General Surgery - Acute Abdomen & Referred Pain Flashcards
What is an “acute abdomen”?
Acute abdominal pain so severe that the patient seeks medical attention
Note: NOT THE SAME AS “surgical abdomen,” because most cases of acute abdominal pain do not require surgical treatment
What are peritoneal signs?
Signs of peritoneal irritation:
extreme tenderness
percussion tenderness
rebound tenderness
voluntary guarding
motion pain
INVOLUNTARY guarding/rigidity (late)
Define rebound tenderness
pain upon releasing the palpating hand pushing on the abdomen
Define motion pain
abdominal pain upon moving, pelvic rocking, moving of stretcher, or heel strike
Voluntary guarding
Abdominal muscle contraction with palpation of the abdomen
Involuntary guarding
Rigid abdomen as the muscles “guard” involuntarily
Colic
Intermittent severe pain
Usually because of intermittent contraction of a hollow viscus against an obstruction
what conditions can mask abdominal pain?
steroids
diabetes
paraplegia
What is the most common cause of acute abdominal surgery in the United States?
Acute appendicitis (7% of the population will develop it sometime during their lives)
What important questions should be asked when obtaining the history of a patient with an acute abdomen? (This is a LONG answer card)
Have you had this pain before?
On a scale from 1 to 10…
fevers? chills?
duration? (comes and goes vs constant)
Quality? (sharp vs dull)
Does anything make the pain better or worse?
Migration?
Point of maximal pain?
Urinary symptoms?
Nausea/vomiting/diarrhea?
Anorexia?
Constipation?
Last bowel movement?
Any change in bowel habits?
Any relation to eating?
Last menses?
Last meal?
Vaginal discharge?
Melena?
Hematochezia?
Hematemesis?
Medications?
Allergies?
Past Medical History?
Past Surgical History?
Family History?
Tobacco/EtOH/drugs?
What should the acute abdomen physical exam include?
Inspection (e.g. surgical scars, distention)
Auscultation (e.g. bowel sounds, bruits)
Palpation (e.g. tenderness, R/O hernia, CVAT (CostoVertebral Angle Tenderness), rectal, pelvic exam, rebound, voluntary guard, motion tenderness)
Percussion (e.g. liver size, spleen size)
What is the best way to have a patient localize abdominal pain?
Point with ONE finger to where the pain is worse
What is the classic position of a patient with peritonitis?
Motionless (often with knees flexed)
What is the classic position of a patient with a kidney stone?
Cannot stay still, restless, writhing in pain
What is the best way to examine a scared child or histrionic (drama queen) adult’s abdomen?
Use stethoscope to palpate abdomen
What lab tests are used to evaluate the patient with an acute abdomen?
CBC with DIFFERENTIAL!!!, Chem-10, amylase, Type & Screen, urinalysis, LFTs (liver function tests)
What is a “left shift” on CBC differential?
Sign of inflammatory response:
Immature neutrophils (bands)
Note: Many call >80% of WBCs as neutrophils a “left shift”
Ike’s note: left shift not only bands! ALL immature forms are sent out, including not just bands, but even metamyelocytes, myelocytes, promyelocytes
What lab test should every woman of childbearing age with an acute abdomen receive?
ß-hCG (human chorionic gonadotropin)
must rule out pregnancy/ectopic pregnancy
which x-rays are used to evaluate the patient with an acute abdomen?
upright chest x-ray, upright abdominal film, supine abdominal x-ray (if patient cannot stand, left lateral decubitus abdominal film)
How is free air ruled out if the patient cannot stand?
Left lateral decubitus-free air collects over the liver and does not get confused with the gastric bubble
What diagnosis must be considered in every patient with an acute abdomen?
APPENDICITIS!
RUQ Differential diagnosis?
Cholecystitis, hepatitis, PUD, perforated ulcer, pancreatitis, liver tumors, gastritis, hepatic abscess, choledocholithiasis, cholangitis, pyelonephritis, nephrolithiasis, appendicitis (ESPECIALLY DURING PREGNANCY), thoracic causes (e.g. pleurisy/pneumona), PE, pericarditis, MI (ESP inferior MI)
LUQ Differential diagnosis?
PUD, perforated ulcer, 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
LLQ Differential diagnosis
DIVERTICULITIS, sigmoid volvulus, perforated colon, colon cancer, urinary tract infection, small bowel obstruction, inflammatory bowel disease, nephrolithiasis, pyelonephritis, fluid accumulation from aneurysm or perforation, referred hip pain, gynecologic causes, appendicitis (RARE)
RLQ Differential diagnosis?
APPENDICITIS! same as LLQ, also mesenteric lymphadenitis, cecal diverticulitis, Meckel’s diverticulum, intussusception
Epigastric pain differential diagnosis?
PUD, gastritis, MI, pancreatitis, biliary colic, gastric volvulus, Mallory-Weiss
Gynecologic pain differential diagnosis?
Ovarian cyst, ovarian torsion, PID, mittelschmerz, tubo-ovarian abscess (TOA), uterine fibroid, necrotic fibroid, pregnancy, ectopic pregnancy, endometriosis, cancer of the cervix/uterus/ovary, endometrioma, gynecologic tumor, torsion of the cyst or fallopian tube
Thoracic causes of abdominal pain differential diagnosis?
MI (esp inferior), pneumonia, dissecting aorta, aortic aneurysm, empyema, esophageal rupture/tear, PTX, esophageal foreign body
What is the differential diagnosis of scrotal causes of lower abdominal pain?
Testicular torsion, epididymitis, orchitis, inguinal hernia, referred pain from nephrolithiasis or appendicitis
What are nonsurgical causes of abdominal pain?
Gastroenteritis, DKA, sickle cell crisis, rectus sheath hematoma, acute porphyria, PID, kidney stone, pyelonephritis, hepatitis, pancreatitis, pneumonia, MI, C.difficile colitis
What is the unique differential diagnosis for the patient with AIDS and abdominal pain?
In addition to all common abdominal conditions:
CMV (most COMMON)
Kaposis sarcoma
Lymphoma
TB
MAI (Mycobacterium Avium Intracellulare)
What are the possible causes of suprapubic pain?
Cystitis, colonic pain, gynecologic causes (and of course appendicitis)
What causes pain limited to specific dermatomes?
Early zoster before vesicles erupt
What is referred pain?
Pain felt at a site distant from a disease process, caused by the convergence of multiple pain afferents in the posterior horn of the spinal cord
What is gastroenteritis?
Viral or bacterial infection of the Gi tract, usually with vomiting and diarrhea, pain (usually AFTER vomiting), nonsurgical
What is classically stated to be the “great imitator”?
Constipation
Classic location of referred pain for cholecystitis?
Right subscapular pain (also epigastric)
Classic location of referred pain for appendicitis?
Early: periumbilical
Rarely: testicular pain
Classic location of referred pain for Diaphragmatic irritation (from spleen, perforated ulcer, or abscess)?
Shoulder pain (+Kehr’s sign on the left)
Classic location of referred pain for pancreatitis/cancer?
back pain
Classic location of referred pain for rectal disease?
Pain in the small of the back
Classic location of referred pain of Nephrolithiasis?
Testicular pain/flank pain
Classic location of referred pain for Rectal pain?
Midline small of back pain
Classic location of referred pain for Small bowel?
periumbilical pain
Classic location of referred pain for Uterine pain?
Midline small of back pain
Classic diagnosis for “Abdominal pain out of proportion to exam”
Rule out mesenteric ischemia
Classic diagnosis for hypotension and pulsatile abdominal mass
Ruptured AAA
GO TO THE OR
Classic diagnosis for Fever, LLQ pain, change in bowel habits
Diverticulitis
Test of choice for cholelithiasis
Ultrasound
Test of choice for Bile duct obstruction?
Ultrasound
Test of choice for mesenteric ischemia?
mesenteric angiogram
test of choice for ruptured abdominal aortic aneurysm
NONE - emergent laparotomy
Test of choice for AAA
Abdominal CT scan/Ultrasound
Test of choice for Abdominal abscess
Abdominal CT scan
Test of choice for severe diverticulitis
Abdominal CT scan
Most common cause of RUQ pain?
Cholelithiasis
Most common cause of surgical RLQ pain?
Acute appendicitis
Most common cause of GI tract LLQ pain?
Diverticulitis
Classically, what endocrine problems can cause abdominal pain?
- Addisonian crisis
- DKA (Diabetic Ketoacidosis)
