Acute Abdomen - Exam 4 Flashcards by Johannah Crumpton

What information do you really need to obtain from the patient when evaluating an acute abdomen?

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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)

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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

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How long should you listen to the abdomen for peristalsis?

at least 2-3 minutes especially in those who have not eaten

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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

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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

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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

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What is the Psoas sign? What does it indicate?

The patient flexes the thigh against the resistance of the examiner’s hand.

appendicitis

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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

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What is the management for an AA?

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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

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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

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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

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-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

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______ establishes diagnosis of volvulus (can be cecal or sigmoid). What 2 findings are common

abdominal CT

“whirl” pattern

“Bird-beak” appearance

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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”)

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What is this? What dx is it associated with?

whirl pattern on CT

volvulus

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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

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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

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What are the risk factors for cecal volvulus?

pregnancy, tumors, exertion, violent coughing, colon muscle weakness, infections

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-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”

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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

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What is this? What dx is it associated with?

“coffee bean” sign

cecal volvulus

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______ can be seen on rectal barium for a volvulus dx

“birds beak”

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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.