1 - Acute ABD Pain Flashcards by Samuel Halajian

What is the MC reason for an ER visit in the US?

ABD pain / cramps / spasms / whatever — some kind of abdominal thing

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What is often req’d for dx?

Imaging to make a specific dx

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Visceral pain

Form the organ

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Parietal pain

From the overlying serosa

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Referred pain

Felt somewhere else

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Causes of visceral pain

Obstruction
Ischemia
Inflammation

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Visceral pain feels:

Crampy, dull, achey

Can be either steady or intermittent (colicky)

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Is visceral pain highly specific?

No, generalized due to nerve segmental distribution

Body can’t really locate it bc it’s fed by the spinal cord

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Epigastric pain

Stomach, 1st / 2nd parts of duodenum, liver, gallbladder, pancreas

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Periumbilical pain

Third/fourth parts of duodenum, jejunum, ileum, cecum, appendix, ascending colon, first two-thirds of transverse colon

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Suprapubic pain

Last third of transverse colon, descending colon, sigmoid, rectum

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Why is parietal pain (somatic pain) more localized?

Irritation of the myelinated fibers that innervate the parietal peritoneum

Can be localized to the dermatome superficial to the painful stimulus

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As the dz process evolves:

Sxs change from visceral pain -> parietal pain, causing tenderness and guarding

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Pts c peritonitis prefer to remain:

Immobile

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Referred pain patterns are based on

Developmental embryology

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Referred pain is usually perceived:

Ipsilateral

Only midline if process is midline

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Markers high acuity:

I.e. they are not doing well

Age
Severe pain c rapid onset
Abnormal V/S
Dehydration
Evidence of visceral involvement

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ABD pain then shock?

Suspect bleeding (AAA)

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How much blood loss required to see SBP drop?

30-40 percent of normal volume (so, by the time you see a drop in BP, that means they’ve lost a lot (30-40 percent of their blood!))

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Does the absence of tachycardia mean their fluid level is good?

No - they could just be compensating in other ways

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Tachypnea may indicate

Cardiopulmonary process
Metabolic acidosis
Anxiety
Pain

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If you suspect hemorrhage or urgent transfusion is anticipated, what should you order?

Cross-matched blood

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How can I quickly measure and visualize the ABD aorta?

Bedside ultrasound

ID a AAA quickly

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High-risk groups:

Cognitive impairment
Cannot communicate effectively
Asplenic patients
Neutropenic patients
Transplant patients
Immunosuppressed

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What’s the problem with assessing immunosuppressed?

They can have delayed or atypical presentation Also, more likely to present c opportunistic infx

What’s the most important measure of immunocompetence in an HIV (+) patient?

CD4 count If over 200, less likely to have opportunistic stuff

Don’t forget to check what?

SKIN! Color, temp, turgor, perfusion status Also, targeted heart and lung exam

Distention could mean:

Ascites Ileus Obstruction Volvulus

Obvious masses could mean:

Hernia Tumor Aneurysm Distended bladder

Surgical scars could mean:

Adhesions

Ecchymoses could mean:

Trauma | Bleeding diathesis

Stigmata of liver disease is:

Spider angiomata | Caput medusa

Decreased BS, consider:

Ileus, mesenteric infarction, narcotic use, or peritonitis

Hyperactive BS, consider:

Small bowel obstruction

Abdominal rigidity and involuntary guarding reflex suggests:

Peritoneal irritation

How common is rebound tenderness in appendicitis?

About a third

Lower abd pain in a female?

Its wise to do a pelvic exam in women who have not had a complete hysterectomy Lower quadrant vs pelvic / suprapubic can be difficult to differentiate

With lower abd pain in males, you also wanna check for:

Hernia | Testicular and prostate exams

What is the main value of the rectal examination?

Detection of grossly bloody, maroon, or melanotic stool

Two main approaches to grouping ABD pain

1. By location (quadrant) | 2. By presenting symptomalogy

Slide 30

Breakdown of ddx by quadrant

Slides 31-32

Ddx by symptomalogy

Will opioid analgesia obscure exam findings?

No - treat the pain

Consider placing what while waiting for surgical consult?

NG tube (can confirm bleeding, decompress the stomach) Foley Cath (can relieve bladder obstruction and help gauge renal function by measuring UOP)

What’s the deal with lab tests?

Comprehensive H and P, PE, way more important Pt’s can have real disease c (-) lab findings ex. - up to 25% of pts with acute mesenteric ischemia have normal serum lactate initially

Slide 36 and 37

If you suspect this, order that

If suspect pancreatitis , order:

Lipase

Is suspect pregnancy, get

HCG

Abdominal series usually includes:

Upright ABD or upright chest

Plain radiographs to check for:

Obstruction Sigmoid volvulus Perforation Severe constipation

Contrast options:

PO PR IV Protocols vary

Preferred imaging modality for dx’ing kidney and urethral stones

Noncontrast CT

Slides 44 through 49

The super mega chart (don’t need to memorize) | But it helps

If dx is unclear, you should have the pt follow up:

Within 12 hrs

Any woman of reproductive age c hemodynamic collapse?

R/o ectopic pregnancy

Slide 55

Common GYN causes of lower abdominal or pelvic pain Some of them potentially life-threatening

MC surgical entity in elderly c ABD pain?

Cholecystitis

Concern for bariatric surgery patients?

Enteric leak -> sepsis

Air fluid levels may suggest but don’t confirm:

Obstruction

I’m sorry to hear about your abdominal pain

If you could put down the mountain dew and wipe the Cheetos dust off your hands i’ll be happy to jump right into your emergency

1 - Acute ABD Pain Flashcards

(60 cards)