Approach to acute abdomen

Question 1

_____ is the most common chief complaint in
Emergency Medicine

Answer 1

Abdominal Pain

Question 2

Measure Acuity / Critically ill with acute abdomen

Answer 2

○ Extremes of age
○ Severe pain with rapid onset
○ Abnormal vitals (especially HR and BP)
○ Dehydration
○ Visceral involvement
○ Fever (unreliable for medical vs surgery)
○ Orthostatic Vitals are useful

Question 3

Types of abdominal pain:

Answer 3

○ Visceral Pain- pain derived from an organ.
● “Crampy dull achy”
● Activate pain fibers near organs
○ Parietal Pain- pain derived from irritation of the parietal
peritoneum.
● Rigid, guarded pain
● Prefers holding still - can be very telling
○ Referred Pain- felt at a location away from diseased
area. Embryologic development of contiguous
innervation.

Question 4

Acute Abdomen associated symptoms:

Answer 4

○ Nausea/vomiting ○ Constipation ○ Diarrhea ○ Fever ○ Weight loss ○ Jaundice ○ Hematemesis ○ Blood in stool- ■ Hematochezia, melena ○ Indigestion ○ Dysuria

Question 5

Risk Factors for acute abdomen

Answer 5

○ Elicited during PMHx, FMHx, SHx
■ Liver disease
■ Diabetes
■ Prior abdominal surgeries- raises concern for ileus
(post-op bowel obstruction)
■ Pregnancy and menstrual history, G?P?
■ Medications- Recent antibiotics, “blood thinners”
■ Allergies
■ Recent trauma
■ Immunologic conditions- such as HIV

Question 6

Some “rules” to consider with acute abdomen

Answer 6

■ #1- Diagnostic Imaging does not replace a good history and physical.
■ #2 - Imaging takes time (Ex: CT vs Bedside US).
■ #3 - If you are going back and forth about ordering something,
considering evidence-based medicine, maybe good to error on the
side of caution and order the test rather than miss something.

Question 7

Bedside Ultrasound (POCUS) uses:

Answer 7

■ Becoming much more common (eg. FAST)
■ Measure a AAA (consider with pts >50)
■ Used to detect abscess formation in cellulitis
■ Bladder US/scan- Urinary Retention

Question 8

Radiology-Based Ultrasound uses

Answer 8

■ Great for gallbladder, biliary tract, liver,
pancreas, kidneys, ureters, pelvic pathology,
OB/Gyn emergencies (such as torsion,
ectopic preg, etc.)
■ Can be considered for Appendicitis (not great)

Question 9

CT Abd/Pelvis can be used with contrast for:

Answer 9

● Bowel mucosa, appendicitis, abscess,
obstruction, AAA, ischemia, hernia.
● Order at least 1 liter IV fluids

Question 10

CT Abd/Pelvis can be used without contrast for:

Answer 10

■ Without contrast for kidney stones or in
those with contraindication for contrast.
■ You should obtain POC creatinine if contrast

Question 11

Management of Acute Abdomen in ED

Answer 11

○ Pain control- Studies show this does not obscure findings or
the exam. Do not withhold analgesics in significant abd pain.
○ Keep your patient NPO if surgery is even a slight possibility.
○ For nausea/vomiting- multiple options. Two common ones:
■ Zofran- IV or ODT
■ Metoclopramide (Reglan)
○ Urinary catheter may be needed.
○ NG Tube - Decompress the bowel in obstructions
○ Urgent antibiotics in cases of possible sepsis and peritonitis,
given empirically. Get Blood cultures first

Question 12

In cases of possible or suspected Sepsis

Answer 12

○ Early recognition is vital.
○ Reversal of hemodynamic compromise.
■ Goal to improve perfusion and O2 delivery
■ IV access and 2-6 L IV fluid bolus (30 mL/KG)
■ Vasopressors may be needed if BP is not responding to
fluids (>90 systolic)
○ Infection Control- Empiric broad-spectrum antibiotics.
○ Lactic Acid- Repeat and watch for clearance (< 2 mmol/L or
10% reduction).

Question 13

Approach to treatment for abdominal infections

Answer 13

○ Choice of antibiotics preference vs availability.
○ Here are some commonly-used antibiotic options
for when suspected intra-abdominal source:
● Ampicillin/Sulbactam (Unasyn)- 1.5-3 gm IV
● Piperacillin/Tazobactam (Zosyn)- 3.375 gm IV
● Vancomycin- 15 mg/kg IV
○ C.Diff, Staph, Pre-operative
● Metronidazole (Flagyl)- 500 mg IV- Anaerobic
● Levofloxacin (Levaquin)- 750 mg IV- Urinary,
Pyelonephritis

Question 14

Reasons to admit for acute abdomen:

Answer 14

■ Intractable pain or vomiting.
● Hospitalist may admit, may want surgeon too.
■ SBO- Can hydrate, make NPO, initiate “bowel rest.”
● Typically surgery is not indicated.
● However, still consult surgery who will manage.
■ Lack of social support, the elderly, etc.
● Admission is more liberal with the elderly,
especially when diagnosis is not certain
■ Ask yourself- Is the patient safe to discharge home?

Question 15

Acute Cholecystitis

Answer 15

● Inflammation arises from obstruction of the of the
gallbladder or biliary duct by gallstones
● More common in biologically female individuals.
○ “Female, Forties, Fertile (pregnant), Fat”
● Although occurs in all age groups though, not just 40s.
● Can be associated with:
○ Gallstone Pancreatitis and Ascending Cholangitis

Question 16

Signs and symptoms of Acute Cholecystitis in the ED

Answer 16

○ Typically RUQ pain
■ Colicky, can refer to right scapula
○ Nausea, vomiting, often made worse w/ greasy food.
○ +Murphy’s Sign

Question 17

ED Workup for acute cholecystitis

Answer 17

○ Keep the patient NPO
○ Ultrasound is best
○ CT if Dx is unclear after ultrasound
○ Labs- CBC, CMP, Urinalysis, HCG, Lipase
○ HIDA scan? Rare from the ED

Question 18

ED Management of Acute Cholecystitis

Answer 18

○ NPO, General Surgery consult, and admit

Question 19

Ascending Cholangitis (Acute Cholangitis)

Answer 19

○ Superimposed Infection of the bile duct-
○ That can be life threatening.
■ Urgent Surgery / GI Consult (ERCP)
■ Sepsis- Triple coverage
Charcots triad~

Question 20

Charcot’s Triad

Answer 20

1. Fever
2. Jaundice
3. RUQ pain

Question 21

Acute Pancreatitis

Answer 21

● Inflammation of the Pancreas.
○ Can range from mild to severe systemic inflammatory
response with multiorgan failure.

Question 22

Acute pancreatitis risk factors

Answer 22

Alcoholism, cholelithiasis, high triglycerides,
some medications, and male sex (higher incidence).

Question 23

Acute Pancreatitis patient presentation & exam

Answer 23

● History- Midepigastric boring pain radiates to mid back
● Associated with nausea, vomiting, anorexia, low grade
fever. Epigastric pain and vomiting predominate the Dx.
● Physical Exam-
○ Epigastric tenderness, guarding, mild-moderate distress.
○ Can be hypotensive, AMS, or ARF in severe cases / SIRS.
○ Gray Turner Sign and Cullen’s Sign if hemorrhagic.

Question 24

Acute Pancreatitis ED workup

Answer 24

○ Abd/Pelvis CT with contrast
○ Ultrasound potentially
○ Lipase at 2-3 times upper limit of normal
○ CBC, CMP
○ Ranson Criteria- Predicts mortality at point of admission and 48 hrs

Question 25

ED Management of acute pancreatitis

Answer 25

Mostly Supportive ○ NPO (Bowel Rest) + Pain Control + Antiemetics = Mainstay of Tx ○ Lots of IV fluids (NS or LR), and pressors if needed ○ GI Consult for Gallstone Pancreatitis (ERCP). ○ Most are admitted, but in mild disease can be sent home

Question 26

Acute Hepatitis

Answer 26

● Inflammation of liver from toxic, metabolic, or infectious causes. ○ Can be worsening on top of Chronic Liver Disease

Question 27

Acute Hepatitis presentation

Answer 27

○ Recent ingestions- Alcohol, certain medications, some herbals, some mushrooms. ○ Can be seen with some STDs, or recent travel. ○ History of Hepatitis A and B, C, HIV. ○ RUQ or epigastric abdominal pain. ○ Jaundice. ○ Nausea/vomiting, malaise. ○ Pale stools, dark urine Physical - RUQ pain over the liver

Question 28

Acute Hepatitis ED workup

Answer 28

○ CBC, CMP, Lipase are mainstay of labs. ■ AST/ALT ratio greater than 2 suggests Alcoholic Hepatitis ■ Elevated Alk Phosphatase (Biliary) ○ Elevations in Bilirubin and PT/INR poor prognostic indicators. ○ Serum Tylenol levels may need to be considered.

Question 29

ED Management for Acute Hepatitis

Answer 29

IV fluids and then largely supportive ○ Viral Hepatitis- largely supportive. At risk for chronic? ○ Alcoholic Hepatitis- Supportive and prophylaxis for alcohol withdrawal. ○ Admit high risk of liver failure as they are at increased mortality risk. ■ ↑INR, ↑Bilirubin, Encephalopathy, Pregnancy, Immune suppressed, toxin-induced

Question 30

Acute Appendicitis

Answer 30

Common surgical emergency, most common in children and young adults (can happen in all ages).

Question 31

Acute Appendicitis presentation

Answer 31

○ RLQ pain that is commonly severe but can be vague. ○ More obvious as it progresses. ○ Classic- Pain that is periumbilical then migrates to RLQ over perhaps 1-2 days. ○ Often will not want to move, voluntary guarding. ○ “Speed Bump Sign” ○ Pain that suddenly resolves could mean it perforated. ○ Fever not always present (but may suggest perforation)

Question 32

Acute Appendicitis physical exam

Answer 32

○ Interestingly, pretty nonspecific. ○ Mcburney point TTP ○ Rovsing Sign ○ Obturator Sign ○ Psoas Sign ○ Rebound tenderness ○ “Heel Jar” sign. ○ Should you do all of the tests?

Question 33

Acute Appendicitis ED workup

Answer 33

○ If high clinical suspicion, do extensive workup ○ Serum HCG, CBC, CMP are helpful ○ Urinalysis- Pyuria, Hematuria (irritation of ureter) ○ Ultrasound for kids and in pregnancy ■ MRI is an option sometimes ○ Ultrasound for Gynecologic etiology rule out ○ CT Abd/Pelvis with IV contrast is imaging of choice

Question 34

ED management

Answer 34

- Consider early surgical consult ○ Keep NPO and Preop Abx

Question 35

Acute Diverticulitis

Answer 35

● Inflammation/infection of colonic diverticula. ○ Most common in older patients (~50 plus). ● Can be complicated by perforation, abscess, obstructions.

Question 36

Acute Diverticulitis presentation

Answer 36

○ Constipation and/or diarrhea (sometimes bloody) ○ Bloating and acute LLQ pain with acute onset ■ Generally develops over 1-2 days ○ May or may not have fever ○ Palpable mass is possible (uncommon, unreliable)

Question 37

Acute Diverticulitis physical exam

Answer 37

○ LLQ tenderness to palpation ○ Mild to severe peritonitis signs ○ Possible blood in stool (hemoccult)

Question 38

Acute Diverticulitis ED workup

Answer 38

○ Consider gynecologic etiology in females (PID, torsion, ectopic preg, etc.). ○ CT Abd/Pelvis w/ IV contrast is imaging of choice ○ CBC, CMP ○ Urine/serum HcG (consider) ○ Urinalysis

Question 39

Acute Diverticulitis ED management

Answer 39

○ No abscess = “uncomplicated diverticulitis.” Abscess = “complicated.” ○ As long as no abscess, consider outpatient - Abx, pain control, fluid diet. ○ If there is an abscess, surgical consult and likely admission. ○ Antibiotics- Metronidazole w/ Cipro or Clindamycin or Augmentin ○ If outpatient Tx, quick return precautions (Ex: “come back if worsening”)

Question 40

Ischemic Bowel Disease

Answer 40

● Acute blockage of arterial blood flow to the small or large bowel. ● Rare but devastating condition, more common in the elderly. ○ Risk factors: Afib, severe atherosclerosis, CHF, hypercoagulable, diabetes. ● Considered a life-threatening emergency condition

Question 41

Ischemic Bowel Disease Presentation

Answer 41

○ Ill patients with CAD and/or peripheral vascular disease, recent MI, other cardiovascular issues. ○ Classically, pain is sudden onset, worsened with eating.

Question 42

Ischemic Bowel Disease PE

Answer 42

○ Also classically, pain out of proportion to exam (Ischemic Visceral Pain), rebound tenderness, +/- blood in stool.

Question 43

Ischemic Bowel Disease ED workup

Answer 43

○ Be highly suspicious in the elderly. ○ Get CBC, CMP- Elevated WBC usually. ○ Abdominal XR- Can be normal, may see dilated loops of bowel later on. ○ CT Angiogram- Most common imaging. ○ Angiography- Historic study of choice. ■ Potentially therapeutic as well, although accessibility is an issue

Question 44

Ischemic Bowel Disease ED management

Answer 44

○ Early Recognition is key. Don’t miss! ○ Keep NPO, get surgical consult early. ○ Interventional Radiology- Angiography. ○ Usually requires bowel resection, anticoagulation.

Question 45

Abdominal Aortic Aneurysm risk factors

Answer 45

○ Most commonly in older individuals (esp males), history of smoking, HTN, family Hx of AAA, Hx atherosclerosis. ○ Acute rupture means that your patient is bleeding to death

Question 46

Abdominal Aortic Aneurysm presentation

Answer 46

○ If found when asymptomatic, may be treated before rupture. ○ Severe abrupt onset tearing or ripping pain that is usually deep and boring, abdomen or lumbar region. Syncope

Question 47

Abdominal Aortic Aneurysm PE

Answer 47

○ Palpable pulsatile mass, abdominal bruit, Cullen sign and/or Grey-Turner sign. ○ Class ruptured AAA- Abdominal pain, back pain, hypotension, tachycardia, hypovolemic shock

Question 48

Abdominal Aortic Aneurysm ED workup

Answer 48

○ Very quickly obtain two large-bore IV access points. ○ Obtain type and cross. ○ CBC, CMP ○ Bedside US can be used for unstable patients- (FAST exam) ○ CT is highly sensitive, but slow- don’t send unstable patients to CT! ○ Cardiac Monitor

Question 49

Abdominal Aortic Aneurysm ED management

Answer 49

○ Can seek Vascular surgeon consult on clinical grounds (without imaging). ○ Do not delay Emergency Surgery for diagnostic studies. ○ If found incidentally (asymptomatically), consult with vascular surgery, which can be outpatient. ○ Pain control

Question 50

Toxic Megacolon

Answer 50

● Toxic Megacolon is a complication of Ulcerative Colitis, Crohn's, Infectious problems, radiation, C.Diff. ○ Paralyzing the smooth muscle. ○ Leads to colon distension and progresses to perforation

Question 51

Toxic Megacolon presentation

Answer 51

○ Building abdominal pain and distension. ○ May or may not have diarrhea, constipation, blood in stool. ○ As about risk factors (see above).

Question 52

Toxic Megacolon PE

Answer 52

○ Abdominal tenderness to palpation and distended ○ In severe cases, may be rigid, potentially tympanic. ○ Generally rectal bleeding ○ Fever, tachycardia, hypotension - SIRS, sepsis potential ○ Presents like peritonitis

Question 53

Toxic Megacolon ED workup

Answer 53

○ CBC, CMP (>WBC, Anemia) ○ ESR, CRP ○ Abdominal X-ray- Colonic Dilation > 6cm, Free Air ○ Criteria 3 of the following: ■ Fever, Tachycardia >120, Leukocytosis, Anemia ○ CT Abd/Pelvis is important too

Question 54

Toxic Megacolon ED management

Answer 54

- Can be Fatal ○ NPO and placement of NG tube ○ IV Prednisolone or Methylprednisolone ○ Antibiotics- Include for Anaerobes ○ Copious IV fluids ○ Surgical Consultation ASAP- Perforation, Lower GI Bleed, Persistent Sx

Question 55

Bowel Obstruction

Answer 55

● Mechanical blockage or loss of peristalsis, large or small bowel. ● Small Bowel Obstruction- ○ Postoperative adhesions, strangulated hernia, inflammatory ● Large Bowel Obstruction- ○ Colon cancer, diverticulitis, sigmoid volvulus, fecal impaction

Question 56

Bowel Obstruction presentation & PE

Answer 56

○ Crampy, intermittent pain, constipation/obstipation, vomiting ○ Pain is “crescendo-decrescendo” ● Physical Exam- ○ Abdominal tenderness to palpation, distension ○ High-pitched bowel sounds are possible ○ Tympany with percussion, fecal Impaction on rectal

Question 57

Bowel Obstruction ED workup

Answer 57

○ CBC, CMP, PT/INR, PTT, blood typing ○ X-ray Abdominal series (Air/fluid level) ○ Chest X-ray (perforation?) ○ Abd/Pelvis CT with contrast

Question 58

Bowel Obstruction ED management

Answer 58

○ NG tube- decompression of bowel ■ May fix the problem for some ○ Pre-op Antibiotics ○ IV fluids ○ Bowel rest, NPO ○ Surgical Consult in all cases ○ Antiemetics ○ Pain Control

Question 59

Perforated Ulcers

Answer 59

● Peptic ulcer- Recurrent ulcers to stomach and duodenum. ○ When erodes through completely and perforates ● Risk factors- H. Pylori or NSAIDs ● With perforation may have no known Hx of ulcer. ● Most common in the elderly, but can be seen in any

Question 60

Perforated Ulcers presentation

Answer 60

○ Hematemesis, melena, dyspepsia, weakness, hypotension ○ Alcohol use, medication history, change in appetite ○ With perforation, abrupt onset of epigastric pain, peritonitis

Question 61

Perforated Ulcers PE

Answer 61

○ Rectal exam w/ Hemoccult ○ Peritonitis, rigid guarded abdomen. ○ Significant pain with tachycardia, signs of distress.

Question 62

Perforated Ulcers ED workup

Answer 62

○ CBC, CMP, Lipase, Blood typing ○ Cardiac Monitor ○ Chest and KUB X-ray (air under diaphragm). Do 1st! ○ Abdominal US (FAST exam) ○ Consider ECG, Troponin ○ CT Abd/Pelvis with contrast

Question 63

Perforated Ulcers ED management

Answer 63

○ For perforation- Immediate resuscitation, oxygen, IV fluids ○ NG tube? Ask surgeon first… ○ Broad-spectrum antibiotics ○ Surgical Consult immediately. Nearly always surgical! ○ Simple uncomplicated ulcer (not perforated) ■ May be able to be discharged from ER

Question 64

Hernias

Answer 64

● Most hernias are not going to be complicated. ○ Complicated = Strangulated or incarcerated ● Arise from a point of weakness of the abdominal wall ● Hernias described as: ○ Reducible → Incarcerated → Strangulated ○ Incarcerated - Stuck, can’t reduce ○ Strangulated - Incarcerated & blood flow is cut off ● Complicated hernias should be seen in the ED. ○ Surgical emergency to avoid gangrene, perforation and/or infection

Question 65

Hernia types

Answer 65

○ Direct ○ Indirect ○ Femoral ○ Umbilical ○ Incisional

Question 66

Incarcerated/Strangulated Hernia presentation

Answer 66

○ Pain is severe and localized with strangulated hernia ○ Nausea/vomiting, potentially fever ○ May have a history of known hernias

Question 67

Incarcerated/Strangulated Hernia PE

Answer 67

○ Diagnosed with clinical exam ○ Protruding, palpable mass- Irreducible ○ For inguinal hernias, check testicles as well (Torsion?) ○ Strangulated- severe pain, systemic signs, peritonitis, potential skin changes

Question 68

Incarcerated/Strangulated Hernia ED workup

Answer 68

○ Labs may not help with diagnosis (but may get pre-op labs, etc.). ○ Ultrasound (Bedside possible, Radiology is better). ○ CT w/ contrast of the area is most sensitive radiographic test.

Question 69

Incarcerated/Strangulated Hernia ED management

Answer 69

○ Do not try to reduce strangulated hernia! Can push necrotic or gangrenous tissue into abdominal cavity. Call surgeon ASAP. ○ If confident not strangulated - Can attempt incarcerated hernia reduction 1-2 times. ○ Surgical consult is indicated. Outpatient if easily reducible. ○ IV antibiotics, pain medication, antiemetics

Question 70

Bleeding Esophageal Varices

Answer 70

● Submucosal veins secondary to portal hypertension. ○ Increased risk in chronic liver disease, alcoholics. ● Can result in massive life threatening hemorrhage

Question 71

Bleeding Esophageal Varices presentation

Answer 71

○ Hematemesis ○ Dysphagia ○ Higher risk with advanced age

Question 72

Bleeding Esophageal Varices PE

Answer 72

○ ↑ JVD, caput medusae, hepatomegaly, orthostatic hypotension and tachycardia. Hypovolemic Shock. ○ Look for bloody emesis.

Question 73

Bleeding Esophageal Varices ED workup

Answer 73

○ CBC, CMP, PT/INR, PTT, blood typing, emergent transfusion if signs of shock starting ○ CT Chest/Abd/Pelvis w/ Contrast (if stable enough) ○ Cardiac Monitor and EKG

Question 74

Bleeding Esophageal Varices ED management

Answer 74

○ Resuscitative measures (volume resuscitation) ○ NG tube aspirate for guaiac testing ○ Balloon tamponade (ED physician or surgeon) ○ IV PPI- Pantoprazole 80 mg ○ Emergent Consultation with GI for Endoscopy ○ TIPS- Transjugular Intrahepatic Portosystemic Shunt

Question 75

Nausea Vomiting in the ED history clues

Answer 75

○ Onset, duration ○ Hematemesis, neurologic symptoms ○ Food borne, sick contacts, fever, diarrhea

Question 76

Nausea Vomiting ED workup

Answer 76

○ Directed at the “Why?” N/V are a symptom ○ Labs to consider: ■ HcG, CBC, CMP, Urinalysis, etc.

Question 77

ED management of N/V

Answer 77

○ Again, directed at the “Why?” ○ IV Fluids? Potentially. ■ Oral Fluids for mild dehydration ○ BRAT diet until recovered. ○ Antiemetic: Zofran, Reglan, Promethazine ■ Meclizine for Vertigo ■ Droperidol (Inapsine) is becoming popular ○ Consider admit for intractable vomiting