midterm - midterm pt 2 Flashcards
AAA
-Nonruptured:
-50% Asymptomatic! -> Incidental finding
-pulsatile mass
-lower back pain
-Ruptured:
-!!!ABDOMEN (80%) BACK & FLANK (60%), OR GROIN (22%)
-Triad (<50%)
-!Sudden Abdominal/back pain + Hypotension + Pulsatile abdominal mass!!
-syncope alone (rare)
-Lightheadedness or dizziness, Sweating, Clammy skin
-Rare- pulse deficit, or lower limb ischemia
-US:
-dilated aorta - measure from outside wall to outside wall (avoids false lumen)
-cant tell you if ruptured or not bc blood goes retroperitoneal -> cant detect dissection
-diameter >=3cm or >50% aortic diameter proximal to dilation
-Tx:
-3-5cm - serial US
->5cm - referral to repair w/ open surgery or endovascular repair within 3-5 days
-SUSPECTED RUPTURE:
-RESUSCITATE
-!!!surgical consult!!!!, 2 IV, fluids, type and cross, EKG
-massive transfusion protocol
appendicitis
-!!Periumbilical or epigastric pain initially -> 4-48 hrs -> RLQ
-!Fever (low grade)
-N/V (typically after pain started!!!!)!*- GASTRITIS IS BEFORE
-Pain !worse w/ movement!
-CHILDREN: Diarrhea, Limp, Anorexia, nausea
-ELDERLY: late presentation masking of VS
-Retrocecal appendix -> right flank / low back
-Retroileal appendix -> testicle, suprapubic area, or cause dysuria
-Low appendix -> left sided or rectal pain
-Pregnant -> RLQ or RUQ pain -> due to enlarged uterus
-significant pain -> decreased pain -> perforation
-US- 1st choice for kids and pregnant- >6mm or >2mm wall
-!!CTAP w/ IV contrast- >7mm, mural enhancement, stranding - best
urine analysis/culture in appendicitis
-Typically normal
-Possible findings:
-Mild pyuria (WBCs in urine)
-Mild hematuria
-due to irritation of right ureter, especially if retrocecal
-differentiates from UTI and nephrolithiasis
-Culture- Not typically needed
RLQ
-appendicitis
-ectopic pregnancy
-ovarian torsion
-testicular torsion
-diverticulitis
-meckels diverticulum
-inguinal hernia
-ovarian cyst rupture
-PID
-psoas abscess
-TOA
-ureteral calculi
biliary colic/cholelithiasis VS cholecystitis
-Biliary colic- <6hrs and less severe
-intermittent
-no fever, normal labs, gallstones with no inflammation
-pain control, elective cholecystectomy
-CHOLECYSTITIS:
-Fat, female, fertile, forty
-pain after eating >6 hrs
-± Kehr’s sign
-Fever, N/V, RUQ TTP
-!Murphy’s sign
-Voluntary guarding
-stones + inflammation
-Dx-
-Labs: High WBC, ALP
-US 1st line:
-Gallstone w/ shadowing
-Pericholecystic fluid
-!GB wall >3mm
-Sonographic murphys sign
-GB distension (diameter >5cm, length >10cm)
if dilated CBD, consider choledocholithiasis
-Tx:
-analgesics
-IV antibiotics
-Lap cholecystectomy
choledocholithiasis
-gallstones in CBD
-post prandial, N/V
-!AND EXTRAHEPATIC CHOLESTASIS:
-jaundice and itching
-pale stool/dark urine
-Dx: LFTs, RUQ US
-high bilirubin, ALP, GGT, AST/ALT
-Tx: MRCP -> ERCP, cholecystectomy
gallstone pancreatitis
-ABNORMAL LIPASE/AMPLYASE
-gallstone obstructs ampulla of vater -> inflammation of pancreas
-epigastric pain radiating to back
-maybe jaundice
-Dx:
-US- pancreatic inflammation, CT is best
-Tx: supportive
-ERCP if needed
ascending cholangitis
-obstruction with bacterial infection (usually CBD)
-MCC- gallstones, ERCP, cholangiocarcinoma
-Charcots triad- RUQ pain, fever, jaundice
-Reynold pentad- charcots + AMS and shock
-Dx:
-Labs- high WBC, ALP, ALT/AST, GGT, bilirubin
-blood cultures
-US- dilated CBD, +/- pus
-Tx:
-ASAP tx- IV fluids, NPO
-IV antibiotics!, pressors if hypotension
-!ERCP (suction vs stent)
-percutaneous cholecystostomy if cant get ERCP
-call critical care + surgery
What lab results and U/S imaging findings help you differentiate a cholecystitis vs. a choledocholithiasis?
-CHOLECYSTITIS:
-murpheys and kernh
-high WBC
-mild ALP/AST/ALT
-US- wall thickening, pericholecystic fluid, distention
CHOLEDOCHOLITHIASIS:
-fever
-jaundice
-Labs: high bilirubin, ALP, GGT, AST/ALT
-US- CBD dilation, stone
Mallory Weiss tear (AKA esophageal laceration or gastroesophageal mucosal tear) vs. esophageal perforation (AKA Booerhaeve’s or esophageal rupture)
-Mallory Weiss:
-partial thickness at the gastroesophageal junction
-BLEEDING!!!!!
-vomiting with blood in it
-pain is mild
-normal PE
-EGD
-Esophageal rupture:
-NO BLEEDING
-transmural rupture due to increased intrathoracic pressure
-sever retrosternal or epigastric pain
-CT, x-ray
-emergent surgery, IV antibiotics
esophageal varices
-RF: 50% have cirrhosis
-Tx in brisk bleed:
-OCTREOTIDE
-PPI
-Broad spectrum antibiotics
-unstable -> !Balloon tamponade!- Sengstaken-Blakemore -> do ET tube first
-stable- Endoscopic variceal ligation
-TIPS procedure
Mesenteric ischemia
-Embolism- sudden diffuse abdominal pain, N/V, +/- GI bleeding or (bloody) diarrhea
-Chronic- postprandial pain
-Venous thrombosis- gradual onset
-pain out of proportion to exam!!
-non-specific sx -> difficult to dx
-soft abdomen although extreme pain
-MC- SMA
-RF: afib, endocarditis (murmur), hypotensive, dehydration, shock, hemorrhage, CHF, vasopressor use, hypercoaguable states, PVD
-Labs:
-WBC (25+)
-Blood gas- high lactate, lactic acidosis
-Def dx: CT angiography
-cutoff sign in vessel or filling defects
-ascites, wall thickening, edema -> gas (pneumatosis portalis), pneumoperitoneum after perf, intramural gas (intestinal pneumatosis)
peritonitis
-MCC- spontaneous bacterial peritonitis (SBP)
-RF- cirrhosis with ASCITES, portal HTN, perforation (surgery, PUD), dialysis, hepatic encephalopathy
-S&S:
-severe, diffuse pain
-distention
-rebound tenderness
-involuntary guarding
-rigidity
-absent or hypoactive bowel sounds
-fever, chills, tachy, tachypnea, hypotension, shock
-N/V
-ileus
SBO
-crampy, colicky, N/V
-distention, tympanic
-obstipation
-early diarrhea -> late constipation
-peritoneal signs if perf
-dehydration -> hypotensive, tachy
-RF- past surgery, IBD, obesity, radiation, opioids, anticholinergics, FB
-Causes: ADHESIONS,HERNIA (esp testicular), neoplasm, strictures, intussusception, IBD
-Imaging:
-CXR- air under diaphragm
-Abdominal XR- air fluid levels, string of pearls, plicae circulares/valvular coniventes
-Supine XR- distended loops of bowel >3cm, no gas in rectum
-!CTAP- find transition point, pneumatosis intestinalis +/-
LBO volvulus imaging
-1. SIGMOID (MC): Abdominal XR- coffee bean sign
-2. CECAL
-CT- best test -> whirl sign
-3. MIDGUT (infants)- Upper GI series is gold standard in stable, barium enema (bird beak), US,
MCC LBO:
- CRC
- volvulus
- diverticulitis
hernias
-OBTRUCTED:
-can be manually reduced at bedside
-pain meds to relax surrounding musculature
-ice packs to reduce swelling
-URGENT
-SBO sx
-If suspicion of strangulation -> DONT attempt reduction
-STRANGULATED:
-non-reducable-> compromised blood supply and necrosis
-tender, red, warm, fever, sepsis
-reducing -> reintroduces ischemic/necrotic bowel -> perf and sepsis
-contact surgery ASAP - EMERGENCY
-begin broad spectrum antibiotics
-pre op labs, control pain, and resuscitate if needed
Swallowed foreign body
-Conservatively:
-meat <12hrs
-removal w/o complication
-blunt, short, narrow
-non-toxic
-EGD within 24hrs
-Emergently:
-respiratory sx, drooling
-complete obstruction
-button battery
-persistent/severe sx
-multiple magnets, or single with metallic object
->24hrs w/o passing pylorus
-sharp -> that can perf
-large (>2.5cm width or >6cm length)
-multiple objects
-coin @ criopharyngeous
-past LES (stomach)- observe
-past the pylorus -> let them pass it bc it will require surgery if it perfs anyways
spontaneous bacterial peritonitis
-chronic liver disease or cirrhotic pts
-portal HTN -> bowel edema -> transmigration of enteric bacteria
-consider in any pt with ascites AND hepatic encephalopathy, abd pain, fever, leukocytosis, renal failure
-DX- PARACENTESIS -> neutrophils >250
-+grain stain
Tx = cefotaxime
FAST exam
-looking for intraperitoneal fluid
-4 places:
-epigastric- subxiphoid
-RUQ
-LUQ
-suprapubic
