ER: abdominal pain

Question 1

What is mid-epigastric pain radiating to the back?

Answer 1

Pancreatitis

until ruled out

Question 2

What is RUQ pain that radiates to the right shoulder?

Answer 2

Gallbladder

Question 3

What is RLQ pain that radiates to the right shoulder?

Answer 3

Appendicitis or Ectopic pregnancy

Question 4

What is LLQ pain that radiates to the left shoulder?

Answer 4

Diverticulitis

Question 5

What two common ER conditions have improved symptoms when lying flat?

Answer 5

1. Appendicitis

2. Peritonitis

Question 6

What condition in the ER does not show any improvement regardless of positioning?

Answer 6

Testicular torsion, orchitis

really anything wrong down there is very uncomfortable

Question 7

What is a common finding on PE for aortic dissection?

Answer 7

Unequal femoral pulses

Question 8

What is suspected when there is “pain out of proportion to the exam”?

Answer 8

Mesenteric Ischemia

Question 9

Necrosis during appendicitis allows these two organisms to grow.

Answer 9

1. Bacteroides f.

2. E. coli

Question 10

Diagnostic procedure of choice for appendicitis.

Answer 10

CT scan

Question 11

Triad associated with acute cholecystitis.

Answer 11

Fat
Fertile
Forty

Question 12

What are the characteristics of black vs. brown gall stones?

Answer 12

Black: hemolysis, in gallbladder
Brown: infection, in ducts

Question 13

Two best tests to diagnose cholecystitis.

Answer 13

1. CT

2. Ultrasound

Question 14

Two most common causes of small bowel obstruction.

Answer 14

1. Adhesions (scar tissue from previous surgery)

2. Hernias

Question 15

Leading cause of large bowel obstruction.

Answer 15

Carcinoma

Question 16

How does large bowel obstruction appear on X-ray?

Answer 16

Dilated bowel with flat lines indicating air-fluid levels within the colon

Question 17

What is Ogilvie Syndrome?

Answer 17

Pseudo-obstruction of the large bowel most likely due to neurological malfunction. Nothing mechanical actually blocks the colon. Most commonly seen in the cecum and right colon.

Question 18

How does a low fiber diet lead to diverticulosis?

Answer 18

Fiber aids in motility in the colon. Low fiber means that the colon has to increase its workload to move fecal material.

This increase in workload leads to an increase in the lumen pressure which causes weakened areas of the bowel to form “out-pouches”.

Question 19

In patients suspected to have diverticulitis, what is important to avoid?

Answer 19

Barium enema and colonoscopy due to risk of perforation.

Question 20

Red current jelly stool.

Sausage-shaped mass on palpation

Answer 20

Intussusception

Question 21

Best diagnostic tool for intussusception and treatment.

Answer 21

Ultrasound

Treatment: barium enema, water enema, air enema
Surgery if recurrence happens

Question 22

Bacteria associated with MALT B lymphomas

Answer 22

H. pylori

Question 23

What can indicate a perforated peptic ulcer on X-ray.

Answer 23

Air under the diaphragm

although 40% do not show this

Question 24

What is Cullen Sign and Grey Turner sign?

Answer 24

CS: umbilical ecchymosis (small bruises)
GTS: flank ecchymosis

Both indicate acute pancreatitis

Question 25

Most common cause of pancreatitis

Answer 25

Alcohol | gall stones is #2

Question 26

Name and describe the worst complication of acute pancreatitis.

Answer 26

Systemic Inflammatory Response Syndrome (SIRS) Inflammation spreads throughout the whole body, leads to: Temperature 38 C(100.4 F) Fall in body temperature to < 36 C (96.8 F) Tachycardia >90 per minute Tachypnea > 20 per minute

Question 27

``` Describe Ranson Criteria for diagnosing acute pancreatitis. At presentation Age WBC Glucose LDH AST ``` ``` After 48 hrs. Fall in hematocrit Increase in BUN Calcium Arterial Po2 Base deficit Fluid deficit ```

Answer 27

``` At presentation Age >55 WBC > 16,000/mm3 Glucose >200 mg/dl LDH >350 IU/L AST >250 IU/L ``` ``` After 48 hrs. Fall in hematocrit > 10% Increase in BUN >5 mg/dl Calcium 4 mg/L Fluid deficit > 6L ```

Question 28

Name and describe the two types of mesenteric ischemia/infarction.

Answer 28

Arterial: 1. occlusive - embolus or thrombus occluding SMA 2. Non-occlusive - low flow state Venous: Mesenteric venous thrombus

Question 29

Most common situation when patients present with Mesenteric ischemia.

Answer 29

2-3 hrs. after a triple bypass heart surgery.

Question 30

Name and describe the 3 phases of Mesenteric Ischemia.

Answer 30

1. Hyperactive: increased bowel sounds, bloody stool, abdominal pain 2. Paralytic: absent bowel sounds, increased abdominal pain 3. Shock: fluids leak thru damaged colon lining, acidosis, dehydration, confusion, hypotension, tachycardia