CPS: Abdominal Pain and Ischemia

Question 1

Two types of GI Pain sensation

Answer 1

1. visceral: vage and not well localized, associated with stretch inflammation
2. somatic pain: well localized, fibers associated with the peritoneum and carried by the somatic nerves.

Question 2

if a person has inflammation of the peritoneum and is showing guarding, what type of abdominal pain would they be displaying?

Answer 2

somatic pain

Question 3

common right upper quandrant abdominal pain causes

Answer 3

• biliary colic, cholescystitis (murphys sign), cholangitis (obstruction in CBD), choledocholithiases.
• hepatitis
• PUD
• pancreatitis
• cancer (colon, liver, kidney)
• thoracic causes

Question 4

common causes of left upper quandrant abdomen pain

Answer 4

• Peptic ulcer disease, perforated ulcer, gastritis
• Splenic disease or rupture
• Pancreatitis often also in the epigastrium
• Abscess, reflux,
• Dissecting aortic aneurysm
• Thoracic causes (pneumonia, PE, Pericarditis, MI)
• Hiatal hernia paraesophageal hernia

Question 5

common causes of left lower quadrant abdominal pain

Answer 5

• Left Lower Quadrant
• Diverticulitis
• Sigmoid volvulus
• Perforated colon
• Colon cancer
• Small bowel obstruction
• IBD
• Urinary tract infection, nephrolithiasis, pyelonephritis
• Referred hip pain
• Gynecologic causes
• Fluid accumulation from aneurysm or perforatio

Question 6

common causes of right lower quadrant abdominal pain

Answer 6

• Appendicitis • Mesenteric lymphadenitis • Cecal diverticulitis • Perforated colon • Colon cancer • Meckel’s diverticulum • Small bowel obstruction • IBD • Urinary tract infection, nephrolithiasis, pyelonephritis • Referred hip pain • Gynecologic causes • Fluid accumulation from aneurysm or perforation

Question 7

lab tests for abdominal pain

Answer 7

CBC, lytes, Cr, Lipase, Liver function tests (ALP, Bili, AST, Creatinine, albumin, INR)

also should do CT scan

Question 8

intussception

Answer 8

when the small bowel gets pulled into the cecum (seen in younger patients), it s like pulling your arm through your sleeve

Question 9

complete vs incomplete bowel obstruction

Answer 9

• Complete
• No gas or stool. Less likely to resolve
• Generally we do not wait longer than 24 to 36 hours for nonoperative
management to work • If no resolution in this time period then the patient should go to the operating
room

Incomplete
• Passing gas usually no bowel movement
• More likely to clear with non operative management and can be investigated
further • Be careful, the distal intestine can clear below the obstruction and mislead
you

Question 10

clinical symptoms of a bowel obstruction

Answer 10

Symptoms

• colicky abdominal pain, often in waves
• Varying degree of distension, bloating ( air, intestinal secretions, food)

• Nausea, vomiting depending on the location; cessation of flatus and bowel movement
• Distal obstruction larger reservoir; pain and distension is more marked than emesis
• Proximal obstruction; minimal abdominal tenderness but marked emesis
History (disease specific portion)

• Abdominal neoplasia, hernia or hernia repair, IBD, inflammatory conditions such as diverticulitis • Recent change in bowel habits • Previous episodes

Question 11

causes for acute peritonitis

Answer 11

perforation, ischemia, pancreatitis, appendicitis, diverticulitis, intraabdominal abscess, retroperitoneal process.

Question 12

urgent care of an acute abdomen

Answer 12

urgently resuscitated with fluid, an NG tube is placed and they are
taken urgently to the operating room within an hour or 2 and the
situation managed.

If there is a recognized hernia an attempt is made to reduce the
hernia pushing the intestine back into the abdomen. If this is not
possible the patient goes to the operating room urgently to prevent
loss of intestine.

Question 13

most common causes of small vs large bowel obstruction

Answer 13

small: adhesions, groin hernia
large: cancer, IBD, diverticulitis

Question 14

signs and symptoms of small vs large bowel obstruction

Answer 14

small: abdominal cramps and vomiting, mild to morderate abdonmen distestion
large: abdominal cramps, LESS VOMITING. Moderate to marked distention

Question 15

Note: basically, if theyre stable, do a CT and don’t allow any oral intake. If unstable or see perforation or doesn’t resolve within 24-28 hours, exploratory laparotomy

Question 16

triad for thrombosis

Answer 16

1. venous stasis
2. hypercoagulable state
3. damage to endothelium

Question 17

etiologies behind ischemic enteritis

Answer 17

1. arterial - ambolus, thrombosis, low flow state
2. venous - thrombosis

Question 18

arterial embolus and arterial thrombosis

Answer 18

• Arterial Embolus
• From the heart atrial fibrillation with clot in the atrium
• cl_ot usually goes out into the superior mesenteric artery lodges at the take off of
the middle colic artery_ • Ischemia from proximal jejunum to mid transverse colon • Sudden onset of acute pain
• Arterial Thrombosis
• Usually a narrowed artery secondary to vascular disease that closes off
• Pattern of ischemia is variable depending on location of narrowing
• Dehydration gastroenteritis, sepsis and hypotension (ie)
• Slower onset, very hard to reverse

Question 19

low flow stasis can cause ischemia predominantly on the ___ side of the colon

Answer 19

• The splanchnic vessels are some of the most active in the body with blood
flow varying from 10-35% of cardiac output depending on physiology and other conditions
• Pattern will be variable. Commonly in the colon as the blood supply is not as
reliable • Occurs on he left side of the colon more than the right at the watershed areas • Often patchy with intermittent death of tissue

Question 20

ischemic enteritis can be excerbated by which conditions:

Answer 20

COPS, thrombophilia (essential thrombocythemia, polycythemia vera), diabetes, renal failure, hypertension, myocardial infarction, history of vascular disase, atrial fibrillation

Extreme exercise has also been shown to cause a reversible type of
colonic ischemia

Question 21

presentaiton of ischemia

Answer 21

• Abdominal pain out of proportion to the physical findings
• Distention, nausea and vomiting mimics an obstructive pattern

• When in the colon or rectum may present with bloody diarrhea
• When the mucosa is ischemic the patient is not as sick and the pain
may not be as significant
• With transmural ischemia the patient has much more significant pain,
peritonitis and may show signs of systemic sepsis

• CT • Lack of blood flow to the intestine • Pericolonic fluid • Change in bowel wall density and thickening of the bowel wall • Pneumatosis is present in < 5% patients but is an ominous sign • Portal venous gas is also an ominous sign usually associated withfull
thickness necrosis
• CT angiography may be used to rule out superior mesenteric
occlusion

Question 22

treatment for ischemia

Answer 22

• thrombolytics/anticoagulants?
• broad spectrum antibiotics
• well hydrated
• if there is suspicion of full thickness necrosis then the patient has to go to the operating room for resection.

Question 23

what is a closed loop obstruction

Answer 23