Lecture 7: Abdominal Topics

Question 1

What disease presents with the following Sxs: peri-umbilical pain–> RLQ, N/V, and anorexia

Answer 1

Appendicitis

Question 2

What PE & Lab findings are present in appendicitis?

Answer 2

Low grade fever, TTP to McBurny’s pt, + Psoas, Rovsing, Dunphy, & Obturator signs

Lab: Leukocytosis w/L shift

Question 3

What is the Dx test of choice for appendicitis & what confirms the Dx?

Answer 3

Abd & pelvic CT w/contrast

- enlarged appendix w/wall thickening

Question 4

What type of surgical treatment is used for appendicitis?

Answer 4

Appendectomy

- laparoscopic or open

Question 5

What are the common sxs of acute cholecystitis?

Answer 5

Prolonged, STEADY, severe RUQ pain, fever, Hx of biliary colic

+/- N/V and R side back pain

Question 6

What PE & lab findings are consistent w/acute cholecystitis?

Answer 6

Febrile, appear ill, RUQ/epigastric tenderness, guarding, Murphy’s sign

Lab: Leukocytosis w/bands

Question 7

What tests are used to Dx acute cholecystitis?

Answer 7

1. US
   (gallbladder wall thickened/edema, fluid around gallbladder w/+ Murphy’s sign)
2. HIDA scan - measures EF of bladder

Question 8

What causes Chronic cholecystitis?

Answer 8

Gallstones or gallbladder polyps

Question 9

What is characteristically seen in chronic cholecystitis?

Answer 9

Fibrosis & thickening of gallbladder wall

Question 10

What is the name of the triad seen in Cholangitis & what does it include?

Answer 10

Charcot’s Triad

1. Fever
2. RUQ pain
3. Jaundice

Question 11

To make a definitive Dx of cholangitis what must be seen on US?

Answer 11

Biliary dilatation, stricture or obstruction on US

Question 12

What Lab findings are associated with cholangitis?

Answer 12

Leukocytosis, elevated LFTs and bilirubin

Question 13

What do you Tx cholangitis like since it can progress quickly?

Answer 13

Sepsis

- give fluids & ABX, get blood cultures

Question 14

What are the two types of surgical interventions for cholangitis?

Answer 14

ERCP - for CBD clearance

PTC - if cant access CBD

Question 15

Common Sx for esophageal perforated viscus?

Answer 15

SUDDEN ONSET of ATYPICAL CP or abd pain

PE: SubQ emphysema, Tachypnea/cardia, diminished breath sounds

Question 16

What tests are used to Dx esophageal perforated viscus?

Answer 16

1. XR (pneumomediastinum & subQ emphysema)
2. CT w/contrast
3. Gastrografin esophagram

Question 17

What is the surgical Tx for esophageal perforated viscus?

Answer 17

IR drainage, chest tubes, stenting (so tear can heal)

Question 18

Common Sx/PE findings for Stomach/SI perforated viscus?

Answer 18

Generalized abd pain & diffuse TTP

tenderness, rigidity, N/V/anorexia, tachycardia, peritoneal signs

Question 19

What tests are used to Dx stomach/SI perforated viscus?

Answer 19

CXR (free air)

CT w/contrast via NG tube

Question 20

What does an apple core lesion suggest?

Answer 20

colon cancer

Question 21

Presentation of SBO?

Answer 21

Bloating, N/V, crampy pain, obstipation

May include: distention, dehydration, fever, abnormal sounds, tympani, peritoneal signs, hernias, masses

Question 22

Tests for Dx SBO?

Answer 22

XR: upright and supine abd
CXR (best to see free air)

Abd & pelvic CT with IV contrast (PO not helpful)

CBC, CMP, lactate, ABG

Question 23

Tx for SBO?

Answer 23

IV fluids, NG decompression, bowel rest, +/- abx

If no improvement: then surgery

Question 24

What is the biggest indicator of small bowel function?

Answer 24

passing gas

Question 25

What is seen on XR and CT when an ileus is present that differentiates it from a SBO?

Answer 25

XR: Air in the colon and rectum CT: NO transition zone (diffuse dilated bowel)

Question 26

After what type of procedure is an ileus common?

Answer 26

open abd surgery

Question 27

What are the positive signs seen in appendicitis?

Answer 27

McBurney's, Psoas, Obturator, Rovsing, Dunphy's "DR. MOP will tx your appendicitis"

Question 28

A DM patient present to the ED w/ very painful gallstones, does this patient require surgery?

Answer 28

YES - surg is indicated in DM and immunocompromised pts Note: Gallstones w/no Sxs - NO SURGERY

Question 29

What is the ABX prophylaxis for appendicitis?

Answer 29

Either cefazolin, cefoxitin, or cefotetan PLUS metronidazole

Question 30

What is the ABX prophylaxis for acute cholecystitis?

Answer 30

None or IV cefazolin

Question 31

What is typically the main surgical Tx for acute cholecystitis? Others?

Answer 31

Cholecystectomy Others: IOC, percutaneous cholecystectomy

Question 32

Why is gallstones in the presence of gallbladder polyps an indication for surgery?

Answer 32

Its a RF for gallbladder cancer

Question 33

What are the ABX treatments for someone with cholangitis?

Answer 33

Zosyn or Meropenem | give broad spectrum b/c can progress to sepsis quickly

Question 34

What are the ABX treatments for any perforated viscus?

Answer 34

Zosyn or Cefepime + Metronidazole

Question 35

What is the common finding indicating a tumor in the small bowel?

Answer 35

Target sign/intussessception (one loop of bowel inside another)

Question 36

What is the MC cause of SBO?

Answer 36

Adhesions

Question 37

What are the 3 common causes of colon obstruction?

Answer 37

tumors, diverticulitis, volvulus

Question 38

What is the advantage of CT for SBO?

Answer 38

It can identify complications - closed loop, ischemia, perforation & **pneumoperitoneum**

Question 39

What is the difference b/t diverticulosis and diverticulitis?

Answer 39

Diverticulosis - normal out-pouching (sac like protrusion) of the abd wall Diverticulitis - inflam/infection of diverticulosis

Question 40

What are the 2 common presentations with diverticulosis?

Answer 40

MC = Asx | Painless hematochezia

Question 41

What is the Dx test and Tx for diverticulosis?

Answer 41

Colonoscopy Tx: fluids, endoscopic therapy (dont usu operate)

Question 42

What triad of S/S is highly suggestive of diverticulitis?

Answer 42

LUQ TTP + fever + leukocytosis

Question 43

What is the Dx test for for diverticulitis?

Answer 43

CT (abd/pelvic) w/IV & PO contrast Note: NOT confirmatory

Question 44

Why is it necessary to get a colonoscopy after an acute episode of diverticulitis?

Answer 44

CT findings are similar to colon CA - must r/o w/colonoscopy

Question 45

What is the ABX treatment for diverticulitis in the outpatient setting?

Answer 45

ORAL ABX!! | - PO fluoroquinolone + metronidazole

Question 46

What is the ABX treatment for diverticulitis in the inpatient setting

Answer 46

IV ABX!! - IV fluoroquinolone + metronidazole or... - IV ceftriaxone + metronidazole

Question 47

What is the ABX treatment for diverticulitis in the inpatient setting

Answer 47

IV ABX!! - IV fluoroquinolone + metronidazole or... - IV ceftriaxone + metronidazole

Question 48

What are the elective surgical options for diverticulitis?

Answer 48

percutaneous drainage | - if cant do that then --> laparoscopic lavage

Question 49

What are the emergent surgical options for diverticulitis? | When do you consider these options?

Answer 49

Resection or Hartmann procedure Considered if peritonitis, massive free air or failed non-operative Tx