Elkins Abdominal Pain Notes - Exam 2 Flashcards by Johannah Crumpton

What age range is appendicitis MC?

MC between patients age 10 to 19 years

How well did you know this?

Not at all

Perfectly

general malaise, indigestion, bowel irregularity, anorexia
periumbilical or central abdominal discomfort that progresses to RLQ pain and tenderness

What am I?
What order does N/V and pain occur in?
What does sudden improvement of symptoms mean?

appendicitis

N/V may occur AFTER onset of pain

perforation

How well did you know this?

Not at all

Perfectly

Where will the atypical appendicitis presentation pain be located?

retrocecal appendix

malrotation of the colon

Gravid uterus

a retrocecal appendix = right flank or pelvic pain

malrotation of the colon = left upper quadrant

Gravid uterus = RUQ or RLQ

How well did you know this?

Not at all

Perfectly

pain with deep breathing
pain with heel tap or bumps in road during drive to hospital
Rebound tenderness, voluntary guarding, CVA tenderness

What am I?

peritonitis

How well did you know this?

Not at all

Perfectly

What is the earliest lab finding in appendicitis?

elevated WBC

How well did you know this?

Not at all

Perfectly

____ is indicated for append in children, pregnant women and thin adults

How well did you know this?

Not at all

Perfectly

______ is typically ordered in most adult population if you suspect append

CT Abd/Pelvis with IV contrast

How well did you know this?

Not at all

Perfectly

____ is ordered in append as the initial dx study, what should you do if ___ is NOT diagnostic?

if not diagnostic consult radiology for further recommendations

How well did you know this?

Not at all

Perfectly

What is the management of append?

NPO with IV fluids

pain control

antiemetics

preop abx options:
amp/sulb
pip/taz
cefoxitin
metro PLUS cipro

surgical consult!! may be ordered before imaging in straightforward cases

How well did you know this?

Not at all

Perfectly

What are the 4 presentations of gallstone dz?

biliary colic
acute cholecystitis
gallstone obstructing pancreatitis
ascending cholangitis (infection of the biliary tree)

How well did you know this?

Not at all

Perfectly

______ recurrent attacks of upper abdominal pain that typically last no more than a few hours and resolve spontaneously when the _____ moves from its obstructing position

biliary colic

gallstone

How well did you know this?

Not at all

Perfectly

______ occurs when the obstructing stone remains in place leading to a distended, inflamed and sometimes infected gallbladder

acute cholecystitis

How well did you know this?

Not at all

Perfectly

_____ life threatening condition with complete biliary obstruction with a complicated super infection. What is the MC cause?

ascending cholangitis

choledocholithiasis

How well did you know this?

Not at all

Perfectly

RUQ or epigastric pain and occasionally radiates to the back or right scapula
(+) N/V
RUQ tenderness
+/- jaundice

What am I?
What is Charcot’s triad?

Cholecystitis

fever, RUQ pain and jaundice

How well did you know this?

Not at all

Perfectly

What will a CBC show in biliary colic? When will LFTs be elevated?

CBC will be normal in biliary colic

elevated in choledocholithiasis

How well did you know this?

Not at all

Perfectly

____ will confirm the presence of stone. What are some non-specific findings?

RUQ US

gallbladder wall thickening and pericholecystic fluid

How well did you know this?

Not at all

Perfectly

What US finding would make you suspect choledocholithiasis?

CBD is greater than 5-7mm

How well did you know this?

Not at all

Perfectly

What is the next imaging choice in gallbladder dz? Is it commonly done in the ER?

HIDA scan

not performed in the ED - pt must fast for 4-12 hours

How well did you know this?

Not at all

Perfectly

What is the tx for gallbladder dz? What do you need to keep O2 stat at?

NPO with IV Fluids - NS or LR

antiemetics

pain control: morphine or ketorolac

keep O2 sat > 95%

How well did you know this?

Not at all

Perfectly

When are abx indicated for gb dz?

cholecystitis or cholangitis

How well did you know this?

Not at all

Perfectly

What is the abx of choice for uncomplicated cholecystitis?

metronidazole (Flagyl) + ceftriaxone (Rocephin)

How well did you know this?

Not at all

Perfectly

What is the abx of choice for Ascending cholangitis, associated sepsis or peritonitis? What if there is an PCN allergy?

ampicillin + gentamicin + clindamycin = Ascending cholangitis

substitute ampicillin with 3rd gen ceph (ceftriaxone) or fluoroquinolone (levofloxacin)

clindamycin allergy - metronidazole (Flagyl)

How well did you know this?

Not at all

Perfectly

What consults are needed for Acute cholecystitis and Ascending cholangitis or choledocholithiasis?

Acute cholecystitis - urgent consult to general surgery

Ascending cholangitis or choledocholithiasis - urgent consult to general surgery/gastroenterology for ERCP and sphincterotomy

What is the criteria for biliary colic pts to be discharged home?

symptoms improve within 4-6 hours of supportive therapy and able to tolerate oral hydration

rx: opioids, antiemetics and need outpt sx consult!!

LLQ abdominal pain- intermittent or constant fever leukocytosis bowel habits N/V anorexia urinary symptoms may have tender palpable mass distended abdomen peritonitis with rebound and guarding What am I? What is the imaging of choice for a pt in their first episode?

Diverticulitis CT of the abd/pelvic with IV contrast +/- oral or rectal contras

increased soft tissue density within the pericolic fat presence of diverticula bowel wall thickening >4 mm soft tissue masses representing phlegmon These are common CT findings for _____. What finding would indicate an abscess?

diverticulitis pericolic fluid collections representing abscesses

What is the first step in determining treatment for diverticulitis?

is it uncomplicated or complicated?

______ isolated inflammation of the diverticula with or without phlegmon or small abscess confined to the bowel wall

uncomplicated divertic

______ diverticular inflammation associated with abscess, stricture, obstruction, fistula, or perforation

complicated divertic

What age range makes it an automatic complicated divertic case? Or meets _____ criteria

over 70 sepsis or SIRS criteria (there is an entire list but FUCK that)

What is the tx for complicated divertic?

admit NPO- bowel rest IV fluids and abx sx consult

What are the abx in moderate complicated divertic? Severe?

moderate: metronidazole (Flagyl) + FQ (cipro, levaquin) severe (life-threatening cases): piperacillin-tazobactam (Zosyn)

What is the EMB tx for uncomplicated divertic?

liquid diet slowly advancing diet as tolerated and pain control avoid dairy and red meat

What is the abx of choice for uncomplicated divertic? When should they f/u with PCP?

augmentin F/u in 2-3 d with PCP

What are the 2 MC causes of pancreatitis?

gallstones or alcohol consumption

acute, severe, and persistent epigastric abdominal pain pain may radiate to the back, chest, or flanks What am I? What makes it better? What makes it worse?

pancreatitis better: sitting up with the knees flexed worse: worse with oral intake or lying supine

What are signs of severe necrotizing pancreatitis?

Cullen’s sign Grey-Turner sign erythematous skin nodules from focal subcutaneous fat necrosis

What are the dx criteria for acute pancreatitis?

need 2 out of 3: clinical presentation consistent with acute pancreatitis a serum LIPASE (preferred) or amylase value significantly elevated above the ULN Imaging findings characteristic of acute pancreatitis (enlargement of pancreas)

**What does an ALT > ____ within the first 48 hours of pancreatitis symptoms = _____. **What does an elevated alk phos indicate?

ALT > 150 w/i the 1st 48 hrs of symptom onset = gallstone Elevated Alk Phos = biliary disease or gallstone

What are 2 lung findings associated with pancreatitis? Need to order _____

pleural effusions and pulm infiltrates CXR

_____ can be done in the ED if concerned about gallstone pancreatitis

transbdominal US

**When would you order abdominal CT with IV contrast in the setting for pancreatitis?

abdominal CT with IV contrast indicated ONLY if dx is questionable or trying to rule in/out biliary involvement

What is the management of pancreatitis?

NPO fluids: early aggressive hydration 2.5- 4 liters of fluid in the first 12-24 hours oxygen >95% pain control: usually IV opiate IV abx only if infection present: imipenem-cilastatin (Primaxin IV) meropenem (Merrem) ciprofloxacin (Cipro) with metronidazole (Flagyl)

What is considered mild acute pancreatitis?

no evidence of biliary involvement pain and vomiting controlled with oral agents tolerate clear liquid diets good social support

What does the first episode of pancreatitis automatically indicate?

needs to be admitted! first = admission

What are the 4 different classifications of SBO?

partial complete simple strangulated

What is considered a partial SBO?

gas and liquid stool can pass through the point of narrowing

What is the MC etiology of SBO? What is the 2nd MC

MC= adhesions after abdominal sx 2nd MC= incarceration of hernia

What are less common intraluminal causes of SBO?

polyps, lymphoma or adenocarcinoma

What is the difference between an ileus and a SBO?

Ileus: a condition in which the bowel does not work correctly, but there is no structural problem causing it SBO: something physically blocking it

Crampy and intermittent abdominal pain - lasting for a few minutes at a time vomiting diminished appetite reduced oral intake change in bowel habits abdominal distention abdominal tenderness What am I? What is the imaging modality of choice?

SBO CT of the abdomen and pelvis with IV contrast

How does the change in bowel habits differ from complete vs partial obstruction?

Complete obstruction will result in constipation Partial obstruction will allow for BM and gas production

What does a WBC over 40K indicate in the presence of SBO s/s?

mesenteric vascular occlusion

What is a good INITIAL test to help rule out perforation in SBO? What will it show?

X-ray Dilated loops of bowel with air–fluid levels, with a small amount of colonic gas on flat and upright abdominal

What is the management for a partial obstruction or ileus?

NPO with IV fluids NG with light suction Antiemetic, analgesics Admit for observation Most will resolve without surgery within 72 hours

What is the management for a complete obstruction?

NPO, start IV fluids, NG tube with light suction for symptomatic relief until surgery Immediate surgical consult!! sx will provide guidance with regards to abx of choice