exam 1 - abdomen pt 1 Flashcards
PEDIATRIC PRESENTATION
A child between the ages of 6 months and 6 years who ingested a coin, as witnessed by or reported to a caregiver.
Followed by coughing, choking, drooling, refusal to eat, and/or difficulty swallowing.
Initial symptoms are often transient and self-resolving.
Up to 50% of children may have no signs or symptoms of ingestion at all.
Followed by coughing, choking, drooling, refusal to eat, and/or difficulty swallowing.
Initial symptoms are often transient and self-resolving.
Up to 50% of children may have no signs or symptoms of ingestion at all.
Common symptoms include retrosternal pain, dysphagia, odynophagia, and drooling.
This condition is commonly associated with an underlying pathology in adults, such as strictures, eosinophilic esophagitis, dysmotility disorders, esophageal diverticulum, esophageal web, Schatzki ring, or malignancy
esophageal FB
-80% of all cases are pediatric
-Peds = often objects like coins (MC), toys, pen caps, magnets
-Symptoms: Coughing, choking, drooling, refusal to eat, vomiting, painful swallow
-Possible perforation: Neck swelling, pain, or crepitus
-Possible airway compression by foreign body: Wheezing or stridor
-Adults = Often food impaction (meat) and bones
-Retrosternal chest pain, retching, odono-/dys-phagia, choking, coughing
-PE may include oropharyngeal erythema, neck tenderness, or swelling.
-Possible perforation: Crepitus
-Intentional ingestions are more likely to occur in those with psychiatric disorders, intellectual disability, prisoners, body packers
-Psych and prisoners -> Razors, spoons, etc.
-90% of esophageal foreign bodies will pass through the GI system spontaneously
esophageal FB: Where do objects tend to get stuck?
Cricopharyngeus muscle (C6/T1) (MC peds)
GE junction (T11) (MC adults)
esophageal FB: dx
-Diagnostic tests
-History and physical alone are enough to make diagnosis
-Laboratory tests are not often needed in uncomplicated cases
-XR imaging: helpful, but many objects are not radio-opaque
-AP/Lateral soft tissue neck
-AP/Lateral chest xray
-AP/Lateral abdominal xr
-Serial XRAYS for monitoring progression
-CT is preferred for locating small, radiolucent objects or if there is concern for perforation
-Chicken or fish bone
-Small plastic pieces
-Endoscopy = locates / removes the FB, procedure of choice!
diff dx: esophageal FB
Tracheal foreign body
Esophageal spasm- nutcracker
Infectious esophagitis
Pill esophagitis
Reflux esophagitis
Globus pharyngeus (globus sensation)
esophageal FB: when do we do endoscopy
-Urgent GI consult for endoscopy within 4-6 hrs if:
-*Button battery – most dangerous
-Persistent or Severe symptoms (cannot tolerate secretions or airway compromise)
-Multiple magnets, or, single magnet PLUS metallic objects
-> 24 hours without passing the pylorus
-Sharp objects in esophagus that can perforate
-Large size (width>2.5 or length>6 cm)
-Multiple objects
-Coin at the criopharyngeous
-Urgent EGD can be performed within 24 hours in patients without concerning symptoms or history
coin ingestion
-35% asymptomatic
-Trachea = sagittal plane
-Esophagus = frontal plane
-Tx: Endoscopy
-Prior to endoscopy, protect the airway =ET tube
-Asymptomatic= within 24 hours
-Symptomatic (respiratory symptoms, drooling) = emergent
button battery
-TRUE EMERGENCY
-Burns within 4 hours
-Perforation within 6 hours
-XR: “double halo” (sometimes)
-Consult GI for EMERGENT endoscopy
-Start broad spectrum antibiotics
-!Honey can be given at regular intervals to patients with button battery ingestion
-Honey acts by neutralizing the tissue pH, which helps to reduce the severity of tissue damage by the button battery.
-If passed pylorus and asymptomatic can monitor
-Should pass within 2-3 days!
objects pass the pylorus
-2 year old swallowed two nails approximately 4cm in length
-XR showed passed pylorus
-No evidence of perforation
-Opted for medical management
-Successful passing after 4 days
-lets the kid poop it out…if it perforates you need surgery anyways -> wait
esophageal food impaction
-Meat = give time and sedation, often passes spontaneously, do not allow to sit > 12 hours in esophagus
-Treatment options
-!Endoscopic retrieval
-!Glucagon: 0.5-1mg IV relaxes lower esophageal sphincter (side effect: nausea + vomiting)
-Nitroglycerin SL 0.4mg has been described in case reports to resolve impaction in adults
-Nifedipine: 10mg SL reduces lower esophageal tone (caution: hypotension)
-Not recommended:
-Carbonated beverage: gaseous distension to push it down
-Meat tenderizer – causes perforations!
-Consider WHY they had an impaction
-Esophageal dysmotility?
-Anatomic barriers such as schatzkis ring, strictures, malignancy?
disposition for esophageal FB
-Admission
-Those with esophageal foreign bodies and related complications require immediate consultation with a gastroenterologist or surgeon and may need retrieval within 6 hours.
-These patients likely require admission to the operating room or ICU:
-Patients with inability to tolerate oral intake
-Patients with persistent symptoms
-Discharge home
-Patients who pass their foreign body or have removal without complication can be safely discharged home.
-Follow-up with primary care and gastroenterology should be considered in all patients, especially those with food impaction, due to the high rate of underlying pathology.
-Caregivers should have education on home safety and avoidance of high-risk objects.
approach to N/V
-MC in adults: Gastritis, Gastroenteritis, Febrile systemic illness, Drug effects
-MC in peds: Infections
-Expand your differentials past GI
-Alcohol
-Drug toxicities
-Infections – Viral syndromes, Sepsis
-Neuro – brain bleeds, pseudotumor
-Cardiovascular – MI
-Endocrine – DKA
-Pregnancy – Hyperemesis gravidarum
-Vestibular system
-Cancer side effects
-Miscellaneous – Glaucoma, psychiatric, cannabinoid hyperemesis syndrome
key concepts for abdominal pain
-Acute abdominal pain = pain of non traumatic origin for max 5 days
-Abdominal pain accounts for 7-10% of all ED visits in the US
-dx challenge:
-dx of “non-specific abdominal pain” (31%)
-dx of renal colic (31%)
-Conventional plain film is of limited utility as routine investigation
-Only valuable in patients with suspected perforated viscus and LBO
-Surgery begets surgery
-After an appropriate evaluation showing no emergent cause of abdominal pain, a trial of oral intake, a repeat abdominal physical exam … a clear timeline for follow up and strict return to ED precautions should be discussed. Remind the patient that some causes of abdominal pain only reveal themselves in time.
top 5 CANT MISS causes of abdominal pain
-aortic dissection
-ruptured AAA
-mesenteric ischemia
-intestinal obstruction
-perforated viscus
-ectopic pregnancy
-extra-abdominal diseases
-ALWAYS consider a pelvic exam in females, and a testicular exam in males
-ALWAYS consider pulmonary or cardiac cause for upper abdominal pain
general lab eval
-Basic Labs are generally within normal limits
-Lipase =
-Lactate is often elevated in sepsis and bowel ischemia / mesenteric ischemia
-Troponin consideration in epigastric pain
-UA
-Hematuria is found in cystitis, nephrolithiasis, renal vein occlusion, AAA
-Pyuria is found in UTI and sometimes appendicitis
-Pregnancy testing
imaging in abdominal pain
-Plain radiography
-Not generally helpful. Can be a good screening for bowel obstruction, bowel perforation (upright CXR), and radioopaque foreign bodies
-Ultrasound
-Initial study of choice for pregnancy women, suspected AAA (unstable at bedside), gallbladder disease, pediatric appendicitis.
-CT is the study of choice for undifferentiated abdominal pain in patients not expected to have biliary or reproductive disease
-MRI
-Consider in pediatric appendicitis, pregnancy appendicitis
acute abdominal pain management
-Antiemetics for nausea vomiting
-In a pinch: Isopropyl alcohol swabs
-Ondansetron (Zofran) is generally first line
-Metoclopramide (Reglan) with -Benadryl to decrease dystonia risk
-Haloperidol (Haldol) is good for intractable N/V in gastroparesis, cannabinoid hyperemesis syndrome, and acute on chronic abdominal pain
-Topical capsacin : For cannabinoid hyperemesis syndrome or gastroparesis (applied to abdomen)
-Pain control
-Typically patients are kept NPO until sure there is no surgical intervention
-Acetaminophen
-Opioids: morphine, hydromorphone, fentanyl
-Ketorolac (Toradol) is an NSAID, used for renal colic, but not generally due to contraindications if patient goes for surgery
-“GI Cocktail”
-Antacid such as Maalox or Mylanta, viscous lidocaine, and H2 block famotidine
-Treatment for likely dyspepsia and gastritis
abdominal pain the ER
-After a thorough workup, the large majority of discharged patients with abdominal pain of unknown origin are found to have a benign condition and discharged.
-In a retrospective study of discharged ED patients with abdominal pain, only 7.9% re-presented with abdominal pain, and 76% of these patients were once again given the same diagnosis of non-specific abdominal pain
acute abdomen
-Acute abdomen = urgent attention and treatment
-Often due to: infection, inflammation, ischemia, obstruction, free air
-ILL-APPEARING
-Peritoneal signs: rigid abdomen, guarding, rebound, absent bowel sounds
-Diagnosing a patient with a full-blown acute abdomen is easy!!!
-It’s the early presentations that are hard to detect
CL is a 71M hx HLD, squamous cell CA of tonsil diagnosed 11/12/18, admitted 11/20-11/30/18 from ENT clinic for oncology workup and PEG tube placement on 11/26, BIBEMS from home for severe abdominal pain on attempted use of PEG tube. The last time it was used normally was yesterday morning (12/1). Around 4pm today, a helper at home tried to push water and then tube feed through the tube, but it caused excruciating pain. Patient also endorses nausea but no vomiting. Has been passing gas but has not had a bowel movement in a few days. Currently has LUQ abdominal pain that is non-radiating and severe. +Nausea without emesis.
What do you want to do based off the information so far?
Moved to monitored area, 2 large bore IV placed, fluids given, pain control given
Physical exam:
General: Cachetic, NAD, A&Ox3
HEENT: Normocephalic, non-icteric sclera, normal ROM of neck/supple
CV: RRR, normal heart sounds without murmur
Pulm: Crackles in LLL, diminished on right side. Effort normal, no distress, no stridor, no wheezing.
Skin: Warm and dry without noted rash. Extremities without edema
-PERFORATED VISCUS
perforated viscus
-causes: inflammation, ulceration, trauma, obstruction
-leads to peritonitis -> life threatening
-anywhere from stomach to the rectum
-Extremely dangerous!
-Peritoneum does not like air
-Peritoneum does not like gut microbes -> sepsis
-Typical presentation:
-!!Abrupt, severe pain
-↑ HR, ↓ BP, ± fever
-Exam: Distress w/ peritoneal signs
-!Rigidity
-!Pain to light palpation
-!Involuntary guarding
-sepsis/shock
-ill appearing
-early -> focal tenderness
-late -> Peritoneal signs, laying still (shake the bed, jump), difuse tenderness and rigidity, rebound and guarding
causes of perforated viscus
-perforated peptic ulcer -MC
-NSAIDs, smoking, ETOH use, gastritis
-hematemesis, melena, hematochezia
-local inflammation
-appendicitis, diverticulitis!!!!, crohns, etc.
-post-instrumentation
-colonoscopy, postop, PEG, foreign body
-bowel perforation/ischemia
-prior abdominal surgery, SBO, cancer
perforated viscus: labs
-Labs will not dx
-Pre operative labs
-Urine hcg
-Lactic acid level
-xray:
-Peritoneal air under diaphragm in upright CXR
-Lateral decubitus -> free air between liver edge and wall
-False neg -> If minimal air, might miss it
-Limitations -> doesnt tell us WHERE
-CT abdomen pelvis
-Both sensitive & specific for free air
-Can localize the perforation
-Evaluates for other cause of pain
-Limitations -> Requires pt to be stable
-Limitations -> Needs IV contrast and if time permits, water soluble PO contrast
left lateral decubitis
-perforated viscus
CT shows free air
perforated viscus: tx
-Resus, Resus, Resus
-2 large bore IV
-Get blood products ready
-NPO, IVF
-Broad spectrum antibiotics
-Definitive treatment is surgical repair
56yoF PMHx HLD, Obesity, PSHx appendectomy, cholecystectomy, tubal ligation, cervical conization, presents with complaint of RLQ pain x 1 week. Seen on 1 week ago for mid-abdominal pain, and diagnosed with UTI and given macrobid (culture shows appropriate sensitivity) +Constipation x 3 days but is passing flatus.
Denies fevers, chills, nausea, vomiting, change in appetite, chest pain, SOB, dysuria/frequency/urgency/foul smell.
BP 119/71 | Pulse 90 | Temp 97.3 °F (36.3 °C) (Skin) | Resp 18 | LMP 09/11/2013 (Approximate) | SpO2 99%
A&Ox3, NAD, CTAB no WRR, RRR no MRG, warm extremities
Abdomen: Soft, non-distended. +Exquisitely tender RLQ without rebound or guarding.
Denies fevers, chills, nausea, vomiting, change in appetite, chest pain, SOB, dysuria/frequency/urgency/foul smell.
BP 119/71 | Pulse 90 | Temp 97.3 °F (36.3 °C) (Skin) | Resp 18 | LMP 09/11/2013 (Approximate) | SpO2 99%
apendicitis
appendicitis stats
-Lifetime risk of appendicitis is 7-8%
-70% of cases occur in people <30 years old
-Missed appendicitis in the leading source of malpractice suits in adults with abdominal pain
-There is no individual sign or symptom that can reliably exclude appendicitis in any patient
-Lack of distress, no rebound/guarding, or having diarrhea are not reasons enough to exclude appendicitis
appendicitis sx
-!!!Periumbilical or epigastric pain initially
-Due to lumen distension which triggers VISCERAL pain fibers
-4-48 hours later the pain migrates to the RLQ
-Due to somatic pain fiber innervation
-Other classic findings:
-!Fever (low grade)
-Nausea, !vomiting (typically after pain started!!!!)!*- GASTRITIS IS BEFORE
-!Loss of appetite (anorexia)
-Pain !worsens with abdominal movement!
-CHILDREN: Diarrhea, Limp, Anorexia, nausea
-ELDERLY: late presentation masking of VS
appendicitis atypical sx
-Retrocecal appendix -> right flank / low back
-Retroileal appendix -> testicle, suprapubic area, or cause dysuria
-Low appendix -> left sided or rectal pain
-Appendicitis in pregnancy -> RLQ or RUQ pain
-Occurs due to enlarged uterus during pregnancy displacing the appendix
-RLQ is still MC
-Sudden significant increase in pain (and possibly a decreased in pain later on) in perforation
appendicitis PE
-Tenderness to palpation in the RLQ
-Special manuevers
-McBurney’s point
-Rovsing sign
-Psoas sign
-Obturator sign
-Involuntary guarding*
-Rebound tenderness
-Fever
-If the peritoneum is affected
-the child will often be laying still
-Rebound tenderness
-Involuntary guarding
appendicitis dx
-XRAY- not useful
-US:
-About 86% sensitive
-No radiation
-1st choice in children or pregnancy
-Obesity, bowel gas, perforation make it less sensitive
-Look for: !Thick, non-compressible appendix ≥6mm in diameter, or >2mm wall thickness!
-CTAP w/ IV contrast
-Most sensitive & specific
-Eval for DDX
-Will need oral contrast in low BMI pts
-Findings: !thickened appendix >7mm diameter, mural enhancement, stranding!
-Perforation will have periappendicial fluid or air
-MRI:
-Used to confirm in pregnancy if ultrasound was non-confirmatory
(non-contrast study, IV gadolinium is toxic to fetus)
appendicitis
appendicitis tx
-NPO with maintenance IVF
-Antiemetics, Antipyretics/Analgesia as appropriate
-Antibiotics with Gram +, Gram -, anaerobes coverage
-Combination therapy: Ceftriaxone + metronidazole
-If perforated (peritonitis), cover pseudomonas and ecoli
-Piperacillin-tazobactam (Zosyn) 4.5g IV q6h as a single agent
-General surgery consult for appendectomy
-If perforated or abscess -> Delayed appendectomy or percutaneous drainage
-In children, reasonable to admit for serial exams for patients in whom early appendicitis is suspected and imaging is non-diagnostic.
what is the best imaging modality that can be used in pregnant pts presenting with signs of appendicitis
-endoscopy
-MRI w/o contrast!!!!!!!!!!
-plain abdominal film
-CT scan
-MRI with contrast
History– This patient had surgery 2 days prior to these images for a ruptured appendix.
Symptoms– Vague abdominal pain, low-grade fever (37.9C), Not passing flatus or stool for 2 days.
Physical– The abdomen was mildly distended. The laparoscopic access sites were normal. There was a paucity of bowel gas sounds. No focal tenderness, guarding or rebound.
Symptoms– Vague abdominal pain, low-grade fever (37.9C), Not passing flatus or stool for 2 days.
Physical– The abdomen was mildly distended. The laparoscopic access sites were normal. There was a paucity of bowel gas sounds. No focal tenderness, guarding or rebound.
ILEUS
ileus
-NO normal peristalsis w/o mechanical obstruction
-Continuous pain, distention, decreased bowel sounds, minimal or no tenderness, no flatus/BM, usually self limited
-MC than obstructions post op!
-XRAY will show dilated fluid filled loops throughout entire bowel (small and large) that are persistent over time
-Many causes (MC post-op) including when there is adjacent pathology: pancreatitis, appendicitis, abscess, medications, lyte abnl
-Mostly supportive care, gastric decompression for relief, IVF
bowel obstruction
-bowel dilation from blockage -> increase intraluminal pressure -> compromised blood flow to bowel wall -> edema and transudation of fluid into the lumen -> compromised arterial flow leads to ischemia and gangrene -> eventually perforation
-partial obstruction = ileus
causes of SBO
-Adhesions (#1 cause)
-Hernia (#1 cause w/o PSH)
-Neoplasm
-Strictures
-Intussusception
-IBD
SBO hx and PE
-History of abdominal surgery*
-Crampy Abdominal pain, colicky
-Nausea, Vomiting
-↓ Flatus = ↑ distension
-Early diarrhea, late constipation or obstipation
-Physical
-Dehydration -> hypotensive and tachycardic
-Distended
-Tympanic to percussion
-Initially hyperactive BS, late is hypoactive BS
-If perforated: peritoneal signs and sepsis
-Look for hernias esp testicular
SBO dx
-Labs (pre-op)
-CBC
-CMP + lipase + mag
-T&S, Coags
-VBG
-↑ Lactate supports strangulation
-Acidosis in bowel infarct
-Plain upright CXR
-Air under the diaphragm can indicate perforation
-Upright abdominal XR
-!Air fluid levels in dilated loops
-These can be seen in ileus too
-String of pearls
-Plicae circulares =
Valvular coniventes
-Supine abdominal XR
-Distended loops of bowel >3cm
-In complete obstruction, no gas in rectum
-CTAP is way more sensitive for obstruction (and perforation)
-Find transition point
-May see pneumatosis intestinalis
SBO
SBO
what do you think the MC metabolic derangement is in early SBO
Metabolic alkalosis
Metabolic acidosis
Respiratory alkalosis
Respiratory acidosis
Hypochloremic hypokalemic metabolic alkalosis
LBO
-Typically in older pts (73 avg)
-Causes:
-Colorectal malignancy (MC,50%)
-Volvulus
-Diverticulitis
-Strictures from IBD
-Hernia w/ incarceration
-Adhesions
-Rare causes: ischemia, adhesions, intussusception
Dilated loops of small bowel and large bowel to the region of the splenic flexure on the erect projection. Air-fluid level in the region of the distal transverse colon on the erect projection.The distal large bowel is collapsed. No free gas or pneumotosis. No bony mets seen.
volvulus
-Obstruction from !twisting or looping! of the bowel
-Same complications as SBO and mesenteric: infarction, perforation, infection [e.g. peritonitis]
-Types:
-SIGMOID (MC)
-CECAL
-MIDGUT (infants)
what is the imaging modality of choice in the eval of bowel obstruction
CT scan!!!!!!!!
MRI
Plain x-ray radiograph
Colonoscopy
Ultrasound
65yoM with a history of paroxysmal atrial fibrillation, peripheral vascular disease, and HTN presents to the ED with diffuse abdominal pain.
The pain started after dinner last night and has progressed since with nausea and emesis.
He’s previously had these symptoms after eating, but they have usually resolve.
The patient is not currently on any anticoagulation but takes HCTZ-lisinopril. Social history pertinent for 48 ppy tobacco use. ROS pertinent for noted blood in stool.
Vitals: HR 112, BP 98/61, RR 22, T 101.1, SpO2 98% on RA
The pain started after dinner last night and has progressed since with nausea and emesis.
He’s previously had these symptoms after eating, but they have usually resolve.
The patient is not currently on any anticoagulation but takes HCTZ-lisinopril. Social history pertinent for 48 ppy tobacco use. ROS pertinent for noted blood in stool.
Vitals: HR 112, BP 98/61, RR 22, T 101.1, SpO2 98% on RA
General: Older male, in mild distress;
CV: Tachycardic, irregularly irregular, no murmur, 2+ pulses in UE, 1+ in LE BL;
Skin: Lower extremities without hair;
Rectal: Bloody stool
What do you need to consider, and what’s the next step in your evaluation and treatment?
CT angiography = demonstrated an embolus in his superior mesenteric artery and bowel wall thickening.
IV fluids, antibiotics, and heparin, but still has pain.
OR = exploratory laparotomy. Surgeons note a segment of small intestine that appears ischemic, but no necrosis. The clot from the superior mesenteric artery is removed and the bowel is re-evaluated. The segment of bowel that was ischemic in appearance is now pink.
Your patient has an uncomplicated post-op recovery and is thankful that your early diagnosis of mesenteric ischemia saved him from having any bowel resected.
mesenteric ischemia
-low incidence (0.09%)
-high mortality rate in first 24hrs - 60-80%
-decreased blood flow to bowel can be chronic or acute
-acute- sudden decreased perfusion
-chronic- episodic with digestion (d/t atherosclerosis of mesentery)
-poor perfusion -> ischemia -> infarction/necrosis -> bacterial translocation + possible perforation
mesenteric ischemic: etiologies
-ACUTE MESENTERIC ARTERIAL EMBOLUS (~40-50%)!
-Atrial fibrillation!
-Endocarditis
-MESENTERIC ARTERIAL THROMBOSIS (20-35%)!
-Kind of “myocardial infarction” of the gut from previous atherosclerosis
-NON-OCCLUSIVE (5-15%)
-Low perfusion states!: Hypotension, dehydration, shock, hemorrhage, CHF
-Vasopressor use
-MESENTERIC VENOUS THROMBOSIS (5-15%)
-Hypercoagulable! states: OCPs, Anti-thrombin III, protein C/S def, Factor V Leiden
mesenteric ischemia S&S
-History depends on underlying cause
-Historic triad in embolism:
-!!Severe sudden diffuse abdominal pain
-!N/V
-± GI bleeding or diarrhea
-Hx of cardiovascular dz
-Chronic mesenteric ischemia
-Post-prandial abd pain (30-60 minutes after a meal)
-Food avoidance
-Mesenteric Venous thrombosis
-More gradual symptom onset
-Physical
-Early VS normal, can progress to hypotension, tachycardia, fever
-!Pain out of proportion to exam
-Soft abdomen!- Peritoneal signs: Distension / Guarding / rebound once infarcted
-Signs of PVD
-CV: Murmur if endocarditis
-CV: Irregularly irregular if afib
-Rectal: ± guaiac positive
mesenteric ischemia Dx
-ECG looking for cause
-Labs -ECG, CBC (WBC 25+), CMP, Blood gas (↑ Lactate, lactic acidosis)
-!CT angiography (speak to radiologist for protocol)
-May see abrupt termination of the vessel (cutoff sign) or filing defects
-Early bowel findings are non-specific: ascites, bowel wall thickening, edema
-Late: portal gas (pneumatosis portalis), free air (pneumoperitoneum occurs when the bowel perforates secondary to ishcemia), intramural bowel gas (intestinal pneumatosis)
pneumatosis intestinalis in mesenteric ischemia
mesenteric ishemia
-mesenteric ischemia
-portal gas
-Dilated loops of bowel with thickened, less contrasted, walls seen in ischemic bowel
mesenteric ischemia tx
-NPO, fluids, analgesics, bowel rest
-Broad spectrum antibiotics (ceftriaxone+flagyl, or, zosyn)
-If venous thrombosis, consider starting heparin
-Early surgical consultation
-Possible IR for mesenteric angiogram w/ thrombectomy
-Possible stenting
-Open surgery to bypass the obstruction and remove dead bowel
A 71-year-old female presents to her primary care physician with a four-day history of left lower quadrant abdominal pain. The patient also complains of diarrhea and mild nausea. She continues to tolerate a diet, though reduced in quantity. On exam, her vitals are T 101F HR 86, BP 130/92, RR 15, and SaO2 100%. Abdominal exam is notable for LLQ tenderness to palpation without rebound or guarding. Urine dipstick is normal and complete blood count shows a minor leukocytosis with a left shift. A screening colonoscopy from a year ago is shown. What is the next best step in management?
-Immediate colonoscopy
-Trimethoprim-sulfamethoxazole and a liquid diet
-Abdominal CT with IV contrast
-CTA of the mesenteric vessels
-Laparotomy and surgical management
-Immediate colonoscopy
-Trimethoprim-sulfamethoxazole and a liquid diet
-Abdominal CT with IV contrast
-CTA of the mesenteric vessels
-Laparotomy and surgical management
-Abdominal CT with IV contrast
