L5: Acute Abdominal Pain: pt 1 Flashcards
1
Q
Life threatening causes of abdominal pain that must be ruled out
A
Abdominal aortic aneurysm Abdominal aortic dissection GI perforation Incarcerated hernia Acute bowel obstruction Mesenteric ischemia Ectopic pregnancy Placental abruption Splenic rupture
2
Q
Top 10 abdominal pain diagnoses in the ED
A
Appendicitis Biliary tract disease Small bowel obstruction GYN disease Pancreatitis Renal colic Perforated ulcer Cancer Diverticular disease Non-specific abd pain
3
Q
Red flags in history
A
Age >65 Alcoholism Immunocompromised Cardiovascular disease Comorbidities Prior abdominal surgery→ always ask Recent GI instrumentation Early pregnancy
4
Q
Red flags on physical exam
A
Rigid abdomen
Signs of shock
Involuntary guarding
5
Q
Red flags in characteristics of pain
A
Acute onset
Significant pain at onset
Pain followed by emesis
Constant pain for <2 days
6
Q
Gallbladder refers pain to
A
Right sub-scapular
7
Q
Perforated duodenal ulcer refers pain to
A
Shoulders
8
Q
Ureteral obstruction refers pain to
A
Testicles
9
Q
MI refers pain to
A
epigastric
jaw
neck
upper extremity
10
Q
GYN issues refer pain to
A
Low back
11
Q
Visceral pain vs parietal pain: character
A
Visceral pain: dull, achy, colicky
Parietal pain: sharp
12
Q
Visceral pain vs parietal pain: localization
A
Visceral pain: poorly localized
Parietal pain: well localized
13
Q
Visceral pain vs parietal pain: causes
A
Visceral pain: Distention, ischemia, inflammation/spasm of hollow organ
Parietal pain: Peritoneal irritation, ischemia, inflammation/stretching of parietal peritoneum
14
Q
Buzzword: restless, can’t sit still
A
Renal colic
15
Q
Buzzword: laying perfectly still/supine
A
Peritonitis
16
Q
Buzzword: increased respiratory rate
A
metabolic acidosis
pain
17
Q
Buzzword: hypotension
A
sepsis
GI bleed
18
Q
Buzzword: bruits heard on auscultation
A
Abdominal Aortic Aneurysm
19
Q
Buzzword: hypoactive bowel sounds
A
peritonitis
small bowel obstruction
20
Q
Buzzword: hyperactive bowel sounds
A
blood/inflammation in the GI tract
21
Q
Buzzword: lower quadrant or hypogastric pain
A
always do a testicular or pelvic exam
22
Q
On physical exam, always
A
Listen to heart for afib Listen to lungs for pneumonia Check for CVAT hepatosplenomegaly abdominal hernias
23
Q
Initial diagnostics for acute abdominal pain
A
CBC with differential BMP/ CMP AST, ALT, Alk Phos Total Bilirubin Lipase/amylase Lactic Acid UA Urine Pregnancy in females Stool guaiac
24
Q
Plain films can show
A
Dilated bowel loops air-fluid levels free air constipation foreign body
25
CT without contrast is for
renal stone
| obstruction
26
CT with IV contrast is for
Ischemic bowel
diverticulitis
peritonitis
abdominal aortic aneurysm
27
CT with oral contrast can be used for
children
| skinny adults
28
Ultrasounds can show
```
gallbladder
free fluid
renal
ovaries
testicles
```
29
Monitor for signs of sepsis and shock such as
fever
tachycardia
hypotension
AMS
30
URGENTLY refer to surgery if....
```
Obstruction
Perforation
Peritonitis
Ischemic bowel
Dissection
```
Rapid symptom evolution:
1. Increasing tenderness and rigidity
2. Pain is severe, is it out of proportion to exam
31
Who might present with vague, nonspecific symptoms
Elderly
DM
Immunocompromised
32
Causes of perforation of the GI tract
Inflammatory changes→gallbladder,
appendix→ "spontaneous"
Bowel obstruction
Trauma
Instrumentation
33
Perforation presentation
Depends on organ affected and contents releases→ air, stool, gas
Localized tenderness followed by diffuse pain
+/- Pain relief followed by peritonitis
Most common: <10 years or >50 years
34
Succus entericus
enzymes (lipases, lactase, amylase) + mucus
35
Complications of peritonitis
sepsis
| death
36
Peritonitis
Occurs after perforation
Localized→ contained by surrounding viscera or omentum
Generalized→ gross spillage into peritoneal cavity
37
Peritonitis presentation
High fever
Patients look sick
Lie still → minimize discomfort
Bloating/feeling of fullness
Rebound tenderness, tenderness to percussion, Pain with light palpation
Diminished bowel sounds, Inability to pass stool/gas
N/V/A, Low urine output
38
Spontaneous bacterial peritonitis vs secondary bacterial peritonitis: causes
Spontaneous bacterial peritonitis: liver cirrhosis
| Secondary bacterial peritonitis: Possible perforation: ulcer, appendicitis
39
Spontaneous bacterial peritonitis vs secondary bacterial peritonitis: diagnostics
Spontaneous bacterial peritonitis: NO exploratory laparotomy
Secondary bacterial peritonitis: Exploratory laparotomy
Both: paracentesis
40
Spontaneous bacterial peritonitis vs secondary bacterial peritonitis: presentation
Both:
Ascites
Fever, AMS
Abdominal pain +/- hypotension
41
Most common bacterial causes of peritonitis and which abx to use
E coli or Klebsiella
| Cefotaxime
42
Acute Cholecystitis
Gallbladder inflammation
| related to gallstone disease
43
The most common surgical emergency in elderly
Acute Cholecystitis
44
Acute Cholecystitis presentation
Severe, constant pain RUQ pain > 6hrs
+/- radiate to epigastric area, right shoulder
N/V, increase pain with fatty food intake
Guarding, RUQ pain with palpation
(+) Murphy’s sign
Ill appearing, tend to lie still
Tachycardia
45
Acute cholecystitis labs show
Leukocytosis with bands
Elevated CRP
Normal Alk Phos, transaminases, bilirubin
46
RUQ ultrasound of acute cholecystitis will show
Gallbladder wall thickening
Sonographic “Murphy’s sign”
Gallstones, sludge
Pericholecystic fluid
47
acute cholecystitis management
IV fluids, Analgesia, NPO
Ceftriaxone or cefuroxime
1. Cholecystectomy
2. Non-Operative Management +/- elective procedure rather than emergent→ Lack of noticeable improvement within 1-2 days→ surgery
3. Percutaneous Drainage
Unstable patients
Saves surgery until patient is more stable
Uses radiologic guidance
48
Primary Choldecholithiasis
Presence of gallstones within the common bile duct due to formation of stones within common bile duct (rare)
49
Secondary Choldecholithiasis
Presence of gallstones within the common bile duct due to passage of stone from gallbladder to common bile duct
50
Courvoisier’s sign
Palpable gallbladder in Choldecholithiasis
51
Choldecholithiasis presentation
```
Colicky, biliary type pain
RUQ pain→ +/- epigastric region
N/V
Transient blockage→ intermittent pain
RUQ/epigastric pain with palpation
Courvoisier’s sign
Jaundice
```
52
Choldecholithiasis labs
Elevated:
Bilirubin
Alk phos
Transaminases
GTT
53
Choldecholithiasis transabdominal presentation
Stones in gallbladder or common bile duct
54
High risk Choldecholithiasis tx
ERCP (85-90% success rate)
Remove stone via endoscopy or surgery→ then elective
Cholecystectomy
55
low risk Choldecholithiasis tx
Cholecystectomy
| Complications: acute pancreatitis, acute cholangitis
56
acute cholangitis
Ascending bacterial infection → Medical Emergency
| Obstruction of the biliary ducts
57
Possible causes of acute cholangitis: medical and bacterial
*Choledocholithiasis*
Biliary calculi
Malignancy
Benign stenosis
Enterococci 40%
E. coli 17%
Klebsiella 10%
58
Charcot’s triad
acute cholangitis
Fever/chills
RUQ abdominal pain
Jaundice
59
Reynold’s pentad
```
acute cholangitis
Fever/chills
RUQ abdominal pain
Jaundice
AMS
Hypotension
```
60
acute cholangitis labs
Leukocytosis (neutrophilia)
```
Elevated:
Bilirubin
Alk phos
Transaminases
GTT
*amylase→ pancreatic involvement*
```
61
acute cholangitis imaging
Transabdominal US:
common bile duct dilatation or stones
```
Endoscopic ultrasound (EUS)
Endoscopic retrograde cholangiopancreatography (ERCP)
```
Magnetic Resonance cholangiopancreatography
(MRCP)
62
If you have a pregnant patient with suspected acute cholangitis
1st Ultrasound
| 2nd ERCP + fetal shielding
63
Acute cholangitis management
Admit, NPO, IV fluids, Analgesia
Consult GI, +/- ID
Monitor for sepsis→ blood cultures x 2
Empiric abx→ ceftriaxone + metronidazole
Biliary drainage:
ERCP→ Diagnostic and therapeutic
64
Hepatitis A presentation
```
Abrupt onset RUQ abdominal pain
N/V/A
Fever/malaise
Dark urine (bilirubinuria)
Pale stools
Jaundice/scleral icterus
Hepatomegaly (80%)
Splenomegaly (less common)
```
65
Hepatitis A diagnostics
Elevated:
ALT>AST
Alk Phos
Bilirubin
66
Hepatitis A management
Symptomatic
| Counsel on hygiene→ prevent fecal oral spread
67
Hepatitis A is contagious for...
28 day incubation period + 1 week following onset of jaundice
68
Pancreatitis classifications
Acute inflammatory process
Mild→ no organ failure or systemic complications
Moderate→ transient organ failure, resolves in 48 hours
Severe→ persistent organ failure, >1 organ
69
Causes of pancreatitis with well localized pain and rapid onset
Gallstone
70
Causes of pancreatitis with less well localized pain and a slower progression
Alcohol
Severe hyperlipidemia
Idiopathic
Drugs: amiodarone, antivirals, diuretics, NSAIDs, abx
71
Pancreatitis presentation
Persistent severe, boring acute epigastric or RUQ pain
Radiates to back
+/- relieved by leaning forward
+/- dyspnea due to diaphragmatic inflammation
N/V, bloating
Fever, Tachypnea, Hypotension
Epigastric or diffuse tenderness, Abdominal distention
Hypoactive bowel sounds
Choledocholithiasis→ Scleral icterus/jaundice
Cullen’s sign
Grey Turner sign
72
Cullen's sign
Pancreatitis
Periumbilical region
Superficial edema and bruising in subcutaneous fatty tissue
73
Grey turner sign
Pancreatitis
Bruising along the flank
Pancreatic necrosis→ Retroperitoneal bleeding→ ecchymosis
74
Pancreatitis management
Admit→ ICU monitoring
NPO, IV fluids
NG tube, Foley catheter
Serial labs
Amylase and electrolytes →monitor
Opiates
Gallstone→ GI consult→ ERCP
75
You can actually give opiates for....
* Pancreatitis*
* aortic dissection* (morphine)
this is the only time in this whole unit
the rest are just "analgesics"
76
Pancreatitis labs
Up to 3x normal lipase + amylase
+/- mild leukocytosis
Increased CRP
77
Pancreatitis imaging
US→ diffusely enlarged, stones
CT + IV contrast→ late disease→ diffuse enlargement, necrosis, stones
MRI→ early disease
78
Pancreatitis diagnosis
2 of the following (if 1st 2, no imaging required)
1. Acute onset of constant, severe epigastric pain radiating to back
2. Elevated serum lipase or amylase to 3x+ normal
3. Findings of acute pancreatitis on imaging
79
How often will a peptic ulcer perforate
10% of the time
80
Increased risk for peptic ulcer disease
NSAID use
H. pylori
Smoking
```
Excessive vomiting: Gastroparesis
Gastroenteritis
Anorexia
nervosa
Bulimia
```
81
Peptic ulcer disease presentation
```
*Elderly→ atypical*
Epigastric pain, pain radiating to mid thoracic region
Early satiety, dyspepsia, “heartburn”, pain with eating
SOB, cough, when lying flat
N/V/A
Hematemesis
Melena
Perforation→ Hematochezia
```
82
Peptic ulcer disease labs
CBC→ H/H
BMP→ electrolytes (vomiting)
Hemoccult
KUB xray, CXR→ check for free air
83
Peptic ulcer disease management
GI consult
Endoscopy with biopsy
Medical management: d/c NSAIDS, treat H.pylori
Perforated→ surgical intervention
