the acute abdomen, peritonitis Flashcards
sudden onset, severe abdominal pain
acute abdomen
when should you hold analgesics until w/ an acute abdomen
until after initial eval
if a patient doesn’t go to the ER w/ an acute abdomen what should happen?
serial exams by the same provider
what is the “policeman” of the abdomen
omentum- likes to clean up the mess and wall off any infection
what drug should you not give someone w/ an acute abdomen because it could make it so they can’t give an accurate history?
promethazine (Phenergan)
what is visceral pain?
generalized
cause by stretching/ ischemia
what mediates visceral pain?
autonomic nerves (sympathetic and parasympathetic)
where are receptors for vsiceral pain located?
mucosa or muscularis on hollow visceral and the visceral peritoneum
location of visceral pain depends on what?
dermatones of the organ involves
what is parietal pain?
more intense, acute
sharp and better localized
what mediates parietal pain?
somatic nerves
what leads to more precisely localized pain?
Direct irritation of the parietal peritoneum by pus, bile, urine, and GI secretions
Visceral pain shifting to parietal pain indicates
extension of the underlying process
where does referred pain usually arise from?
deep structure
why would a patient have pain in the shoulder after a laparoscopic surgery?
air under the diaphragm
if a patient has shoulder pain a week after surgery what should you consider?
abscess
for duration of pain what should you get?
rate on onset and progression of pain (explosive, rapidly progressive, gradual)
with N/V what should you ask about?
what came first, pain or vomiting?
women on oral contraceptives for a long time who look shocky what should you think of?
hepatic adenomas
what do steroids blunt?
inflammation and wound healing
individual on steroids may present how?
have less pain due to lack of inflammation
what should you ask a person with an acute abdomen about?
gallbaldder
appendix
uterus
ovaries
does a hx of appendectomy entirely rule out appendicitis?
no - can have a stump of appendix left
does a hx of cholecystectomy rule out CBD stones?
no - can have common bile duct stones
what family hx is important?
IBD
sickle cell
AAA
colon cancer
for an acute abdomen what should you do for an HEENT exam?
lymph nodes
sclera color- yellow
if a person has post prandial abdominal pain and you hear bruits what should you consider?
clots in the messenteric arteries
what does involuntary guarding and rebound tenderness indicate?
peritoneal inflammation
what is Rovsing’s sign?
pain at McBurney’s point with palpation of LLQ
iliopsoas sign
pain when hip passively extended or actively flexed against resistance
indicates inflammation on the psoas muscle
retrosecal appendix
obturator sign
pain with internal rotation of the flexed thigh
one long appendix onto obturator
what does costovertebral angle tenderness indicatie
pyelonephritis
Murphy’s sign
Pain at RUQ with inspiration – ceases inspiration
when would you do a CT scan?
appendicitis
for trauma do you need contrast
yes, (IV) need to see bleeding
to figure out an abscess what can you do with contrast ?
PO and IV
need PO to see intestines
IV for blood
what type contrast do you use for suspected appendicitis?
PO contrast
what does an upper endoscopy look at (EGD)?
esophagus
stomach
duodenum
What is an ERCP
endoscopic
retrograde
coloangial
pancreatography
what is an ERCP used for?
bile duct etiology
what can you see w/ colonoscopy?
colon
terminal ileum
used to identify mesentaric ischemia and to identify and possibly stop bleeding
angiography
what else could upper quadrant pain present as?
pneumonia
Ddx for RUQ pain
hepatitis
Gallbladder
pneumonia
diverticulitis
epigastic DDx
pancreatitis cardiac GERD PUD biliary vascular
DDx for LUQ
spleen
DDx for RLQ
appendicitis ectopic ovarian cyst PID ovarian torsion rectus sheath hematoma
Ddx for LLQ
sigmoid divericulus
suprapubic DDx
bladder
colonic
gynecology
pain onset w/i minutes think of…
Perforated viscera, testicular or ovarian torsion, ruptured AAA, ectopic pregnancy, pancreatitis, mesenteric ischemia
pain onset w/i hours think of…
Biliary disease, appendicitis, diverticulitis, SBO, PUD
pain onset w/i days think of…
IBD
when do consult a surgeon….
Peritonitis
Incarcerated hernia
Tender abdomen with high fever or hypotension
Suspected ischemia
if you suspect chronic cholecystitis what should you get before sending them to the surgeon?
US and LFTs
if vomitting a lot/ distended what can you place?
NG tube
well-vascularized, pliable, mobile double fold of peritoneum and fat that is involved in control of peritoneal inflammation and leaking viscus or area of infection
omentum
– inflammation or suppurative response of the peritoneal lining to direct irritant
peritonitis
local findings of peritonitis
“Acute abdomen” Abdominal tenderness Rebound tenderness Guarding Rigidity Distention Diminished bowel signs Free air
systemic findings of peritonitis
Fever Chills Rigors Tachycardia Diaphoresis Tachypnea Restlessness Dehydration Oliguria Disorientation Shock
Labs to get w/ peritonitis
CBC w/ diff cross-match ABGs electrolytes BUN and creatinine blood clotting profile lifer and renal function tests blood and urine cultures pre-abx peritoneal fluid pre-abx if possible
Can occur after perforation, inflammatory, infectious or ischemic injuries of the GI or GU systems
secondary peritonitis
what are examples of secondary peritonitis
Appendicitis Perforated gastroduodenal ulcers Acute salpingitis Diverticulitis Bowel perforation Trauma Ischemic bowel Acute necrotizing pancreatitis
Tx for 2ndary peritonitis
IV fluids consider central venous cath may need cardiovascular agents mechanical ventilation consider A-line (arterial line for beat by beat BP) ABX- broad spectrum
how long do you continue abx w/ 2ndary periotnitis?
patient is afebrile w/ normal WBC
peritonitis that occurs in the absence of GI perforation
primary peritonitis
what mainly causes primary peritonitis
hematogenous spread
occasionally transluminal or direct bacterial invasion
what is primary peritonitis associated w/?
cirrhosis
advanced liver dz
nephrotic syndrome
SLE
will you see free air w/ primary periotnitis
no
patient w/ cirrhosis, no free air but has free fluid what do you suspect?
primary peritonitis
> 90% of primary peritonitis are _______- microbial infection
mono
Tx for primary peritonitis
abx- not surgery
tx for secondary peritonitis
surgery
