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GIR Test 1 > B5.015 - Abdominal Pain Big Case > Flashcards

B5.015 - Abdominal Pain Big Case Flashcards

1
Q

what percentage of ED visits are due to abdominal pain

A

5-10%

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2
Q

how many abdominal pain patients have non specific findings and how many have a more serious disease

A

half and half

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3
Q

what are the 3 types of pain

A

visceral somatic parietal referred

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4
Q

how is visceral pain transmitted

A

transmitted by C fibers that are found in muscle, peritoneum, mesentery, periosteum and viscera

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5
Q

most painful stimuli from abdominal viscera are conveyed by which type of fiber

A

C fibers visceral pain

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6
Q

C fibers are highly sensitive to what

A

distension, inflammation, ischemia

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7
Q

describe visceral pain

A

dull cramping burning gnawing squeezing deep sickening poorly localized often referred to more distant superficial structure

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8
Q

why is visceral pain usually perceived to be midline

A

because abdominal organs transmit sensory afferents to both sides of the spinal cord

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9
Q

why is visceral pain not well localized

A

because the number of nerve endings and viscera is low

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10
Q

secondary autonomic effects of visceral pain

A

sweating restlessness nausea vomiting perspiration pallor pt may move to try and relieve pain

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11
Q

typical localization of visceral pain

A

epigastrium midabdomin hypogastrium

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12
Q

how does visceral pain interact with the CNS

A

visceral afferent fibers including vagal and pelvic parasympathetic nerves travel with autonomic nerves (SYM and PARA stimulated)

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13
Q

how is somatic parietal pain mediated

A

by alpha gamma fibers that are distributed principally to the skin and muscle

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14
Q

describe somatic parietal pain

A

sharp, stabbing, well localized usually aggravated by movement or vibration

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15
Q

describe lateralization of somatic parietal pain

A

only possible bc only one side of the nervous system innervates the given part of the parietal peritoneum

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16
Q

classic presentation of appendicitis

A

involves both visceral and parietal pain Pain of early presentation is often paraumbilical (visceral) but often localizes to the right lower quadrant when inflammation extends to peritoneum (parietal)

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17
Q

what is McBurneys point

A

localized somatic parietal pain seen in appendicitis produced by inflammatory involvement of the parietal peritoneum

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18
Q

compare and contrast visceral and somatic pain

A
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19
Q

describe referred pain

A

felt in areas removed from the diseased organ and results when visceral afferent neurons and somatic afferent neurons from a different anatomic region converge on second order neurons in the spinal cord at same spinal segement

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20
Q

examples of referred pain

A

gallbladder inflammation can irritate the diaphragm which is innervated by C3,4,5

dermatomes of these spinal cord segments supply the shoulder, hence you can get shoulder tip pain.

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21
Q

what is Kehrs sign

A

diaphragmatic irritation froma subphrenic hematoma or splenic rupture being perceived as shoulder pain

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22
Q

55 yo male presents to ER with 3 days of slowly progressing LLQ pain, constant, dull, has been having some increased constipation of the last few weeks and low grade fever. Some nausea, no vomiting. No blood in stool. What type of pain?

A

visceral

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23
Q

most important compontent of evaluation of abdominal pain

A

history taking

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24
Q

what components of the Hx are important for creating a differential

A

chronology

location

intensity, character

aggravating/relieving factors

associated symptoms

PMH

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25
what can cause pain that subsides spontaneously with time
gastroenteritis
26
what is colicky pain and what can cause it
progresses and remits intestinal, biliary, or renal pain Gallstones, kidney stones
27
what can cause progressive pain
appendicitis, diverticulitis, pancreatitis
28
what can cause catastrophic onset of pain
ruptures of AAA, perforated viscus, mesenteric infarction
29
what pain chronolgies are associated with each line
a - subsides spontaneously with time, gastroenteritis b - colicky, gall stones, kidney stones c - progressive - appendicitis, pancreatitis d - catastrophic, AAA rupture, perforated viscus, mesenteric infarction
30
noxious stimuli may result in what
visceral, somatic and referred pain
31
onset, location, character, descriptor, radiation and intenisty of appendicitis
gradual paraumbilica --\> RLQ diffuse ealry, then localized ache no radiation ++
32
onset, location, character, descriptor, radiation and intenisty of cholecystitis
acute RUQ localized constricting scapula ++
33
pancreatitis
acute epigastrum, back localized boring midback ++
34
diverticulitis
gradual LLQ localized ache none +++
35
onset, location, character, descriptor, radiation and intenisty of perforated peptic ulcer
sudden epigastrum localized --\> diffuse burning none +++
36
onset, location, character, descriptor, radiation and intenisty of small bowel obstruction
gradual periumbilical diffuse cramping none ++
37
onset, location, character, descriptor, radiation and intenisty of mesenteric ischemia
sudden periumbilical diffuse agonizing none +++
38
onset, location, character, descriptor, radiation and intenisty of ruptured AAA
sudden abdomen, back, flank diffuse tearing none +++
39
onset, location, character, descriptor, radiation and intenisty of gastroenteritis
gradual periumbilical diffuse spasmodic none +, ++
40
onset, location, character, descriptor, radiation and intenisty of PID
gradual either LQ, pelvis localized ache upper thigh ++
41
describe aggravative and alleviated factors for peritonitis
they lie motionless
42
describe aggravative and alleviated factors for renal colic pain
may writhe in pain
43
describe aggravative and alleviated factors for biliary pain
fatty foods make it worse
44
describe aggravative and alleviated factors for duodenal ucler
relieved by foos
45
describe aggravative and alleviated factors for gastric ulcer or mesenteric ischemia
worsened by food
46
describe aggravative and alleviated factors for pancreatitis
relieved by sitting up or leaning forward
47
CVD raises suspicion for what
mesenteric ischemia
48
meds that can cause upper GI pain
NSAIDS - ischemia, PUD narcotics - constipation chronic steroid use - adrenal isufficiency, immunosuppressed and atypical presentation
49
hydrochlorothiazide is associated with what
pacreatitis
50
aspirin is associated with what
peptic ulcers
51
straie from pregnancy or weight gain
recent origin are pink or blue but turn silvery white over time striae of cushings remain purplish
52
what is cullens sign
periumbilical ecchymosis results from tracking of blood from retroperitoneum to umbilicus along the gastrohepatic and falciform ligament and subsequently to subcutaneous tissues thru the connective tissue covering the round ligament
53
what is grey turners sign
produced by hemorrhagic fluid spreading from the posterior pararenal space to the lateral edge of the quadratus lumborum muscle and therafter to the subq tissues by means of a defect in the fascia of the flank
54
left - cullens sign right - grey turners sign
55
what are borborygmi
stomach growling
56
what does high pitched tinkling suggest
intestinal fluid and air under pressure, suggests early bowel obstruction
57
what does a friction rub suggest
high pitched associated with inspirations indicates inflammation of peritoneal surface from tumor, infection or infarct
58
how many minutes does it take to establish absent bowel sounds
5 minutes of continuous listening
59
what does shifting dullness of percussion suggest
ascites, hepatomegaly
60
where do you start palpation
where patient is experiencing least pain assess for numbness that may be a nerve problem assess for MSK pain
61
what is carnetts sign
ask pt to do a crunch/lift legs to activate abdominal muscles, if pain worsens thing MSK problem
62
what does a rectal exam check for
fecal imaction
63
what lab data do you want in abdominal pain cases
CBC with diff CMP UA lipase/amylase Urine pregancy test
64
what imaging studies do you want to get
US - can be used quickly and reliably to detect fluid in abdomen eval quickly for AAA
65
what is a CT
combination of many x rays take from multiple angles to create a cross sectional image
66
what is MRI
use of magnetic fields to create virtual slices different from CT bc doesnt use x rays or ionizing radiation
67
what is HIDA
hepatobiliary scan uses tracer that is injected inot your vein that helps cature images of teh liver, gallbladder, bile ducts and small intestine
68
what is endoscopy
tube with camera that allows direct visualization of the GI tract
69
sigmoid diverticulitis with abcsess formation sigmoid colon displaying mural thickening, diverticulosis and pericolic fat stranding (arrow) circle - abscess formation bc low attenuation
70
what is the difference between diverticulosis and diverticulitis
diverticulosis is the development of diverticula (sac like protrusions of the colonic wall, form where the wall is weakest, typically where blood vessesl enter the colon) diverticulitis - inflammation of the diverticulum, complications can lead to abceses, perforation, fistula, bowel obstruction
71
symptoms of diverticulitis acute
abdominal pain LLQ due to involvement of sigmoid most commonly in mesenteric side of two bands of the tinea coli pain constant and usually present for days prior to presentation change in bowel habits leukocytosis serum amylase, lipase mildly elevated
72
imaging for diverticulitis
US shows peridiverticular inflammation, abscesses with or without gas bubbles, but not super sensitive/specific CT is the go to, increase in soft tissue density, pericolonic fat stranding the presence of diverticula, super specific and sensitive MRI can but ites expensive, avoids radiation not everyone has one
73
disease course of diverticulosis
70-80% asymptomatic 5-15% diverticular bleeding 4% diverticulitis of those with diverticulitis 85% are simple 15% are complicated by abscesses, obstruction, perforation, fistula
74
management of diverticulitis
nutrition - higher fiber, low fat medical - antibiotis (cipro) and flagyl vs augmentis, laxatives, stool softeners complications - surgical consult, perforation, peritonitis, obstruction, hermorrhge
75
appendicitis
76
where is McBurneys point
1/3 of the distance from ASIS towards umbilicus
77
acute biliary disease, choledicolithiasis with pancreatitis
78
small bowel obstruction
79
upright abdominal x ray with dilated small bowel loops and air fluid levels in stair step pattern, indicative of small bowel obstruction
80
acute mesenteric ischemia
81
major causes of mesenteric ischemia
CVD blood clots drugs hypercholesterolemia
82
peptic ulcer disease Increased risk of H. Pylori infection leading to peptic ulcer desease and hes also using NSAIDs

GIR Test 1 (15 decks)

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