomes drawn into lumen of distal segment of bowel
idiopathic
**What is the MC pt range of intussusception? Male or female? Where is the MC location?
6 months and 3 years
male
ileocolic
______ is the MC cause of intestinal obstruction between 6 months and 3 years
Intussusception
What is the pathogenesis for intusseception?
As the intussusception develops, the mesentery is dragged into the bowel. This leads to the development of venous and lymphatic congestion with resulting edema.
Can lead to ischemia, perforation, and or peritonitis
-Previously healthy infant 3-36 months develops recurring paroxysms of abd pain with screaming and drawing up knees
-Abdominal pain can be severe
- Child is characteristically lethargic/febrile between episodes
- Abdomen tender and distended
What am I?
**What will the pt’s stool look like?
Intussusception
“currant jelly” stools
in intussusception, a _____ mass can be felt on the right side of the abdomen
“Sausage-shaped”
What is the FIRST diagnostic imaging ordered in Intussusception? What is the finding? ______ is confirmatory and ______.
Ultrasound (#1) then abdominal xray to exclude perforation
“coiled spring” or “bullseye” lesion
Barium enema
frequently curative
What does a “coiled spring or “bullseye” lesion represent on abdominal US?
Intussusception
Representing layers of the intestines within the intestines
What is the tx of choice for a stable Intussusception pt? _______ has high success rates in children with ileocolic intussusception
Nonoperative reduction using hydrostatic or pneumatic pressure by enema
Enema reduction
What are the 2 different kinds of Non-operative Reduction in Intussusception when using fluoroscopy? sonography?
fluoroscopy: Pneumatic (air) or hydrostatic (saline or contrast) when us
sonography: Hydrostatic only because air blocks the sound waves
What does a successful fluoroscopy guided intussusception procedure look like? Sonographic?
Fluoro: Successful reduction is indicated by the free flow of contrast or air into the small bowel
Sono: Successful reduction include disappearance of the intussusception and the appearance of water bubbles in the terminal ileum
for both: successful reduction include relief of symptoms and disappearance of the abdominal mass
Which kind of reduction techniques has a higher success rates and less chance of perforation?
pneumatic is preferred
____ is the MC abdominal surgical emergency. What is the MC age range?
Appendicitis
MC between ages of 10 and 30
What is a major underlying cause of appendicitis?
Initiated by obstruction of the appendix by a fecalith (stone made of feces), inflammation, foreign body, neoplasm
Vague, colicky, Abdominal pain
Dull pain originating in periumbilical or epigastric region
Worsened by walking or coughing
N/V, anorexia, obstipation, low grade fever
rebound tenderness
What am I?
Where does the pain localize?
appendicitis
localize to RIGHT LOWER quadrant
What is McBurney’s point tenderness? What dx is it associated with?
appendicitis
What is the imaging study of choice for appendicitis? **What is the tx of choice?
CT scan
**Laparoscopic appendectomy
What are the pre-op abx for appendicitis?
Cefoxitin or ampicillin-sulbactam
What is is the BEST imaging for volvulus? What will it show?
CT scan
whirlwind sign
What is the etiology of toxic megacolon? What is it defined as?
Potentially lethal complication of inflammatory bowel disease or infectious colitis
Total or segmental nonobstructive colonic dilatation of at least 6 cm plus systemic toxicity
What is the hallmark of toxic megacolon? What other dz is it common seen with?
characterized by severe inflammation extending into the smooth muscle layer
IBD, specifically Crohn Colitis,
What does the severe inflammation extending into the smooth muscle layer in toxic megacolon result in? What happens next?
Paralyzing the colonic smooth muscle and leading to dilation
Inflammatory mediators released, inhibiting smooth muscle tone
Malaise
Abdominal pain and distention
Vomiting
Tenesmus
Severe bloody diarrhea
S&S of colitis resistant to therapy often present for at least 1 week prior to onset
dehydration
What am I?
What is the MC presenting symptom?
toxic megacolon
severe bloody diarrhea
**What is the diagnostic imaging of choice for toxic megacolon? **What are the 2 complications? What do you also need to do?
Abdominal CT
perforation and vascular compromise
stool specimen for culture
What is the criteria to dx toxic megacolon?
What part of the colon is often the most dilated in toxic megacolon?
The transverse or right colon is usually most dilated, often >6 cm and occasionally up to 15 cm on supine films
What color is air on CT?
air is BLACK on CT
What is the tx for toxic megacolon?
______ refers to sudden onset of small intestinal hypoperfusion. **What artery does it most commonly affect?
Acute Mesenteric Ischemia
superior mesenteric artery
**What is the MC PE finding in Acute Mesenteric Ischemia?
Abdominal pain out of proportion to PE findings
the rest of the PE will likely be unimpressive
** A useful clinical guideline is any pt with ______ and _____ has Acute Mesenteric Ischemia until proven otherwise
acute abd pain
metabolic acidosis
In Acute Mesenteric Ischemia ____ is performed first but findings are nonspecific. _________ will look at the arteries
Diagnosis Mesenteric Arteriography
**What will Diagnosis Mesenteric Arteriography show in Acute Mesenteric Ischemia?
Shows narrowing/spasming of mesenteric arteries, reduced filling, irregularity of arterial branches
What is the tx for Acute Mesenteric Ischemia?
What is considered an acute upper GI bleed? What is another name for it?
originating proximal to the ligament of Treitz
Suspensory Muscle of the
Duodenum
What is the MC cause of an upper GI bleed?
Peptic ulcer disease
**What is the MC cause of a lower GI bleed?
Diverticulosis
Hematemesis or coffee-ground emesis suggest?
Suggests source proximal to right colon
Ingestion of _____ or _____ - can simulate melena
iron or bismuth
ingestion of _____ can stimulate hematochezia
beets
What abx can result in red stools?
cefdinir
What are predisposing factors to umbilical hernias?
(1) multiple pregnancies with prolonged labor
(2) ascites
(3) obesity
(4) large intra-abdominal tumors
What is this?
umbilical hernia
the umbilical hernia sac usually contain ______. ____ and _____ may be present
omentum
small and large bowel
If _____ or ______ are present in umbilical repair it is consider emergent. Are they common?
if incarceration and strangulation
YES!
How will umbilical hernias present?
often associated with sharp pain with coughing or straining
large hernias will commonly produce an aching sensation
What is the tx for umbilical hernias? give both normal and large hernias options
Mesh repair laparoscopically
Open repair for larger hernias
What are incisional hernias a result from? How common are they?
Result from a breakdown of the fascial closure
10% of abdominal operations result in incisional hernia
What are incisional hernia risk factors?
Small incisional hernias should be treated by early repair since they may cause _____
bowel obstruction
What are some concerning clinical features for ventral hernia strangulation?
include a very firm incarcerated hernia, severe tenderness on exam, and redness or other discoloration of the overlying skin.
Additionally, obstruction leads to abdominal distention
What is the tx for a ventral hernia if the pt is not a surgical candidate?
an abdominal binder or other type of elastic undergarment for compression.
