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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
Q

what can cause pain that subsides spontaneously with time

A

gastroenteritis

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26
Q

what is colicky pain and what can cause it

A

progresses and remits

intestinal, biliary, or renal pain

Gallstones, kidney stones

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27
Q

what can cause progressive pain

A

appendicitis, diverticulitis, pancreatitis

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28
Q

what can cause catastrophic onset of pain

A

ruptures of AAA, perforated viscus, mesenteric infarction

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29
Q

what pain chronolgies are associated with each line

A

a - subsides spontaneously with time, gastroenteritis

b - colicky, gall stones, kidney stones

c - progressive - appendicitis, pancreatitis

d - catastrophic, AAA rupture, perforated viscus, mesenteric infarction

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30
Q

noxious stimuli may result in what

A

visceral, somatic and referred pain

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31
Q

onset, location, character, descriptor, radiation and intenisty of appendicitis

A

gradual

paraumbilica –> RLQ

diffuse ealry, then localized

ache

no radiation

++

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32
Q

onset, location, character, descriptor, radiation and intenisty of cholecystitis

A

acute

RUQ

localized

constricting

scapula

++

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33
Q

pancreatitis

A

acute

epigastrum, back

localized

boring

midback

++

34
Q

diverticulitis

A

gradual

LLQ

localized

ache

none

+++

35
Q

onset, location, character, descriptor, radiation and intenisty of perforated peptic ulcer

A

sudden

epigastrum

localized –> diffuse

burning

none

+++

36
Q

onset, location, character, descriptor, radiation and intenisty of small bowel obstruction

A

gradual

periumbilical

diffuse

cramping

none

++

37
Q

onset, location, character, descriptor, radiation and intenisty of mesenteric ischemia

A

sudden

periumbilical

diffuse

agonizing

none

+++

38
Q

onset, location, character, descriptor, radiation and intenisty of ruptured AAA

A

sudden

abdomen, back, flank

diffuse

tearing

none

+++

39
Q

onset, location, character, descriptor, radiation and intenisty of gastroenteritis

A

gradual

periumbilical

diffuse

spasmodic

none

+, ++

40
Q

onset, location, character, descriptor, radiation and intenisty of PID

A

gradual

either LQ, pelvis

localized

ache

upper thigh

++

41
Q

describe aggravative and alleviated factors for peritonitis

A

they lie motionless

42
Q

describe aggravative and alleviated factors for renal colic pain

A

may writhe in pain

43
Q

describe aggravative and alleviated factors for biliary pain

A

fatty foods make it worse

44
Q

describe aggravative and alleviated factors for duodenal ucler

A

relieved by foos

45
Q

describe aggravative and alleviated factors for gastric ulcer or mesenteric ischemia

A

worsened by food

46
Q

describe aggravative and alleviated factors for pancreatitis

A

relieved by sitting up or leaning forward

47
Q

CVD raises suspicion for what

A

mesenteric ischemia

48
Q

meds that can cause upper GI pain

A

NSAIDS - ischemia, PUD

narcotics - constipation

chronic steroid use - adrenal isufficiency, immunosuppressed and atypical presentation

49
Q

hydrochlorothiazide is associated with what

A

pacreatitis

50
Q

aspirin is associated with what

A

peptic ulcers

51
Q

straie from pregnancy or weight gain

A

recent origin are pink or blue but turn silvery white over time

striae of cushings remain purplish

52
Q

what is cullens sign

A

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
Q

what is grey turners sign

A

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
Q
A

left - cullens sign

right - grey turners sign

55
Q

what are borborygmi

A

stomach growling

56
Q

what does high pitched tinkling suggest

A

intestinal fluid and air under pressure, suggests early bowel obstruction

57
Q

what does a friction rub suggest

A

high pitched associated with inspirations

indicates inflammation of peritoneal surface from tumor, infection or infarct

58
Q

how many minutes does it take to establish absent bowel sounds

A

5 minutes of continuous listening

59
Q

what does shifting dullness of percussion suggest

A

ascites, hepatomegaly

60
Q

where do you start palpation

A

where patient is experiencing least pain

assess for numbness that may be a nerve problem

assess for MSK pain

61
Q

what is carnetts sign

A

ask pt to do a crunch/lift legs to activate abdominal muscles, if pain worsens thing MSK problem

62
Q

what does a rectal exam check for

A

fecal imaction

63
Q

what lab data do you want in abdominal pain cases

A

CBC with diff

CMP

UA

lipase/amylase

Urine pregancy test

64
Q

what imaging studies do you want to get

A

US - can be used quickly and reliably to detect fluid in abdomen

eval quickly for AAA

65
Q

what is a CT

A

combination of many x rays take from multiple angles to create a cross sectional image

66
Q

what is MRI

A

use of magnetic fields to create virtual slices

different from CT bc doesnt use x rays or ionizing radiation

67
Q

what is HIDA

A

hepatobiliary scan

uses tracer that is injected inot your vein that helps cature images of teh liver, gallbladder, bile ducts and small intestine

68
Q

what is endoscopy

A

tube with camera that allows direct visualization of the GI tract

69
Q
A

sigmoid diverticulitis with abcsess formation

sigmoid colon displaying mural thickening, diverticulosis and pericolic fat stranding (arrow)

circle - abscess formation bc low attenuation

70
Q

what is the difference between diverticulosis and diverticulitis

A

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
Q

symptoms of diverticulitis acute

A

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
Q

imaging for diverticulitis

A

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
Q

disease course of diverticulosis

A

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
Q

management of diverticulitis

A

nutrition - higher fiber, low fat

medical - antibiotis (cipro) and flagyl vs augmentis, laxatives, stool softeners

complications - surgical consult, perforation, peritonitis, obstruction, hermorrhge

75
Q
A

appendicitis

76
Q

where is McBurneys point

A

1/3 of the distance from ASIS towards umbilicus

77
Q
A

acute biliary disease, choledicolithiasis with pancreatitis

78
Q
A

small bowel obstruction

79
Q
A

upright abdominal x ray with dilated small bowel loops and air fluid levels in stair step pattern, indicative of small bowel obstruction

80
Q
A

acute mesenteric ischemia

81
Q

major causes of mesenteric ischemia

A

CVD

blood clots

drugs

hypercholesterolemia

82
Q
A

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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