surgical abdomen Flashcards
Sudden/rapid onset and escalation
- Vascular -
hemorrhage, ischemia
Sudden/rapid onset and escalation
Perforation
hollow viscous, ulcer/tumor erosion
meds that matter with a surgical abdomen
Steroids
coumadin
NSAID’s Pepto Bismal anticholenergics CAM current/recent antibiotics
Sudden/rapid onset and escalation
- Vascular - hemorrhage, ischemia
- Perforation - hollow viscous, ulcer/tumor erosion
- Rupture - appy, ectopic pregnancy, ovarian etiology
- Obstruction - bowel, gallbladder, ureter
- Trauma
PMH you want to consider in a surgical abdomen
GI, DM, atherosclerosis, cardiac, renal, CA, Sickle Cell, HIV
Elderly - pain out of proportion to exam
Think mesenteric ischemia
Stimulants w/ abdominal pain (stimulants are vasoconstrictors)
Think mesenteric ischemia
Abd pain, hypotension, tachy, pale, syncope
think
hemorrhagic AAA Massive GI bleeds hemorrhagic pancreatitis eroding tumors massive bleeding in pregnancy
Testicular torsion
Testicle pain, abd/flank pain (referred)
Doppler ULS
refer to a urologist
ddx for all female pelvic pain
i. In DDx for all female pelvic pain
ii. +/- Ovarian cyst hx
iii. Formal ULS for flow, upreg
Ischemic colitis - General Surgeon
Hx Crohn’s, ulcerative colitis
ii. Fever, WBC’s/lactate up, +/- peritoneal; CT for dx
incarcerated vs strangulate
Can’t reduce incarcerated
skin over the hernia is hot, red, and hurts to the touch, fever; WBC’s, lactate up
Mesenteric ischemia
can be
SMA or IMA
mesenteric ischemia presentation
Pain out of proportion to exam – severe tenderness but soft abd, non-peritoneal
N/V/D, bloody BM, hx pain after eating
labs seen with mesenteric ischemia
Metabolic acidosis, high WBC’s, lactic acid, amylase; hypotension, tachycardia
dx mesenteric ischemia
CT angiography for dx
IV fluids, antibiotics, surgical consult
Time to surgery predictor of survival
different presentation with elderly
Mesenteric Ischemia AAA Appendicitis Acute Cholecystitis Perforated Peptic Ulcer
20-40% of elderly w/ abdominal pain will require surgery!
> 60yo + Abd Pain = High Risk patient
Small Bowel Obstruction
Intermittent, crampy, periumbilical
Rapid, not sudden onset - hours
Intermittent, crampy, periumbilical
Rapid, not sudden onset - hours
Distention, diffusely tender, “tinkling” bowel sounds
Dehydration, low grade temp, tachy/tachy, +/- hypotension
Intermittent, crampy, periumbilical
Rapid, not sudden onset - hours
first orders and second orders
IV fluids, pain control, antiemetic, belly labs, lactic acid, EKG, CXR-KUB
Dehydration, low grade temp, tachy/tachy, +/- hypotension
Bowel Obstruction
functional
Ileus - adynamic/paralytic; bowel stops functioning due to infection, irritation, inflammation –>
Search for the cause and fix it
Distention both large/small bowel
“Sentinal Loop” can be seen in both
Mechanical
Obstruction, compression, rotation
Usually needs surgical intervention
sentinal loops
is a sign seen on a radiograph that indicates localized ileus from nearby inflammation.
functional;
MCC of LBO
CA
Labs that would indicate necrosis in a pt owth LBO
Fever, toxic, WBC’s or high lactate = worrisome for necrosis
Ogilvie’s Syndrome)
Distended large bowel but not obstructed
Think tricyclics, anticholenergic agents
in old people
Elderly, bedridden, psych, anticholinergics
Same presentation as LBO
Elderly, bedridden, psych, anticholinergics
Same presentation as LBO
think
volvulus
MC site of a volvulus
Sigmoid (most common)
cecal
CT AP IV contrast for dx and for location
Antibiotics, surgical consult
Pneumoperitoneum
Perforated viscous: air, bowel contents escape – air rises, see it under diaphragm
Rapid onset, constant, epigastric then generalized pain
Vomiting; fever 50%; tachy/tachy
RF for pneumoperitoneum
Hx PUD/gastritis, NSAIDS, steroids. CXR negative in 50%! Get CT
51yo male, epigastric pain
WBC 17k,
Lactate 3.0
Cholecystitis labs seen with
LFT’s: AST 95 (nl ~5-35), ALT 112 (nl ~10-40), Alk Phos 180 (nl ~40-140), T.Bili 2.2 (nl ~0.3-2.0)
charcots triad what is it and what is it for
RUQ pain, fever, jaundice
Plus - shock, altered mental status
reynolds
cholangitis
unlikely alvardo
5 unlikely
possible alverado
5-6 possible
probably appy alvarado
7-8 prob,
probably alvarado
> 9 very prob
how would retrocecal appy present
(flank/genital pain),
pelvic appy sxs
(rectal/pelvic pain: less abd pain
psitive psoas, obturator, rebound, Rovsings seen when
- Positive psoas, obturator, rebound, Rovsings
a. ONLY if peritoneal irritation – late signs, usually perf’ed
presentations of appy in elderly
No RLQ pain in 25%, no migration of pain in 50%
UTI, kidney stone, AGE all common misdiagnoses
story of TOA
a. Late progression/complication of PID
b. Low abd pain, n/v, fever, +CMT
c. Hypotensive? Sepsis if ruptures
TOA workup
Endovaginal US first, then CT for extent
Sudden unilateral pain, n/v, usually afebrile
d. Endovaginal US w/ doppler for flow, cysts
e. Gyn consult, admit
12-24 hr
Sudden unilateral pain, +/- n/v
Transabd US for fluid, endovag US for DDx
MCC of 1st trimester bleeding
Pregnancy MAY progress or ABORTION MAY follow **MC of 1st Trimester BLEEDING
NO POC expelled from Uterus
closed
threatened picture
5wks - gestational sac with fetal cardiac activity
Supportive: Rest @ HOME Return to ER if SX. Persist of PASAGE of POC.
*Serial B-hCG to se if Doubling
- Os closed
- +/- abd pain, no passage of POC’s
- No fetal cardiac activity on EVUS
Missed abortion (fetal death <20wks)
Septic abortion
• EVUS: thickened, irregular endometrium, no clear sac
- Os open or closed
- Abd pain, fever, + CMT, foul smelling d/c, may be peritoneal
what do you do for a packer.
Go-Lytely (they will poop it all out) if stable, not obstructed
Plain KUB, CT if need surgery to remove
