Approach to acute abdomen Flashcards
_____ is the most common chief complaint in
Emergency Medicine
Abdominal Pain
Measure Acuity / Critically ill with acute abdomen
○ 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
Types of abdominal pain:
○ 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.
Acute Abdomen associated symptoms:
○ Nausea/vomiting ○ Constipation ○ Diarrhea ○ Fever ○ Weight loss ○ Jaundice ○ Hematemesis ○ Blood in stool- ■ Hematochezia, melena ○ Indigestion ○ Dysuria
Risk Factors for acute abdomen
○ 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
Some “rules” to consider with acute abdomen
■ #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.
Bedside Ultrasound (POCUS) uses:
■ 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
Radiology-Based Ultrasound uses
■ 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)
CT Abd/Pelvis can be used with contrast for:
● Bowel mucosa, appendicitis, abscess,
obstruction, AAA, ischemia, hernia.
● Order at least 1 liter IV fluids
CT Abd/Pelvis can be used without contrast for:
■ Without contrast for kidney stones or in
those with contraindication for contrast.
■ You should obtain POC creatinine if contrast
Management of Acute Abdomen in ED
○ 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
In cases of possible or suspected Sepsis
○ 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).
Approach to treatment for abdominal infections
○ 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
Reasons to admit for acute abdomen:
■ 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?
Acute Cholecystitis
● 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
Signs and symptoms of Acute Cholecystitis in the ED
○ Typically RUQ pain
■ Colicky, can refer to right scapula
○ Nausea, vomiting, often made worse w/ greasy food.
○ +Murphy’s Sign
ED Workup for acute cholecystitis
○ 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
ED Management of Acute Cholecystitis
○ NPO, General Surgery consult, and admit
Ascending Cholangitis (Acute Cholangitis)
○ Superimposed Infection of the bile duct-
○ That can be life threatening.
■ Urgent Surgery / GI Consult (ERCP)
■ Sepsis- Triple coverage
Charcots triad~
Charcot’s Triad
- Fever
- Jaundice
- RUQ pain
Acute Pancreatitis
● Inflammation of the Pancreas.
○ Can range from mild to severe systemic inflammatory
response with multiorgan failure.
Acute pancreatitis risk factors
Alcoholism, cholelithiasis, high triglycerides,
some medications, and male sex (higher incidence).
Acute Pancreatitis patient presentation & exam
● 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.
Acute Pancreatitis ED workup
○ 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
ED Management of acute pancreatitis
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
Acute Hepatitis
● Inflammation of liver from toxic, metabolic, or infectious causes.
○ Can be worsening on top of Chronic Liver Disease
Acute Hepatitis presentation
○ 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
Acute Hepatitis ED workup
○ 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.
ED Management for Acute Hepatitis
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
Acute Appendicitis
Common surgical emergency, most common in children and young adults (can happen in all ages).
