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Tintinalli Section 9 - Gastrointestinal Emergencies > S09C74 - Acute Abdominal Pain > Flashcards

S09C74 - Acute Abdominal Pain Flashcards

1
Q

Visceral abdo pain

A
  • caused by stretching of nerves in the walls and capsules of organs
  • vague, generalized pain
  • foregut (stomach, liver, GB, pancreas, 1/2 duo) = epigastric
  • midgut (3/4 duo, jej, ileum, cecum, appy, asc colon, 2/3 transverse colon) = periumbilical
  • hindgut (1/3 transverse, desc colon, sigmoid, rectum, intraperitoneal GU organs = suprapubic)
  • b/l innervation so pain is felt in midline (eg. appy is midline of T10)
  • colickly like pain
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2
Q

Parietal pain (somatic)

A

Irritation of myelinated fibers that innervate the parietal peritoneum

  • localized to dermatome superficial to the site of painful stimulus
  • tenderness and guarding, rigidity, rebound
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3
Q

Referred pain

A
  • based on embryology

- eg. ureter and testes have same segmental innervation

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4
Q

Red flags for critically ill pts presenting with abdo pain:

A
  • extremes of age
  • severe pain with rapid onset
  • abnormal vital signs
  • dehydration
  • pallor, diaphoresis, vomiting
  • rapid onset of shock is usually d/t intra-abdominal hemorrhage
  • BP may not drop until blood loss reaches 30-40% of normal blood volume

-incr of HR by 30 or near-syncope after standing for 1 min represents 1L of blood loss

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5
Q

Lab work for critically ill abdo pt:

A
  • CBC
  • lytes, BUN, Cr, glucose
  • coags
  • type and screen
  • hcg for women
  • liver enzymes
  • lipase
  • u/a
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6
Q

Distension =

A

-ascites, ileus, obstruction, volvulus

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7
Q

Mass =

A

-hernia, tumor, aneurysm, distended bladder

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8
Q

Hyperactive bowel sounds =

A

-SBO

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9
Q

> 50yo with abdo pain

A

-must always r/o AAA

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10
Q

Female and lower abdo pain

A

-everyone should get a pelvic

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11
Q

Male and lower abdo pain

A

-testicular and prostate exam should be done

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12
Q

Pain management

A

-opioid analgesia does not obscure findings, delay dx or cause incr morbidity/mortality

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13
Q

Abdo pain ddx by area (less commonly thought of):

A

generalized:
- diabetic gastric paresis
- familial mediterranean fever
- heavy metal poisoning
- hereditary angioedema
- malaria
- metabolic - addisonian crisis, AKA, DKA, porphyria, uremia
- narcotic w/d
- sickle cell crisis

RUQ:

  • hepatic abscess-
  • herpes zoster

RLQ:

  • endometriosis
  • epiploic appendagitis
  • hernia
  • ischemic colitis
  • meckel diverticulum
  • psoas abscess

LUQ:
-splenic rupture/distension

LLQ:

  • endometriosis
  • epiploic appendagitis
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14
Q

Pain with n/v and rigidity:

A
  • acute pancreatitis
  • diabetic gastric paresis
  • DKA
  • incarcerated hernia
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15
Q

Pain/shock

A
  • abdo sepsis
  • Ao dissection
  • hemorrhagic pancreatitis
  • leaking AAA
  • mesenteric ischemia
  • MI
  • ruptured ectopic
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16
Q

Pain, n/v, distension ddx:

A
  • obstruction

- cecal volvulus

17
Q

Pain, shock, rigidity

A
  • perforated appy
  • perforated diverticulum
  • perforated ulcer
  • ruptured esophagus
  • splenic rupture
18
Q

Pain and n/v ddx:

A
  • acute diverticulitis
  • adnexal torsion
  • mesenteric ischemia
  • myocardial ischemia
  • testicular torsion
19
Q

Plain abdo series, indication and sensitivity:

A
  • mostly used for detecting perforation
  • 20% of pts with perforation will not demonstrate free air
  • restrict AXR to pts with suspicion of obstruction, perforation or severe constipation
  • u/s may be better for detection of free air!
20
Q

U/s indications

A

-use for pts with suspected biliary tract dz

21
Q

ECG

A

-consider if upper abdo pain and pts >40y

22
Q

Appendicitis

A
  • peak age adolescence and young adults

- CT preferred for dx in adults and non-pregnant pts

23
Q

Biliary colic

A
  • F»M before 60yo

- colic pain usually resolves in

24
Q

Bladder outlet obstruction

A
  • BPH

- dx with u/s

25
Q

Bowel obstruction

A
  • plain films 77% sens
  • CT 93% sens
  • complications: incarceration, strangulation
26
Q

Cholecystitis

A
  • 90% afebrile
  • incr WBC in 63%
  • incr WBC in 80% if cholangitis
  • incr bili/AST/ALT/ALP
  • u/s 91% sensitive
  • complications: common bile duct obstruction, asc cholangitis, gangrene
27
Q

Diverticulitis

A
  • M>F before 40yo
  • sigmoid in 85% of cases, otheres are cecal, meckal, RLQ
  • 25% will have + FOB
  • CT 93-100% sn, highly sp
  • complications: perforation, abscess, fistula, obstruction
28
Q

Epiploic appendagitis

A
  • middle age
  • M>F
  • LLQ
  • fever unusual, n/v infrequent, diarrhea 25%
  • dx: CT
29
Q

Mesenteric arterial occlusion

A
  • n/v, diarrhea
  • lactate 75-90% sn
  • elevated WBC 90%
  • CT angio 96% sn
30
Q

Mesenteric venous thrombosis

A
  • occurs in hypercoagulable states and liver dz

- CT with contrast to dx

31
Q

Pancreatitis

A
  • M>F
  • EtOH, biliary dz, drugs, ERCP
  • lipase is 90% sn in first 24h
  • CT 78%sn, 86% sp
  • complications: hemorrhage, pseudocyst, ARDS, sepsis
32
Q

PUD

A

-RF: peak age 50s, M>F, ASA/NSAID use, smoking, EtOH, h.py

33
Q

Renal/ureteral colic

A
  • RF: 30-40yo, FmHx
  • 85-90% have hematuria
  • Dx: u/a, sprial CT
  • complications: obstruction, infxn
34
Q

Abx for intra-abdominal infections:

A

-should target anaerobes and facultative aerobic gm-
-if SBP - need gm+ coverage for pneumococcus
-traditional tx: gentamicin/tobramycin plus flagyl/clinda
-suspected biliary sepsis: pip-tazo or imipenem
-SBP: CTX
-PID: CTX 250mg IM once plus doxy 100mg BID x14d +/- flagyl 500mg PO BID for mild infxn
in-pt cefoxitin plus doxy or clinda plus genta

35
Q

Ectopic pregnancy

A
  • pain in almost all cases
  • PV bleed in 90% of cases
  • all child-bearing age women with abdo pain should have a bHcG done, if positive then do an u/s
  • if b-hCG is >1500mIU/mL a gestational sac should be visible
  • in pts not undergoing infertility tx, visualization of an intrauterine pregnancy in 2 perpendicualr views excludes an ectopic pregnancy
  • 2 b-hCG 48h apart that rises
36
Q

PID

A
  • occurs in 40% of women infected with STI
  • 20% of women with PID will get infertility from tubal scarring, 9% will have an ectopic pregnancy, 18% will get chronic pelvic pain
  • 50% gonorrhea/70% chlam. infxn in wmn are asymptomatic
37
Q

Post bypass complications:

A
  • dumping syndrome - post-prandial gastric emptying, increased gastric homrones and splanchnic vasodilation
  • Sx: n/v, bloating, abdo cramps, diarrhea, sweating 30-60mins post meal
  • late dumping is 1-4h after eating
  • hyperinsulinemic and hypoglycemic
  • avoid highly concentrated foods and separate eating and drinking
  • tx: ocreotide

-enteric leak can occur and presents like sepsis

38
Q

Epiploic Appendagitis

A
  • appendages are mostly found on sigmoid and cecum, unknown fxn
  • self-limited, usually caused by torsion
  • usually middle-aged man with LLQ pain, usually no feveri, diarrhea in 25% of cases, n/v rare
  • tx: analgesia, ost resolve spontaneously in 1-2w
39
Q

Clostridium Difficile

A
  • anaerobic, gm+, spore-forming bacillus
  • causes: severe diarrhea, pseudomembranous colitis, toxic megacolon, sepsis, death
  • pathophys: fecal-oral transmission, release of clostridial toxins, intestinal imflm
  • RF: >65y, illness, NG intubation, antiulcer Rx, Abx, long hospital stay
  • usually begins 4-5d after Abx Tx
  • common Abx assoc: amox, ampic, cephalosporins, clindamycin, quinolones
  • Sx: mild/mod nonbloody diarrhea to perfuse diarrhea hemoccult +, abdo pain, distension, fever, nausea
  • high WBC in fulminant dz
  • Dx: enzyme immunosorbent assay has 80% Sn for A and 95% for B, or can do an anaerobic stool Cx
  • Tx: stop inciting Abx, oral flagyl 250mg QID or 500mg TID x10d
  • severe dz: oral vanco 500mg QID x10d
  • colectomy for toxic megacolon

Tintinalli Section 9 - Gastrointestinal Emergencies (17 decks)

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