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Unit 1 Emerg/Surg > L5: Acute Abdominal pain: pt 2 > Flashcards

L5: Acute Abdominal pain: pt 2 Flashcards

1
Q

Splenic abscess results from

A

endocarditis

seeding from another site

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2
Q

Splenic infarct

A

Splenic artery or sub-branch occluded by embolus, clot, or infection

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3
Q

Splenic rupture

A 
Traumatic
or 
Atraumatic: 
Leukemia, lymphoma
Mononucleosis, CMV, HIV
Acute/chronic pancreatitis
Anticoagulants
Pregnancy related
Idiopathic
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4
Q

At risk of splenic infarct

A 
Hypercoagulable state (malignancy)
Embolic disease (afib, infective endocarditis)
Sickle cell disease
Trauma
Complication of EBV
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5
Q

Splenic abscess presentation

A

LUQ pain
Fever
+/- splenomegaly
+/- left side pleural effusion

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6
Q

Splenic infarct presentation

A 
Acute LUQ pain + Fever
N/V
Elevated LDH
Leukocytosis
\+/- splenomegaly
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7
Q

How to diagnose splenic abscess or infarct

A

CT scan with IV contrast

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8
Q

Splenic rupture presentation

A

LUQ pain, fullness
Referred left shoulder pain
Pleuritic pain
Early satiety

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9
Q

How to diagnose splenic rupture

A

Ultrasound→ Gold standard

CT with IV contrast

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10
Q

Splenic abscess tx

A

Admit, IV fluids, abx
NPO
Surgeon→ splenectomy
+/- Infectious disease consult

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11
Q

Splenic infarct tx

A

Uncomplicated→ analgesia, monitor

Complicated→ abscess, sepsis, hemorrhage→ splenectomy

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12
Q

Splenic rupture tx

A

NPO, IV fluids
Type + Cross for transfusion
Emergent Splenectomy

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13
Q

At risk for small bowel obstruction

A 
Prior abdominal/pelvic surgery→ adhesions
Abdominal wall/groin hernia
Intestinal inflammation
Neoplasm
Prior irradiation
Foreign body (FB) ingestion
*Intussusception/volvulus*
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14
Q

Acute mesenteric ischemia

A

Decreased/no perfusion to section of colon

Occlusive, arterial/venous
Embolic, thrombotic, atherosclerotic

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15
Q

At risk for acute mesenteric ischemia

A 
Cardiac arrhythmias
Advanced age
Low cardiac output states
Valvular heart disease
MI
Malignancy
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16
Q

Small bowel obstruction presentation

A

N/V

Cramping abdominal pain, periumbilical

Ischemia/necrosis→ More focal pain

Obstipation→ inability to pass flatus or stool

+/- dehydration

+/- fever if abscess/ischemia/necrosis

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17
Q

Acute mesenteric ischemia presentation if due to thrombosis or emboli

A 
Rapid onset, severe periumbilical pain out of proportion
N/V
\+/- forceful bowel evacuation
Postprandial pain (15-30 min)
\+/- Hematochezia
High mortality
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18
Q

Acute mesenteric ischemia presentation if due to venous thrombosis

A

More indolent, lower mortality

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19
Q

Abdominal xray of small bowel obstruction

A

Dilated loops of bowel with air-fluid levels

Proximal bowel dilation with distal bowel collapse

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20
Q

CT of small bowel obstruction

A 
Severity, masses
Inflammation
Necrosis
Perforation
Ischemia 
Non-viable bowel does not enhance with contrast
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21
Q

Early labs of acute mesenteric ischemia

A

often nonspecific

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22
Q

Labs of acute mesenteric ischemia may include

A

+/- leukocytosis

Hemoconcentration

Increased lactate, LDH

+/- elevated serum amylase (50%)

Check d-dimer

Advanced disease/necrosis→ metabolic acidosis

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23
Q

Imaging for acute mesenteric ischemia

A

Xray: Free air, “dead bowel”→ laparotomy

No signs on xray→ abdominal CT angiography IV contrast

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24
Q

Small bowel obstruction tx

A

Admit, NP, IV fluids

Antiemetics

NG tube, bowel rest

Consult surgery, GI

Not resolving→ Surgical intervention

Complicated bowel obstruction→ surgery, abx

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25
Q

Acute mesenteric ischemia management

A

Admit, IV fluids, NPO

Foley catheter

Ceftriaxone + Metronidazole (empiric)

+/- systemic anticoagulation

Consult GI, surgery, Vascular/Cardiology

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26
Q

Most common abdominal emergency

A

appendicitis

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27
Q

Who has a high risk of perforation with appendicitis?

In whom is appendicitis usually missed?

A

perforation <4 years

missed <12 years

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28
Q

Appendicitis presentation

A 
N/V/A
Fever (late finding)
Rebound tenderness/ (+) Rovsing’s
\+/- rigidity, voluntary guarding, pain on rectal exam
RLQ pain starts periumbilical + migrates
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29
Q

Retrocecal appendicitis:

A

Back/flank/testicular pain

+Psoas sign

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30
Q

Pelvic appendicitis:

A

Suprapubic/rectal pain/ dysuria/diarrhea

+Obturator sign

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31
Q

If your patient has clinical appendicitis

A

no further imaging is needed, you can go straight to surgical consult

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32
Q

Appendicitis labs

A

Leukocytosis (bands) → if extremely elevated→ perforation

Normal WBC doesn’t rule out appendicitis

UA→ +/- pyuria, bacteria, hematuria (if appendix near bladder/ureter)

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33
Q

Appendicitis if the patient is pregnant

A

Pain in RUQ instead of RLQ

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34
Q

Imaging for appendicitis

A

Abdomen xray→ free air, appendicolith (calcification)

US→ limited by obesity or retrocecal appendix

CT + contrast→ inflammation, abscesses, fat stranding, fluid collection

MRI + contrast→ pregnancy

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35
Q

Appendicitis treatment

A

Admit, IV fluids

NPO, analgesia

Cefoxitin
OR
cefazolin + metronidazole

Surgical consult

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36
Q

Diverticulitis

A

Microperforation of a diverticulum→ Inflammation

LLQ/sigmoid

Risk: age, diverticulosis

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37
Q

Diverticulitis presentation

A 
Steady, deep, constant pain
N/V, low grade fever
Change in bowel habits
Urinary urgency, frequency, dysuria
Rebound, guarding, localized tenderness
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38
Q

An acute attack of diverticulitis might present with

A

edema/compression of colon→ obstruction/paralytic ileus

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39
Q

Diverticulitis DRE

A

left sided tender mass

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40
Q

Complications of diverticulitis

A

Obstruction (hyperactive/ high pitched bowel sounds)

Peritonitis (hypoactive/ absent bowel sounds)

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41
Q

Diverticulitis labs

A

(+) stool guaiac
+/- mild leukocytosis
UA→ pyuria

42
Q

Diverticulitis imaging

A

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

43
Q

Uncomplicated diverticulitis tx

A

Ciprofloxacin + metronidazole

Follow up 2 days with GI

44
Q

Complicated diverticulitis is ______ and tx is _____

A

perforation, abscesses, fistula, obstruction

Admit, IV fluids+abx, NPO
Consult GI +/- surgery

45
Q

Toxic megacolon is a complication of…

A 
*IBD*
volvulus
diverticulitis
obstructive colon cancer
C diff
CMV in HIV pts
46
Q

Toxic megacolon presentation

A 
Severe, bloody diarrhea
Toxic appearing patient
AMS
Tachycardia
Fever
Postural hypotension
47
Q

Toxic megacolon complications

A

perforation
massive hemorrhage
progression of dilatation

48
Q

Diagnostic criteria for toxic megacolon

A

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
49
Q

Toxic megacolon tx

A

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

50
Q

Hemorrhoid presentation

A

Copious bright red rectal bleeding

Anal pruritus, prolapse

Acute perianal pain

“lump” due to thrombosis

51
Q

Perianal abscess presentation

A

Severe pain in anal area

Cellulitis or extension→ fever (otherwise rare)

52
Q

Rectal foreign body presentation

A

Usually long delay→ hours/days

Anorectal or abdominal pain

Blood per rectum

Mucus discharge

53
Q

Thrombosed hemorrhoid complications

A

prolapse
strangulation
gangrene

54
Q

Hemorrhoid diagnosis

A

Visual inspection + DRE

Anoscopy, endoscopic procedures

55
Q

Perianal abscess diagnosis

A

Perianal fluctuance/indurated skin

normal DRE

56
Q

Rectal foreign body diagnosis

A

Normal to diffuse peritonitis

DRE→ +/- palpable foreign body, can’t rule out

Pain radiograph, flat + upright

If radio-opaque→ CT

57
Q

Hemorrhoids treatment

A

Increased fluids, fiber

Excision by surgeon

58
Q

Thrombosed hemorrhoids treatement

A

incise overlying skin, evacuate small clot→ immediate relief (non-surgical practitioner)

59
Q

Simple anorectal abscess treatment

A

drain in ER: anesthetize, open wound, evacuate pus, irrigate. (no packing)

Home: sitz baths

60
Q

Anorectal abscess associated with cellulitis, systemic infection, DM, valvular heart disease, immunosuppression treatment

A

Augmentin
OR
Cipro + Metronidazole

61
Q

Non-superficial anorectal abscess treatment

A

Non-superficial abscess
CT/MRI→ determine extension
Admit, GI + surgical consult
Surgical drainage

62
Q

Rectal foreign body management

A

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

63
Q

After a rectal foreign body is removed…

A

rigid proctoscopy or flexible sigmoidoscopy

64
Q

Pelvic pain exam

A

Pelvic exam→ cervical motion tenderness, erythema/edema?

Palpate ovaries→ size, pain, masses?

65
Q

Pelvic pain labs

A 
CBC with differential
BMP
Urinalysis
HCG→ if (+) get quantitative
Nucleic acid amplification test (NAAT) for chlamydia and
gonococcus
Gram stain, cultures
66
Q

Pelvic pain imaging

A

Transvaginal Ultrasound→ Ovarian neoplasms/masses. Torsion, Ectopic pregnancy

CT→ further evaluation following ultrasound

MRI→ pregnant women

67
Q

Ectopic pregnancy most likely extrauterine location

A

Fallopian tubes

68
Q

Ectopic pregnancy presentation

A

Vaginal bleeding + pain
6-8 weeks after LMP
Ruptured→ life threatening hemorrhage

69
Q

PID causes

A 
STI related (85%) → N gonorrhoeae, C trachomatis
Involves uterus, fallopian tubes/ovaries, +/- abscesses
70
Q

Ovarian torsion

A

Partial or complete rotation of ovary→

71
Q

Most common GYN emergency

A

ovarian torsion

72
Q

Risk of ovarian torsion

A

Pregnancy

73
Q

Ovarian cancer presentation

A 
Adnexal mass, abdominal distention
Bloating, early satiety
Weight loss
Urinary urgency, frequency
Acute presentation→ +/- malignant effusion, SBO
74
Q

Postpartum endometritis

A

infection

of endometrium after delivery→ Postpartum febrile mortality

75
Q

Postpartum endometritis presentation

A

Fever/chills
Uterine tenderness
Lochia (foul smelling discharge)
+/- soft uterus, excessive uterine bleeding

76
Q

PID presentation

A 
Fever, chill
New mucopurulent vaginal discharge 
Intermenstrual bleeding
Pelvic TTP
Cervical friability
77
Q

Ovarian torsion presentation

A 
Acute onset of pain
\+/- radiate to back/flank/groin
N/V
Adnexal mass on exam
\+/- abnormal genital tract bleeding
 \+/- fever (marker of necrosis)
78
Q

Diagnose ectopic pregnancy

A

Transvaginal ultrasound

(+) hCG

79
Q

PID diagnostics

A

Saline microscopy of vaginal fluid→ abundant WBCs
Transvaginal ultrasound→ +/- abscess, pelvic free fluid
NAATs→ chlamydia, gonorrhea
G stain + cultures
+/- elevated ESR/CRP

80
Q

With ectopic pregnancy, be surer to

A

Monitor Hgb/Hct

81
Q

Diagnose ovarian torsion

A

Ultrasound with duplex
Transvaginal + transabdominal

Direct visualization during surgical eval

82
Q

Diagnose ovarian cancer

A 
Transvaginal + transabdominal ultrasound
Tumor markers (CA 125)
83
Q

Diagnose postpartum endometritis

A

Clinical diagnosis

Elevated WBC with bands

84
Q

postpartum endometritis tx

A

Admit, consult GYN

IV Clindamycin + Gentamycin

85
Q

Ovarian cancer tx

A

Consult surgery, oncology, GYN

86
Q

Ovarian torsion tx if premenopausal, viable ovary, no malignancy

A

Laparoscopic detorsion

87
Q

Ovarian torsion tx if post-menopausal, nonviable ovary or suspected malignancy

A

Salpingo-oophorectomy

88
Q

Ectopic pregnancy tx if patient is stable and will follow up

A

Methotrexate

89
Q

Ectopic pregnancy tx if suspected tubal rupture or hemodynamically unstable pt

A

Salpingectomy

90
Q

When can’t methotrexate be used?

A 
high hCG
fetal heart activity
large ectopic size
renal/liver disease
breastfeeding
91
Q

General tx for PID

A

Consult GYN
IV fluids, pain control
Antiemetic
+/- syphilis, HIV testing

92
Q

Outpatient tx for PID

A

Ceftriaxone + doxy

93
Q

Inpatient tx for PID

A

Cefoxitin + doxy

94
Q

Hospitalize a patient with PID if…

A

Severe clinical illness

Unable to tolerate PO

Complicated PID with abscess

Pregnancy or post-partum
→ Get blood cultures x 2

95
Q

Can you attribute significant abdominal pain to gastroenteritis?

A

NO, never

96
Q

Old patient has risk factors + abdominal pain, so you have to rule out

A

Abdominal aortic aneurysm

97
Q

In surgical cases, which comes first, pain or vomiting?

A

Pain

98
Q

If a patient’s pain wakes them up from sleep…

A

that’s “significant”

99
Q

Can a lack of free air on CXR rule out perforation?

A

Nope

100
Q

What can mask pain?

A

Chronic steroids or opiates

101
Q

Who perceives pain less?

A

The elderly

102
Q

If you’re concerned your patient might have a GI bleed and need surgery…

A

order a blood type/cross

Unit 1 Emerg/Surg (10 decks)

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