The Acute Abdomen and Peritonitis Flashcards
How long should you hold analgesics for an acute abdomen?
Until after initial surgical evaluation is done
What is visceral pain?
Slow in onset, dull, poorly localized, protracted
What are the primary signals for visceral pain?
Distension and stretch
What types of nerves is visceral pain mediated by?
Autonomic (sympathetic and parasympathetic)
Where are receptors for visceral pain located?
Mucosa or muscularis on hollow viscera and the visceral peritoneum
What is parietal pain?
Intense, acute, sharp, better localized
What type of nerves is parietal pain mediated by?
Somatic
What causes precisely localized parietal pain?
Direct irritation of parietal peritoneum by pus, bile, urine, and GI secretions
What is referred pain?
Noxious sensations perceived at a site distant from that of a strong primary stimulus
What does referred pain feel like?
Arises from a deep structure. The pain is superficial, sharp, localized, and persistent
What times should be asked about when taking the history of the pain?
At onset and at presentation
What is explosive pain?
Pain that develops within seconds
What is Rapidly Progressive pain?
Pain that develops over 1-2 hours
What is gradual pain?
Pain that develops over several hours
What is important to ask about N/V and pain?
Which came first, the pain or vomiting
What organs should you specifically ask if the pt still has intact?
Gallbladder, appendix, uterus, ovaries
How much of the abdomen should you expose?
from the nipples to below inguinal region
What are the stages of the abdominal exam?
inspection
Auscultation
percussion
palpation
What should you ask the patient to do and then point to area of maximal pain?
cough
What does involuntary guarding on palpation indicate?
Peritoneal inflammation
What does rebound tenderness indicate?
peritoneal inflammation
What are some methods to elicit peritoneal pain?
Push with stethoscope
Bump bed
Shake pelvis
What is rigidity a sign of?
Peritonitis
What imaging should be ordered for an acute abdomen?
Abdominal xrays flat and upright with pa upright cxr
Abdominal us
Pelvic US
CT of abdomen and pelvis
What is the ddx for right upper quadrant pain?
Biliary Colon Hepatic Pulmonary Renal
What is the ddx for epigastric pain?
Biliary Cardiac Gastric Pancreatic Esophagus Vascular
What is the ddx for left upper quadrant pain?
Cardiac Gastric Colon Pancreatic Renal Vascular Splenic Pulmonary
What is the ddx for RLQ pain?
Colonic GYN renal Rectus sheath Hematoma
What is the ddx for umbilical pain?
Colonic
Gastric
Vascular
What is the ddx for LLQ pain?
Colonic GYN Renal Rectus sheath Hematoma
What is the ddx for suprapubic pain?
Colonic
GYN
Renal
What is the ddx for pain whose onset is minutes?
Perforated viscera, testicular or ovarian torsion, ruptured AAA, ectopic pregnancy, pancreatitis, mesenteric ischemia
What is the ddx for pain whose onset is hours?
Biliary, appendicitis, diverticulitis, SBO, PUD
What is the ddx for pain whose onset is days?
IBD
What are the PE findings that indicated a surgical consult?
Peritonitis
incarcerated hernia
Tender abdomen with a high fever or hypotension
Suspected ischemia
What should be done after initial assessment ?
Resuscitation Pain meds Abx NGT Foley
What is peritonitis?
Inflammation or suppurative response of the peritoneal lining to direct irritant
What are the local findings of peritonitis?
Acute abdomen Abdominal tenderness Rebound tenderness guarding rigidity distention Diminished bowel sounds Free air
What are the systemic findings of peritonitis?
Fever/chills/rigors tachycardia Diaphoresis tachypnea restlessness dehydration/oliguria disorientation shock
What is secondary peritonitis?
Occurs after perforation, inflammation, infection, or ischemic injuries
What bacteria are responsible for peritonitis from PUD?
Usually no bacteria for first 12 hrs (peritonitis from chemical irritation)
>12 hrs then gram + and - w/ or w/o fungus
Fecal spoilage can be associated with what bacteria?
Gram - and anaerobic bacteria
Most common= ecoli, strep proteus, enterobacter-klebsiella groups, anaerobes, bacteroides fragilis, cocci and clostridia
What is the preop treatment for secondary peritonitis?
IVF Central venous catheter Cardiovascular agents Mechanical vent A-line ABX (broad spectrum)
How long should abx be continued post op for peritonitis?
Until pt has remained afebrile with normal WBC
What is primary peritonitis?
Occurs in absence of GI perforation
Hematogenous spread
What diseases is primary peritonitis associated with?
Cirrhosis, liver disease, nephrotic syndrome, SLE
How is primary peritonitis diagnosed?
peritoneal fluid analysis for c&s
What does imaging show for primary peritonitis?
free fluid without free air
What is the treatment for primary peritonitis?
Abx. No surgery
