Acute Abdomen & Referred Pain

Question 1

What is an acute abdomen?

Answer 1

Acute abdominal pain so severe that the patient seeks medical attention

Question 2

What are peritoneal signs?

Answer 2

Signs of peritoneal irritation (extreme tenderness, percussion tenderness, rebound tenderness, voluntary guarding, motion pain, involuntary guarding (late))

Question 3

What is rebound tenderness?

Answer 3

Pain upon releasing the palpating hand pushing on the abdomen

Question 4

What is motion pain?

Answer 4

Abdominal pain upon moving, pelvic rocking, moving of stretcher, or heel strike

Question 5

What is voluntary guarding?

Answer 5

Abdominal muscle contraction with palpation of the abdomen

Question 6

What is involuntary guarding?

Answer 6

Rigid abdomen as the muscles guard involuntarily

Question 7

What is colic?

Answer 7

Intermittent severe pain (usually because of intermittent contraction of a hollow viscus against an obstruction)

Question 8

What conditions can mask abdominal pain?

Answer 8

Steroids, diabetes, paraplegia

Question 9

What is the most common cause of acute abdominal surgery in the US?

Answer 9

Acute appendicitis

Question 10

What should the acute abdomen physical exam include?

Answer 10

Inspection (surgical scars, distention).
Auscultation (bowel sounds, bruits).
Palpation (tenderness, R/O hernia, CVAT, rectal, pelvic exam, rebound, voluntary guard, motion tenderness).
Percussion (liver size, spleen size).

Question 11

What is the best way to have a patient localize abdominal pain?

Answer 11

Point with one finger to where the pain is worse

Question 12

What is the classic position of a patient with peritonitis?

Answer 12

Motionless (often with knees flexed)

Question 13

What is the classic position of a patient with a kidney stone?

Answer 13

Cannot stay still, restless, writhing in pain

Question 14

What is the best way to examine a scared child or histrionic adult’s abdomen?

Answer 14

Use stethoscope to palpate abdomen

Question 15

What lab tests are used to evaluate the patient with an acute abdomen?

Answer 15

CBC with differential, Chem-10, amylase, T&S, U/A, LFTs

Question 16

What is a left shift on CBC differential?

Answer 16

Immature neutrophils; sign of inflammatory response

Question 17

What lab test should every woman of childbearing age with an acute abdomen receive?

Answer 17

B-HCG

Question 18

Which XRs are used to evaluate the patient with an acute abdomen?

Answer 18

Upright CXR, upright AXR, supine AXR.

If patient cannot stand, left lateral decubitus AXR.

Question 19

How is free air ruled out if the patient cannot stand?

Answer 19

Left lateral decubitus (free air collects over the liver and does not get confused with the gastric bubble)

Question 20

What is the differential diagnosis for RUQ pain?

Answer 20

Cholecystitis, hepatitis, PUD, perforated ulcer, pancreatitis, liver tumors, gastritis, hepatic abscess, choledocholithiasis, cholangitis, pyelonephritis, nephrolithiasis, appendicitis, pleurisy, pneumonia, PE, pericarditis, MI

Question 21

What is the differential diagnosis for LUQ pain?

Answer 21

PUD, perforated ulcer, gastritis, splenic injury, abscess, reflux, dissecting aortic aneurysm, pyelonephritis, nephrolithiasis, hiatal hernia, Boerhaave’s syndrome, Mallory-Weiss tear, splenic artery aneurysm, colon disease, pleurisy, pneumonia, PE, pericarditis, MI

Question 22

What is the differential diagnosis for LLQ pain?

Answer 22

Diverticulitis, sigmoid volvulus, perforated colon, colon cancer, UTI, SBO, IBD, nephrolithiasis, pyelonephritis, fluid accumulation from aneurysm or perforation, referred hip pain, gynecologic cause

Question 23

What is the differential diagnosis for RLQ pain?

Answer 23

Appendicitis, mesenteric LAD, cecal diverticulitis, Meckel’s diverticulum, intussusception, sigmoid volvulus, perforated colon, colon cancer, UTI, SBO, IBD, nephrolithiasis, pyelonephritis, fluid accumulation from aneurysm or perforation, referred hip pain, gynecologic cause

Question 24

What is the differential diagnosis for epigastric pain?

Answer 24

PUD, gastritis, MI, pancreatitis, biliary colic, gastric volvulus, Mallory-Weiss tear

Question 25

What is the differential diagnosis for gynecologic pain?

Answer 25

Ovarian cyst, ovarian torsion, PID, mittelschmerz, TOA, uterine fibroid, necrotic fibroid, pregnancy, ectopic pregnancy, endometriosis, cancer (cervix, uterus, ovary), endometrioma

Question 26

What is the differential diagnosis for thoracic causes of abdominal pain?

Answer 26

MI, pneumonia, dissecting aorta, aortic aneurysm, empyema, esophageal rupture or tear, PTX, esophageal foreign body

Question 27

What is the differential diagnosis for scrotal causes of lower abdominal pain?

Answer 27

Testicular torsion, epididymitis, orchitis, inguinal hernia, referred pain from nephrolithiasis or appendicitis

Question 28

What are nonsurgical causes of abdominal pain?

Answer 28

Gastroenteritis, DKA, sickle-cell crisis, rectus sheath hematoma, acute porphyria, PID, kidney stone, pyelonephritis, hepatitis, pancreatitis, pneumonia, MI, C. difficile colitis

Question 29

What is the unique differential diagnosis for the patient with AIDS and abdominal pain?

Answer 29

CMV, Kaposi's sarcoma, lymphoma, TB, MAC

Question 30

What are the possible causes of suprapubic pain?

Answer 30

Cystitis, colonic pain, gynecologic causes, appendicitis

Question 31

What causes pain limited to specific dermatomes?

Answer 31

Zoster

Question 32

What is referred pain?

Answer 32

Pain felt at a site distant from a disease process. | Caused by the convergence of multiple pain afferents in the posterior horn of the spinal cord.

Question 33

What is gastroenteritis?

Answer 33

Viral or bacterial infection of the GI tract, usually with vomiting and diarrhea, pain (usually after vomiting)

Question 34

What is classically stated to be the great imitator?

Answer 34

Constipation

Question 35

What are the classic locations of referred pain with cholecystitis?

Answer 35

Right subscapular pain

Question 36

What are the classic locations of referred pain with appendicitis?

Answer 36

Early: periumbilical pain Late: testicular pain

Question 37

What are the classic locations of referred pain with diaphragmatic irritation (from spleen, perforated ulcer or abscess)?

Answer 37

Shoulder pain

Question 38

What are the classic locations of referred pain with pancreatitis or pancreatic cancer?

Answer 38

Back pain

Question 39

What are the classic locations of referred pain with rectal disease?

Answer 39

Pain in the small of the back

Question 40

What are the classic locations of referred pain with nephrolithiasis?

Answer 40

Testicular or flank pain

Question 41

What are the classic locations of referred pain with small bowel disease?

Answer 41

Periumbilical pain

Question 42

What are the classic locations of referred pain with uterine disease?

Answer 42

Midline small of back pain

Question 43

What disease classically presents as hypotension and pulsatile abdominal mass?

Answer 43

Ruptured AAA

Question 44

What disease classically presents as fever, LLQ pain, and change in bowel habits?

Answer 44

Diverticulitis

Question 45

What is the test of choice for cholelithiasis?

Answer 45

U/S

Question 46

What is the test of choice for bile duct obstruction?

Answer 46

U/S

Question 47

What is the test of choice for mesenteric ischemia?

Answer 47

Mesenteric A-gram

Question 48

What is the test of choice for ruptured abdominal aortic aneurysm?

Answer 48

None - operate

Question 49

What is the test of choice for AAA?

Answer 49

Abdominal CT or U/S

Question 50

What is the test of choice for abdominal abscess?

Answer 50

Abdominal CT

Question 51

What is the test of choice for severe diverticulitis?

Answer 51

Abdominal CT

Question 52

What is the most common cause of RUQ pain?

Answer 52

Cholelithiasis

Question 53

What is the most common cause of surgical RLQ pain?

Answer 53

Acute appendicitis

Question 54

What is the most common cause of LLQ pain?

Answer 54

Diverticulitis

Question 55

What endocrine problems can cause abdominal pain?

Answer 55

Addisonian crisis, DKA