EOR GI part 1: abdominal pain

Question 1

What is an acute abdomen?

Answer 1

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

Question 2

What are peritoneal signs?

Answer 2

Signs of peritoneal irritation:

• Extreme tenderness
• Percussion tenderness
• Rebound tenderness
• Voluntary guarding
• Motion pain
• Involuntary guarding/rigidity

Question 3

Rebound tenderness

Answer 3

Pain upon releasing the palpating hand pushing on the abdomen

Question 4

Motion pain

Answer 4

Abd pain upon moving, pelvic rocking, moving of stretcher, or heel strike

Question 5

Involuntary guarding

Answer 5

Rigid abdomen as the muscles “guard” involuntarily

Question 6

Voluntary guarding

Answer 6

Abdominal muscle contraction with palpation of the abdomen

Question 7

Colic

Answer 7

Intermittent severe pain (usually because of intermittent contraction of a hollow viscus against an obstruction)

Question 8

What conditions can mask abdominal pain?

Answer 8

Steroids
DM
Paraplegia

Question 9

What is the MCC of acute abdominal surgery in the US?

Answer 9

Acute appendicitis

Question 10

What should go first, auscultation or palpation?

Answer 10

Auscultation

Question 11

What is the best way to have a pt localize abdominal pain?

Answer 11

Point with one finger to where the pain is worse

Question 12

What is the classic position of a pt with peritonitis?

Answer 12

Motionless (often with knees flexed)

Question 13

What is the classic position of a pt with a kidney stone?

Answer 13

Cannot stay still, restless, writhing in pain

Question 14

What is the best way to examine a scared child or histrionic adult’s abdomen?

Answer 14

Use stethoscope to palpate abdomen

Question 15

What lab tests are used to evaluate the pt with an acute abdomen?

Answer 15

CBC with diff
Chem 10
Amylase
Type and screen
UA
LFTs

Question 16

What is a left shift on CBC with diff?

Answer 16

Sign of inflammatory response:

• Immature neutrophils (bands)
• -Note: many call >80% of WBCs as neutrophils a left shift

Question 17

What lab test should every woman of childbearing age with an acute abdomen receive?

Answer 17

Beta-hCG to r/o pregnancy/ectopic pregnancy

Question 18

Which X-rays are used to evaluate the pt with an acute abdomen?

Answer 18

Upright CXR
Upright abdominal film
Supine abd X-ray (if pt cannot stand, left lateral decubitus abdominal film)

Question 19

How is free air ruled out if the pt cannot stand?

Answer 19

Left lateral decubitus- free air collects over the liver and does not get confused with the gastric bubble

Question 20

What dx must be considered in every pt with an acute abdomen?

Answer 20

Appendicitis

Question 21

What are DDx for RUQ pain?

Answer 21

Cholecystitis
Hepatitis
PUD
Perforated ulcer
Pancreatitis
Liver tumors
Gastritis
Hepatic abscess
Choledocholithiasis
Cholangitis
Pyelonephritis
Nephrolithiasis
Appendicitis, esp during pregnancy
Thoracic causes
PE
Pericarditis
MI

Question 22

DDx for LUQ pain

Answer 22

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

Question 23

DDx of LLQ pain

Answer 23

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)

Question 24

DDx of RLQ pain

Answer 24

Appendicitis
Same as LLQ
Mesenteric lymphadenitis
Cecal diverticulitis
Meckel's diverticulum
Intussusception

Question 25

What is the DDx of epigastric pain?

Answer 25

PUD
Gastritis
MI
Pancreatitis
Biliary colic
Gastric volvulus
Mallory-Weiss tear

Question 26

What are nonsurgical causes of abd pain?

Answer 26

Gastroenteritis
DKA
Sickle cell crisis
Rectus sheath hematoma
Acute porphyria
PID
Kidney stone
Pyelonephritis
Hepatitis
Pancreatitis
Penumonia
MI
C. diff colitis

Question 27

What is the unique DDx for the pt with AIDS and abd pain?

Answer 27

In addition to all common abd conditions:
CMV (most common)
Kaposi's sarcoma
Lymphoma
TB
Mycobacterium avium intracellulare

Question 28

What causes pain limited to specific dermatomes?

Answer 28

Early zoster before vesicles erupt

Question 29

What is referred pain?

Answer 29

Pain felt at a site distant from a dz process

Question 30

Referred pain for cholecystitis

Answer 30

Right subscapular pain (also epigastric)

Question 31

Referred pain for appendicitis

Answer 31

Early: periumbilical
Rarely: testicular pain

Question 32

Referred pain for diaphragmatic irritation (from spleen, perforated ulcer, or abscess)

Answer 32

Shoulder pain (+ Kehr’s sign on the left)

Question 33

Referred pain for pancreatitis/CA

Answer 33

Back pain

Question 34

Referred pain for rectal dz

Answer 34

Pain in the small of the back

Question 35

Referred pain for nephrolithiasis

Answer 35

Testicular pain/flank pain

Question 36

Referred pain for rectal pain

Answer 36

Midline small of back pain

Question 37

Referred pain for small bowel

Answer 37

Periumbilical pain

Question 38

Referred pain for uterine pain

Answer 38

Midline small of back pain

Question 39

Classic dx for abdominal pain out of proportion to exam

Answer 39

R/o mesenteric ischemia

Question 40

Classic dx for hypotension and pulsatile abd mass

Answer 40

Ruptured AAA; go to OR

Question 41

Classic dx for fever, LLQ pain, and change in bowel habits

Answer 41

Diverticulitis

Question 42

Classically, what endocrine problems can cause abdominal pain?

Answer 42

Addisonian crisis

DKA