EOR GI part 1: abdominal pain Flashcards
What is an acute abdomen?
Acute abd pain so severe that the pt seeks medical attention
Not the same as a surgical abdomen because most cases of acute abd pain do not require surgical tx
What are peritoneal signs?
Signs of peritoneal irritation:
- Extreme tenderness
- Percussion tenderness
- Rebound tenderness
- Voluntary guarding
- Motion pain
- Involuntary guarding/rigidity
Rebound tenderness
Pain upon releasing the palpating hand pushing on the abdomen
Motion pain
Abd pain upon moving, pelvic rocking, moving of stretcher, or heel strike
Involuntary guarding
Rigid abdomen as the muscles “guard” involuntarily
Voluntary guarding
Abdominal muscle contraction with palpation of the abdomen
Colic
Intermittent severe pain (usually because of intermittent contraction of a hollow viscus against an obstruction)
What conditions can mask abdominal pain?
Steroids
DM
Paraplegia
What is the MCC of acute abdominal surgery in the US?
Acute appendicitis
What should go first, auscultation or palpation?
Auscultation
What is the best way to have a pt localize abdominal pain?
Point with one finger to where the pain is worse
What is the classic position of a pt with peritonitis?
Motionless (often with knees flexed)
What is the classic position of a pt with a kidney stone?
Cannot stay still, restless, writhing in pain
What is the best way to examine a scared child or histrionic adult’s abdomen?
Use stethoscope to palpate abdomen
What lab tests are used to evaluate the pt with an acute abdomen?
CBC with diff Chem 10 Amylase Type and screen UA LFTs
What is a left shift on CBC with diff?
Sign of inflammatory response:
- Immature neutrophils (bands)
- -Note: many call >80% of WBCs as neutrophils a left shift
What lab test should every woman of childbearing age with an acute abdomen receive?
Beta-hCG to r/o pregnancy/ectopic pregnancy
Which X-rays are used to evaluate the pt with an acute abdomen?
Upright CXR
Upright abdominal film
Supine abd X-ray (if pt cannot stand, left lateral decubitus abdominal film)
How is free air ruled out if the pt cannot stand?
Left lateral decubitus- free air collects over the liver and does not get confused with the gastric bubble
What dx must be considered in every pt with an acute abdomen?
Appendicitis
What are DDx for RUQ pain?
Cholecystitis Hepatitis PUD Perforated ulcer Pancreatitis Liver tumors Gastritis Hepatic abscess Choledocholithiasis Cholangitis Pyelonephritis Nephrolithiasis Appendicitis, esp during pregnancy Thoracic causes PE Pericarditis MI
DDx for LUQ pain
PUD Perforated ulcer Gastritis Splenic injury, Abscess Reflux Dissecting aortic aneurysm Thoracic causes Pyelonephritis Nephrolithiasis Hiatal hernia (strangulated paraesophageal hernia) Boerhaave's syndrome Mallory-Weiss tear Splenic artery aneurysm Colon disease
DDx of LLQ pain
Diverticulitis Sigmoid volvulus Perforated colon Colon CA UTI SBO IBD Nephrolithiasis Pyelonephritis Fluid accumulation from aneurysm or perforation Referred hip pain Gynecologic causes Appendicitis (rare)
DDx of RLQ pain
Appendicitis Same as LLQ Mesenteric lymphadenitis Cecal diverticulitis Meckel's diverticulum Intussusception
What is the DDx of epigastric pain?
PUD Gastritis MI Pancreatitis Biliary colic Gastric volvulus Mallory-Weiss tear
What are nonsurgical causes of abd pain?
Gastroenteritis DKA Sickle cell crisis Rectus sheath hematoma Acute porphyria PID Kidney stone Pyelonephritis Hepatitis Pancreatitis Penumonia MI C. diff colitis
What is the unique DDx for the pt with AIDS and abd pain?
In addition to all common abd conditions: CMV (most common) Kaposi's sarcoma Lymphoma TB Mycobacterium avium intracellulare
What causes pain limited to specific dermatomes?
Early zoster before vesicles erupt
What is referred pain?
Pain felt at a site distant from a dz process
Referred pain for cholecystitis
Right subscapular pain (also epigastric)
Referred pain for appendicitis
Early: periumbilical
Rarely: testicular pain
Referred pain for diaphragmatic irritation (from spleen, perforated ulcer, or abscess)
Shoulder pain (+ Kehr’s sign on the left)
Referred pain for pancreatitis/CA
Back pain
Referred pain for rectal dz
Pain in the small of the back
Referred pain for nephrolithiasis
Testicular pain/flank pain
Referred pain for rectal pain
Midline small of back pain
Referred pain for small bowel
Periumbilical pain
Referred pain for uterine pain
Midline small of back pain
Classic dx for abdominal pain out of proportion to exam
R/o mesenteric ischemia
Classic dx for hypotension and pulsatile abd mass
Ruptured AAA; go to OR
Classic dx for fever, LLQ pain, and change in bowel habits
Diverticulitis
Classically, what endocrine problems can cause abdominal pain?
Addisonian crisis
DKA
