Non-OB Abdominal Pain

Question 1

How may appendicitis present in pregnancy?

Answer 1

RUQ pain may be higher d/t displaced GI system

Question 2

What is the effect of progesterone?

Answer 2

smooth muscle relaxation –> decreased LES tone and peristalsis and increased intestinal transit time

appetite stimulant

Question 3

What contributes to N/V?

Answer 3

• hCG
• estrogen
• elevated T4
• altered motility
• reflux
• emotions/psych

Question 4

How do sodium and albumin levels change?

Answer 4

mildly decreased serum levels

Question 5

How does hematocrit change?

Answer 5

moderately decreased blood levels –> physiologic anemia

Question 6

How do serum bile acids, cholesterol, and triglyceride levels change?

Answer 6

mildly increased serum levels

Question 7

ruptured ectopic

location, character, radiation, dx

Answer 7

location: lower abdomen, pelvis
character: localized, severe
radiation: none
dx: serum hCG, abdominal U/S

Question 8

PID

location, character, radiation, dx

Answer 8

location: lower abdomen, pelvis
character: gradual onset, localized
radiation: flanks and thighs
dx: abd U/S

Question 9

appendicitis

location, character, radiation, dx

Answer 9

location: periumbilical –> RLQ (RUQ in late pregnancy)
character: gradual onset –> focal
radiation: back, flank
dx: abd U/S, elevated WBCs

Question 10

acute cholecystitis

location, character, radiation, dx

Answer 10

location: RUQ
character: focal
radiation: right scapula, shoulder, or back; middle of back
dx: abd U/S = thickened gallbladder wall, serum LFTs

Question 11

pancreatitis

location, character, radiation, dx

Answer 11

location: epigastric
character: localized; deep, piercing, midline
radiation: middle of back
dx: (2 out of 3) clinical presentation, abd U/S = pancreatomegaly (CT better), serum lipase and amylase

Question 12

perforated peptic ulcer

location, character, radiation, dx

Answer 12

location: epigastric or RUQ
character: burning, deep, piercing
radiation: right back
dx: abd U/S, laparotomy, H. pylori?

Question 13

urolithiasis

location, character, radiation, dx

Answer 13

location: abdomen or flanks
character: intermittent, aching to severe, unremitting
radiation: groin
dx: abd U/S, urinalysis,, occasional fluoroscopy w/ contrast urography

Question 14

What are abd pain red flags?

Answer 14

1) N/V after 20wks
2) hematemesis
3) blood in diarrhea, stool
4) jaundice

Question 15

What labs should be ordered for abd pain?

Answer 15

1) CBC w/ diff
2) LFTs (alk phos normally elevated; ALT & AST same)
3) Cr > 1.1 = concerning
4) BMP (Na 129-143 = normal - low = concerning!)
5) amylase & lipase (lipase = better)
6) UA

Question 16

What is the preferred dx test in pregnancy for abd pain?

Answer 16

abd U/S

Question 17

What effect does pregnancy have on cholelithiasis?

Answer 17

• increased cholesterol synthesis

- gallbladder hypomotility

Question 18

What is the most common cause of jaundice during pregnancy?

Answer 18

acute viral hepatitis

Question 19

What are 2nd and 3rd trimester differentials for jaundice?

Answer 19

2nd: drug hepatotoxicity and gallstone disease (e.g. acute cholecystitis, gallstone pancreatitis)
3rd: intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy, HELLP syndrome

Question 20

What are differentials of RUQ abdominal pain?

Answer 20

pain characteristics important

pain + abnormal LFTs + new onset HTN = preeclampsia w/ hepatic involvement

Question 21

What are differentials of RLQ pain?

Answer 21

GI d/o: appendicitis, Crohn’s, intussusception, colon cancer, IBS

OB/GYN: ruptured ectopic, ovarian tumor/cyst rupture/torsion, endometriosis, uterine leiomyomas

renal: nephrolithiasis, cystitis

Question 22

What are differentials of N/V?

Answer 22

hyperemesis gravidarum

pancreatitis

cholelithiasis

peptic ulcer disease

acute fatty liver of pregnancy

HELLP

Question 23

Describe presentation of cholestasis

Answer 23

• pruritus in third trimester
• no hx chronic liver disease
• absence of abdominal pain
• affects hands and feet
• mild to mod elevated serum transaminase and bili levels

Question 24

What is the most common non-obstetric surgical emergency in pregnancy?

Answer 24

appendicitis

Question 25

Why is biliary disease more common in pregnancy?

Answer 25

elevated estrogen --> gallstones, thicker bile sludge progesterone --> muscle relaxation

Question 26

What are s/sx of biliary disease?

Answer 26

- RUQ or epigastric pain POSTPRANDIAL - referred back pain - N/V - fever - Murphy's sign

Question 27

What will labs for biliary disease show?

Answer 27

- elevated WBCs | - elevated alk phos, bili

Question 28

What is tx for biliary disease?

Answer 28

conservative management w/ removal PP *recurrent biliary colic/acute cholecystitis --> cholecystectomy

Question 29

When is the best time to perform cholecystectomy?

Answer 29

2nd trimester 1st tri --> fetal loss 3rd --> PTL

Question 30

What is the relationship b/w pregnancy and gallstones (cholesterol stones)?

Answer 30

increased cholesterol secretion into bile --> increased risk of cholesterol stones

Question 31

What are other s/sx of pancreatitis?

Answer 31

``` N/V pyrexia (fever) mid-abdominal tenderness abdominal guarding hypotympany ```

Question 32

How is pancreatitis treated?

Answer 32

acute = mild --> IV fluids, gastric acid suppression, analgesia, NG suction, d/c PO intake surgical = laparascopic cholecystectomy in 2nd tri

Question 33

What are other s/sx of peptic ulcer?

Answer 33

- N/V - anorexia - early satiety * duodenal = eating does not improve pain * gastric = eating improves pain

Question 34

What is the fear w/ antacid use?

Answer 34

CAUTION fluid overload metabolic alkalosis

Question 35

What is tx for peptic ulcer?

Answer 35

PPIs for moderate disease H2 receptors avoid caffeine, alcohol, smoking, NSAIDs

Question 36

Celiac disease

Answer 36

chronic inflammation of small intestine, malabsorption issues

Question 37

Celiac disease s/sx

Answer 37

nausea, diarrhea, pale stools | *dermatitis herptiformis = rash on joints

Question 38

ulcerative colitis s/sx

Answer 38

bloody diarrhea crampy abdominal pain pyrexia

Question 39

Crohn's disease s/sx

Answer 39

``` diarrhea abdominal pain anorexia pyrexia malnutrition ```

Question 40

What part of the GI tract is usually involved in Crohn's?

Answer 40

terminal ileum or colon

Question 41

What are the most common causes of hematemesis?

Answer 41

1) GERD 2) gastritis 3) Mallory-Weiss tears 2/2 vomiting 4) ulcers

Question 42

What is the most common cause of rectal bleeding?

Answer 42

hemorrhoids but also: Crohn's, colitis, rectal fissures