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Unit 1 Emerg/Surg > L5: Acute Abdominal Pain: pt 1 > Flashcards

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
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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
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3
Q

Red flags in history

A 
Age >65
Alcoholism
Immunocompromised
Cardiovascular disease
Comorbidities
Prior abdominal surgery→ always ask
Recent GI instrumentation
Early pregnancy
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4
Q

Red flags on physical exam

A

Rigid abdomen
Signs of shock
Involuntary guarding

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5
Q

Red flags in characteristics of pain

A

Acute onset
Significant pain at onset
Pain followed by emesis
Constant pain for <2 days

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6
Q

Gallbladder refers pain to

A

Right sub-scapular

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7
Q

Perforated duodenal ulcer refers pain to

A

Shoulders

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8
Q

Ureteral obstruction refers pain to

A

Testicles

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9
Q

MI refers pain to

A

epigastric
jaw
neck
upper extremity

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10
Q

GYN issues refer pain to

A

Low back

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11
Q

Visceral pain vs parietal pain: character

A

Visceral pain: dull, achy, colicky

Parietal pain: sharp

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12
Q

Visceral pain vs parietal pain: localization

A

Visceral pain: poorly localized

Parietal pain: well localized

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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

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14
Q

Buzzword: restless, can’t sit still

A

Renal colic

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15
Q

Buzzword: laying perfectly still/supine

A

Peritonitis

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16
Q

Buzzword: increased respiratory rate

A

metabolic acidosis

pain

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17
Q

Buzzword: hypotension

A

sepsis

GI bleed

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18
Q

Buzzword: bruits heard on auscultation

A

Abdominal Aortic Aneurysm

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19
Q

Buzzword: hypoactive bowel sounds

A

peritonitis

small bowel obstruction

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20
Q

Buzzword: hyperactive bowel sounds

A

blood/inflammation in the GI tract

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21
Q

Buzzword: lower quadrant or hypogastric pain

A

always do a testicular or pelvic exam

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22
Q

On physical exam, always

A 
Listen to heart for afib
Listen to lungs for pneumonia
Check for CVAT
hepatosplenomegaly
abdominal hernias
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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
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24
Q

Plain films can show

A 
Dilated bowel loops
air-fluid levels
free air
constipation
foreign body
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25
Q

CT without contrast is for

A

renal stone

obstruction

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26
Q

CT with IV contrast is for

A

Ischemic bowel
diverticulitis
peritonitis
abdominal aortic aneurysm

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27
Q

CT with oral contrast can be used for

A

children

skinny adults

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28
Q

Ultrasounds can show

A 
gallbladder
free fluid
renal
ovaries
testicles
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29
Q

Monitor for signs of sepsis and shock such as

A

fever
tachycardia
hypotension
AMS

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30
Q

URGENTLY refer to surgery if….

A 
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
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31
Q

Who might present with vague, nonspecific symptoms

A

Elderly
DM
Immunocompromised

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32
Q

Causes of perforation of the GI tract

A

Inflammatory changes→gallbladder,
appendix→ “spontaneous”

Bowel obstruction

Trauma

Instrumentation

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33
Q

Perforation presentation

A

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

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34
Q

Succus entericus

A

enzymes (lipases, lactase, amylase) + mucus

35
Q

Complications of peritonitis

A

sepsis

death

36
Q

Peritonitis

A

Occurs after perforation
Localized→ contained by surrounding viscera or omentum
Generalized→ gross spillage into peritoneal cavity

37
Q

Peritonitis presentation

A

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
Q

Spontaneous bacterial peritonitis vs secondary bacterial peritonitis: causes

A

Spontaneous bacterial peritonitis: liver cirrhosis

Secondary bacterial peritonitis: Possible perforation: ulcer, appendicitis

39
Q

Spontaneous bacterial peritonitis vs secondary bacterial peritonitis: diagnostics

A

Spontaneous bacterial peritonitis: NO exploratory laparotomy
Secondary bacterial peritonitis: Exploratory laparotomy
Both: paracentesis

40
Q

Spontaneous bacterial peritonitis vs secondary bacterial peritonitis: presentation

A

Both:
Ascites
Fever, AMS
Abdominal pain +/- hypotension

41
Q

Most common bacterial causes of peritonitis and which abx to use

A

E coli or Klebsiella

Cefotaxime

42
Q

Acute Cholecystitis

A

Gallbladder inflammation

related to gallstone disease

43
Q

The most common surgical emergency in elderly

A

Acute Cholecystitis

44
Q

Acute Cholecystitis presentation

A

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
Q

Acute cholecystitis labs show

A

Leukocytosis with bands
Elevated CRP
Normal Alk Phos, transaminases, bilirubin

46
Q

RUQ ultrasound of acute cholecystitis will show

A

Gallbladder wall thickening

Sonographic “Murphy’s sign”

Gallstones, sludge

Pericholecystic fluid

47
Q

acute cholecystitis management

A

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
Q

Primary Choldecholithiasis

A

Presence of gallstones within the common bile duct due to formation of stones within common bile duct (rare)

49
Q

Secondary Choldecholithiasis

A

Presence of gallstones within the common bile duct due to passage of stone from gallbladder to common bile duct

50
Q

Courvoisier’s sign

A

Palpable gallbladder in Choldecholithiasis

51
Q

Choldecholithiasis presentation

A 
Colicky, biliary type pain
RUQ pain→ +/- epigastric region
N/V
Transient blockage→ intermittent pain
RUQ/epigastric pain with palpation
Courvoisier’s sign
Jaundice
52
Q

Choldecholithiasis labs

A

Elevated:

Bilirubin
Alk phos
Transaminases
GTT

53
Q

Choldecholithiasis transabdominal presentation

A

Stones in gallbladder or common bile duct

54
Q

High risk Choldecholithiasis tx

A

ERCP (85-90% success rate)
Remove stone via endoscopy or surgery→ then elective
Cholecystectomy

55
Q

low risk Choldecholithiasis tx

A

Cholecystectomy

Complications: acute pancreatitis, acute cholangitis

56
Q

acute cholangitis

A

Ascending bacterial infection → Medical Emergency

Obstruction of the biliary ducts

57
Q

Possible causes of acute cholangitis: medical and bacterial

A

Choledocholithiasis
Biliary calculi
Malignancy
Benign stenosis

Enterococci 40%
E. coli 17%
Klebsiella 10%

58
Q

Charcot’s triad

A

acute cholangitis
Fever/chills
RUQ abdominal pain
Jaundice

59
Q

Reynold’s pentad

A 
acute cholangitis
Fever/chills
RUQ abdominal pain
Jaundice
AMS
Hypotension
60
Q

acute cholangitis labs

A

Leukocytosis (neutrophilia)

Elevated:
Bilirubin
Alk phos
Transaminases
GTT
*amylase→ pancreatic involvement*
61
Q

acute cholangitis imaging

A

Transabdominal US:
common bile duct dilatation or stones

Endoscopic ultrasound (EUS)
Endoscopic retrograde cholangiopancreatography (ERCP)

Magnetic Resonance cholangiopancreatography
(MRCP)

62
Q

If you have a pregnant patient with suspected acute cholangitis

A

1st Ultrasound

2nd ERCP + fetal shielding

63
Q

Acute cholangitis management

A

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
Q

Hepatitis A presentation

A 
Abrupt onset RUQ abdominal pain
N/V/A
Fever/malaise
Dark urine (bilirubinuria)
Pale stools
Jaundice/scleral icterus
Hepatomegaly (80%)
Splenomegaly (less common)
65
Q

Hepatitis A diagnostics

A

Elevated:
ALT>AST
Alk Phos
Bilirubin

66
Q

Hepatitis A management

A

Symptomatic

Counsel on hygiene→ prevent fecal oral spread

67
Q

Hepatitis A is contagious for…

A

28 day incubation period + 1 week following onset of jaundice

68
Q

Pancreatitis classifications

A

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
Q

Causes of pancreatitis with well localized pain and rapid onset

A

Gallstone

70
Q

Causes of pancreatitis with less well localized pain and a slower progression

A

Alcohol
Severe hyperlipidemia
Idiopathic
Drugs: amiodarone, antivirals, diuretics, NSAIDs, abx

71
Q

Pancreatitis presentation

A

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
Q

Cullen’s sign

A

Pancreatitis
Periumbilical region
Superficial edema and bruising in subcutaneous fatty tissue

73
Q

Grey turner sign

A

Pancreatitis
Bruising along the flank

Pancreatic necrosis→ Retroperitoneal bleeding→ ecchymosis

74
Q

Pancreatitis management

A

Admit→ ICU monitoring

NPO, IV fluids

NG tube, Foley catheter

Serial labs

Amylase and electrolytes →monitor

Opiates

Gallstone→ GI consult→ ERCP

75
Q

You can actually give opiates for….

A
  • Pancreatitis*
  • aortic dissection* (morphine)

this is the only time in this whole unit
the rest are just “analgesics”

76
Q

Pancreatitis labs

A

Up to 3x normal lipase + amylase
+/- mild leukocytosis
Increased CRP

77
Q

Pancreatitis imaging

A

US→ diffusely enlarged, stones

CT + IV contrast→ late disease→ diffuse enlargement, necrosis, stones

MRI→ early disease

78
Q

Pancreatitis diagnosis

A

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
Q

How often will a peptic ulcer perforate

A

10% of the time

80
Q

Increased risk for peptic ulcer disease

A

NSAID use
H. pylori
Smoking

Excessive vomiting:  Gastroparesis
Gastroenteritis
Anorexia
nervosa
Bulimia
81
Q

Peptic ulcer disease presentation

A 
*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
Q

Peptic ulcer disease labs

A

CBC→ H/H

BMP→ electrolytes (vomiting)

Hemoccult

KUB xray, CXR→ check for free air

83
Q

Peptic ulcer disease management

A

GI consult
Endoscopy with biopsy

Medical management: d/c NSAIDS, treat H.pylori

Perforated→ surgical intervention

Unit 1 Emerg/Surg (10 decks)

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