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Medicine Clerkship > Learning Objectives - Abdominal Pain > Flashcards

Learning Objectives - Abdominal Pain Flashcards

1
Q

List the 4 principle types of abdominal pain.

A
  1. Parietal
  2. Visceral
  3. Vascular
  4. Referred
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2
Q

What is the pathophysiology of parietal abdominal pain?

A

Inflammation of the parietal peritoneum causes localized pain over the inflamed area.

The parietal peritoneum is innervated by somatic nerves (type A delta fibers) that terminate in the thalamus, allowing for localization of pain.

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3
Q

How does parietal abdominal pain present?

A
  • Pain worse with movement or changes in position (patient may lie still and resist movement)
  • Rigid abdomen due to spasm of muscles over the affected peritoneum
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4
Q

What is the pathophysiology of visceral abdominal pain?

A

Obstruction of a hollow viscera leads to deep, poorly localized pain. The viscera are innervated by type C sensory fibers that terminate in the brainstem.

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5
Q

How does visceral abdominal pain present?

A

Pain may be colicky and come and go in waves (as in SBO) or it may be constant (acute biliary tree obstruction)

The patient may be restless as they attempt to find a comfortable position.

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6
Q

What is the pathophysiology of vascular abdominal pain?

A

Viscera that are deprived of blood will inevitably cause pain. This can be sudden and intense in onset or gradual, depending on the vessel and structures involved.

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7
Q

How does vascular abdominal pain present?

A

Inexorable worsening of symptoms and progression of the severity of the pain in a patient with VTE risk factors (hypercoagulability, smoking, HTN, pVD, AF).

If chronic, it may cause postprandial pain analogous to angina.

If acute, it may cause severe abdominal pain disproportionate to physical findings.

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8
Q

What is the pathophysiology of referred abdominal pain?

A

Due to the innervation pattern of the viscera, pain from diseases of the heart, lungs, and testicles can be referred to the abdomen.

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9
Q

How does referred abdominal pain present?

A

Poorly localized

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10
Q

What are 4 causes of referred abdominal pain?

A

Pneumonia, empyema
MI
Testicular torsion

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11
Q

What 3 major systems should be considered in the differential of abdominal pain?

A

GI
GU
CV

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12
Q

DDx - GI causes of abdominal pain (16)?

A
  1. Acute cholecystitis
  2. Acute cholangitis
  3. Small bowel obstruction
  4. Spontaneous bacterial peritonitis
  5. Appendicitis
  6. Gastroenteritis
  7. Gastritis
  8. Pancreatitis
  9. Hepatitis
  10. PUD
  11. Gastric outlet obstruction
  12. Diverticulitis
  13. Pseudomembranous colitis (C. difficile infection)
  14. IBD (UC or Crohn’s)
  15. IBS
  16. Colon Cancer
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13
Q

DDx - GU causes of abdominal pain (6)?

A
  1. Pyelonephritis
  2. Nephrolithiasis
  3. PID
  4. Ectopic pregnancy (if pre-menopausal)
  5. Endometriosis (if pre-menopausal)
  6. Ruptured ovarian cyst (if pre-menopausal)
  7. Ovarian torsion
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14
Q

DDx - CV causes of abdominal pain (4)?

A
  1. Angina
  2. ACS
  3. Vasculitis
  4. Mesenteric ischemia
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15
Q

Pathophysiology of diverticulitis?

A

Inflammation caused by trapping of particulate matter and/or microperforation of a diverticulum

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16
Q

Presentation of diverticulitis?

A

Fever, change in bowel habits (C or D)
Acute LLQ tenderness
Leukocytosis

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17
Q

How is diverticulitis diagnosed?

A

CT Abdomen and Pelvis showing inflamed diverticula with thickening of the colon wall. May also identify complications, including abscess and perforation

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18
Q

What is diverticulosis and how does it present?

A

Formation of diverticula when the mucosal layer of the intestine herniates through the muscularis propia, weakening the intestinal wall

Presents most commonly in older patients (>60) without symptoms or with chronic mild LLQ cramping relieved by defecation

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19
Q

Diverticulosis is most common in the ___ colon in Western countries and in the ___ colon in Asian countries.

A

Sigmoid; ascending

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20
Q

How does diverticular bleeding present?

A

Painless hematochezia, does not usually occur at the same time as diverticulitis

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21
Q

Pathophysiology of pseudomembranous colitis?

A

Antibiotics kill healthy GI flora. This leads to overgrowth of C. difficile bacteria, which produce exotoxins, leading to mucosal injury, inflammation, and diarrhea

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22
Q

Presentation of pseudomembranous colitis?

A

Watery diarrhea (cardinal symptom) with a low grade fever, abdominal cramping, and leukocytosis, often in patients with a recent history of antibiotic use or hospitalization. Note that community-acquired C. difficile is increasingly common.

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23
Q

How is C. difficile diagnosed?

A

Toxin assay

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24
Q

How is C. difficile managed?

A

IV fluids
Pain medication
Antibiotics (metronidazole or vancomycin)

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25
Q

Etiology of acute mesenteric ischemia in the colon and small bowel?

A

Colitis - usually caused by an acute hypotensive event where blood flow to the colon is temporarily compromised

Small bowel/mesentery - thrombosis or embolization of a mesenteric vessel, often in the setting of cardiac disease

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26
Q

Which part of the colon is at highest risk for ischemic colitis?

A

Splenic flexure (pain in LUQ)

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27
Q

Presentation of acute mesenteric ischemia?

A 
Diffuse periumbilical abdominal pain
Peritoneal signs (if advanced), absent/diminished bowel sounds, rigidity, may show signs of shock, pain out of proportion to the exam, distention, lactic acidosis
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28
Q

How is acute mesenteric ischemia diagnosed?

A

CT with angiography

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29
Q

How is acute mesenteric ischemia managed?

A 
Admit to the ICU
Notify surgery - depending on the cause, embolectomy, anticoagulation, stenting, or surgery may be appropriate
Antibiotics
IV fluids
Oxygen
Reversal of acidosis
Vasopressor support
30
Q

Presentation of appendicitis?

A

Vague periumbilical pain that gradually increases in intensity and travels to the RLQ, vomiting fever

Peritoneal findings if inflammation spreads to the parietal peritoneum

More common in patients in their teens or twenties

31
Q

Presentation of gastroenteritis?

A

Fever, diarrhea, crampy abdominal pain, tenderness (usually generalized), increased suspicion if recent travel or suspicious food ingestion

32
Q

Presentation of IBD?

A

Fever, abdominal pain, diarrhea, chronic symptoms

33
Q

Compare the presenting complaints of CD and UC.

A

Both: diarrhea, fever, weight loss

CD: abdominal pain, palpable mass

UC: rectal bleeding

34
Q

Compare intestinal involvement of CD and UC.

A

Both: colon
CD: ileum, rarely the jejunum/duodenum, esophagus

35
Q

Compare intestinal complications of CD and UC.

A

Both: cancer, perforation (rare)

CD: perforation, abscesses, fistula

UC: toxic megacolon

36
Q

Compare extra-intestinal complications of CD and UC.

A

Both: skin disease (erythema nodosum, pyoderma gangrenosum), arthritis (pauciarticular, large joints), hepato-biliary, renal calculi, anemia, thromboembolism risk, iritis/episcleritis (rare)

37
Q

Presentation of IBS?

A

Episodes of abdominal pain that can vary in nature and severity from patient to patient (functional, not associated with an anatomic cause, diagnosis of exclusion), chronic history of constipation, diarrhea, or both

More common in younger females

38
Q

Most common causes of small bowel obstruction?

A

Adhesions from previous abdominal surgery (most common), hernias, tumors

39
Q

Presentation of small bowel obstruction?

A

Decreased or absent stool and flatus output (if there is a partial obstruction, liquid stool may be present), N/V, distended abdomen, diffuse tenderness, abdominal pain, +/-peritoneal signs, fever if perforation

40
Q

Presentation of ureteral stones?

A

Severe, colicky flank or lower quadrant pain radiating to the testicle (M) or vulva (F)

Fever if complete obstruction with stasis or if struvite stones

41
Q

DDx - Upper Abdominal Pain, Vomiting, Fever, Alcohol Misuse (6)?

A
  1. Cholecystitis
  2. Gastritis
  3. Pancreatitis
  4. PUD
  5. Small bowel obstruction
  6. Spontaneous bacterial peritonitis
42
Q

Presentation of cholecystitis?

A

Vomiting, fever, RUQ colicky pain (may radiate under the right scapula) that steadily worsens until it is constant, may worsen with deep inspiration or jarring of the patient (if peritoneal inflammation)

Would not expect shock/hypotension unless gangrene or gallbladder rupture has occurred

43
Q

Presentation of gastritis?

A

Abdominal pain, vomiting

Would not expect peritoneal signs or fevers, would not expect tachycardia/hypotension unless significant Gi bleeding is present

Alcohol use is a major risk factor

44
Q

Presentation of pancreatitis?

A

Vomiting, fever, peritonitis/peritoneal signs, SIRS (if release of lypolytic enzymes)

45
Q

Two most common causes of pancreatitis?

A

Heavy alcohol use (#1)

Biliary stone obstructing the pancreatic duct (#2)

46
Q

Presentation of PUD?

A

Vomiting, coffee-ground emesis if bleeding is present

Would not expect fever/systemic symptoms unless bleeding/perforation present

Heavy alcohol use is a risk factor

47
Q

Presentation of spontaneous bacterial peritonitis?

A

Poorly localized pain (inflammation/infection of peritoneal fluid due to gut translocation of bacteria), possible vomiting, ascites, ileus, possible guarding/rebound tenderness

48
Q

List the possible components of a work-up for abdominal pain (14).

A
  1. CBC
    - Leukocytosis (infection/inflammation)
    - Anemia, macrocytosis (alcohol abuse)
    - Thrombotyopenia (cirrhosis or sepsis)
  2. BMP
    - Volume status
    - Kidney function (kidney failure in advanced liver disease, AKI with severe infection/inflammation/hypovolemia)
  3. LFTs
    - Hepatobiliary disease
  4. Lipase
    - Essential to diagnose pancreatitis
    - More specific/sensitive than amylase (can be elevated in acute gastroenteritis/liver failure); may be elevated in renal failure
  5. Hemoccult
    - Very sensitive, less useful if acutely ill
  6. Cardiac enzymes
  7. UA
    - Volume status, UTI
  8. Pregnancy test
  9. Serum/urine toxicology screen
  10. Abdominal series (flat/upright abdominal radiographs, upright chest radiograph)
    - Perforation or obstruction
  11. CT Abdomen/Pelvis
    - Diverticulitis, ischemic colitis, appendicitis, other intra-abdominal problems
  12. C. difficile toxin assay
  13. Stool cultures
    - Bacterial causes of gastroenteritis
    - Viral cultures not routinely done in immunocompetent hosts
  14. Colonoscopy
49
Q

Radiographic findings of perforation/obstruction?

A

Air under the diaphragm is pathognomonic of a perforated viscus

Air-fluid levels throughout the bowel can be seen in obstruction

50
Q

When is a colonoscopy contraindicated in evaluating abdominal pain?

A

If concern for diverticulitis, as increased pressure could cause a perforation

51
Q

DDx - abdominal pain with a history of alcohol abuse?

A

Pancreatitis
Gastritis
Hepatitis/cirrhosis

52
Q

DDx - crampy abdominal pain?

A

Diverticulitis, gastroenteritis, intermittent obstruction of a viscus (biliary colic, renal colic, bowel obstruction)

53
Q

What are the major causes of an acute abdomen?

A

Peritonitis from perforation or inflammation of an organ

Obstruction

54
Q

What is the most specific exam finding for diagnosing peritonitis?

A

Rigidity (involuntary contraction of the abdominal muscles)

55
Q

What is the difference between rigidity and guarding?

A

Rigidity - involuntary
Guarding - voluntary contraction of abdominal wall, muscles will relax if the patient is relaxed or distracted (less specific, more sensitive)

56
Q

What is Murphy’s sign?

A

Abrupt cessation of inhalation when palpating deeply under the liver edge, indicates cholecystitis

57
Q

Which peritoneal sign is non-specific and does very little to narrow a differential?

A

Rebound tenderness

58
Q

When should surgeons be consulted in the setting of abdominal pain?

A

Cholecystitis, small bowel obstruction, perforation of an abdominal organ

59
Q

What is the cornerstone of management for uncomplicated diverticulitis?

A

Antibiotics for 7-10 days

60
Q

What bacteria must be covered in treating diverticulitis?

A

Bowel flora: GN rods (E. coli), enteric GP streptococci, anaerobes (B. fragilis)

61
Q

What is the initial antibiotic therapy of choice for diverticulitis?

A

Metronidazole + FQ (like ciprofloxacin)

62
Q

List 2 other reasonable combinations for antibiotic treatment of diverticulitis.

A
  1. Metronidazole + 3rd generation cephalosporin (like ceftriaxone)
  2. Single agent therapy with ertapenem, moxifloxacin, or cefoxitin
63
Q

What are 3 oral treatment options for diverticulitis?

A
  1. Metronidazole + FQ
  2. Metronidazole + TMP-SMX
  3. Moxifloxacin
64
Q

2010 IDSA guidelines recommend what antibiotics for diverticulitis because of high rates of resistance among community-acquired E. coli?

A

Ampicillin-Sulbactam (Unasyn)

Amoxicillin-Clavulanate (Augmentin)

65
Q

In addition to antibiotics, discuss additional management of diverticulitis.

A
  1. Supportive care (NPO or bowel rest, IV fluids)
  2. IV narcotics for severe pain
  3. Follow-up colonoscopy in 2-6 weeks to explore the extent of diverticulosis and rule out polyps/cancer
  4. High-fiber diet (decrease constipation/intraluminal pressure, decrease chance of recurrence)
66
Q

When may surgery be indicated for diverticulitis?

A

Recurrent diverticulitis

Management of complications (free air from perforation, complicated abscess or phelgmon, obstruction, fistula)

67
Q

Prognosis of diverticulitis?

A

~1/3 will have recurrent abdominal cramps
1/3 will have another frank episode

Some with recurrent episodes may require surgery to resect the diseased portion of bowel

68
Q

Recommend a basic management plan for uncomplicated pancreatitis (no vomiting, no ileus)

A

Medical management with IV fluids, pain control, and a soft, low fat diet as tolerated

69
Q

When should surgery be consulted in a patient with pancreatitis?

A

Impacted gallstone not extracted with ERCP, pancreatic abscess, necrotic pancreatitis, symptomatic pancreatic pseudocyst

70
Q

When is imaging indicated for pancreatitis?

A

Confirm the diagnosis when presentation or labs are confusing
Detect gallstones as a possible cause
Detect pancreatitic necrosis, abscesses, and other complications
Guide percutaneous drainage if needed

71
Q

Management of chronic pancreatitis?

A
  1. Narcotic analgesics for pain
  2. Pancreatic enzymes
  3. H2 blockers (prevent degradation of pancreatic enzymes by gastric acid)
  4. Insulin (if severe endocrine insufficiency)
  5. Alcohol abstinence
  6. Frequent small volume low fat meals
72
Q

What is the role of antibiotics in pancreatitis?

A

Remains controversial

For mild cases, prophylaxis is clearly not indicated. With increasing severity of illness, organ dysfunction, and worsening pancreatic necrosis, some studies have shown benefit with prophylaxis and some have not.

Empiric therapy should be used in those who appear to have infection complicating a severe pancreatitis course, such as infected pseudocyst or pancreatic abscess complicating extensive necrosis

Medicine Clerkship (15 decks)

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