CM- Evaluation of Abdominal Pain Flashcards
What is acute abdomen?
What is the typical pathological process?
What are the 2 ways to manage it?
Acute abdomen is sudden onset of abdominal pain that develops within 24 hours or less with an unclear etiology.
The pathological process is inflammation of the peritoneum that results in diffuse abdominal tenderness and distension.
- Surgical abdomen- requires immediate surgical intervention (ex. perforated viscus)
- Conservative management (ex. pancreatitis)
What is the difference between visceral and parietal pain?
Visceral pain - nociceptive pain in the viscera that is dull, poorly localized and often presents as referred
Parietal pain- nociceptive pain from the activation of receptors in the parietal peritoneum. Sharp, localized.
What is Hirschprung’s disease? What is the cause?
It is megacolon due to the failure of migration of intestinal myenteric ganglion cells due to a deficiency in endothelin OR endothelin receptor
What are the 7 main intra-abdominal problems that can cause pain?
- appendicitis
- cholecystitis and biliary colic
- pancreatitis
- perforated viscus
- ischemic bowel
- bowel obstruction
- ruptured aortic aneurysm
What are 3 common non-abdominal pathologies that can present with abdominal complaints?
- pelvic inflammatory disease
- heart disease
- ectopic pregnancy
What constitutes the foregut, midgut and hindgut?
What is the blood supply to each?
Foregut: GI structures ending at the 2nd part of the duodenum - supplied by the Celiac Artery
Midgut: Ampulla of Vater to the proximal 2/3 of the colon– SMA
Hindgut: distal 1/3 of colon and rectum– IMA
Because nerves follow arterial supply, damage to the small intestine will present with ____________ pain whereas colon damage will present with _______________pain.
small intestine –> epigastric
colon–> hypogastric
Why does irritation of organs near the diaphragm lead to pain on the top of the shoulder?
The diaphragm develops in the region of the 4th cervical segment therefore the diaphragm and the shoulder share the same cervical roots (3,4,5)
What abdominal irritations give rise to referred pain in the shoulder?
Anything that occurs near the diaphragm so:
- perforated ulcer
- hepatic abscess
- pancreatitis
- ruptured spleen
- perforated appendicitis WITH peritonitis
Where does biliary pain radiate?
Right scapula
Where does renal pain radiate?
flank and buttock pain
Where does uterine pain radiate?
low back
What three structures were located in the peritoneal cavity but migrated to the retroperitoneal space in embryogenesis?
- head, neck and body of pancreas (NOT tail)
- duodenum (NOT the proximal first segment)
- ascending and descending colon
What 7 structures are exclusively retroperitoneal?
- kidneys
- ureters
- bladder
- aorta
- IVC
- adrenal glands
- rectum
A patient presents with sharp, excruciating pain at a very specific location. What is the likely cause?
Perforation - sudden, sharp, localized
ex. perforated bowel
A patient presents with intermittent dull pain. What is the likely cause?
Obstruction - colicy, dull
ex. biliary colic
A patient presents with constant poorly localized pain. What is the likely cause?
Infection
ex. the patient may give a history consistent with biliary colic but then describe constant RUQ pain. This is more consistent with cholecystitis.
A patient describes her pain as the worst pain she’s ever had in her life, but the physical exam is not impressive. What is the likely cause?
Ischemia = pain out of proportion to the physical exam
Visceral pain is non-specific and poorly localized. In general where does it appear?
Midline at the same dermatome level as the specific organ’s innervation
What organs are associated with RUQ pain? (8)
- liver
- gallbladder
- pancreas
- bililary
- duodenal
- renal
- right phrenic
- right lower lung
What organs are associated with RLQ pain? (6)
- appendix
- distal small bowel
- ascending colon
- right ureteral
- right ovarian
- right fallopian tubes
What organs are associated with LUQ pain? (6)
- spleen
- stomach
- pancreatic
- renal
- left phrenic
- left lower lung
What organs are associated with LLQ pain? (4)
- left fallopian tube
- left ovarian
- left ureter
- descending colon
What are the 3 most common mechanisms that result in abdominal pain?
- distention of a hollow viscus
- soilage of the peritoneum
- ischemia
When doing a DDx, what are the 7 categories you can break them down into?
- Congenital
- Inflammatory
- Trauma
- Vasculitis
- Neoplasm
- Degenerative disease (*rare in the abdomen)
- Metabolic disorders
What are signs and symptoms of abdominal pathology?
- pain and tenderness
- abdominal distension
- muscular rigidity
- vomiting
- hemodynamic instability/tachycardia (shock)
It is important to consider the timing of the pain and vomiting when making a surgical diagnosis. What is a likely cause if the vomiting precedes the pain? What is a cause if the pain precedes the vomiting?
If the vomiting precedes the pain, it may be due to muscular injury from the act of retching.
In the acute surgical abdomen, pain precedes vomiting and usually is consistent with obstruction of a hollow viscus. In response to the obstruction, the visceral afferent fibers go to the medulla and trigger the vomit centers.
A patient presents with a “picket fence” pattern of fever. What abdominal problem is this consistent with?
abscesses
What pathology is each of the following descriptions associated with :
- burning pain
- sudden onset pain
- colicky pain
- picket fence fever
- tearing pain
- duodenal ulcer
- viscus perforation
- intestinal obstruction
- abscesses
- rupture/dissection of the abdominal aorta
In what 3 situations is pain out of proportion to tenderness?
- acute mesenteric ischemia
- retroperitoneal inflammation (pancreatitis, pyelonephritis, aortic dissection)
- intestinal obstruction
For the abdomen, in what order do we perform the physical exam?
- inspection
- auscultation
- percussion
- palpation
On inspection of the abdomen, what key features are you looking for?
- scars (PSHx and can help with determining future surgical needs)
- position of the patient
- spider angioma, palmar erythema, caput medusa
- distension
- weight loss
- evidence of peristalsis
Describe ausculation in an abdominal exam.
Where do you start listening?
How long to declare absent bowel sounds?
What are the 5 characterizations of bowel sound?
Begin at a point furthest from the area of pain.
2 min = minimum to declare bowel sounds absent
- normal
- hyperactive
- high pitched
- hypoactive
- absent
If you have absent bowel sounds, what could be the problem?
- peritonitis
2. adynamic or paralytic ileus - metabolic cause
When palpating the stomach, what is guarding?
Voluntary- movement of hand or tensing a muscle in anticipation of pain
Involuntary- tense muscles
When palpating the stomach what does rigidity describe?
Muscle rigidity is the same as involuntary guarding. It occurs as a result of muscle/muscular fascia irritation due to adjacent inflammation
What is McBurney’s point?
It is the classic point of peritonitis due to appendicitis. It occurs 2/3 of the way down a line from the belly button to the anterior superior iliac spine.
What is Rovsing’s sign?
rebound tenderness - pain increases when the probing hand is removed from the LLQ and the pain increases at McBurney’s point [appendicitis–>peritonitis]
What is the Psoas sign?
When the patient actively or passively flexes the psoas muscle, there is increased pain due to inflammation along the psoas–>retroperitoneal disease from abscess, bleed, adenopathy
What is the obturator sign?
flexing the hip and knee and internally rotating. If there is pain it suggest pelvic inflammation
What is the indication for CBC in patients with abdominal issues?
If a person has an obstruction and now there WBC count is elevated, this indicates a need for more aggressive treatment.
Hb and Hct are important to consider before surgery
A diagnosis of pancreatitis can be made with the history and physical exam along with elevated levels of what?
amylase
If a patient presents with partial small bowel obstruction and prior history of abdominal or pelvic operations, what test should you run?
Lactic acid because if it is elevated it will indicate vascular compromise of the bowel –>surgical intervention
When should you order an acute abdominal series?
suspected bowel perforation or mechanical obstruction
What is RUQ ultrasound most frequently used for?
Gallbladder pathology- acute cholecystitis:
- Thickening of the wall >4mm
- gallstones (white with shadow)
- pericholecystic fluid (edema)
It can also do:
- pancreatic edema (pancreatitis)
- dilated biliary tree (choledocholithiasis)
Today what is the standard of care for patients with ruptured appendicitis without peritonitis?
CT-guided abscess draining with interval appendectomy (removed 4-6 wks later)
What are the 5 main causes of surgical abdomen?
- appendicitis
- peritonitis
- acute pancreatitis
- acute diverticulitis
- mesenteric ischemia
What is the order of progression of symptoms of appendicitis?
- epigastric or periumbilical pain
- nausea, vomiting, loss of appetite
- abdominal tenderness
- fever and leukocytosis
You are doing a physical exam on a patient that presented with acute abdominal pain. There is generalized tenderness with rigidity and rebound tenderness. Bowel sounds are absent. What is the likely problem? What do you do next?
What are 4 potential underlying causes?
Peritonitis- exploratory laparotomy/laproscopy.
- perforated ulcer
- perforated cancer
- perforated appendicitis with purulence
- perforated diverticulitis
Where is the most common place for acute diverticulitis to occur? What causes it?
It most frequently occurs in the sigmoid colon and is caused by obstruction and ensuing inflammation/perforation of a diverticulum.
A patient presents with LLQ abdominal pain, fever and leukocytosis. What is the problem? What should you use to guide therapeutic options?
It is acute diverticulitis.
CT scan will guide therapeutic options:
- mild diverticulitis is treated with antibiotics/IV fluids
- local abscess = CT guided drainage
- with peritonitis= surgical intervention
What are the 3 major causes of acute mesenteric ischemia? What is the unusual cause?
What test is used to study each?
Angiography:
- mesenteric artery embolism
- mesenteric artery thrombosis
- non-occlusive mesenteric ischemia
Rarely: mesenteric vein thrombosis- CT
What are the 3 most common causes of obstructed bowel in adults?
- adhesions
- hernia
- neoplasm
A patient presents with ab pain, diarrhea, bleeding and crampy rectal pain. What is the likely cause?
Ulcerative colitis
A patient presents with abdominal pain, diarrhea, constipation, obstruction and GI bleeding. What is a potential cause?
Crohn’s
What are the symptoms associated with irritable bowel disease?
- abnormal frequency
- abnormal stool form
- abnormal stool passage (straining, urgency, incomplete evacuation)
- passage of mucus
- bloating or feeling distenstion
