Acute Abdomen Surgery-Safaoui/Davis Flashcards
What is acute abdominal pain?
Severe abdominal pain with an acute onset (<8 hours) that lasts for several hours
- 2/3 of hospital admissions for this are associated with high morbidity and mortality
- surgical evaluation is warranted*
What is the difference in the presentation of visceral vs parietal pain? (trigger, characteristics of pain, autonomics, surgical intervention needed?)
Visceral:
- Triggered by inflammation, ischemia, distention, traction, and pressure
- pain is vague, deep, dull and poorly localized
- bilateral autonomics
- intra-abd disease but not necessarily surgical
Parietal:
- triggered by irritation of the parietal peritoneum
- sharp, severe, well-localized
- unilateral somatics
- frequently needs surgical intervention
What is the most common cause of acute abd pain in young people? Old people? In pregnancy?
young=appendicitis
old=biliary disease then SBO
pregnancy=appendicitis (might be in location other than RLQ)
What type of pain do foregut problems present with? Midgut? Hindgut?
Foregut (stomach, duodenum, liver, pancreas, spleen, biliary tract) =epigastric pain
Midgut (small bowel to proximal 2/3 of transverse colon) =periumbilical
Hindgut (Distal 1/3 of transverse colon to anal verge) =suprapubic pain
What comes first in a surgical conditions, pain or nausea and vomiting? Medical conditions?
surgical =pain first then n/v
medical=n/v then pain
What problems can present with RUQ pain? (3)
- Cholecystitis
- PNA
- Pyelonephritis
What problems can present with LUQ pain? (5)
- PUD
- Splenic infarct
- pancreatitis
- PNA
- Pyelonephritis
What problems can present with RLQ pain? (5)
- appendicitis (late)
- IBD
- OB/GYN
- Pyelonephritis
- Hernia
What problems can present with LLQ pain? (4)
- OB/GYN
- Pyelonephritis
- Diverticulitis
- Hernia
What problems can present with suprapubic pain? (4)
- IBD
- OB/GYN
- Diverticulitis
- UTI
What problems can present with periumbilical pain? (4)
- appendicitis (early)
- SBO
- Mesenteric ischemia
- AAA
What is the differential for colicky, crampy, intermittent pain?(4)
- Biliary colic
- Ureteral colic (kidney stones)
- Small bowel obstruction
- Large bowel obstruction
What is the differential for gradual progressive pain? (7)
- Hepatitis
- Cholecystitis
- Pancreatitis
- Appendicitis
- Diverticulitis
- Tubo-ovarian abscess
- Ectopic pregnancy
What is the differential for sudden, severe abd pain? (3)
- Ruptured AAA
- Perforated ulcer
- ureteral colic
What refers pain to the right shoulder? (3)
- liver
- gallbladder
- right hemidiaphragm
What refers pain to the left shoulder? (3)
-Heart
-Tail of pancreas
Spleen
-Left hemidiaphragm
What refers to scrotum and testicular pain?
Ureter
What is the most common type of hernia in males and females?
Indirect inguinal hernia
What are the borders of Hesselbach’s triangle? What does this determine?
- Inferior epigastrics
- Lateral edge of the rectus abdominis m.
- Inguinal ligament
- Inside triangle (Medial to epigastrics)=DIRECT hernia
- Lateral to epigastrics=INDIRECT hernia
What is the most frequently encountered surgical disorder of the small intestine? What is the most common cause in pts with previous surgery? Pts without previous surgery?
Small bowel obstruction
- previous surgery: adhesions
- without surgery: hernia
What does air in the biliary tree indicate?
Gallstone ileus
How does a Partial SBO present?
- Continued passage of flatus and/or stool beyond 6 to 12 hours after onset of symptoms
- Occurs slowly
- Strangulation is less likely to develop (much more/faster in a closed loop SBO)
What is the presence of fat wrapping, mesenteric fat creeping onto the serosal surface of the bowel pathognomonic for?
Crohns
can have a “beefy-red appearance of terminal ileum
What is toxic colitis? What can it lead to?
- > 6 bloody stools/d
- fever
- tachycardia
- inc WBC
- dec Hgb/Hct
can get toxic megacolon (all of the above symptoms w/ abd pain, tenderness and distention)
What is the key to finding the appendix?
finding the tenia
What are the complications of acute appendicitis?
- perforation (normally on ante mesenteric border)–> peritonitis
- abscess or phlegmon
- sepsis
What is the most common cause of acute appendicitis in children? In adults?
Children=hypertrophied lymph tissues
adult=fecalith
If carcinoid is found >2 cm and involving the base on the path report of an appendectomy, what should be done?
right hemicolectomy
What is the most common cause of fistulas in the GI tract?
diverticulitis
LLQ pain, obstipation, fever, leukocytosis
What is the best imaging to diagnose diverticulitis?
CT with contrast
What is the first line treatment for uncomplicated diverticulitis?
- antibiotics (metronidazone + cipro or amoxicillin)
- bowel rest
When should surgery be consulted for diverticulitis?
Perforation with Peritonitis
Decompensated Clinical Status
Failure to respond to Medical Management after 72 hrs.
What is the most common cause of a large bowel obstruction (distal to ileocecal valve)?
cancer
How does acute mesenteric ischemia present? What is the most common cause?
- > 60 yo
- 3x more common in women
- sudden onset of mid abdominal pain OUT OF PROPORTION TO PE
- esp in pts with hx of CV disease, CHF, MI or arrhythmias, or stroke
- most common cause=atherosclerotic vascular disease
- 80% mortality
–> needs early recognition
What is acute mesenteric ischemia?
-Reduction in intestinal blood flow
- Most commonly due to:
- Occlusion (arterial embolus or thrombosis or venous thrombosis)
- Vasospasm (least likely)
- Hypoperfusion
What is the gold standard for acute mesenteric ischemia?
mesenteric arteriography
What is chronic mesenteric ischemia?
- Lack of blood supply in splanchnic region.
- From atherosclerotic lesions
- Develops slowly allowing for the development of collaterals.
- Rarely causes intestinal infarction.
- At least 2 of the arteries are occluded or stenosed.
How does Chronic Mesenteric Ischemia typically present? what often happens with these pts?
- Postprandial abdominal pain
- “food-fear”
- weight loss.
-These patients are often thought to have a malignancy and are misdiagnosed.
What is the gold standard for chronic mesenteric ischemia?
angiography
What is the most common cause of mesenteric ischemia? What areas are normally affected?
- ischemic colitis (colonic ischemia)
- watershed areas with limited collateral blood supply (splenic flexure and left colon)
What is the typical presentation of ischemic colitis? What test makes the definitive diagnosis?
-Acute onset of LLQ pain followed by
Mild to moderate rectal bleeding or bloody diarrhea within the first 24 hours
-Physical examination reveals mild to moderate abdominal tenderness over the affected bowel, most often left-sided
*colonoscopy with biopsy
