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NU734 Acute Care I > Nu 735 GI Elderly Abdominal Pain > Flashcards

Nu 735 GI Elderly Abdominal Pain Flashcards

1
Q

Complicated Abd pain elderly ?

A

Abdominal pain elderly comples:
* Mortality rate 10%
* Geriatic > 9 fold young
* Longer ER 20%
* Consume more time, resources compare to others
* 33% urgen surgical interventions

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2
Q

Presentation elderly abd pain

A
  • **Present letter **: creats problem
  • Vascular Emergency AlWAYs 2nd DX
  • **Polypharmacy: mask symptoms , alter VSS, constion, steroids

Vascular ER always 2nd DX

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3
Q

Elderly : Physical Assissment

A
  • PHA : can be benigh at 1st
  • VSS less reliable : Normothermi or Hypothermic
  • Examine for scars, bruit, bruising

*** Riginity & Muschle tone : **
* due to less abd muschle mass ;
* Absent up to 80% perforated ulcers

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4
Q

Consider ETIOLOGY

A
  • left Lower Lobe PNA
  • CHF w hepatic congestion
  • Acute MI : female pt abdominal pain
  • Afib : RISK Messenteric Ischemia
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5
Q

Ruptured AAA :
**Clinical Findings **

A
  • Leading cause of death :
  • Mortality rate 70%
    * Misdiagnosed as Renal Colic b/c overlap symtoms:
  • ** sym: pain radiating go groin, microscopic Hematuria**
  • **New onset Kidney STONES after age 50: CT AORTA before D/C **

New onset Kidney STONES after age 50: CT AORTA before D/C

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6
Q

AAA
Majority of Rupture SPace

A
  • Intraperitoneally OR
  • Left Retroperioneal Space
    *
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7
Q

AAA Rupture
**Clinical Findings **

A
  • Abdominal Pain
  • Hypotension
  • Pulsatitile Abdominal MASS
  • Ecchymosis of TOES: due to EMBOLI from Thrombus

**Rupture: **
**Abdominal pain ; flank pain , Groin Ecchymosis **

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8
Q

Ruptured AAA
< TX Plan >

A

Depends on Stability
Consult Vascular Surgery
* Unstable Pt: OR
*
*** STable or Suspacted

**CT w Contrast
Avoid Aggressive Volume Repletion
Consider Needs For TRansfusion

  • *Surgical Needs: OPEN vs Endovascular repair up to surgen
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9
Q

Acute Mesenteric Ischemia
What is Mesenteric ? +Anatomy

A
  • It Attaches the Intestinve to abdominal wall and Hold it in place
  • Aids in Storing FAT
  • Supply Blood Vessels, Lymphatics and Nerves to Intenes
    * Blood Flow to Abdominal Organs via Splanchinic Perfusion (aka circulation )

**Types: Superior and Inverior **

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10
Q

Superior Messenteric Artery Blood Supply via blood bransches

A
  • Pancreas
  • Portion of Stomach
  • Small INtestines (Duodenum, Jejunum, Ilium
    * Portion Large Bowel: Cecum, Ascending Colon , Proximal 2/3 of TRansverse Colon
  • Cecum: begining of Large intestine; connect illium to small intestine
  • Ascending “ TRavels upward on RT side of abd
  • Transverse: Crosses abdomen horizontally from rt to to left
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11
Q

Inferior Mesenteric Artery (IMA )

A

Comes off below abdominal Aorta and supply to
* Transvese other 3rd
* Descending (Down on the Left )
* Sigmoid : S shape connect Descending colon to Rectum
* Rectum

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12
Q

Superior Mesenteric Artery
SMA Embolus

A
  • **Most common type **
  • AFib : most common Ediology
  • Any STATIS of Left Ventrical can lead to this
  • MisDX as GAstroenteritis
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13
Q

SMA Embolus S/S

A
  • **Acute Abdominal Pain
  • Gut Emptying: V/D
  • MisDX as Gasroenteritis **
  • **Hx of Embolitic Event (collect hx) **
  • OLD pt W > Afib > Diarrhea > Abdominal Pain - DO NOT DX them W GAstroenteritis
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14
Q

SMA/**Arterial THROMBOSIS **
Not Venous

A
  • Similar Pathology to ACS
  • Turbulent Flow at SMA Plaque Deposit
  • R/F: Hx Smoking & Atherosclerosis
    1. Limited Blood Flow : due to stenosis > Intestinal Angina > Posrprandial Angina
      80% previous Ishemia

**Postrandial Abdominal Pain : Food fear and wt loss last month or year

  1. Rupture Plaguq:** Abrump blood flow reductio
    s/s similar SMA embolus

Thrombus > Limited Blood Flow b/c Stenosis > Intestinal Angina as post P

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15
Q

Acute Mesenteric Ishemia
Messentieric Venour Thrombosis(MVT)

A

Not common
Occur younger cohor
HX: Hypercoagulatlable STATE
50% personal of family HX of venous Thromboembolism

Indolent Symptoms:
Symptoms onset days to weeks
Difficult to DX

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16
Q

Nonocclusive Mesenteric Ishcemia

A

* Low Flow Etiology >
* Sepsis
* Volume Depletion
* Cardiogenic shock
*** Transient Hypoperfusion **
Diallysis
Digoxin use

ICU pt:Abdominal distention pain + GI bleeding

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17
Q

Acute Mesenteric Ishemia
Work UP

A

Emolitic +Thombus > Out of Proportion Pain
* **Clinical eval & Vascular Imaging **
* Determine Vascular intervantion
* Occlusio Emolic and Thrombolic
* Labs:
* CBC (leukocytosis ) ; BMP, LA, Amylase (elevated )
*
* **Plain Imaging : ** Abdominal XRAY
* Early features show : Thumpring “ : Bowerl edema
* Ischemia Progerssion : Pneumatosis Intestinalis (Air Within a WAll
* Free Intraperitonea Air: Perforated Viscus (ER Exploration)
* **Messenteric Duplex Imaging (GET IT DONe ) **
* 80% possitive Predictive value of Mesenteric Ischemia
* R/O with negative duplex Messenteric Ischemia
* Body Habitus limits imaging . obese pt
*

18
Q

Thumping on XRAy

A

Early features show . Bowel edema

19
Q

Pneumatosis Intestinalis

A
  • Ischemia Progerssion; Air Within a Wall
20
Q

Perforated Viscus

A

Free Intraperitonea Air: ER Exploration

21
Q

Acute Mesenteric Ischemia
Tx

A

***** ICU Admission
VS, Abdominal EXap, UO, ABG, Lactate

Medical Attention” **
NPO , NGT
IV Fluids (Isotonic Crystalloid IV Solution )
Avod if can Vasopressins
Anticoagulation : Antithrombotic therapy can be given with Antiplatelets
Empiric ABD : Gm negative Anarobs +MRSA
PPI**
O2
I/O
NOMI no caogulation

22
Q

Acute Mesenteric Ishcemia
Surgical TX plan

A
  • Messeteric ANgiography
  • Gold Standard
  • Reduce Mortality
  • **Goal of Vascular Intevention **
  • Reset comppromised Bowel
  • Restore INtertinal Blood Flow
  • **TX Plan
  • **Depends on Clinical Status
  • Etiology and location of occlusio
  • Open vs Endovascular vs Combined approach determine by vascular surgen **
23
Q

Acute Mesenteric Ishcemia
Surgical TX plan
Arterial Embolus

A
  • ARterial Embolus
    * Done by small inscion in Artery where clot is restrive
  • Laparotomy With Assessment of Viability
  • Resection of dead Bowel
  • Vascular Bypass
  • Embolectomy
24
Q

Surgery
Arterial Thrombosis

A
  • Endarterectomy
  • Thrombectomy
  • Vascular Bypass
  • Thrombolysis
  • Angioplasty and Stending usually W Chronic Eschemia most of time
25
Q
A
26
Q

Mesenteric Venous Thrombosis

A

Catheter directed Thrombolysis

27
Q

Nonocclusive Mesenteric Ishemia

A

Laparotomy

28
Q

Acute Interstinal Obstruction
Extentinal Obstruction

A
  • 80 % Small Bowel
  • 1/3 Significant Ichemia
  • Partial vs High Grade vs Complete
  • Simple vs Stranguated
  • Mechanical (blockege ) vs Functional ( not blockege)
29
Q

Bowel Obstructin
Extrisic Disease Mechanical obstruction

A
  • **Most common cause to Small Intestine Obstruction **
  • Post operative adhesions
  • Herniation of Anterior Abdominal wall
  • Carcinomatosis (segmoid colon)
30
Q

Mechanical Obstruction
Intrisic Diseases

A
  • **Congenital
  • Inflammatory
  • Neoplasic
  • Traumatic
  • Vovulus (when b**owel twist on its mesenteric axis causing partial or complete obstruction and vascular infufficiecy
    Sigmoid colon affected
    Risk factors Psychotropic meds, Chronic constipation and advanced age
31
Q

Common Insults to Colon

A
  • 2/3 Cases are cancer of :
    Descending (L) and Rectum
  • Diverticulitis and Volvulus: Rare for adhesions or hernias to obstraction
32
Q

*Emesis and Dehydration **
*Emesis and Dehydration **

A

Intravascular volume Depletion
Loss of gastric Potassium, hydrogen and cL

33
Q

Bowel wall Hypoxemia

A

**Edema proximal to side of blockage may become Hypoximic
If not fixed may lead to Epithelial necrosis can idenfity withing 12 hrs obstruction

34
Q

Compromised arterial Blood supply

A

Flll thickness ischemia, necrosis, and perforation will lead to …

35
Q

Bowel Statis increased bacterial growth

A

E coli,
Streptococcus faecalis
Klemsiella

36
Q

**Closed loop obstruction resolved when proximal and distal opening given bowel segment are both occluded > pre course to **

A
  • Strangulation
  • Vascular insufficiency
  • Systemic inflammation
  • Hemodynamic compromise
  • Irreversible intestinal ischemia
    *
37
Q

obstruction clinical Findings

A

Cardinal Signs
Colicky abdominal pain, abdominal distention, emesis & obstipation

*** Classic bowel sounds: **
* Early SBO high pitched AKA borborygmi
* Absent or hypoactive later in course

**Partial obstruction **
Pass flatus & stool

Complete blockage
Evacuate bowel contents downstream

Severe pain & Peritoneal irritation
* Strangulation
Closed loop obstruction * **

Fever: Strangulation or systemic inflammation

38
Q

obstruction
Work up and DX

A

CBC, CMP & lactic acid
* High WBC association
* Severe volume depletion or ischemic necrosis
* * * * Hypokalemia, Hypochloremia, elevated
* * BUN/creatinine ratio, Metabolic alkalolosis
* Hyponatremia
Obtain occult stool & Fe+ studies
* Abnormal suggest malignancy **
Imaging
* Abdominal x-ray
* **CT scan PO/IV contrast: Identify ischemia
*
CT post water soluble contrast enema
* Ileus vs pseudo-obstruction
*
Contrast enemas or colonoscopies
Identify causes of acute colonic obstruction

39
Q

large vs small Bowel obs

A
  • Large Bowel obstruction less comment then small bowel obstruction ( small bowel obstruction account only 20% of all obstruction )
  • Large BO : etiology Age depandant
  • In adulthood most common reason is 1st : Colon CA tipicaly Sigmoid
    2nd one is Acute Diverticulitis involving Sigmoid colon

Together obstructive Tumor and Acute Diverticulitis account for 90% of all causes Large BO

40
Q

bowel obstructio Tx plan

A

Fluid resuscitation & electrolyte repletion

Intestinal decompression
Nasogastric to suction

Antibiotics
**Controversial.
Prophylactic administration for surgery

**Monitor urinary output assess May be Foley
Ileus **
Peripheral active opioid receptor antagonist (i.e. Alvimopan)
Accelerates GI recovery

Colonic pseudo obstructions
* Acetylcholinesterase inhibitor (i.e. Neostigmine) stimulate motility
* Cardiac monitoring must

Sigmoid volvulus
Decompressed with flexible sigmoidoscope
Allows for definitive elective correction

Cecum Volvulus
Laparotomy or laparoscopic correction

41
Q
A

NU734 Acute Care I (25 decks)

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