Disorders of the Acute Abdomen Flashcards
What are the 3 types of pain that may occur in the acute abdomen?
- Visceral: Slow, poorly localized, dull
- Somatic/Parietal: Sudden, sharp, localized
- Referred pain
When auscultating for peristalsis, what should we keep in mind?
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
What is Carnett’s sign?
- Tense abdominal wall by tensing neck
- Worsening pain upon palpation = abdominal wall disorder
- Lessening pain upon palpation = intra-abdominal
What is Murphy’s sign?
- Inspiratory arrest
- Deep palpation of RUQ during inspiration
- Arrest of inspiration due to pain = positive
- Gallbladder inflammation
What is Rovsing’s sign?
- Indirect tenderness
- RLQ pain elicited by LLQ palpation
- Appendicitis
Rovsing is the roving sign
What is a Psoas sign?
- Patient flexes thigh against resistance of examiner’s hand
- Increased RLQ pain = positive
- Appendicitis
What is an obturator sign?
- Patient thigh flexed to a right angle.
- Thigh is then gently rotated internally and then externally.
- Appendicitis, Diverticulitis, PID
Summary Table of the abdominal signs
Note that most tests are LOW sensitivity
What would indicate us to admit for acute abdomen?
- Toxic appearance
- Unclear dx in elderly or immunocompromised
- Inability to exclude more serious etiologies
- Intractable pain or vomiting
- AMS
- Inability to follow discharge instructions
What is volvulus?
Torsion of the bowel, twisting about its mesentery, leading to bowel obstruction
What is the MC type of volvulus?
Sigmoid
Who does volvulus typically occur in?
70+ with history of institutionalization and debilitation
At what point does obstruction of the intestinal lumen occur due to volvulus?
Greater than 180 deg of twisting
What are the risk factors for sigmoid volvulus?
- Long, redundant sigmoid with narrow mesentery
- Chronic fecal overloading due to constipation
How does sigmoid volvulus present?
- 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)
How do you diagnose sigmoid volvulus?
- Abdominal CT showing whirlwind pattern
- Barium GI series: bird-beak pattern
If an abdominal XRAY is taken of sigmoid volvulus, what might we see?
U-shaped, distended sigmoid Bent inner tube
Obtained if no immediate access to CT
How do we manage sigmoid volvulus?
- 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.
What is a cecal volvulus?
- Rotation of cecum and ascending colon due to lack of fixation of the right colon
- More rare than sigmoid volvulus
What are the risk factors for cecal volvulus?
- Pregnancy
- Tumors
- Exertion
- Violent coughing
- Colon muscle weakness
- Infections
What are the 3 types of cecal volvulus?
- Type 1: axial cecal
- Type 2: Loop cecal
- Type 3: Cecal bascule
Do not have to know
How does cecal volvulus present?
- 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?
What is the 1st line and confirmatory test for cecal volvulus?
Abdominal CT showing whirlwind sign
same as sigmoid, just in a different area.
What might be seen on flat abdominal XRAY for cecal volvulus?
- Coffee bean sign
- Comma sign
What is the last resort testing for Cecal volvulus?
Barium GI series showing a bird’s beak sign
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
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
What is intussusception?
Portion of bowel gets telescoped into another segment.
What is intussusception the MC cause of?
Intestinal obstruction between 6mo and 3y, esp in males
What is the MCC of intussusception?
Idiopathic (75%)
What segment of bowel is MC intussuscepted?
Ileocolic
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
What is the imaging of choice for intussusception?
US showing a bullseye lesion or coiled spring
How do we both confirm and cure intussusception?
Barium enema
What is the treatment of choice for intussusception?
Nonoperative reduction via hydrostatic or pneumatic pressure via enema
US guidance: Hydrostatic only
Fluoroscopy: Hydrostatic or pneumatic
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
What is the MC abdominal surgical emergency?
Appendicitis
When is appendicitis MC?
10-30
What initiates appendicitis?
Fecalith
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
What signs can be positive in appendicitis?
- McBurney’s point tenderness
- Rovsing sign
- Psoas sign
- Obturator sign
- Heel slap sign
What is the imaging of choice for appendicitis?
Abd CT w/ contrast
What is the treatment of choice for appendicitis?
Lap Appendectomy
What are the pre-op ABX for appendectomy?
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!
What is toxic megacolon a complication of?
- IBD (CD mostly)
- Infectious colitis
What is toxic megacolon?
Total or segmental nonobstructive colonic dilatation of > 6cm + systemic toxicity
What is the hallmark of toxic megacolon?
Severe inflammation extending into the smooth muscle layer
What is the MC presenting symptom of toxic megacolon?
Severe bloody diarrhea
How does someone with toxic megacolon present?
- Fever
- AMS
- Tachy
- Fever
- Postural hypotension
- Malaise
- Resistant to therapy
Very sick with systemic signs
What is the imaging of choice for toxic megacolon?
Abd CT to confirm and exclude complications
What is the more probable 1st line imaging for toxic megacolon?
Flat abdominal XRAY
What is the diagnostic criteria for toxic megacolon?
- Radiographic evidence of colonic distension
- 3 of the following: fever >38C, HR> 120, Neutrophilic leukocytosis > 10.5k, or anemia
- 1 of the following: dehydration, AMS, lyte abnormalities, or hypotension
What part of the colon tends to be the most distended in toxic megacolon?
Transverse or right colon
What does dark on an XRAY mean?
Air
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
What is most commonly affected in acute mesenteric ischemia?
Superior mesenteric artery
How does acute mesenteric ischemia present?
- Abd pain far out of proportion to exam
- Bowel sounds absent
- Bloody stool
- Feculent odor to breath
What pH abnormality may occur in acute mesenteric ischemia?
Metabolic acidosis
Tissue hypoperfusion => release of lactic acid
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
What imaging can actually diagnose acute mesenteric ischemia?
Mesenteric arteriography showing narrowing of arteries, reduced filling, irregularity of arterial branches
How do we treat acute mesenteric ischemia?
- Pain control
- Broad spectrum ABX
- Anticoags
- NTG
- Abd exploration
What is the MCC of Upper GI bleed?
PUD
What anatomic location delineates an upper GI bleed from lower?
Ligament of Treitz/suspensory muscle of duodenum
What is the MCC of a Lower GI bleed?
Bleeding diverticulum in diverticulosis
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
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
What are the predisposing factors to umbilical hernias?
- Mutiple pregnancies with prolonged labor
- Ascites
- Obesity
- Large intra-abdominal tumors
What would prompt an emergent repair of an umbilical hernia?
Incarceration or strangulation
How do umbilical hernias typically present?
- Increasing in size
- Often contain omentum and portions of bowel
- Tight rings: Sharper pain
- Larger: aching pain
What is the treatment of choice for a normal size umbilical hernia?
Mesh repair laparoscopically
Open if big
What kind of hernia occurs from prior abdominal surgery and why?
Incisional hernias due to breakdown of the fascial closure
What would make a ventral/incisional hernia concerning for strangulation?
- Firm, incarcerated
- Severe tenderness on exam
- Redness/discoloration
When is an abdominal binder used?
- Awaiting surgery
- Unwilling to undergo surgery
- Poor surgical candidate
