Acute Abdominal Pain Flashcards

Question

Etiology of Cholecystitis

Answer 1

-Gallstone- most common form of GB disease --Formed from cholesterol ---Stone becomes impacted within the cystic duct ---Inflammation occurs behind the obstruction -Bacterial agents -Neoplasm -Stricture of the common bile duct -Ischemia -Torsion (twisting of the duct)

Answer 2

-Obesity, pregnancy, sedentary lifestyle, low fiber diet -Risk factors: Female, advanced age, rapid weight loss, fad diets, high cholesterol

Answer 3

-Often precipitated by a large or fatty meal -Sudden severe pain in the epigastric or RUQ area -Vomiting sometimes an alleviating factor -referred pain in right shoulder or back.

Answer 4

-Murphy’s sign: Deep pain on inspiration while palpating under the right rib cage -RUQ tenderness to palpation; palpable gallbladder in 15% of cases -Muscle guarding and rebound pain -Fever

Answer 5

-Leukocytosis -Elevated serum bilirubin Serum ALT, AST, LDH, and alk phos elevation -Amylase may be elevated -Xray may show stones ---RUQ US is the gold standard -HIDA scan (will show obstructed bile duct) -ERCP- assesses diagnose stones and assess biliary and pancreatic ducts -Amylase (rule out concomitant pancreatitis -EKG- Remember to assess above and below -CXR- r/o pneumonia

Answer 6

-Pain management -NPO ---If significant vomiting, consider NGT for decompression -Crystalloids for hydration -Antiemetics -Broad spectrum antibiotics (i.e Zosyn)- after blood cultures are obtained -Surgical consultation for cholecystectomy -Biliary decompression via endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and extraction of stones

Answer 7

Acute inflammatory autodigestive process of the pancreas

Answer 8

-Gallbladder Disease -Alcoholism or acute intoxication -Hypercalcemia -Hyperlipidemia -Trauma/Surgery -Medications- Sulfonamides, Thiazides, Furosemide, Estrogen, Azathioprine -Ischemia -PUD -Pregnancy -Neoplasm -Idiopathic

Answer 9

-Abrupt onset of steady severe epigastric pain usually worsened by walking or lying supine -Pain improves when sitting up and leaning forward or when holding the knees to the chest -Pain that radiates to the back or elsewhere -Nausea and Vomiting usually present -Pending severity: weakness, sweating, anxiety -Ileus -Fever -Tachycardia, hypotension, cool/pale skin (hypovolemia

Answer 10

-Distended abdomen -Mild jaundice may occur -Grey-Turner sign -Flank discoloration -Umbilical discoloration (Cullen's sign) -Absent bowel sound if ileus present

Answer 11

-Leukocytosis -Hyperglycemia -Elevated LDH, AST Serum amylase (50-180 U/dL) and lipase (14-280 U/L) are elevated in 90% of cases -BUN may be elevated -Hypocalcemia -Elevated CRP suggests pancreatic necrosis -CT is preferred over US to assess for pseudocysts, necrosis, and fistulas

Answer 12

-Severe, constant upper abdominal pain -Elevated amylase and/or lipase levels (≥3 times the upper limit of normal). Due to greater specificity, the measure of lipase is preferred to amylase -Evidence on imaging studies (CT, ultrasound, or MRI) -Ranson's criteria assesses prognosis

Answer 13

-Maintain NPO -Aggressive IV volume repletion ---Unless prevented by cardiovascular or renal comorbidities, aggressive IV fluids (250 to 350 cc/hr) should be given to the patient immediately to decrease blood urea nitrogen (BUN). This is the most important goal of initial treatment. -NG suction if needed d/t ileus -Pain control -Once pain free and bowel sounds present may start diet and advance as tolerated -Stone management if causing blockage -Manage electrolyte abnormalities -Failure to improve, consider empiric antibiotics ---Piperacillin-Tazobactam Cefepime +/- metronidazole

Answer 14

Inflammation of the appendix, precipitated by obstruction of the appendiceal lumen, If untreated treatment is delayed it can lead to gangrene and perforation within 36 hours

Answer 15

-Fecalith (undigested food) -Foreign body -Inflammation -Neoplasm

Answer 16

Obstruction of the appendix caused by fecalith, inflammation, foreign body, intestinal worms, strictures or tumors leads to inflammation of the appendix. If left untreated it can quickly evolve into a life threatening crisis.

Answer 17

-Initially subtle and nonspecific -Anorexia and periumbilical discomfort -Progresses to RLQ pain -Nausea and vomiting x 1-2 episodes Persistent vomiting consider alternative diagnosis

Answer 18

-RLQ guarding with rebound tenderness -Psoas sign- pain with right thigh extension -Obturator sign- Pain with internal rotation of flexed right thigh -Positive Rovsing’s sign- RLQ pain when pressure applied to the LLQ -Localized (point) abdominal tenderness (McBurney’s point) -Low grade fever

Answer 19

-Alvarado Score -Labs will show leukocytosis -CT or US is diagnostic US is 98% accurate as long as it can be visualized CT can detect perforation, assess for abscess -UA to rule out urinary tract infection -Pregnancy test to rule out ectopic pregnancy

Answer 20

-Surgical evaluation -IV antibiotics ----A cephalosporin (ceftriaxone or cefazolin) with metronidazole ----Piperacillin-tazobactam If penicillin allergic, consider ciprofloxacin or levofloxacin with metronidazole -IV fluids -Pain & Nausea management -Risk of perforation if treatment is delayed -If on initial presentation appendicitis is ruled out but symptoms persist, patient should have a repeat reevaluation within 12-24 hours

Answer 21

Inflammation or localized perforation of one or more diverticula with abscess formation

Answer 22

-Not clearly proven -Low fiber diet -More common in men than women -Weakness or defect in the colon

Answer 23

-Mild to moderate abdominal pain in the LLQ -Constipation common but may alternate with diarrhea -Nausea and vomiting -Abdominal distention -Dysuria and frequency- inflammatory bowel that causes irritation to the bladder -Low grade fever -severity may indicative of perforation

Answer 24

Patients with diverticulosis are usually asymptomatic. Diverticulitis occurs when a diverticulum becomes inflamed and often presents with: •Abdominal pain (often left lower quadrant) •Constipation •Nausea and fever (systemic symptoms) •Usually marked tenderness on an abdominal exam due to peritoneal irritation from the microperforation -can include hematochezia

Answer 25

-Leukocytosis -Elevated ESR and CRP -Plain Xray- to assess for perforation -Avoid Barium Enema or Flex Sig in the acute phases -CT may reveal abscess -Stool hemoquant + 25% of cases

Answer 26

-can be treated at home -Bowel rest Clear liquids and advance to low residue for 24-48 hours Progress to high fiber diet as bowel function normalizes -Antibiotics •Ciprofloxacin 500 mg orally 2 times daily combined with metronidazole 500 mg orally 3 times daily for 10 to 14 days •Amoxicillin 875 mg and clavulanate 125 mg orally 2 times daily for 10 to 14 days

Answer 27

-NPO versus low residue -diet -IV fluids -Antibiotics -Treat GI bleeding if present -Surgical consult as 20-30% of patients will require surgical management -Hospitalization: complicated diverticulitis, inability to tolerate orals, high fever or significant leukocytosis, immunocompromised

Answer 28

-Adhesion- most common (50-70%) -Hernia (15%) -Malignancy (15%) -Volvulus- twisting of bowel on itself -Stricture- r/t Crohn’s disease, radiation, ischemia -Hematoma- trauma related, anticoagulation -Intussusception- slipping of once part of an intestine into another part just below it -Fecal impaction -Foreign bodies

Answer 29

-Cramping periumbilical pain initially but later becomes constant and diffuse -Vomiting within minutes of pain (think proximal) -Vomiting hours after onset (think distal) -Most likely afebrile

Answer 30

-Minimal abdominal distention- proximal -Pronounced abdominal distention- distal -Mild tenderness but not peritonitic -High pitched, tinkling bowel sounds -Unable to pass gas/or stool per rectum -Watery or mucousy stool may be present in partial obstruction -Dehydration

Answer 31

-Normal labs in the early stages -Later stages may see leukocytosis and labs consistent with dehydration -Plain X-Ray will show dilated loops of bowel and air-filled fluid levels -A horizontal pattern in a small bowel obstruction -Frame pattern in large bowel obstruction -CT is helpful to determine level of obstruction and cause if X-ray is unrevealing -Key diagnostic sign is finding a transition point between dilated and collapsed, nondistended bowel to locate the obstruction

Answer 32

-Bowel rest. NGT to LIS -Fluid and electrolyte management -Surgery consult if complete obstruction or if partial obstruction fails to respond to medical management -Treat the underlying cause -Steroids helpful if secondary to malignancy -PPI, H2 blockers and Octreotide

Answer 33

Acute inflammation of the visceral and parietal peritoneum

Answer 34

-Spontaneous bacterial peritonitis -E. Coli is most common organism along with Klebsiella, Pneumococcus, and Enterococcus

Answer 35

-Following trauma or penetrating wounds -Peritoneal dialysis -Perforation -Postop -Bowel ischemia -TB -Familial Mediterranean fever

Answer 36

-Acute abdominal pain- worse with motion -High fevers -N/V and Constipation -Ascites -Ill appearing, septic

Answer 37

-Distention -Rebound tenderness -Generalized rigidity -Decreased bowel sounds -Hyperresonance to percussion

Answer 38

-Peritoneal aspirate ---Leukocyte count >10,000/mm3 ---LDH >225 mU/ml ---Protein levels >1 g/dl ---Glucose <50 mg/dl --Presence of multi organisms on gram stain and/or culture -Blood cultures -Leukocytosis -Elevated BUN -Mixed acidosis -Elevated serum amylase -Abdominal XR will show ---Free air in the peritoneal cavity ---Dilation of large or small bowel -CXR will show elevated diaphragm

Answer 39

-Surgical consult -Antibiotics- third-generation cephalosporin ----Cefotaxime (Claforan) 2 g IV q8h ----Ceftriaxone (Rocephin) 2 g IV q24h ----Ampicillin or Unasyn should be added if concern for enterococcus ----Severe cases call for Aminoglycoside such as Gentamycin + Metronidazole ---Caution use of aminoglycosides in chronic liver failure patient's d/t risk of nephrotoxicity -Fluid resuscitation -NPO, NG if needed -Continuous ambulatory -peritoneal dialysis -Intraperitoneal vancomycin, ----20 mg/L dialysate + 1 g IV load, plus gentamicin, 6-8 mg/L dialysate ---Intraperitoneal cefazolin (Ancef)

Answer 40

SBP is an acute bacterial infection of ascites fluid in patients with cirrhotic liver disease. Usually there is no source of infection. Mortality in these patients is high.

Answer 41

-Albumin shown to increase survival rate 25% albumin administered intravenously on day 1 (1.5 g/kg) and on day 3 (1 g/kg) has been shown to decrease mortality -Repeat paracentesis 48 hours after treatment to ensure decrease in PMN cell count -Prophylaxis indicated as it is likely to reoccur

Answer 42

Result of inadequate blood flow through the mesenteric circulation leading to ischemia and gangrene of the bowel

Answer 43

-Thrombus or Embolism -Surgical complication -Trauma -Malignancy -Occlusion of arterioles with systemic disease ----i.e. TTP, DIC, Polyarteritis nodosa, SLE -Nonocclusive mesenteric vascular disease ---i.e. CHF, AS, Shock, Cardiac arrhythmia, vasoconstrictors -Older adults -Smokers

Answer 44

-Sudden onset of cramping, colicky pain that is out of proportion to physical exam findings. -N/V -Fever -Abdominal guarding and tenderness -Bowel sounds can be hyperactive or absent -Shock- tachycardic and hypotensive -Rectal bleeding if colonic ischemia

Answer 45

-Leukocytosis -Lactic acidosis -Mesenteric Angiography is useful to determine the -location of vascular lesions -MRA has sensitivity and specificity in detecting mesenteric ischemia -CT can show mesenteric ischemia, focal or segmental bowel wall thickening, submucosal edema or hemorrhage, pneumatosis, portal venous gas ------The findings of pneumatosis intestinalis or portal venous gas on CT, along with peritoneal signs, indicate a medical and surgical emergency.-----

Answer 46

-surgical consult -Embolectomy or bypass of the occluded vessel to prevent infarction -Bowel resection if infarction has occurred

Answer 47

-Correct volume deficits -Treat heart failure -Reverse digitalis toxicity -NG tube for decompression -Antibiotics if peritonitis is suspected -Vasodilators may be utilized once volume has been restored -The goal for management is to restore intestinal perfusion, reverse ischemia and prevent infarction.

Answer 48

-Abdominal aortic aneurysm -Mesenteric ischemia -Perforation of GI tract (peptic ulcer, bowel, eso, appendix) -Acute bowel obstruction -Volvulus -Ectopic pregnancy -Placental abruption -Myocardial infarction -Splenic rupture

Answer 49

-Focal dilatation of at least 50% compared to normal though any measurement >3cm is abnormal. Pulsatile mass on PE in some patients pending body habitus Some manifest as abdominal, back, or flank pain -Rupture causes hemorrhage and unstable hypotension -Most common in men >60yo -Those with COPD, PVD, HTN, smoking, and a family history of AAA are at higher risk -US is diagnostic but not helpful in the setting of rupture -CT abd/pelvis without contrast if the patient is stable -STAT surgery consult if the patient is unstable ---As AAA can cause back pain and hematuria- there is potential to be misdiagnosed as nephrolithiasis.----

Answer 50

Splenic rupture in the setting of Epstein Barr virus (EBV), leukemia, and trauma may present with life-threatening abdominal pain.