Acute Abdomen & Referred Pain Flashcards
What is an acute abdomen?
Acute abdominal pain so severe that the patient seeks medical attention
What are peritoneal signs?
Signs of peritoneal irritation (extreme tenderness, percussion tenderness, rebound tenderness, voluntary guarding, motion pain, involuntary guarding (late))
What is rebound tenderness?
Pain upon releasing the palpating hand pushing on the abdomen
What is motion pain?
Abdominal pain upon moving, pelvic rocking, moving of stretcher, or heel strike
What is voluntary guarding?
Abdominal muscle contraction with palpation of the abdomen
What is involuntary guarding?
Rigid abdomen as the muscles guard involuntarily
What is colic?
Intermittent severe pain (usually because of intermittent contraction of a hollow viscus against an obstruction)
What conditions can mask abdominal pain?
Steroids, diabetes, paraplegia
What is the most common cause of acute abdominal surgery in the US?
Acute appendicitis
What should the acute abdomen physical exam include?
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).
What is the best way to have a patient localize abdominal pain?
Point with one finger to where the pain is worse
What is the classic position of a patient with peritonitis?
Motionless (often with knees flexed)
What is the classic position of a patient with a kidney stone?
Cannot stay still, restless, writhing in pain
What is the best way to examine a scared child or histrionic adult’s abdomen?
Use stethoscope to palpate abdomen
What lab tests are used to evaluate the patient with an acute abdomen?
CBC with differential, Chem-10, amylase, T&S, U/A, LFTs
What is a left shift on CBC differential?
Immature neutrophils; sign of inflammatory response
What lab test should every woman of childbearing age with an acute abdomen receive?
B-HCG
Which XRs are used to evaluate the patient with an acute abdomen?
Upright CXR, upright AXR, supine AXR.
If patient cannot stand, left lateral decubitus AXR.
How is free air ruled out if the patient cannot stand?
Left lateral decubitus (free air collects over the liver and does not get confused with the gastric bubble)
What is the differential diagnosis for RUQ pain?
Cholecystitis, hepatitis, PUD, perforated ulcer, pancreatitis, liver tumors, gastritis, hepatic abscess, choledocholithiasis, cholangitis, pyelonephritis, nephrolithiasis, appendicitis, pleurisy, pneumonia, PE, pericarditis, MI
What is the differential diagnosis for LUQ pain?
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
What is the differential diagnosis for LLQ pain?
Diverticulitis, sigmoid volvulus, perforated colon, colon cancer, UTI, SBO, IBD, nephrolithiasis, pyelonephritis, fluid accumulation from aneurysm or perforation, referred hip pain, gynecologic cause
What is the differential diagnosis for RLQ pain?
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
What is the differential diagnosis for epigastric pain?
PUD, gastritis, MI, pancreatitis, biliary colic, gastric volvulus, Mallory-Weiss tear
What is the differential diagnosis for gynecologic pain?
Ovarian cyst, ovarian torsion, PID, mittelschmerz, TOA, uterine fibroid, necrotic fibroid, pregnancy, ectopic pregnancy, endometriosis, cancer (cervix, uterus, ovary), endometrioma
What is the differential diagnosis for thoracic causes of abdominal pain?
MI, pneumonia, dissecting aorta, aortic aneurysm, empyema, esophageal rupture or tear, PTX, esophageal foreign body
What is the differential diagnosis for scrotal causes of lower abdominal pain?
Testicular torsion, epididymitis, orchitis, inguinal hernia, referred pain from nephrolithiasis or appendicitis
What are nonsurgical causes of abdominal pain?
Gastroenteritis, DKA, sickle-cell crisis, rectus sheath hematoma, acute porphyria, PID, kidney stone, pyelonephritis, hepatitis, pancreatitis, pneumonia, MI, C. difficile colitis
What is the unique differential diagnosis for the patient with AIDS and abdominal pain?
CMV, Kaposi’s sarcoma, lymphoma, TB, MAC
What are the possible causes of suprapubic pain?
Cystitis, colonic pain, gynecologic causes, appendicitis
What causes pain limited to specific dermatomes?
Zoster
What is referred pain?
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.
What is gastroenteritis?
Viral or bacterial infection of the GI tract, usually with vomiting and diarrhea, pain (usually after vomiting)
What is classically stated to be the great imitator?
Constipation
What are the classic locations of referred pain with cholecystitis?
Right subscapular pain
What are the classic locations of referred pain with appendicitis?
Early: periumbilical pain
Late: testicular pain
What are the classic locations of referred pain with diaphragmatic irritation (from spleen, perforated ulcer or abscess)?
Shoulder pain
What are the classic locations of referred pain with pancreatitis or pancreatic cancer?
Back pain
What are the classic locations of referred pain with rectal disease?
Pain in the small of the back
What are the classic locations of referred pain with nephrolithiasis?
Testicular or flank pain
What are the classic locations of referred pain with small bowel disease?
Periumbilical pain
What are the classic locations of referred pain with uterine disease?
Midline small of back pain
What disease classically presents as hypotension and pulsatile abdominal mass?
Ruptured AAA
What disease classically presents as fever, LLQ pain, and change in bowel habits?
Diverticulitis
What is the test of choice for cholelithiasis?
U/S
What is the test of choice for bile duct obstruction?
U/S
What is the test of choice for mesenteric ischemia?
Mesenteric A-gram
What is the test of choice for ruptured abdominal aortic aneurysm?
None - operate
What is the test of choice for AAA?
Abdominal CT or U/S
What is the test of choice for abdominal abscess?
Abdominal CT
What is the test of choice for severe diverticulitis?
Abdominal CT
What is the most common cause of RUQ pain?
Cholelithiasis
What is the most common cause of surgical RLQ pain?
Acute appendicitis
What is the most common cause of LLQ pain?
Diverticulitis
What endocrine problems can cause abdominal pain?
Addisonian crisis, DKA
