LECTURES: Acute Abdomen Flashcards
Define “acute abdomen”.
“Undiagnosed pain that develops suddenly and is less than 7 days duration”
projection of pain usually onto a specific dermatome or myotome of the corresponding segment of the spinal cord, corresponds to embryonic anatomic origin
Referred pain
Pain from the stomach to the second portion of the duodenum, pancreas, gallbladder, and liver is transmitted via the _________ plexus and may be experienced as pain in the ___________________________ by the patient
via the celiac plexus, experienced in the EPIGASTRUM
Pain from the third part of the duodenum to the first two thirds of the transverse colon is transmitted via ______________________ and is experienced where for the patient?
Celiac plexus, experienced in the periumbilical region
Pain from the last thrid of the transverse colon to rectum is transmitted via the _______ and is experienced in the ___________ region
epigastric plexus, and is experienced in the suprapubic region
A patient comes in with periumbilical pain and a fever but they exhibit no signs of rebound tenderness/somatic tenderness. Why can you not rule out appendicitis?
A pelvic or retrocecal inflammed appendix may not generate somatic or rebound tenderness.
A patient comes in with a positive murphy’s and right shoulder pain with no hx of trauma, injury, or hx of arthiritis in the joint. Why might the pt have shoulder pain?
Referred pain from cholecystitis
Which type of pain tends to be more diffuse?
Visceral pain
Differential by location: RUQ
biliary colic, acute cholecystitis, acute cholangitis, sphincter of oddi dysfunction, acute hepatitis, liver abscess, budd-chiari, portal vein thrombosis, fitz-hugh-curtis
Differential by location: LUQ
splenomegaly, spenic abscess, splenic infarct, splenic rupture
Differential by location: Epigastric
MI, peptic ulcer disease, acute/chronic pancreatitis, GERD, gastritis, biliary colic, acute cholecystitis.
Differential by location: LLQ/RLQ
appendicitis, diverticulitis, nephrolithiasis, pyelonephritis, acute urinary rentention, cystitis, infectios colitis, gyenocologic
Pain association: burning pain
associated w/ perforated gastric ulcer or acute pancreatitis as well as acute perotinitis
Pain association: sharp, constricting pain
biliary colic
Pain association: tearing pain
dissecting aneurysm
pain association: gripping pain
intestinal obstruction
pain association: constant, dull, fixed pain
abscess
Ab pain associated w/driving over bumps
peritonitis
Where is the obstruction: bilious vomiting
nonspecific or early obstruction
Where is the obstruction: food particles vomiting
proximal obstruction
Where is the obstruction: feculent vommiting
prolonged distal small bowel obstruction, rare in colonic obstruction
Charcot triad
intermittent right upper quadrant pain, jaundice, and fever
Points to choleangitis
recall that reynolds pentad is also for cholangitis, it just points to sepsis from it
Murphy Sign is suggestive of
acute cholecystitis
Rovsing sign is suggestive of
acute appendicitis
What is cullen sign?
periumbilical darkening of skin from blood
A physical examination characterized by periumbilical ecchymosis and bluish-red discoloration. Can be seen in any disease that causes retroperitoneal hemorrhage (e.g., ruptured abdominal aortic aneurysm). Classically associated with pancreatitis.
What is cullen sign suggestive of?
Hemoperitoneum
*A physical examination characterized by periumbilical ecchymosis and bluish-red discoloration. Can be seen in any disease that causes retroperitoneal hemorrhage (e.g., ruptured abdominal aortic aneurysm). Classically associated with pancreatitis.
Flexion of right thigh at right angles to trunk and external rotation of same leg in supine position results in hypogastric pain is called what sign?
obturator
obturator sign is indicative of
appendicitis, pelvic abscess, inflammatory mass
Left shoulder pain when patient is supine or in trendelenburg
Kehr sign
A referred pain to the left shoulder as a result of irritation of the left hemidiaphragm. Occurs because both left phrenic nerve, which innervates the left hemidiaphragm, and the left supraclavicular nerves, which innervate the skin over the shoulder, have common cranial nerve roots (C3 and C4). Most common cause is splenic injury.
what is Kehr sign indicative of?
hemoperitoneum
A referred pain to the left shoulder as a result of irritation of the left hemidiaphragm. Occurs because both left phrenic nerve, which innervates the left hemidiaphragm, and the left supraclavicular nerves, which innervate the skin over the shoulder, have common cranial nerve roots (C3 and C4). Most common cause is splenic injury.
Parietal Pain
Where the peritoneum touches the abdominal wall, called the parietal peritoneum, it is somatically innervated and produces parietal pain.
Parietal pain, like somatic pain, is punctate, localizable, and sharp.
Pain that is punctate, localizable, and sharp
Somatic and Parietal Pain
Most abdominal pain can be narrowed down to what 4 major mechnisms?
obstruction (distention and peristalsis), inflammation (not just infection), perforation, and ischemia.
Sudden onset of severe, sharp tearing chest or abdominal pain that radiates to the back
Likely an aortic dissection
Sudden, severe central abdominal, chest, and/or back pain
Hypotension, shock
Pulsatile mass in the midline of the abdomen
Grey Turner sign and/or Cullen sign
Ruptured AAA
What are some cardiovascular causes of acute abdomen?
ACS, Acute Mesenteric Ischemia, AAA/aortic dissection
A full-thickness injury of the wall of the gastrointestinal tract that results in leakage of enteric contents. Causes include direct trauma (e.g., penetrating injury) and ischemia (e.g., due to bowel obstruction).
GI performation
Ulcer where pain is releived with food
duodenal ulcer
Ulcer where pain is exacerbated by food
gastric ulcer
Presents as:
Fever
LLQ pain
Constipation
Tender mass in LLQ
diverticulitis
Severe epigastric pain that radiates to the back (circumferential pain), ↑ Lipase, amylase
Hypocalcemia (poor prognostic indicator)
Acute pancreatitis
A membrane-bound enzyme of glutathione metabolism and amino acid transport. The most sensitive parameter for diseases of the liver and/or biliary tract. However, it is not very specific, as it is found in many tissues.
Gamma-glutamyl transferase
Genitourinary causes of acute abdominal pain
ruptured ectopic pregnancy, ovarian torsion, testicular torsion, acute pyelonephritis, nephrolithiasis, PID, acute urinary retention
RUQ diff dx
Biliary colic
Acute cholecystitis
Acute cholangitis
Emphysematous cholecystitis
Acute hepatitis
Pyogenic liver abscess
Duodenal ulcer
Portal vein thrombosis
A condition of ischemic infarction of an epiploic appendage (e.g., due to torsion or spontaneous thrombosis of an associated vein). The most common manifestation is lower abdominal pain. Other manifestations include early satiety, nausea and vomiting, and diarrhea.
Epiploic appendagitis
LUQ diff dx
Gastric ulcer
Splenic abscess
Splenic laceration
Splenic infarction
RLQ diff dx
Acute appendicitis
Colitis
IBD
Epiploic appendagitis
Neutropenic enterocolitis
LLQ diff dx
Diverticulitis
Colitis
IBD
Epiploic appendagitis
Epigastrum diff dx
Acute esophagitis
Acute gastritis
Acute pancreatitis
Acute mesenteric ischemia
PUD
GERD
Functional dyspepsia
Mallory Weiss syndrome
differential dx for diffuse ab pain GI differntial
Bowel obstruction
Bowel perforation (peritonitis)
Mesenteric ischemia (peritonitis)
Irritable bowel syndrome
Constipation
Gastroenteritis
Spontaneous bacterial peritonitis
abdominal pain with hip extension is called what sign?
psoas sign
Psoas sign can be indicative of…
psoas abscess, retro appendicitis
_______________ commonly presents subacutely with fever and lowed ab pain or flank pain that radiates to the groin. Positive psoas sign.
Psoas abscess
How does obstruction pain, inflammation pain, perforation pain, and ischemic pain differ from one another?
Obstruction: The pain from obstruction is colicky in nature, is not associated with fever or leukocytosis, and will either be crescendo-descrescendo (peristalsis) or occur whenever the organ contracts (such as the gallbladder after a meal).
Perforation pain (and we mean free perforation) presents “SAS.” There will be high acuity and high toxicity—severe leukocytosis, severe fever, obvious signs of sepsis, and diffuse peritonitis.
Ischemia pain presents as pain out of proportion to the physical exam. The patient will not be tender on exam, but they will be in tremendous pain and moving around trying to find a comfortable position.
Referred pain was chosen because we wanted to satisfy the requirements of five answer choices with one best answer. Referred pain is not a pain category in the Vengry Robot model but rather used differently. Knowing where organ pain typically radiates, such as from the pancreas to the back or from the gallbladder to the shoulder, can help identify the dysfunctional organ, but referred pain is not one of the four subtypes of visceral pain used in our advanced organizer.
