Approach to the Acute Abdomen -- SD Flashcards
When would we get an MRI for an abdominal complaint?
Pregnant woman with abdominal pain – especially in 1st trimester
Women of child-bearing age presenting with abdominal pain, what must we do on PE?
Pelvic exam
1 month old presenting with nonbilious vomiting – what’s on your DDx?
GERD, hypertrophic pyloric stenosis
2 month old presenting with bilious vomiting – whats on your DDx?
malrotation, volvulus, Hirschsprung’s disease, hernias, meningitis, sepsis
2 year old presenting with abdominal pain – DDx?
Intussusception, Wilm’s tumor
Most common ages to present with appendicitis?
6-18
What is the most common cause of abdominal pain in children?
Constipation
Severe, explosive pain should make you think of?
Perforation of hollow viscous
Progressive, severe pain?
Worsening disease – ischemic necrosis
Localized, then generalized pain?
Perforation
Crampy, crescendo-descrescendo pain?
Obstruction
Pain radiating to the low back?
Salpingitis or cystitis
Pain radiating to the mid-back?
Pancreatitis, ulcer, or cholecystitis
When does pain radiate to the shoulder?
Diaphragmatic irritation
Can you give pain medication to someone with acute abdominal pain before a surgical consult?
Yes!
Localized, unrelieved epigastric pain that increases with swallowing
Esophageal perforation
What is an esophageal perforation typically preceded by?
Violent emesis
What is the main cause of an esophageal perforation?
50-60% iatrogenic
15% Borhaave’s
What populations are at risk for gastric ulcers?
Males and older folks
Those with heavy NSAID and ASA use
EtOH and smoking
Periodic pain, awakens patient at night, may be better or worse with food
Gastric ulcers
What is a Mallory-Weiss tear?
A partial thickness tear of esophagogastric junction
Hematemesis after repetitive vomiting, chest pain, and coughing should make you think of?
Mallory-Weiss tear
How do we treat gastric ulcers?
GI cocktail – IV PPI/H2 blocker
How do we diagnose a Mallory-Weiss tear?
Need EGD but not emergently
Chest x-ray to rule out free air/pneumomediastinum
How do we treat a Mallory-Weiss tear?
Conservatively
What are the most common type of gallstones?
Cholesterol stones
What do we call the presence of stones in the gallbladder?
Cholelithiasis
What are risk factors for developing gallstones? Hint** 5 F’s
Female, fat, forty, fair, and fertile
These people will often have pain after a fatty meal in the RUQ – may radiate to chest, right shoulder or scapula
Cholelithiasis
What is the best diagnostic test for diagnosing cholelithiasis?
Ultrasound
Should you see gallbladder thickening on ultrasound for someone with cholelithiasis?
No
How do we treat cholelithiasis?
Toradol, morphine, zofran for symptom control
Patients will present with fever, chills, vomiting, and severe pain that is often postprandial
Cholecystitis
What is murphy’s sign?
When you push on the RUQ, patient will stop taking breath in due to pain
What’s going on with Cholecystitis?
gallstone obstructing the cystic duct
Who is at greatest risk for developing cholecystitis?
Women ages 30-80
If cholelithiasis is left untreated, what can develop?
Empyema, gangenous gallbladder, perforation
How do we treat cholecystitis?
Surgery is definitive!
This will present with intermittent, colicky pain that may radiate to the back. Patient may be jaundiced.
Choledocholithiasis
Where is the blockage occurring in choledocholithiasis?
Common bile duct
Choledocholithiasis is a common cause of?
Pancreatitis
How do we treat choledocholithiasis?
Emergency surgery consult
IV abx necessary because likely have associated cholecystitis
What is the most common cause of pancreatitis?
Alcoholism
What presents with severe, unrelenting pain that radiates to the back? Nausea and vomiting are also very common.
pancreatitis
True or false
patients with pancreatitis often feel better if they are lying down
False!
Pain is worse when lying down – feel better if slumped forward
Do patients with pancreatitis typically exhibit both guarding and rebound tenderness?
Guarding, yes.
Usually no rebound tenderness.
What will a patient’s vitals look like with pancreatitis?
Fever, tachycardia, may be hypotensive
True or False
patient’s with pancreatitis will have hypoactive bowel sounds?
True! Decreased to no bowel sounds.
This lab value three times its normal value has greater than 95% positive predictive value for biliary pancreatitis
ALT
What criteria do we use for prognosis for pancreatitis?
Ranson’s
What lab value three times its normal has nearly 100% sensitivity and specificity for pancreatitis?
Lipase
How do we treat pancreatitis?
IV hydration with large amounts of fluid. IV nausea and pain meds.
Elderly person with back pain is treated as a _________ until prover otherwise
AAA
Sudden onset of pain, mid abdomen, radiating to back or groin think of?
AAA
When will you find asymmetric femoral pulses?
AAA
What do vitals signs look like when someone is experiencing a AAA?
Vital signs are initially normal and then tank rapidly
What is the only treatment for unstable patient with known leaking AAA?
Emergent surgery
What population does mesenteric adenitis usually present in?
Children and young adults
Appendicitis in this population is very difficult to diagnose.
Pregnant women
How does pain for appendicitis classically present?
Starts in periumbilical region and migrates to RLQ
Appendicitis is most common between these ages
10-40
Appendicitis in children less than ______ years old is very rare
Five
What are four signs we can look for on physical exam to test for appendicitis?
Rovsing’s, Heel strike, Obturator, and Psoas
90% of diverticulitis occurs in what part of the colon?
Sigmoid
What are symptoms of diverticulitis?
Constant pain, fever, constipation, and anorexia
How do we diagnose diverticulitis in the ED setting?
CT scan with PO and IV contrast
X-rays not helpful unless looking for obstruction
These patients will present with abdominal pain, nausea/vomiting, diarrhea, pencil-like stools, or no bowel movement
Bowel obstruction
For bowel obstructions –
Abdomen will be distended or non-distended? Have hypo or hyperactive bowel sounds? Be tender or non-tender?
Abdomen is distended, hyperactive bowel sounds, and diffusely tender
How do we diagnose a bowel obstruction?
KUB with upright abdomen
CT if indicated
How do we treat a bowel obstruction?
NPO, NG tube to wall suction, pain medications, surgery consult
Painless rectal bleeding with blood/mucus is associated with crohn’s or ulcerative colitis?
Ulcerative colitis
