L5: Acute Abdominal pain: pt 2 Flashcards
Splenic abscess results from
endocarditis
seeding from another site
Splenic infarct
Splenic artery or sub-branch occluded by embolus, clot, or infection
Splenic rupture
Traumatic or Atraumatic: Leukemia, lymphoma Mononucleosis, CMV, HIV Acute/chronic pancreatitis Anticoagulants Pregnancy related Idiopathic
At risk of splenic infarct
Hypercoagulable state (malignancy) Embolic disease (afib, infective endocarditis) Sickle cell disease Trauma Complication of EBV
Splenic abscess presentation
LUQ pain
Fever
+/- splenomegaly
+/- left side pleural effusion
Splenic infarct presentation
Acute LUQ pain + Fever N/V Elevated LDH Leukocytosis \+/- splenomegaly
How to diagnose splenic abscess or infarct
CT scan with IV contrast
Splenic rupture presentation
LUQ pain, fullness
Referred left shoulder pain
Pleuritic pain
Early satiety
How to diagnose splenic rupture
Ultrasound→ Gold standard
CT with IV contrast
Splenic abscess tx
Admit, IV fluids, abx
NPO
Surgeon→ splenectomy
+/- Infectious disease consult
Splenic infarct tx
Uncomplicated→ analgesia, monitor
Complicated→ abscess, sepsis, hemorrhage→ splenectomy
Splenic rupture tx
NPO, IV fluids
Type + Cross for transfusion
Emergent Splenectomy
At risk for small bowel obstruction
Prior abdominal/pelvic surgery→ adhesions Abdominal wall/groin hernia Intestinal inflammation Neoplasm Prior irradiation Foreign body (FB) ingestion *Intussusception/volvulus*
Acute mesenteric ischemia
Decreased/no perfusion to section of colon
Occlusive, arterial/venous
Embolic, thrombotic, atherosclerotic
At risk for acute mesenteric ischemia
Cardiac arrhythmias Advanced age Low cardiac output states Valvular heart disease MI Malignancy
Small bowel obstruction presentation
N/V
Cramping abdominal pain, periumbilical
Ischemia/necrosis→ More focal pain
Obstipation→ inability to pass flatus or stool
+/- dehydration
+/- fever if abscess/ischemia/necrosis
Acute mesenteric ischemia presentation if due to thrombosis or emboli
Rapid onset, severe periumbilical pain out of proportion N/V \+/- forceful bowel evacuation Postprandial pain (15-30 min) \+/- Hematochezia High mortality
Acute mesenteric ischemia presentation if due to venous thrombosis
More indolent, lower mortality
Abdominal xray of small bowel obstruction
Dilated loops of bowel with air-fluid levels
Proximal bowel dilation with distal bowel collapse
CT of small bowel obstruction
Severity, masses Inflammation Necrosis Perforation Ischemia Non-viable bowel does not enhance with contrast
Early labs of acute mesenteric ischemia
often nonspecific
Labs of acute mesenteric ischemia may include
+/- leukocytosis
Hemoconcentration
Increased lactate, LDH
+/- elevated serum amylase (50%)
Check d-dimer
Advanced disease/necrosis→ metabolic acidosis
Imaging for acute mesenteric ischemia
Xray: Free air, “dead bowel”→ laparotomy
No signs on xray→ abdominal CT angiography IV contrast
Small bowel obstruction tx
Admit, NP, IV fluids
Antiemetics
NG tube, bowel rest
Consult surgery, GI
Not resolving→ Surgical intervention
Complicated bowel obstruction→ surgery, abx
Acute mesenteric ischemia management
Admit, IV fluids, NPO
Foley catheter
Ceftriaxone + Metronidazole (empiric)
+/- systemic anticoagulation
Consult GI, surgery, Vascular/Cardiology
Most common abdominal emergency
appendicitis
Who has a high risk of perforation with appendicitis?
In whom is appendicitis usually missed?
perforation <4 years
missed <12 years
Appendicitis presentation
N/V/A Fever (late finding) Rebound tenderness/ (+) Rovsing’s \+/- rigidity, voluntary guarding, pain on rectal exam RLQ pain starts periumbilical + migrates
Retrocecal appendicitis:
Back/flank/testicular pain
+Psoas sign
Pelvic appendicitis:
Suprapubic/rectal pain/ dysuria/diarrhea
+Obturator sign
If your patient has clinical appendicitis
no further imaging is needed, you can go straight to surgical consult
Appendicitis labs
Leukocytosis (bands) → if extremely elevated→ perforation
Normal WBC doesn’t rule out appendicitis
UA→ +/- pyuria, bacteria, hematuria (if appendix near bladder/ureter)
Appendicitis if the patient is pregnant
Pain in RUQ instead of RLQ
Imaging for appendicitis
Abdomen xray→ free air, appendicolith (calcification)
US→ limited by obesity or retrocecal appendix
CT + contrast→ inflammation, abscesses, fat stranding, fluid collection
MRI + contrast→ pregnancy
Appendicitis treatment
Admit, IV fluids
NPO, analgesia
Cefoxitin
OR
cefazolin + metronidazole
Surgical consult
Diverticulitis
Microperforation of a diverticulum→ Inflammation
LLQ/sigmoid
Risk: age, diverticulosis
Diverticulitis presentation
Steady, deep, constant pain N/V, low grade fever Change in bowel habits Urinary urgency, frequency, dysuria Rebound, guarding, localized tenderness
An acute attack of diverticulitis might present with
edema/compression of colon→ obstruction/paralytic ileus
Diverticulitis DRE
left sided tender mass
Complications of diverticulitis
Obstruction (hyperactive/ high pitched bowel sounds)
Peritonitis (hypoactive/ absent bowel sounds)
Diverticulitis labs
(+) stool guaiac
+/- mild leukocytosis
UA→ pyuria
Diverticulitis imaging
Abdominal xray→ non-specific
US→ abscesses, bowel wall thickening, diverticula, fistulas
CT with contrast → localized bowel thickening, colonic diverticula, abscesses, fistulas
Obstruction→ dilated loops of bowel
Uncomplicated diverticulitis tx
Ciprofloxacin + metronidazole
Follow up 2 days with GI
Complicated diverticulitis is ______ and tx is _____
perforation, abscesses, fistula, obstruction
Admit, IV fluids+abx, NPO
Consult GI +/- surgery
Toxic megacolon is a complication of…
*IBD* volvulus diverticulitis obstructive colon cancer C diff CMV in HIV pts
Toxic megacolon presentation
Severe, bloody diarrhea Toxic appearing patient AMS Tachycardia Fever Postural hypotension
Toxic megacolon complications
perforation
massive hemorrhage
progression of dilatation
Diagnostic criteria for toxic megacolon
Xray→ transverse/right colon dilated up to 15 cm +/- air fluid levels
Fever >38 C, HR >120
Neutrophilic leukocytosis >10,500
PLUS: dehydration AMS hypotension electrolyte disturbance
Toxic megacolon tx
Admit, IV fluids, NPO
NG tube
IV abx→ ampicillin, gentamicin, or metronidazole
IV steroids→ prednisolone or methylprednisolone
Consult surgery, GI
NO antimotility agents or opioids
Hemorrhoid presentation
Copious bright red rectal bleeding
Anal pruritus, prolapse
Acute perianal pain
“lump” due to thrombosis
Perianal abscess presentation
Severe pain in anal area
Cellulitis or extension→ fever (otherwise rare)
Rectal foreign body presentation
Usually long delay→ hours/days
Anorectal or abdominal pain
Blood per rectum
Mucus discharge
Thrombosed hemorrhoid complications
prolapse
strangulation
gangrene
Hemorrhoid diagnosis
Visual inspection + DRE
Anoscopy, endoscopic procedures
Perianal abscess diagnosis
Perianal fluctuance/indurated skin
normal DRE
Rectal foreign body diagnosis
Normal to diffuse peritonitis
DRE→ +/- palpable foreign body, can’t rule out
Pain radiograph, flat + upright
If radio-opaque→ CT
Hemorrhoids treatment
Increased fluids, fiber
Excision by surgeon
Thrombosed hemorrhoids treatement
incise overlying skin, evacuate small clot→ immediate relief (non-surgical practitioner)
Simple anorectal abscess treatment
drain in ER: anesthetize, open wound, evacuate pus, irrigate. (no packing)
Home: sitz baths
Anorectal abscess associated with cellulitis, systemic infection, DM, valvular heart disease, immunosuppression treatment
Augmentin
OR
Cipro + Metronidazole
Non-superficial anorectal abscess treatment
Non-superficial abscess
CT/MRI→ determine extension
Admit, GI + surgical consult
Surgical drainage
Rectal foreign body management
Shape and size of object influences management:
IV sedation + transanal removal
OR
Consult surgeon→ surgical removal:
Abdominal palpation for caudal pressure + stabilization
Laparoscopy
Colotomy with primary closure
After a rectal foreign body is removed…
rigid proctoscopy or flexible sigmoidoscopy
Pelvic pain exam
Pelvic exam→ cervical motion tenderness, erythema/edema?
Palpate ovaries→ size, pain, masses?
Pelvic pain labs
CBC with differential BMP Urinalysis HCG→ if (+) get quantitative Nucleic acid amplification test (NAAT) for chlamydia and gonococcus Gram stain, cultures
Pelvic pain imaging
Transvaginal Ultrasound→ Ovarian neoplasms/masses. Torsion, Ectopic pregnancy
CT→ further evaluation following ultrasound
MRI→ pregnant women
Ectopic pregnancy most likely extrauterine location
Fallopian tubes
Ectopic pregnancy presentation
Vaginal bleeding + pain
6-8 weeks after LMP
Ruptured→ life threatening hemorrhage
PID causes
STI related (85%) → N gonorrhoeae, C trachomatis Involves uterus, fallopian tubes/ovaries, +/- abscesses
Ovarian torsion
Partial or complete rotation of ovary→
Most common GYN emergency
ovarian torsion
Risk of ovarian torsion
Pregnancy
Ovarian cancer presentation
Adnexal mass, abdominal distention Bloating, early satiety Weight loss Urinary urgency, frequency Acute presentation→ +/- malignant effusion, SBO
Postpartum endometritis
infection
of endometrium after delivery→ Postpartum febrile mortality
Postpartum endometritis presentation
Fever/chills
Uterine tenderness
Lochia (foul smelling discharge)
+/- soft uterus, excessive uterine bleeding
PID presentation
Fever, chill New mucopurulent vaginal discharge Intermenstrual bleeding Pelvic TTP Cervical friability
Ovarian torsion presentation
Acute onset of pain \+/- radiate to back/flank/groin N/V Adnexal mass on exam \+/- abnormal genital tract bleeding \+/- fever (marker of necrosis)
Diagnose ectopic pregnancy
Transvaginal ultrasound
(+) hCG
PID diagnostics
Saline microscopy of vaginal fluid→ abundant WBCs
Transvaginal ultrasound→ +/- abscess, pelvic free fluid
NAATs→ chlamydia, gonorrhea
G stain + cultures
+/- elevated ESR/CRP
With ectopic pregnancy, be surer to
Monitor Hgb/Hct
Diagnose ovarian torsion
Ultrasound with duplex
Transvaginal + transabdominal
Direct visualization during surgical eval
Diagnose ovarian cancer
Transvaginal + transabdominal ultrasound Tumor markers (CA 125)
Diagnose postpartum endometritis
Clinical diagnosis
Elevated WBC with bands
postpartum endometritis tx
Admit, consult GYN
IV Clindamycin + Gentamycin
Ovarian cancer tx
Consult surgery, oncology, GYN
Ovarian torsion tx if premenopausal, viable ovary, no malignancy
Laparoscopic detorsion
Ovarian torsion tx if post-menopausal, nonviable ovary or suspected malignancy
Salpingo-oophorectomy
Ectopic pregnancy tx if patient is stable and will follow up
Methotrexate
Ectopic pregnancy tx if suspected tubal rupture or hemodynamically unstable pt
Salpingectomy
When can’t methotrexate be used?
high hCG fetal heart activity large ectopic size renal/liver disease breastfeeding
General tx for PID
Consult GYN
IV fluids, pain control
Antiemetic
+/- syphilis, HIV testing
Outpatient tx for PID
Ceftriaxone + doxy
Inpatient tx for PID
Cefoxitin + doxy
Hospitalize a patient with PID if…
Severe clinical illness
Unable to tolerate PO
Complicated PID with abscess
Pregnancy or post-partum
→ Get blood cultures x 2
Can you attribute significant abdominal pain to gastroenteritis?
NO, never
Old patient has risk factors + abdominal pain, so you have to rule out
Abdominal aortic aneurysm
In surgical cases, which comes first, pain or vomiting?
Pain
If a patient’s pain wakes them up from sleep…
that’s “significant”
Can a lack of free air on CXR rule out perforation?
Nope
What can mask pain?
Chronic steroids or opiates
Who perceives pain less?
The elderly
If you’re concerned your patient might have a GI bleed and need surgery…
order a blood type/cross