SR 35 - Acute Abdomen and Referred Pain Flashcards
What are peritoneal signs?
Signs of peritoneal irritation:
- Extreme tenderness
- Percussion tenderness
- Rebound tenderness
- Voluntary gaurding
- Motion pain
- Involuntary gaurding/rigidity
Define colic
Intermittent severe pain
Due to intermittent contraction of a hollow viscus against an obstruction
What conditions can mask abdominal pain?
Steroids
Diabetes
Paraplegia
What is the classic position of a patient with peritonitis?
Motionless, with knees flexed
What is the classic positino of a patient with a kidney stone?
Cannot stay still, restless, writhing in pain
Appropriate lab tests in acute abdomen?
CBC with differential Chem-10 Amylase Type and screen Urinalysis LFTs Pregnancy test
What is a left shift on CBC differential?
Sign of inflammatory response
Immature neutrophils (bands)
(sometimes >80% neutrophils)
Which x-rays are used in an acute abdomen?
Upright CXR
Upright AXR
Supine AXR
If patient cannot stand - left lateral decubitus AXR (need to see free air)
What are DDx of acute abdomen - RUQ?
Cholecystitis, hepatitis, PUD, perforated ulcer, pancreatitis, liver tumor, gastritis, hepatic abscess, choledocholithiasis, cholangitis, pyelonephritis, nephrolithiasis, appendicitis Thoracic causes (i.e. pleurisy, pneumonia), PE, pericarditis, MI (espeically inferior wall)
What are DDx of acute abdomen - LUQ?
PUD, perforated ulcer, gastritis, splenic injury, abscess, reflux, dissecting aortic aneurysm, thoracic causes, pyelonephritis, nephrolithiasis, hiatal hernia (strangulated paraesophageal hernia), Boerhaave’s syndrome, Mallory-Weiss tear, splenic artery aneurysm, colon disease
What are DDx of acute abdomen - LLQ?
Diverticulitis
Sigmoid volvulus, perforated colon, colon cancer, UTI, SBO, IBD, nephrolithiasis, pyelonephritis, fluid accumulation from aneurysm or perforation, referred hip pain, gynecologic causes, appendicitis (rare)
What are DDx of acute abdomen - RLQ?
Appendicitis!!
And same as LLQ - Diverticulitis, sigmoid volvulus, perforated colon, colon cancer, UTI, SBO, IBD, nephrolithiasis, pyelonephritis, fluid accumulation from aneurysm or perforation, referred hip pain, gynecologic causes
What are DDx of epigastric pain?
PUD, gastritis, MI, pancreatitis, biliary colic, gastric volvulus, Mallory-Weiss
What are the DDx of gynecologic pain?
Ovarian cyst, ovarian torsion, PID, mittelschmerz, tubo-ovarian abscess, uterine fibroid, necrotic fibroid, pregnancy, ectopic pregnancy, endometriosis, cancer, endometrioma, torsion of cyst or fallopian tube
What are the DDx of thoracic causes of abdominal pain?
MI (especially inferior), pneumonia, dissecting aorta, aortic aneurysm, empyema, esophageal rupture/tear, PTX, esophageal foreign body
What are the DDx of scrotal cause of lower abdominal pain?
Testicular torsion, epididymitis, orchitis, inguinal hernia, referred pain from nephrolithiasis or appendicitis
Non-surgical causes of abdominal pain?
Gastroeneteritis, DKA, Sickle cell crisis, rectus sheath hematoma, acute porphyria, PID, kidney stone, pyelonephritis, hepatitis, pancreatitis, pneumonia, MI, C. difficile colitis
What is the DDx for a patient with AIDS and abdominal pain?
All common causes + CMV (most common) Kaposi's sarcoma Lymphoma TB MAI (Mycobacterium Avium Intracellulare)
What is the DDx of suprapubic pain?
Cystitis, colonic pain, gynecologic causes (and appendicitis)
What is gastroenteritis?
Viral or bacterial infection of the GIT
Associated with vomiting (after pain) and diarrhea
Non-surgical
Classic location of referred pain - Cholecystitis?
Right subscapular pain (also epigastric)
Classic location of referred pain - Appendicitis?
Early - periumbilical
Rare - testicular pain
Classic location of referred pain - Diaphragmatic irritation?
Shoulder pain (+ Kehr’s sign on the left)
Classic location of referred pain - Pancreatitis/cancer?
Back pain
Classic location of referred pain - Rectal disease?
Pain in the small of the back
Classic location of referred pain - Nephrolithiasis?
Testicular pain or flank pain
Classic location of referred pain - Rectal pain?
Midline small of back pain
Classic location of referred pain - Small bowel?
Periumbilical pain
Classic location of referred pain - Uterine pain?
Midline small of back pain
Classic diagnosis?
Abdominal pain out of proportion to exam
Rule out mesenteric ischemia
Classic diagnosis?
Hypotension and pulsatile abdominal mass
Ruptured AAA
Go to the OR
Classic diagnosis?
Fever, LLQ pain, and change in bowel habits
Diverticulitis
Test of choice?
Cholelithiasis
US
Test of choice?
Bile duct obstruction
US
Test of choice?
Ruptured AAA
NONE - emergent laparotomy
Test of choice?
AAA
Abdominal CT or US
Test of choice?
Abdominal abscess
Abdominal CT
Test of choice?
Severe diverticulitis
Abdominal CT
What is the most common cause of RUQ pain?
Cholithiasis
What is the most common surgical cause of RLQ pain?
Acute appendicitis
What is the most common GIT LLQ pain?
Diverticulitis
What endocrine problems can cause abdominal pain?
Addisonian crisis
DKA
