powerpoints CA Flashcards
More adult patients visit the ED for _________ than for any other CC
“stomach and abdominal pain, cramps, or spasms”
influence both incidence and clinical expression of abdominal disease
Demographics (age, gender, ethnicity, family history, sexual orientation, cultural practices, geography)
__________ is often required to make a specific diagnosis
imaging
Best way to practice a GI exam
Thorough approach
Logical approach
LOCATION of the pain drives the evaluation
Begin the evaluation by ruling out serious disease and/or surgical conditions
what drives the evaluation
LOCATION
STEPS of Triage and Transfer
Step 1: Is the patient critically ill?
Check ABCs, resuscitate if needed
Step 2: Acute abdominal pain may need transfer to acute care facility if…
- -> Suspected surgical abdomen
- -> Requiring resuscitation or IV analgesia
Step 3: Less acute illness, often detailed history and initial assessment
what is life threatening in the album?
- -> ruptured appendix
- -> malignancy: not usually acute though
- ->AAA: will radiate to back
- -> mesenteric ischemia: block blood flow to abdomen
- -> hypo profusion: acute blood loss… abdomen gets left out from blood flow
what is a sterile spot
stuff in the abdomen…
Cognitive impairment secondary to dementia Intoxication Psychosis Intellectual disability Autism Patients w/ aphasia or language barriers Older adults (physical or laboratory findings may be minimal) Spinal cord injury patients Asplenic patients Neutropenic patients Transplant patients Immunosuppressed patients (eg, HIV) Immune-suppressive or immune-modulating medications (eg, steroids, chemotherapy agents)
HIGH risk groups
this is an LO:
8. Identify and recognize high-risk patients in which critical illness may be “camouflaged” by their medical/physical/mental condition
Critical illness in high risk pt may be
camouflaged
Requires understanding of possible mechanisms responsible for pain
Broad differential of common causes (abdominal and extra-abdominal causes)
Recognition of typical patterns and clinical presentations
Consider unusual causes, especially in older adults and immunocompromised patients
Differential Diagnosis
Pain receptors in the abdomen respond to (2)
- Mechanical stimuli (eg, stretch, distention, contraction, traction, compression, torsion)
- Chemical stimuli due to inflammation or ischemia
TRUE or FALSE: multiple stimuli may be occurring at once
TRUE
what about not understood pain?
Perception of pain not completely understood:
Psychologic factors likely important factor
3 types of pain
visceral
parietal
referred
dull, aching, can be colicky, poorly localized; arises from distension of hollow organ (eg, bowel obstruction)
when pushing deep
visceral
sharp, very well localized; arises from peritoneal irritation (eg, appendicitis)
inflammation of peritoneum
parietal
aching, perceived to be near surface of body (eg, cholecystitis referred to right scapula)
referred
aka gallbladder and scapula
ADD PICTURE FROM SLIDE 10!
…..
What is included in the Pain Hx.?
Location, Location, Location!
Key to formulating DDx list!
Where does the patient POINT to?
Do they point with one finger or use their whole hand (specific vs vague)
what are the locations pain can be (8)
RUQ LUQ RLQ LLQ Epigastric Periumbilical Suprapubic Diffuse
add picture from slide 14
….
what organs are in the RIGHT UPPER QUADRANT
Liver, gallbladder Pylorus, duodenum Head of pancreas Ascending/transverse colon Right kidney/adrenal
what organs are in the LEFT UPPER QUADRANT
Liver (left lobe) Spleen Stomach Body of pancreas Descending/transverse colon Left kidney/adrenal
what organs are in the RIGHT LOWER QUADRANT
Right kidney and ureter Cecum/appendix/ascending colon Ovary, fallopian tube Spermatic cord Uterus/bladder (if enlarged)
what organs are in the LEFT LOWER QUADRANT
Left kidney and ureter Sigmoid/descending colon Ovary/fallopian tube Spermatic cord Uterus/bladder (if enlarged)
ADD PICTURE FROM SLIDE 17
….
RIGHT UPPER QUADRANT: biliary: Colonic: hepatic: Pulmonary: Renal:
Biliary: Cholecystitis, Cholelithiasis, Cholangitis
Colonic: Colitis, Diverticulitis
Hepatic: Abscess, Hepatitis, Mass
Pulmonary: Pneumonia
Renal: Nephrolithiasis, Pyelonephritis
Left Upper Quadrant
cardiac gastric spleen pancreatic renal
Cardiac: Angina, Myocardial Infarction, Pericarditis
Gastric: Gastritis, Peptic Ulcer Disease
Spleen: Abscess, Infarct, Splenic Rupture
Pancreatic: Mass, Pancreatitis
Renal: Nephrolithiasis, Pyelonephritis
***stars mean emergency :)
Right Lower Quadrant
colonic
gynecologic
GU
Renal
Colonic: Appendicitis, Inflammatory Bowel Disease
Gynecologic: Ectopic Pregnancy, Fibroids, Ovarian Mass, Torsion, Pelvic Inflammatory Disease
GU: Inguinal Hernia
Renal: Nephrolithiasis
***stars mean emergency :)
Left Lower Quadrant
colonic
gynecologic
GU
Renal
Colonic: Diverticulitis, Inflammatory Bowel Disease, Irritable Bowel Syndrome
Gynecologic: Ectopic Pregnancy, Fibroids, Ovarian Mass, Torsion, Pelvic Inflammatory Disease
GU: Inguinal Hernia
Renal: Nephrolithiasis
Epigastric Pain
cardiac
gastric
pancreatic
vascular
Cardiac: *Myocardial Infarction, Pericarditis
Gastric: GERD, Gastritis, Peptic Ulcer Disease, Incarcerated Hiatal Hernia
Pancreatic: Mass, Pancreatitis
Vascular: Ruptured Aortic Aneurysm*
abrupt change in vital sign
means not stable
really low blood pressure
could be bleeding out
really high HR
warning sign for blood loss … could be dehyrdated too (hypovolemia)… could be trying to compensate
FEVER
warning sign for acute issues going on
Periumbilical
colonic
vascular
Colonic: Early Appendicitis, Gastroenteritis, Bowel Obstruction
Vascular: Ruptured Aortic Aneurysm
Suprapubic
colonic
gynecologic
urinary tract
Colonic: Appendicitis, Colitis, Diverticulitis, Irritable Bowel Syndrome
Gynecologic: **Ectopic Pregnancy*, Fibroids, Ovarian Mass, Torsion, Pelvic Inflammatory Disease
Urinary Tract: Cystitis, Nephrolithiasis, Pyelonephritis, Bladder Outlet Obstruction
Diffuse
colonic
metabolic
Heme
infectious
Colonic: Gastroenteritis, Mesenteric Ischemia, Bowel Obstruction, Peritonitis*, Irritable Bowel Syndrome
Metabolic: Diabetic Ketoacidosis
Heme: Sickle Cell Crisis, Heavy Metal Intoxication
Infectious: Malaria
***stars mean emergency :)
alright guys here are a bunch of cards of a summary of all the Key patterns of pain!
RUQ
cholecystitis, hepatitis
key patterns of pain RLQ
appendicitis (starts periumbilically)
Key patterns of pain LLQ
diverticulitis (can be midline)
Key patterns of pain in epigastric area
esophagitis, PUD
pain radiating to back
pancreatitis
pain radiating to R shoulder
cholecystitis
pain radiating to groin
renal colic
six important thing to remember with pain HIstory
- onset/ frequency/ duration
- quality
- severity (can be subjective)
- aggrevating factors
- relieving factors
- associated symptoms
Steady, rapid increase in pain: pancreatitis
Several days of pain prior to presentation: diverticulitis
Sudden, abrupt onset, severe: rupture of viscus (eg, appendix, aorta)
explaining Onset/frequency/duration of pain
Burning, gnawing: GERD or PUD
Colicky: gastroenteritis, bowel obstruction, nephrolithiasis
explaining
Quality of pain
High intensity: biliary or renal colic, mesenteric infarction
Lower intensity: gastroenteritis
explaining severity of pain
Pain 1 hour after eating: mesenteric ischemia (aka “intestinal angina”)
Pain w/ empty stomach: PUD
Pain w/ any movement: peritonitis
Pain worse after eating lactose: lactose intolerance
Pain worse after eating gluten: celiac disease
Pain worse after eating fatty food: cholecystitis
explaining some aggravating factors of pain
- Pain relieved w/ eating:
- Pain resolved w/ sitting up and leaning forward:
- Pain relieved when lying on back motionless:
PUD
- pancreatitis
- peritonitis
Weight loss: malignancy
N/V: bowel obstruction, biliary duct blockage
Change in bowel habits: colon cancer, IBS
“Cough pain”: peritonitis
example: F/C/N/V/D/C
examples of associated symptoms with pain history
PMH – risk factors for CVD (eg, atrial fibrillation – clot to spleen or mesentary), clotting d/o
Past surgical history – abdominal surgeries
FH – bowel disease
Social history – alcohol intake (ascites, pancreatitis)
Medications – NSAIDS, antibiotics
Menstrual + contraceptive hx in women
Pregnancy risk? STIs?
Patients History
_______ should be excluded in ALL women of childbearing age with abdominal pain!
pregnancy
picture from slide 31
…
Vital signs General appearance Skin (color, turgor) Heart/Lungs Abdomen (including DRE) Pelvic (speculum/bimanual exam) GU (CVA tenderness) MSK (abdominal wall)
Physical exam should focus on this
Ok to manage in the ED setting with opiated (does not cause management errors)
PAIN
what three vitals are really important to remember to get!
- Temperature – fever (infection)?
- Heart rate – tachycardiac?
- Orthostatic blood pressure – hypotension, hypovolemic (d/t GI blood loss or dehydration)?
can cause large amounts of 3rd spacing of fluid and intravascular volume depletion or overt shock
Bowel obstruction, peritonitis & bowel infarction
what does NOT rule out infection
Absence of fever in elderly or immunosuppressed does NOT r/o infection
what are some things to notice with patients general appearance
this stuff is common sense.. just read through it
Does the patient look sick?
Level of comfort/discomfort should be noted
What position (eg, sitting, lying) does the patient find most comfortable?
- -> Strict immobility:
- -> Writhing in agony
what could strict immobility make you think of
peritonitis
what would writhing in agony make you think of
biliary or renal colic
pts with IBS have
what kinda pain?
caused by?
does not have?
Suprapubic
lots of conctepation or lots of diarrhea and causes a ton of discomfort
there is no underlying pathology just bowel moving to slow or fast.
Eyes – scleral icterus
Skin – jaundice (eg, hepatitis, cholangitis), rash (eg, herpes zoster), turgor or pallor
Heart – murmurs, rubs
Lungs – signs of consolidation
just look for these things….
Signs of distention (ascites, ileus, obstruction, volvulus)
Obvious masses (hernia, tumor, aneurysm, distended bladder)
Surgical scars (adhesions), ecchymoses (trauma, bleeding diathesis)
Signs of liver disease (spider angiomata, caput medusa)
Inspection
signs of distention in ?
(ascites, ileus, obstruction, volvulus)
signs of obvious masses in?
(hernia, tumor, aneurysm, distended bladder)
surgical scares from
adhesions
ecchymoses from
trauma, bleeding diathesis
signs of liver disease
spider angiomata, caput medusa
SUDDEN AND ABRUPT PAIN… are you worried
HELL YES I AM! SOMETHING BAD IS GOING ON!!!
Normal bowel sounds occur every? and sounds like what two words
every 5-10 seconds
clicks and gurgles
how long do you need to listen for to be able to declare NO BOWEL SOUNDS
2 MINUTES
what is it if you here hyperactive, high pitches bowel sounds
small bowel obstruction
what could it be if it is decreased bowel sounds?
peritonitis, ileus, mesenteric infarction, narcotic use
what could it be if we hear friction rubs
splenic infarction or hepatitic metastasis
what has SEVERE PAIN
mesenteric ischemia
where to listen for bruits
ADD PICTURE FROM SLIDE 39 aorta renalt artery iliac artery femoral artery
what do we hear tympany in?
ascites (“shifting dullness” test), peritonitis, distended bowel
when would you hear dullness?
mass
what are some types of organomegaly?
liver span, splenic enlargement, bladder distention
what could it be if you have CVA tenderness
nephrolithiasis, pyelonephritis
ADD PERCUSSION PICTURE FROM SLIDE 41
….
What is USUALLY PALPABLE?
Sigmoid colon
cecum and ascending colon
normal liver distends
pulsations of the abdominal aorta are frequently visible and usually palpable
what does the sigmoid colon feel like
and what quadrant is it in
firm, narrow tube
in LLQ
what does the cecum and ascending colon feel like
and what quadrant is it in
softer, wider tube in RLQ
black tarry stool
usually issue in the upper GI… takes longer for it to come out
bright red blood
lower GI issue
what does the liver below the costal margin feel like
soft and consistency is difficult to feel
what is usually not palpable
Stomach Spleen Gallbladder Duodenum Pancreas Kidneys
how do you perform palpations
what type of pressure
where do you start
Perform gently (light then deep), distract patient
Start in least painful quadrant
what has rebound tenderness
appendicitis, peritonitis
what has a pulsatile mass
AAA
Rigidity or involuntary “guarding”
with peritoneal inflammation and diffuse
peritonitis
Rigidity or involuntary “guarding”
with inflammatory mass if focal
diverticular abscess
Rigidity or involuntary “guarding”
may be absent with deeper sources ….what 2 things could this?
renal colic or pancreatitis
Liver palpation
SPLEEN PALPATION: on left side
KIDNEY PALPATION: sweep kidneys closer to you!
2 techniques
ADD TO THIS
SLIDE 45
SPECIAL TESTS OF ABDOMEN FOR APPENDICITIS
McBurney’s Point
Rovsing’s Sign
Psoas Sign
Obturator Sign
SPECIAL TESTS OF ABDOMEN FOR GALLBLADDER DISEASE
Murphy’s Sign
For Ascites:
Shifting Dullness
Fluid Wave
McBurney’s Point
for appendicitis : RLQ
it is 2 inches
ASIS to the ____
if you push downward this hurts
ADD PICTURE SLIDE 48
ROVSING’S SIGN
rebound tenderness
push in LLQ
quick release
they will have rebound tenderness as hand is removed in the RLQ!!!!! for appendicitis
ADD PICTURE SLIDE 49
PSOAS SIGN
lift up leg and we push down the leg…
psoas muscle is near appendix so this will hurt them!
ADD PICTURE SLIDE 50
OBTRUATOR SIGN
internal obtruator sign is near appendix
so pt brings knee to 90 degree and internally rotate the hip by rotating lower leg outward this internally rotates the hip and flexes obturator muscle causing RLQ pain when we do this!
ADD PICTURE SLIDE 51
MURPHYS SIGN
for cholecystitis: inflammation of gallbladder
with hands try to get under rib cage on right side and slide hands under… this hurts in the RUQ.
ADD PIC SLIDE 52
ASCITES
fluid accumulation in the abdomen
fluid is heavy so when patient lays down you will see flexing of the flanks or sides
ADD PICTURE SLIDE
SHIFTING DULLNESS
for ascites if you are not sure if they are just fat
have them lay on their side
and they should be tympanic on the side up toward the ceiling and then a dull sound on the side that is on the table because the fluid shifts when they lay on their side if it is ascites
ADD PICTURE SLIDE 54
FLUID WAVE
not the best test
another test for ascites
need two people to do this
1 person: firmly press in the middle of the abdomen so that you don’t have fluid move from one side to the other!
so other person pushes on one side and if the person pushing down in the middle feels a wave then they have ascites
ADD PICTURE SLIDE 55
consider this for all patients
Assess for tenderness, bleeding or masses
Fecal impaction in older adults
Check stool for occult blood (FOBT)… stool color?
DRE
consider for all women w/ acute lower abdominal pain
PID, adnexal mass or cyst, uterine pathology, ectopic pregnancy
Pelvic exam
what exam am i explaining
flank pain, CVA tenderness
In males, hernia, testicular, and prostate exam are indicated b/c disorders of these structures can cause lower abdominal pain
GU
What exam would you find this?
abdominal wall muscles (eg, worse w/ sitting up)
MSK
opioids use can cause
constipation and abdominal pain
NSAIDS CAN LEAD TO
ULCERS
steroids and ABX can lead to
CDiff
what are some challenges with Older Adults w/ Acute Abdominal Pain
Symptoms may be mild, vague, underreported
Presentations may be late and atypical
Poor hearing, decreased vision, impaired cognition may affect ability to give an adequate history
↓ pain perception and ↓ febrile or muscular response to infection/inflammation
Hypotension may NOT be appreciated in hypertensive patients
Comorbid conditions (eg, CVD) more common
Higher operative risk, surgical complications are more common
Higher complication and mortality rates
what percent of older adults with perforated appendicitis have classic presentation
LESS THAN 20%!!!!
Biliary Tract Disease (eg, Cholecystitis)
Diverticulits
Mesenteric Ischemia
Small Bowel Obstruction
Ruptured Aortic Aneurysm
CONDITIONS MORE COMMON IN OLDER ADULTS
WHAT DO WE consider in any patient >50yo w/ pain out of proportion to PE findings
Mesenteric Ischemia
TRUE OR FALSE
misdiagnosis is high in older adults with abdominal pain
TRUE
what do we get because we do not want to miss occult UIT
Check UA/UC
Pelvic Inflammatory Disease
Adnexal pathology (eg, ovarian cyst, torsion, or neoplasm)
Endometriosis (dysmenorrhea, dyspareunia)
Ectopic pregnancy (vaginal bleeding, 6-8 weeks after LMP)
Endometritis
Leiomyomas – uncommon cause, d/t degeneration
DDx in women with acute abdominal pain
Obtain a _____________ in ALL women of childbearing age who have NOT had a hysterectomy
urine hCG or serum hCG
If hCG is POSITIVE, __________________ is the next diagnostic step
transvaginal ultrasound
>1,500mIU/mL hCG is the “discriminatory zone” to see gestational sac of IUP on ultrasound
elevated bilirubin can cause
jaundice in eyes and palms
protracted vomiting
what could this be from
and what does it do to the skin?
bowel obstruction
can be getting dehydrated so bad tugor
Usual Hx + uterine contractions, vaginal bleeding, leaking (rupture of membranes)
Usual PE + fetal heart rate, pelvic (√uterine tenderness and/or contractions, cervical dilation/effacement)
Additionanl DDx: labor, placental abruption, uterine rupture, intraamniotic infection, severe preeclampsia, HELLP syndrome
Pregnant Patients w/ Acute Pain
PICTURE FROM SLIDE 65
….
who May present w/ predominant symptoms other than pain, including vomiting, fever, irritability, or lethargy
Children with acute abdominal pain
in children with abdominal pain Stillness suggests conditions that
irritate the peritoneum, such as appendicitis
in children writhing for a comfortable position suggest
suggests obstruction (eg, intussusception or renal colic)
Emergent and non emergent issues in children at different ages
ADD PICTURE FROM SLIDE 67
_________ relieves pain and will NOT obscure PE findings, delay diagnosis, or lead to increased morbidity/mortality
Opioid analgesia
Administer ________, as needed for symptomatic relief
antiemetics
what is the most important thing with the PE for GI issues
AUSCULTATION OR PALPATION? *** ugh i missed what she said i think auscultation?
Consider placement of nasogastric
Nasogastric aspirate may confirm:
Upper GI bleeding
Consider placement of nasogastric
Nasogastric suction may:
decompress a bowel obstruction
what are some reasons we would consider placement of urinary catheters? (2 reasons)
Relieve bladder obstruction
Hourly urine output helps to gauge renal perfusion
____________ does NOT take the place of a detailed history and physical examination!
Laboratory testing
Lab testing helps with
Helps narrow DDx or alter plan of treatment
does normal WBC result rule out infection
NOOOOOO
can lab values decrease later on….
YESSSSSSS
SO BE AWARE OF LIMITATIONS
REBOUND TENDERNESS
What the heck is this!?
push down on abdomen does not hurt it is the lifting up of the hand that hurts the patients…
ie. appendicitis
peritonitis
involuntary guarding:
overlying musculature begins rigid and tense
THIS IS INVOLUNTARY!!!!!
what are the labs commonly ordered
CBC w/ differential, electrolytes, BUN, creatinine, glucose, ALT/AST, alkaline phosphatase, bilirubin), lipase, UA, hCG
PICTURE FROM SLIDE 71, 72
Diagnostic imaging does ________ take the place of a detailed history and physical examination!
NOT
TRUE OR FALSE
All patients w/ abdominal pain require imaging
FALSE
CORRECT ANSWER: Not all patients w/ abdominal pain require imaging
If clinical impression suggests that need for surgery is obvious, IS IT necessary to wait for diagnostic imaging before surgical consultation is pursued!
nope
If clinical impression suggests that need for surgery is obvious, it is NOT necessary to wait for diagnostic imaging before surgical consultation is pursued!
Plain Radiographs positioning and views
Flat (supine) & upright views
plain radiographs should be limited to screening for: (4)
- obstruction (dilated loops of bowel)
- sigmoid volvulus (coffee bean)
- perforation (free air)
- severe constipation
what can you visualize on ultrasound?
gallbladder pancreas kidneys ureters urinary bladder volume GYN and aortic dimensions
what is the preferred modality to evaluate biliary tract (eg, cholecystitis) and GYN (eg, ectopic pregnancy) conditions
ultrasound
pros of CT of abdomen/pelvis
sensitive and specific diagnostic tool
cons of CT of abdomen/pelvis
delay in surgical management, radiation exposure, cost, IV/PO contrast (√creatinine)
what are the different options for different types of CT of abdomen/pelvis
what to assess with one of these first and what lab to get to assess this
contrast and/or noncontrast, protocols available
for contrast want to assess kidneys first and get a sCr
what are indications for CT of abdomen/pelvis
appendicitis, nephrolithasis, diverticulitis, many more…
UA/UC is _______ in older adults
STANDARD!
GET IT ….
WHAT SHOULD WE CONSIDER IN PATIENTS WITH:
High-risk patients w/ acute abdominal pain
Patients who appear ill
Have intractable pain or vomiting
Unable to comply w/ discharge or follow-up instructions
Lack appropriate social support
Consider hospital admission or observation
HCG HAS TO BE ABOVE ______ TO BE ABLE TO SEE ANYTHING IN THE UTERINE SAC
1,500-2,000
COME BACK TO THIS CARD!!!!
Patients w/ unclear diagnosis at discharge should return for re-evaluation within ____ hours
12 hours
what are reasons the patient should return for another appointment? (5 things)
Return if… increased/different pain, fever, vomiting, syncope, bleeding
what if you REALLY just cant figure out what is going on? (5)
“Wait and watch” – consider hospital admission or observation in ED
Call for help!
Rule out serious or life-threatening conditions
Obtain a detailed H&P, and lab/imaging if warranted, and DOCUMENT these findings (including pertinent negatives)
Patient education critical (“return if…”, provide written information too and document)!
REMEMBER TO ALWAYS DOCUMENT…
PERTINANT NEGATIVE FINDINGS AS WELL!
views of normal abdominal x-rays
Virtually every abdominal plain film X-ray is an AP (anterior to posterior). Film (the beam passes from front to back with the cassette behind the patient, who is lying down with the X-ray machine overhead). These are occasionally accompanied by erect or even decubitus (pt on their side) views.
five basic densities are normally present on X-rays
what are they
Gas……. black Fat……... dark grey Soft tissue/fluid………. light grey Bone/calcification………. white Metal …………….intense white
- Visible or not visible, and therefore whether present or potentially absent
- Normal, too large or too small
- Distorted, dilated, or displaced
- Abnormally calcified
- Containing abnormal gas, fluid or discrete calculi.
Remember plain film xrays can’t always see clearly certain abdominal structures; ie appendix, gallbladder etc
Abdominal contents are often described as noted
Pelvic phleboliths – normal finding.
Joint space narrowing in the hips (normal for this age?).
Granular texture of the fluid fecal matter containing pockets of gas in the caecum.
The ‘R’ or ‘L’ marked low down on the right or left side. The marker can be anywhere on the film and you often have to search for it.
(All references to ‘right’ and ‘left’ refer to the patient’s right and left.
list of signs you will become aware of with repeated viewing of plain film x-rays
Check that the ‘R’ marker is compatible with the visible anatomy, e.g. (5 ways to tell)
– liver on the right – left kidney higher than the right – stomach on the left – spleen on the left , when visible – heart on the left
Intraluminal gas is usually minimal, centrally located within numerous tight loops of small diameter (2.5–3.5 cm), distinguished by valvulae that stretch all the way across the ________ loops.
small bowel
A mixture of gas and feces located within loops
of larger diameter (3–5 cm) around the
periphery, with haustra, that stretch only
part-way across the diameter of the __________
loops.
large bowel
more than 5 fluid levels, greater than 2.5 cm in length is abnormal and associated with obstruction, ileus, ischemia and or gastroenteritis.
Air–fluid levels on erect AXR
abnormal findings
Intramural gas
ischemic colitis
abnormal findings
perforated viscus or penetrating abdominal injury.(However the sensitivity for detecting perforation on AXR is low and is best confirmed as subdiaphragmatic air on erect CXR or with a CT scan).
Intraperitoneal gas
abnormal findings
within the soft tissues, retroperitoneal structures or chest in infection or trauma (often seen with penetrating trauma….gun shots, knife wounds etc)
Extraperitoneal gas
abnormal findings
Dilated loops of small or large bowel
abnormal findings
Identify the retroperitoneal shadow of the psoas muscles. Bulging of the lateral margin or obliteration of the psoas shadow may indicate
retroperitoneal pathology
_______% of renal tract stones are radio-opaque, but will require non-contrast CT or USS to confirm their position in the ureter.
80–90%
Examine the RUQ for evidence of gallstones (15% radio-opaque) or pancreatic calcification. Again, confirmation with _____ or _____ is indicated.
USS or CT
technology that uses computer-processed x-rays to produce tomographic images (virtual ‘slices’) of specific areas of a scanned object, allowing the user to see inside the object without cutting.
X-ray computed tomography (X-ray CT)
This processing is used to generate a three dimensional image of the inside of the object from a large series of two-dimensional radiographic images taken around a single axis of rotation.
X-ray computed tomography (X-ray CT)
has evolved into one of the primary diagnostic tools of the abdomen.
X-ray computed tomography (X-ray CT)
When first unveiled by Sir Godfrey Hounsfield in 1972
X-ray computed tomography (X-ray CT)
_____ produces a volume of data that can be manipulated in order to demonstrate various bodily structures based on their ability to block the X-ray beam.
X-ray CT
the scan is taken slice by slice. After each slice the scan stops and moves down to the next slice (from the top of the abdomen down to the pelvis). This requires patients to hold still to avoid movement artefact.
Conventional CT scan
- this is a continuous scan which is taken in a spiral fashion. It is a much quicker process and the scanned images are contiguous.
Spiral/helical CT scan
have steadily increased the number of rows of detectors (slices) they deploy. 16 multi-slice scanner and 64 multislice scanners are on the market. These can produce images in less than a second.
can obtain images of the heart and its blood vessels (coronary vessels) as if frozen in time.
Helical scan CT machines
works by obtaining a block of raw data in a spiral (helical) rather than a planar manner, with the patient moving in a continuous z-axis direction while in the ‘tube’.
Detector arrays rotate around the patient. This continuous motion allows for a much larger volume to be covered, with less radiation exposure per volume covered when compared with sequential CT.
Spiral CT
allowed for better three-dimensional imaging.
Allows for increased table speed and more distinct longitudinal resolution.
This increase in table speed is valuable in a trauma setting.
Significantly reduces the amount of radiation exposure to the patient for any continuous area.
Spiral CT
X-Ray Computed Tomography
In order to differentiate between different types of fluid and tissue in the abdomen, it is important to understand the concept of _________________ and how they are derived.
Sir Godfrey Hounsfield, developed a method to standardize the density measurements between different machines.
Hounsfield units (HU)
__________ absolute density scale defined air as the minimum density, with a value of -1000 HU, and placed water as the benchmark of 0. The most dense material in the human body, bone, has an upper limit of +1000 HU.
Hounsfield’s
has a heterogeneous appearance and is generally between 45 and 70 HU. tends to congregate close to the original hemorrhage site, producing the so-called “sentinel clot.“
Clotted blood
will have a less dense appearance, and typically ranges from 20 to 45 HU.
Freely flowing blood
Blood can also be identified by __________________, which can accumulate in the abdominal cavity or demonstrate sites of vascular disruption.
extravasation of contrast material
provides images in shades of grey - occasionally the shades are similar, making it difficult to discern between two areas. Contrast enhancement can be used to try to overcome this problem.
CT scanning
_________________ are iodine-based and there is a risk of anaphylaxis with these and worsening of renal impairment.
Newer agents are non-ionic and are less likely to cause allergic reactions. However, they are more expensive.
Intravenous contrast agents
Abdominal CT scans can be done without the use of oral radiopaque contrast agents (termed a non-contrast enhanced CT or NECT).
The advantage of NECT is that the intense radiodensity of these contrast agents can obscure areas of abnormality, like small renal or ureteral stones.
Conversely, the use of a contrast enhanced CT, or CECT, can provide better distinction between tissues and various structures. Most abdominal CT scans are done with intravenous radiocontrast as this approach helps in the identification of inflammatory and neoplastic processes.
Intravenous contrast agents use iodine as the radiopaque agent bound to either an organic (non-ionic) or ionic compound
the pros and cons
_________, an insoluble powder suspended in water is a common radiocontrast used to fill the lumen of gastrointestinal structures during radiography.
agent can be administered by mouth, nasogastric tube, or rectal enema, depending on the structures to be visualized.
Barium sulfate
Many hospitals are using a ______________ product before CT scanning when visualization of the gastrointestinal lumen is desired.
agent can be administered by mouth, nasogastric tube, or rectal enema, depending on the structures to be visualized.
water soluble iodine
Injections are usually given rapidly and can cause a feeling of warmth in the arm, or even severe pain.
Contrast can be extravasated, which can be severe enough to require skin grafting.
Anaphylaxis with bronchospasm, laryngeal edema and hypotension can infrequently occur.
Renal failure: contrast is cleared renally and patients with pre-existing renal impairment may develop worsening renal function and even renal failure requiring dialysis.
Urticaria.
Side-effects of intravenous contrast
Generally, good ________ prior to contrast will reduce the risk of developing renal impairment.
hydration
________ is usually withheld before a CT scan
Continued intake of _______ after the onset of renal failure results in a toxic accumulation of this drug and subsequent lactic acidosis…..(remember from pharm)
(This rare complication occurs only if the contrast medium causes renal failure, and the patient continues to take _________ in the presence of renal failure)
the blanks are all the same word!
Metformin
The routine use of both ________ and __________ for abdominal CT scanning has been greatly debated. Because CT technology has dramatically improved, it is important to consider the costs versus the benefits of oral contrast using current machines.
intravenous and oral contrast
ED time studies typically find that the use of __________ adds 90 to 180 minutes of extra time until the CT scan is completed…
Conversely, radiology-based studies on CT helical scan accuracy find that __________ improves sensitivity and specificity for a variety of conditions, such as appendicitis, by 2-3%. 5
It is often the radiologist who wants _________ to
improve his or her interpretive accuracy!!!
all the blanks are the same word
oral contrast
Each institution has developed an approach for the use of intravenous and/or gastrointestinal contrast according to the patient’s suspected clinical condition as well as discussions with the practicing clinicians for which CT scanning is being done.
so just asking your supervising physician and radiologist about what they suggest to use
okay this was just to read…
An important consideration in the use of CT is the radiation exposure to the patient, especially in pregnant patients and children.
Radiation risks are difficult to quantify and predict.
Some studies state the amount of radiation from a CT is 150 to 1,000 times greater than a single chest x ray.
These values are difficult to quantitate. The bottom line is………..Don’t carelessly order these tests!
Radiation Exposure Concerns.
As in any other imaging analysis, it is important to take a ________ approach when reading abdominal computed tomography (CT).
Always begin cranial and gradually move caudally. Likewise, assess structures from superficial to deep, first analyzing the tissues or abdominal wall and then progressing to the internal structures.
systematic
ways to read a scan from when you are first starting out to when you are an expert :)
long card… just read it :)
For physicians with limited experience reading CT scans, it is best to begin by following one organ and tracking it through the entire sequence.
With experience, the next step is to follow organs that lie in the same transverse plane (axial), such as the liver and spleen, pancreas and adrenals, and the kidneys.
As the CT tracks caudally, identify the appropriate anatomical landmarks, such as the celiac trunk, the superior mesenteric artery, the renal arteries, and the aortic bifurcation.
Follow the major vessels to assure that the IVC and the aorta are intact and without major pathology.
The use of CT scans are increasing almost daily due to the increased availability of CT scans on an emergent basis and the increased quality of diagnostic imaging.
With the number of various imaging technologies available to the practicing clinician it is important to consider when to rely on options that involve less radiation exposure and less cost and when to opt for CT
blessings
blessington said to remember this.. so when blessington says that … it is typically a good idea to remember it…
:)
TONS OF IMAGES IN BLESSINGTON’S PPT. I’m not putting them in the cards … wayyyyy tooooo mannnnyyyyyy
…..
abdominal examination to includes
inspection, auscultation, percussion and palpation of the abdomen and assessment of its organs including the liver, spleen, kidneys, bladder and aorta
After percussing border of tympany and dullness w/ patient supine, ask patient to turn onto one side then percuss and mark borders again
Shifting dullness test to assess for ascites
In ascites, dullness shifts to the more _______ side, whereas tympany shifts to the ______.
dependent
top
Ask patient or assistant to press edges of both hands firmly down the midline of abdomen. While you tap one flank sharply w/ your fingertips, feel on the opposite flank for a “wave” transmitted through the fluid
Findings: An easily palpable “wave” suggests ascites
Fluid wave test to assess for ascites
Find point (lies 2” from ASIS on an imaginary line drawn to umbilicus) Findings: Positive if tender w/ guarding, rigidity and rebound tenderness
McBurney’s point tenderness to assess for appendicitis
Press deeply and evenly in LLQ then quickly withdraw your fingers
Findings: Positive if pain in RLQ during left-sided pressure
Rovsing’s sign to assess for appendicitis
Place hand just above patient’s right knee and ask patient to raise thigh against your hand
Findings: Positive if pain increases
Psoas sign to assess for appendicitis
Flex patient’s right thigh at hip, w/ knee bent, and rotate leg internally at hip (swing lower leg laterally)
Findings: Positive if right-sided pain
Obturator sign to assess for appendicitis
Hook your left thumb or fingers of your right hand under costal margin of RUQ and ask patient to take deep breath
Findings:Positive if sharp increase in pain w/ sudden stop in inspiratory effort or wincing. Less pronounced pain may indicate liver inflammation
Murphy’s sign to assess for acute cholecystitis
Ask patient to raise the head and shoulders off the table
FIndings:Bulge of hernia will usually appear
Ventral hernia assessment (umbilical or incisional)
Ask patient either to raise the head and shoulders off the table or bear down
Findings: Mass in abdominal wall remains palpable
Mass in abdominal wall assessment
- Make patient comfortable – supine position, arms at side, pillow under head, knees bent
- Expose abdomen from xiphoid process to pubic symphysis (drape appropriately)
- Stand at right side of exam table
tips for a good exam
INSPECTION
Scars, striae, rashes, dilated veins & ecchymoses
Contour of the abdomen, peristalsis & pulsations
AUSCULTATION
Four quadrants for bowel sounds
Renal, iliac, & femoral arteries bilaterally and aorta for bruits
Liver and spleen for friction rubs
PERCUSSION
Percuss four quadrant for tympany and dullness
Percuss liver to measure its vertical span
Percuss spleen
Percuss costovertebral angle (CVA) for tenderness bilaterally (on the back)
PALPATION Lightly palpate 4 quadrants Deeply palpate 4 quadrants Guarding, rigidity, rebound tenderness indicate peritonitis or “acute abdomen” Palpate liver Palpate spleen Palpate kidneys bilaterally Palpate aorta
part of the exam
Liver enzyme
which one of these is produced in bone as well and not just liver
AST
ALT
GGT
Alkaline phosphatase: produced in bone as well!
Liver function
Albumin
bilirubin, total and direct
PT/INR
if there is liver damage what will be elvated
all of thsee previous lab test
do these values tell you much seperate like just a GGT?
nope
LFT elevated could be
alvohol
drugs/toxins
risk factors for hepatitis
patterns of abnormal LFTs
–> Hepatocellular damage (hepatitis, cirrhosis) : increased ALT/AST, increases Alkaline phosphatase
–> cholestasis: increased ALT and AST, increase alkaline phosphatase
—> Jaundice: increased total bilirubin, doesn’t differentiate between hepatocellular damage of cholestasis
—> low albumin suggest chronic process (cirrhosis, cancer)
—> prolonged PT/INR- significant hepatocellular dyfunction
what is cholestasis
retention of bile in the liver
AST to ALT ratio greater than or equal to a ratio of 2:1
alcoholic liver disease (with increase GGT), cirrhosis
AST and ALT greater than 4 times normal
nonalcoholic fatty liver disease
AST and ALT greater than 25 times normal
hepatitis/ toxin-related disease
AST and ALT great than 50 times normal
Ischemic hepatopathy
increased bilirubin production (eg hemolytic anemia) or impaired bulirubin uptake and storage
signs and symptoms: mild jaundice, stool and urine normal, splenomeagly in hemolysis
…
missed it… go back
missed it go back….
missed it go back….
bowel obstruction
labs? most likely where? most likely due to? imaging? 2 buzz words to remember and seen more on which imaging positions
CBCD, electrolytes, H&H, most likely in Sm bowel, most likely due to previous surgery,
imaging: standing and supine X-ray
small bowel obstruction
BUZZ WORD!!!!!! : AIR FLUID LEVELS ON STANDING UP seen more
SUPINE YOU CAN SEE THE DILATED LOOPS OF BOWEL more
can also do CT: second step where you also see air fluid levels and dilated loops of bowel
messenteric ischemia
symptoms
process
acute imaging… gold standard
chronic things that make it worse
WHAT IS KEY TO REMEMBER… like this will prob be part of the test question
Symptoms: acute or chronic high intensity, severe, diffuse pain. worse one hour after eating older then 50 y.o. bruit in 50% of pts weight loss they dont want to eat ... because pain an hour after eating
Process: Blood supply to the bowel and mesentery blocked from thrombosis or embolus (acute arterial occlusion), or reduced from hypoperfusion
Acute: ABDOMINAL CT WITH ANGIOGRAM!!!!!!!!
chronic: squatting or lying down makes the pain better
KEY: such acute pain SEEMS OUT OF PROPORTION TO EXAM!
acute cholescystitis
PE/ signs
what labs to get?
what imaging to get?
guarding in RUQ
positive Murphys sign
LABS: CBCD: leukocytosis with left shift… to check for infection
Imaging? Right upper quadrant US: gallbladder wall thickening and sometimes can see stones obstructing
you will see INCREASED COLOR FLOW on US
cholangitis
labs (3)
and what do you do to diagnose and treat
Labs: CBCD: leukocytosis
LFT: specifically billirubin and Alk phosphatase
Blood cultures x 2
ERCP: diagnosis and treatment
acute hepatitis
labs
what panel do you want to get… which part of this means you are immune
LFT: AST/ALT
serum glucose
hepatitis panel : lump together information for you
(core Ab) want to get surface Ag part of this!
positive surface ab means you are immune
PUD
H.pylori
NSAIDS
breath test: for H. pylori
Stool Ag to follow up
upper endoscopy dx: want to know where it is! to see if in stomach or in duodenum
if gastric ulcer more worried for malignancy for get a biopsy
symptoms: epigastric pain not initially when you first eat food but 2-5 hours after and pain at night
fullness
nausea
PE: asymptomatic …. could have some burning pain
Acute pancreatitis
onset:
vitals:
painful.
rapid onset
vitals: tachy may have a fever
LABS: CBC, amylase, lipase (more lipase), LFT (these will be elevated if gallbladder related)
Imaging: CT (angry pancreas) looks more heterogeneous
FAT STRANDING!!!!!
either due to alcohol association or gallstone
Acute Appendicitis
PE
SIGNS?
IMAGING TO CONFIRM?
WHAT DO WE DO?
PERIUMBILICAL PAIN OR DISCOMFORT WITH RLQ PAIN
N/V
PE: rebound tenderness, ridigit, guarding Rovsings sign Murphys sign psoas sign rebound tenderness
CT scan to confirm!
TAKE IT OUT!
Diverticulitis
symptoms:
TOC:
Labs:
Fever, N/V, diarrhea
LLQ
diverticula (pockets) something gets stuck in that and gets inflamed and infected
TOC: diagnosis this with CT scan
Labs: WBC
positive guiac test
