Surgical Abdomen Flashcards
1
Q
the surgical abdomen
A
- Patients with an acute/surgical abdomen are sick
- Surgical/Acute abdomen vs Medical abdomen
- “The Story” of each entity is key – drives your DDx
- Orders: IV NS 1L bolus, pain meds/antiemetic, belly labs, lactic acid, EKG if tachy/risk, CXR; specials
- Dynamic process - serial exams – documentation
- Keep anyone going to surgery NPO
- It is more important to know this abdomen needs a surgeon than to know the exact diagnosis
2
Q
ddx of acute abdomen
A
- 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
- Slower onset
- Infection
- Inflammation
- Abscess
3
Q
approach/history of acute abdomen
A
- Observation: what do they look like, what are they doing?
- Been sick lately? Recent trauma?
- Last food/fluid intake? Are you hungry now?
- Hx surgery, hospitalization, recent procedure?
- PMH: GI, DM, atherosclerosis, cardiac, renal, CA, Sickle Cell, HIV
- Meds that matter
- Steroids, coumadin, NSAID’s, Pepto Bismal, anticholenergics, CAM, current/recent antibiotics
- Family Hx: CAD, abdominal issues
- Habits that matter - ETOH, stimulants, IVDU
- Ever had this before??
4
Q
approach/physical exam
A
- Don’t focus only on the abdomen!
- Skin, lungs, heart, CVAT, Gyn/GU, rectal
- Watch them walk if possible
- The Abdomen: Goal = peritoneal or not?
- One finger – point to where it hurts
- Look at it. Then listen: Bowel sounds? Quality?
- Percuss - organs, tympany, ascites, bladder
- Palpation – Soft or hard? Flat or distended?
- Do all the special moves on first pass
- Guarding?
- Involuntary = muscles rigid, hard = peritoneal
- Voluntary = abd is soft, but pt resists touch
5
Q
Peritoneal signs
A
- Patients with peritoneal irritation lie still - movement is painful, involuntary guarding, abdomen is firm
- Heel tap
- Tap soles of feet = abdominal pain
- “Sorry, I bumped the bed” sign
- Unexpected movement = abdominal pain
- Jump up and down sign
- Kids who do are not peritoneal
6
Q
specific signs
A
- Rebound - peritoneal
- Pain increases as let go during deep palpation
- Psoas sign – peritoneal
- Resisted hyperflexion or hyperextension @ hip
- Obturator – peritoneal
- RLQ pain on flexion, internal rotation of R hip
- Rovsing’s sign - appy
- Palpation of LLQ illicits tenderness in RLQ
- McBurney’s point - Midpoint of right iliac crest and symphysis pubis – appy house
- Murphy’s sign
- Stops inhalation with GB palpation
- Grey-Turner’s signà
- Flank ecchymoses - retroperitoneal bleeding
- Cullen’s signà
- Umbilical ecchymoses - retroperitoneal bleeding
- Grey-Turner or Cullen’s – think hemorrhagic pancreatitis or ruptured AAA
7
Q
“oh my God” signs: big red flags
A
- Significant abdominal pain and:
- Pulsatile abdominal mass
- Pale, diaphoretic, hypotension
- Febrile, rigors, hypotension
- Pregnant with hypotension
- Mottled skin, pettechiae, abd ecchymosis
- Elderly - pain out of proportion to exam
- Think mesenteric ischemia
- Stimulants w/ abdominal pain
- Think mesenteric ischemia
8
Q
Hemorrhage
A
- All look sick, are sick:
- Abd pain, hypotension, tachy, pale, syncope
- Stabilize: 2 IV’s, O2, monitor, EKG, labs, upreg
- Bedside ULS, CT (when stable), consultant
- AAA – Abdominal Aortic Aneurysm
- Leaking or dissecting – “tearing” pain, unstable
- Risks: older, atherosclerosis, HTN, DM, connective tissue dz, Marfan’s, smoking, family hx
- Flank, groin, hip, new atraumatic back pain
- US, CT w/ IV contrast - <5cm dia lower risk rupture
- Ruptured ectopic pregnancy
- Delayed hemorrhage after trauma
- Massive GI bleeds, hemorrhagic pancreatitis, eroding tumors, massive bleeding in pregnancy
9
Q
Ischemia: testicular torsion, ovarian torsion, strangulated hernia, ischemia colitis
A
- Testicular torsion – Urologist
- Testicle pain, abd/flank pain (referred)
- Doppler ULS
- Ovarian torsion - OB/Gyn
- In DDx for all female pelvic pain
- Risk: ovarian cyst hx, polycystic dz
- Formal ULS for flow, upreg
- Strangulated hernia - General Surgeon
- Can’t reduce, hot, red, fever; WBC’s, lactate up
- Ischemic colitis - General Surgeon
- Not common; Hx Crohn’s, ulcerative colitis
- Fever, WBC’s/lactate up, +/- peritoneal; CT for dx
10
Q
mesenteric ischemia
A
- Not common but bad - 70% mortality. Elderly!
- Decreased flow in celiacs, SMA or IMA
- Arterial/venous thrombosis, embolism or spasm
- Pain out of proportion to exam – severe tenderness but soft abd, non-peritoneal
- N/V/D, bloody BM, hx pain after eating
- Risk factors
- Afib, CAD, recent MI, HTN, DM, Cirrhosis
- Cocaine/Meth in younger pt’s
- High index of suspicion required: tough Dx
- Metabolic acidosis, high WBC’s, lactic acid, amylase; hypotension, tachycardia
- CT angiography for dx
- IV fluids, antibiotics, surgical consult
- Time to surgery predictor of survival
- “Mesenteric angina” – pain after eating from atherosclerosis and decreased flow in small bowel vessels
11
Q
the elderly
A
- Frequently missed Dx’s in the elderly:
- Mesenteric Ischemia
- AAA
- Appendicitis
- Acute Cholecystitis
- Perforated Peptic Ulcer
- The elderly are so tricky!
- >60yo + Abd Pain = High Risk patient! Hx/PE/Chart/DDx – you considered
- Elderly delay care, Hx difficult, atypical Hx/PE, no fever, subtle VS changes, comorbidities, etc, etc…
- 20-40% of elderly w/ abdominal pain will require surgery!
12
Q
small bowel obstruction
A
- The Story - significant hx common
- Intermittent, crampy, periumbilical
- Rapid, not sudden onset - hours
- Vomiting – bilious, “feculent” (late)
- No BM - not passing gas - obstipation
- Distention, diffusely tender, “tinkling” bowel sounds
- Dehydration, low grade temp, tachy/tachy, +/- hypotension
- High WBC, a high lactate is worrisome
- High suspicion: plain abdominal series
- CT AP IV con, abx, NG, surgery consult
13
Q
bowel obstruction
A
- Biggest risks: Hx abd surgery, hx same
- Mechanical
- Obstruction, compression, rotation
- Usually needs surgical intervention
- Functional
- Ileus - adynamic/paralytic; bowel stops functioning due to infection, irritation, inflammation à
- Search for the cause and fix it
- Distention both large/small bowel
- “Sentinal Loop”à
- Not a surgical emergency, but consult them
- Tx conservative, NG, Surg admit, observe
14
Q
large bowel obstruction
A
- The Story
- Older, significant Hx, slower onset, +/- severe
- Low, mid-abdominal crampy pain
- Vomiting less common than SBO
- No BM, not passing gas (check for impaction)
- Distended, tachy/tachy, guaiac +/-
- Fever, toxic, WBC’s or high lactate = worrisome for necrosis
- Plain film if suspect it, dilated loops lg bowel
- CT abd/pelvis with IV contrast for dx
- Abx, surgery consult, admit
- Common causes and Risk Factors
- Neoplasm most common cause (~60%)
- Diverticulitis (abscess, stricture)
- Volvulus
- Ulcerative colitis, ischemic colitis
- Pseudo-obstruction (Ogilvie’s Syndrome)
- Distended large bowel but not obstructed
- Think tricyclics, anticholenergic agents
- Fecal impaction - manual dis-impaction
15
Q
LBO - Volvulous
A
- The Story
- Elderly, bedridden, psych, anticholinergics
- Same presentation as LBO
- Sigmoid (most common), cecal
- Loop rotates, twists off, dilation
- Abd distention, tympanic abdomen, pain
- +/- fever, tachy, WBC’s, lactate up
- Will get necrotic, then gangrenous: then septic
- Plain film initially if suspect it – fast/easy
- CT AP IV contrast for dx and for location
- Antibiotics, surgical consult
22
Q
appendicitis - alvarado score
A
- Predicts likelihood of appy - Surgery tool
- “MANTRELS”
- Temp >99.2
- WBC >10k
- Neut >75%
- <5 unlikely, 5-6 possible, 7-8 prob, >9 very prob
- May admit Alvarado 5-6 for observation
