Acute Abdomen Lecture Flashcards
Esophageal perforation
PUD/gastritis
Mallor-Weiss
..will all present with pain where?
Epigastric pain
Associated with high mortality rate
MC type= iatrogenic (50-60%)
Other causes:
Boerhaave’s Syndrome
Trauma
Foreign body ingestion
Esophageal perforation
A full thickness perforation of the esophagus after a sudden rise in the intraesophageal pressure, often due to forceful emesis
*usually associated with alcohol
Boerhaave’s Syndrome
Acute, severe unrelenting and diffuse pain in chest, neck and abdomen
swallowing exacerbates pain
tachypnea, tachycardia
Abrupt onset, usually preceded by violent emesis
Mediastinal (sub Q) emphysema can be seen (but takes time to develop)
Esophageal perforation
A finding caused by air in the mediastinum being moved by the beating heart, can sometimes be ausculated
Hammon’s crunch
(seen with esophageal perforation)
Pleural effusions happen in about ____% of pts with intrathoracic perforations
50%
Diagnosis of esophageal perforation
CXR will suggest
CT confirms
Related to NSAIDs and H Pylori
dyspepsia= continuous or recurrent upper abdominal pain or discomfort +/- associated symptoms
must consider with heavy NSAID, ASA, ETOH and smoking use
PUD, gastritis
H pylori is present in about…
____% of duodenal ulcers
____% gastric ulcers
95% duodenal ulcers
70% gastric ulcers
Burning epigastric pain that is relieved with food, milk or antacids
recurs at night as stomach empties
EPIGASTRIC TENDERNESS on exam
PUD
Gold standard dx of PUD
Upper GI endoscopy
Partial thickness tear of esophogeal-gastric junction
Hematemesis after vomiting, CP, coughing
CXR to R/O free air/pneumomediastinum
Mallory Weiss Tear
gall stones
often found incidentally (asymptomatic)
**pain ususally after fatty meal (may radiate to chest, R shoulder or scapula)
Cholelithiasis
Highest risk= women age 30-80 yo
Usually gallstone obstructing cystic duct
Fever, chills, vomiting, severe pain (often post prandial)
positive murphy’s sign
Acute cholecystitis
Gallstone in common bile duct
pain radiating to middle of back and epigastric tenderness
may be jaundiced
*can produce sepsis, pancreatitis, obstructive jaundice
Choledocholithasis
Bacterial infection of biliary tree as a result of obstruction
Cholangitis
Top 2 causes of acute pancreatitis
- ETOH abuse
- cholelithasis
A central cause of pancreatitis is intracellular activation of..
trypsin
Nausea, vomiting, epigastric pain
May localize to R or L UQ or radiate to back
Usually begins abruptly and lasts for days
Epigastric tenderness
Bowel sounds may be decreased
+ Cullen or Turner sign in SEVERE cases
May have guarding on exam
Pain worse when lying down, better when leaning forward
Pancreatitis
What 2 labs will be elevated in pancreatitis?
Lipase (3x norm; nearly 100% sensitive and specific)
ALT (3x norm; nearly 95% predictive value for biliary pancreatitis)
Age >55
WBC >16,000
Glucose >200
LDH >350
ALT >250
Ranson’s criteria for Pancreatitis Admission
Pain and nausea control
Hydration
Bowel rest
..mainstay tx for?
acute pancreatitis
MC abdominal surgical emergency
Appendicitis
Develops from obstruction of appendiceal lumen
Increased luminal pressure leads to vascular compromise, bacterial invasion, inflammatory response and resultant tissue necrosis with possible perforation and peritoneal contamination
pain from periumbilical area to the RLQ
Appendicitis
MC ages 10-40
VERY rare in kids under 5
bacterial overgrowth by E. Coli occurs in 80%
Rosvings
Heel Strike
Obturator Sign
Psoas Sign
Guarding
Appendicitis
After the onset of vague abdominal pain, the classic triad of symptoms in appendicitis are:
1.
2.
3.
- anorexia
- nausea
- vomiting
What is the most reliable sign for appendicitis in kids?
Guarding
Is fever an early or late sign of appendicitis?
Late
Dx of appendicitis is
most are diagnosed clinically
*but, image of choice = CT scan!
90% occur in sigmoid colon (LLQ pain)
generally in >50 yo
results from high colonic pressures, resulting in erosion and microperforation of the diverticular wall, leading to inflammation of the pericolonic tissue
Diverticulitis
Image of choice for diverticulitis?
CT scan
Flagyl + Cipro = DOC for?
Diverticulitis
Most pts >60
Males
HTN
Family history
Marfan’s Syndrome, smoking, hyperlipidemia, diabetes
AAA
Thinning of the media of the aorta with a reduction in elastic, collagen and fibromellar units results in a decrease in tensile wall strength
as the aorta dilates, the force on the aortic wall increases, causing further aortic dilation
*on avg, can grown 0.25 cm to 0.5 cm a year
AAA
For a AAA, those larger than _____cm are at risk of rupture
5 cm
Classically older males with severe back or abdominal pain who presents with syncope or hypotension
“tearing” or “ripping” pain
Often complain of unilateral flank or groin pain, hip pain or abdominal pain localized to a specific quadrant
AAA
Retroperitoneal hemorrhage on periumbilical
Cullen’s sign
AAA
What is the Grey-Turner sign that can be seen with a AAA?
Flank ecchymosis
Image of choice for AAA
CT scan
(but if pt is really unstable, can do a bedside ultrasound)
Asymmetric femoral pulses can be seen with….
AAA
Periumbilical pain out of proportion to exam
often seen in pts with a fib, hypercoagulable conditions, vasculitis, sickle cell
Ischemic bowel
(usually occurs at: splenic flexure, rectosigmoid jxn, ascending colon)
Inflammation of mesenteric lymph nodes (usually RLQ)
Mesenteric Adenitis
What is more common, large or small bowel obstruction?
Small bowel obstruction
MC cause of small bowel obstruction
Adhesions following surgery
Adhesions
Incarcerated inguinal hernias
Intussusception
Lymphoma
Strictures
..all cause?
Small bowel obstruction
Carcinoma
Fecal impaction
Ulcerative colitis
Volvulus
Diverticulitis
Intussception
Psuedo-obstruction
…all can cause?
Large bowel obstruction
(neoplasm = MC cause)
Vomiting
Abdominal distention
Pain
Past hx of abdominal surgery or hernia
Bowel obstruction
What are the bowel sounds like in a person with an obstruction?
Initially..hyperactive
Later, diminished/absent
