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
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
3
Q
What is Carnett’s sign?
A
- Tense abdominal wall by tensing neck
- Worsening pain upon palpation = abdominal wall disorder
- Lessening pain upon palpation = intra-abdominal
4
Q
What is Murphy’s sign?
A
- Inspiratory arrest
- Deep palpation of RUQ during inspiration
- Arrest of inspiration due to pain = positive
- Gallbladder inflammation
5
Q
What is Rovsing’s sign?
A
- Indirect tenderness
- RLQ pain elicited by LLQ palpation
- Appendicitis
Rovsing is the roving sign
6
Q
What is a Psoas sign?
A
- Patient flexes thigh against resistance of examiner’s hand
- Increased RLQ pain = positive
- Appendicitis
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
8
Q
Summary Table of the abdominal signs
A
Note that most tests are LOW sensitivity
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
10
Q
What is volvulus?
A
Torsion of the bowel, twisting about its mesentery, leading to bowel obstruction
11
Q
What is the MC type of volvulus?
A
Sigmoid
12
Q
Who does volvulus typically occur in?
A
70+ with history of institutionalization and debilitation
13
Q
At what point does obstruction of the intestinal lumen occur due to volvulus?
A
Greater than 180 deg of twisting
14
Q
What are the risk factors for sigmoid volvulus?
A
- Long, redundant sigmoid with narrow mesentery
- Chronic fecal overloading due to constipation
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)
16
Q
How do you diagnose sigmoid volvulus?
A
- Abdominal CT showing whirlwind pattern
- Barium GI series: bird-beak pattern
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
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.
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
20
Q
What are the risk factors for cecal volvulus?
A
- Pregnancy
- Tumors
- Exertion
- Violent coughing
- Colon muscle weakness
- Infections
21
Q
What are the 3 types of cecal volvulus?
A
- Type 1: axial cecal
- Type 2: Loop cecal
- Type 3: Cecal bascule
Do not have to know
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?
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.
24
Q
What might be seen on flat abdominal XRAY for cecal volvulus?
A
- Coffee bean sign
- Comma sign
25
What is the last resort testing for Cecal volvulus?
Barium GI series showing a bird's beak sign
26
How do we treat cecal volvulus without bowel compromise? What if they are unstable?
* **Open surgical** detorsion
* **Ileocecal resection after**
* Unstable: Cecopexy after detorsion (anchoring to the abd wall)
| Main diff from sigmoid volvulus
27
How do we treat cecal volvulus with bowel compromise? What if they are unstable?
* Stable: Ileocolic resection or right colectomy or ileocolic anastomosis
* Unstable: Resection of compromised bowel + ileostomy
| **No detorsion should be performed in bowel compromise**
28
What is intussusception?
Portion of bowel gets telescoped into another segment.
29
What is intussusception the MC cause of?
Intestinal obstruction between **6mo and 3y**, esp in **males**
30
What is the MCC of intussusception?
Idiopathic (75%)
31
What segment of bowel is MC intussuscepted?
Ileocolic
32
How does intussusception typically present?
* 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
What is the imaging of choice for intussusception?
US showing a bullseye lesion or coiled spring
34
How do we both confirm and cure intussusception?
Barium enema
35
What is the treatment of choice for intussusception?
Nonoperative reduction via **hydrostatic or pneumatic pressure via enema**
## Footnote
US guidance: Hydrostatic only
Fluoroscopy: Hydrostatic or pneumatic
36
What would be most preferable in terms of enema for intussusception treatment?
Pneumatic, as it has **higher success rates and lower risk of perforation**
| Pneumatic requires fluoroscopy
37
What is the MC abdominal **surgical** emergency?
Appendicitis
38
When is appendicitis MC?
10-30
39
What initiates appendicitis?
Fecalith
40
How does appendicitis present?
* **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
What signs can be positive in appendicitis?
* McBurney's point tenderness
* Rovsing sign
* Psoas sign
* Obturator sign
* Heel slap sign
42
What is the imaging of choice for appendicitis?
Abd CT w/ contrast
43
What is the treatment of choice for appendicitis?
Lap Appendectomy
44
What are the pre-op ABX for appendectomy?
Cefotixin or amp-sul (Unasyn)
## Footnote
I remember unasyn because Sul has a u in it!
Zosyn is pip-tazo, which has a z in it!
45
What is toxic megacolon a complication of?
* IBD (CD mostly)
* Infectious colitis
46
What is toxic megacolon?
Total or segmental **nonobstructive** colonic dilatation of > 6cm **+ systemic toxicity**
47
What is the hallmark of toxic megacolon?
Severe **inflammation extending into the smooth muscle** layer
48
What is the MC presenting symptom of toxic megacolon?
Severe bloody diarrhea
49
How does someone with toxic megacolon present?
* Fever
* AMS
* Tachy
* Fever
* Postural hypotension
* Malaise
* Resistant to therapy
| Very sick with systemic signs
50
What is the **imaging of choice** for toxic megacolon?
Abd CT to confirm and exclude complications
51
What is the more probable 1st line imaging for toxic megacolon?
Flat abdominal XRAY
52
What is the diagnostic criteria for toxic megacolon?
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
What part of the colon tends to be the most distended in toxic megacolon?
Transverse or right colon
54
What does dark on an XRAY mean?
Air
55
How do we treat toxic megacolon?
* 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
What is most commonly affected in acute mesenteric ischemia?
Superior mesenteric artery
57
How does acute mesenteric ischemia present?
* **Abd pain far out of proportion** to exam
* Bowel sounds absent
* Bloody stool
* **Feculent odor to breath**
58
What pH abnormality may occur in acute mesenteric ischemia?
Metabolic acidosis
| Tissue hypoperfusion => release of lactic acid
59
What is the clinical guideline for acute mesenteric ischemia?
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
What imaging can actually diagnose acute mesenteric ischemia?
Mesenteric arteriography showing **narrowing of arteries, reduced filling, irregularity of arterial branches**
61
How do we treat acute mesenteric ischemia?
* Pain control
* Broad spectrum ABX
* Anticoags
* NTG
* Abd exploration
62
What is the MCC of Upper GI bleed?
PUD
63
What anatomic location delineates an upper GI bleed from lower?
Ligament of Treitz/suspensory muscle of duodenum
64
What is the MCC of a Lower GI bleed?
Bleeding diverticulum in diverticulosis
65
What do the stool types tell you about blood origin?
* Hematemesis/coffee ground emesis = proximal to right colon
* Melena: Upper GI bleed
* Hematochezia: Lower GI bleed
66
Ingestion of what substances can induce certain stool types?
* Ingestion of iron or bismuth: Simulates Melena
* Ingestion of beets: Simulates hematochezia
* Ingestion of **cefdinir: Red stools**
67
What are the predisposing factors to umbilical hernias?
* Mutiple pregnancies with prolonged labor
* Ascites
* Obesity
* Large intra-abdominal tumors
68
What would prompt an emergent repair of an umbilical hernia?
Incarceration or strangulation
69
How do umbilical hernias typically present?
* Increasing in size
* **Often contain omentum and portions of bowel**
* Tight rings: Sharper pain
* Larger: aching pain
70
What is the treatment of choice for a normal size umbilical hernia?
Mesh repair laparoscopically
| Open if big
71
What kind of hernia occurs from prior abdominal surgery and why?
Incisional hernias due to breakdown of the fascial closure
72
What would make a ventral/incisional hernia concerning for strangulation?
* Firm, incarcerated
* Severe tenderness on exam
* Redness/discoloration
73
When is an abdominal binder used?
* Awaiting surgery
* Unwilling to undergo surgery
* Poor surgical candidate
