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GI > Disorders of the Acute Abdomen > Flashcards

Disorders of the Acute Abdomen Flashcards

1
Q

What are the 3 types of pain that may occur in the acute abdomen?

A
  • Visceral: Slow, poorly localized, dull
  • Somatic/Parietal: Sudden, sharp, localized
  • Referred pain
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2
Q

When auscultating for peristalsis, what should we keep in mind?

A

If someone is fasting, it may take 2-3 minutes of auscultation to confirm an absence of peristalsis, since it is related to meal intake

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3
Q

What is Carnett’s sign?

A
  1. Tense abdominal wall by tensing neck
  2. Worsening pain upon palpation = abdominal wall disorder
  3. Lessening pain upon palpation = intra-abdominal
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4
Q

What is Murphy’s sign?

A
  1. Inspiratory arrest
  2. Deep palpation of RUQ during inspiration
  3. Arrest of inspiration due to pain = positive
  4. Gallbladder inflammation
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5
Q

What is Rovsing’s sign?

A
  • Indirect tenderness
  • RLQ pain elicited by LLQ palpation
  • Appendicitis

Rovsing is the roving sign

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6
Q

What is a Psoas sign?

A
  • Patient flexes thigh against resistance of examiner’s hand
  • Increased RLQ pain = positive
  • Appendicitis
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7
Q

What is an obturator sign?

A
  • Patient thigh flexed to a right angle.
  • Thigh is then gently rotated internally and then externally.
  • Appendicitis, Diverticulitis, PID
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8
Q

Summary Table of the abdominal signs

A

Note that most tests are LOW sensitivity

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9
Q

What would indicate us to admit for acute abdomen?

A
  • Toxic appearance
  • Unclear dx in elderly or immunocompromised
  • Inability to exclude more serious etiologies
  • Intractable pain or vomiting
  • AMS
  • Inability to follow discharge instructions
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10
Q

What is volvulus?

A

Torsion of the bowel, twisting about its mesentery, leading to bowel obstruction

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11
Q

What is the MC type of volvulus?

A

Sigmoid

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12
Q

Who does volvulus typically occur in?

A

70+ with history of institutionalization and debilitation

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13
Q

At what point does obstruction of the intestinal lumen occur due to volvulus?

A

Greater than 180 deg of twisting

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14
Q

What are the risk factors for sigmoid volvulus?

A
  • Long, redundant sigmoid with narrow mesentery
  • Chronic fecal overloading due to constipation
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15
Q

How does sigmoid volvulus present?

A
  • Insidious onset of abdominal pain
  • Vomiting a few days after pain onset
  • Colicky during peristalsis
  • Tenderness to palpation
  • Abdominal tympany
  • Early: Fever, tachycardia, hypotension is absent (If present, suggests perforation)
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16
Q

How do you diagnose sigmoid volvulus?

A
  • Abdominal CT showing whirlwind pattern
  • Barium GI series: bird-beak pattern
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17
Q

If an abdominal XRAY is taken of sigmoid volvulus, what might we see?

A

U-shaped, distended sigmoid Bent inner tube

Obtained if no immediate access to CT

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18
Q

How do we manage sigmoid volvulus?

A
  • Endoscopic detorsion with rigid sigmoidoscope
  • Elective sigmoid colectomy can be done if high risk of recurrence.
  • If peritonitis or perf is present, straight to surgery.
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19
Q

What is a cecal volvulus?

A
  • Rotation of cecum and ascending colon due to lack of fixation of the right colon
  • More rare than sigmoid volvulus
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20
Q

What are the risk factors for cecal volvulus?

A
  • Pregnancy
  • Tumors
  • Exertion
  • Violent coughing
  • Colon muscle weakness
  • Infections
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21
Q

What are the 3 types of cecal volvulus?

A
  1. Type 1: axial cecal
  2. Type 2: Loop cecal
  3. Type 3: Cecal bascule

Do not have to know

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22
Q

How does cecal volvulus present?

A
  • Typically: gradual onset of abd pain w/ cramping pain
  • N/V/obstipation
  • Diffuse distension, tympany, and tenderness to palpation
  • Fever or hypotension with peritonitis

Pretty much the same as sigmoid?

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23
Q

What is the 1st line and confirmatory test for cecal volvulus?

A

Abdominal CT showing whirlwind sign

same as sigmoid, just in a different area.

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24
Q

What might be seen on flat abdominal XRAY for cecal volvulus?

A
  • Coffee bean sign
  • Comma sign
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25
Q

What is the last resort testing for Cecal volvulus?

A

Barium GI series showing a bird’s beak sign

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26
Q

How do we treat cecal volvulus without bowel compromise? What if they are unstable?

A
  • Open surgical detorsion
  • Ileocecal resection after
  • Unstable: Cecopexy after detorsion (anchoring to the abd wall)

Main diff from sigmoid volvulus

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27
Q

How do we treat cecal volvulus with bowel compromise? What if they are unstable?

A
  • Stable: Ileocolic resection or right colectomy or ileocolic anastomosis
  • Unstable: Resection of compromised bowel + ileostomy

No detorsion should be performed in bowel compromise

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28
Q

What is intussusception?

A

Portion of bowel gets telescoped into another segment.

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29
Q

What is intussusception the MC cause of?

A

Intestinal obstruction between 6mo and 3y, esp in males

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30
Q

What is the MCC of intussusception?

A

Idiopathic (75%)

31
Q

What segment of bowel is MC intussuscepted?

A

Ileocolic

32
Q

How does intussusception typically present?

A
  • Paroxysms of abd pain with screaming and drawing up of knees
  • Currant-jelly stools after 12 hours
  • Sausage-shaped mass in R abdomen
  • Lethargic/febrile in between episodes
33
Q

What is the imaging of choice for intussusception?

A

US showing a bullseye lesion or coiled spring

34
Q

How do we both confirm and cure intussusception?

A

Barium enema

35
Q

What is the treatment of choice for intussusception?

A

Nonoperative reduction via hydrostatic or pneumatic pressure via enema

US guidance: Hydrostatic only
Fluoroscopy: Hydrostatic or pneumatic

36
Q

What would be most preferable in terms of enema for intussusception treatment?

A

Pneumatic, as it has higher success rates and lower risk of perforation

Pneumatic requires fluoroscopy

37
Q

What is the MC abdominal surgical emergency?

A

Appendicitis

38
Q

When is appendicitis MC?

A

10-30

39
Q

What initiates appendicitis?

A

Fecalith

40
Q

How does appendicitis present?

A
  • Most reliable symptom: Vague, colicky, abd pain
  • Localized to RLQ pain after 12 hours
  • Worsened by walking or coughing
  • N/V, anorexia, obstipation, low grade fever
  • Increasing symptoms
  • McBurney’s may be present
  • Rebound tenderness may be present
41
Q

What signs can be positive in appendicitis?

A
  • McBurney’s point tenderness
  • Rovsing sign
  • Psoas sign
  • Obturator sign
  • Heel slap sign
42
Q

What is the imaging of choice for appendicitis?

A

Abd CT w/ contrast

43
Q

What is the treatment of choice for appendicitis?

A

Lap Appendectomy

44
Q

What are the pre-op ABX for appendectomy?

A

Cefotixin or amp-sul (Unasyn)

I remember unasyn because Sul has a u in it!
Zosyn is pip-tazo, which has a z in it!

45
Q

What is toxic megacolon a complication of?

A
  • IBD (CD mostly)
  • Infectious colitis
46
Q

What is toxic megacolon?

A

Total or segmental nonobstructive colonic dilatation of > 6cm + systemic toxicity

47
Q

What is the hallmark of toxic megacolon?

A

Severe inflammation extending into the smooth muscle layer

48
Q

What is the MC presenting symptom of toxic megacolon?

A

Severe bloody diarrhea

49
Q

How does someone with toxic megacolon present?

A
  • Fever
  • AMS
  • Tachy
  • Fever
  • Postural hypotension
  • Malaise
  • Resistant to therapy

Very sick with systemic signs

50
Q

What is the imaging of choice for toxic megacolon?

A

Abd CT to confirm and exclude complications

51
Q

What is the more probable 1st line imaging for toxic megacolon?

A

Flat abdominal XRAY

52
Q

What is the diagnostic criteria for toxic megacolon?

A
  1. Radiographic evidence of colonic distension
  2. 3 of the following: fever >38C, HR> 120, Neutrophilic leukocytosis > 10.5k, or anemia
  3. 1 of the following: dehydration, AMS, lyte abnormalities, or hypotension
53
Q

What part of the colon tends to be the most distended in toxic megacolon?

A

Transverse or right colon

54
Q

What does dark on an XRAY mean?

A

Air

55
Q

How do we treat toxic megacolon?

A
  • NG tube
  • No usage of opioids, antimotility, or anticholinergics
  • GI prophylaxis via PPI
  • (+/-) ABX: amp/gent/metro OR 3rd gen cephalo + metro
  • IV corticosteroids
  • Surgical consult for colectomy with ileorectal anastomosis
56
Q

What is most commonly affected in acute mesenteric ischemia?

A

Superior mesenteric artery

57
Q

How does acute mesenteric ischemia present?

A
  • Abd pain far out of proportion to exam
  • Bowel sounds absent
  • Bloody stool
  • Feculent odor to breath
58
Q

What pH abnormality may occur in acute mesenteric ischemia?

A

Metabolic acidosis

Tissue hypoperfusion => release of lactic acid

59
Q

What is the clinical guideline for acute mesenteric ischemia?

A

Acute abd pain + metabolic acidosis = acute mesenteric ischemia until proven otherwise.

AKA if she puts metabolic acidosis on a clinical scenario, its prob this

60
Q

What imaging can actually diagnose acute mesenteric ischemia?

A

Mesenteric arteriography showing narrowing of arteries, reduced filling, irregularity of arterial branches

61
Q

How do we treat acute mesenteric ischemia?

A
  • Pain control
  • Broad spectrum ABX
  • Anticoags
  • NTG
  • Abd exploration
62
Q

What is the MCC of Upper GI bleed?

A

PUD

63
Q

What anatomic location delineates an upper GI bleed from lower?

A

Ligament of Treitz/suspensory muscle of duodenum

64
Q

What is the MCC of a Lower GI bleed?

A

Bleeding diverticulum in diverticulosis

65
Q

What do the stool types tell you about blood origin?

A
  • Hematemesis/coffee ground emesis = proximal to right colon
  • Melena: Upper GI bleed
  • Hematochezia: Lower GI bleed
66
Q

Ingestion of what substances can induce certain stool types?

A
  • Ingestion of iron or bismuth: Simulates Melena
  • Ingestion of beets: Simulates hematochezia
  • Ingestion of cefdinir: Red stools
67
Q

What are the predisposing factors to umbilical hernias?

A
  • Mutiple pregnancies with prolonged labor
  • Ascites
  • Obesity
  • Large intra-abdominal tumors
68
Q

What would prompt an emergent repair of an umbilical hernia?

A

Incarceration or strangulation

69
Q

How do umbilical hernias typically present?

A
  • Increasing in size
  • Often contain omentum and portions of bowel
  • Tight rings: Sharper pain
  • Larger: aching pain
70
Q

What is the treatment of choice for a normal size umbilical hernia?

A

Mesh repair laparoscopically

Open if big

71
Q

What kind of hernia occurs from prior abdominal surgery and why?

A

Incisional hernias due to breakdown of the fascial closure

72
Q

What would make a ventral/incisional hernia concerning for strangulation?

A
  • Firm, incarcerated
  • Severe tenderness on exam
  • Redness/discoloration
73
Q

When is an abdominal binder used?

A
  • Awaiting surgery
  • Unwilling to undergo surgery
  • Poor surgical candidate

GI (17 decks)

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