2 - ABD Overview

Question 1

Study radiographs in sequence (ABCDEF):

Answer 1

Adequacy

Bones

Calcifications

Deformity / density

Extraluminal / peritoneal air

Foreign bodies / fractures

Question 2

What film finding may suggest splenomegaly?

Answer 2

Gastric bubble displaced medially

Question 3

Briefly describe CT:

Answer 3

Slices of the body available in axial, sagittal, or coronal views

Appears as if we are standing at the patients feet looking toward the head

Question 4

Marking on the inside of the stomach

Answer 4

Rugae

Question 5

Markings on small intestine

Answer 5

Plicae circulares / valvulae conniventes

Question 6

Markings on the colon

Answer 6

Haustra

Question 7

Air is expected in the stomach and colon - if it’s absent, must r/o:

Answer 7

Gastric outlet obstruction

Question 8

If you have air in the stomach and small bowel but not the colon, must r/o:

Answer 8

Obstruction

Question 9

Air is normally NOT seen in small intestine - if visible, must r/o:

Answer 9

Ileus or obstruction

Question 10

Describe ileus

Answer 10

Impaired GI tract motility

Common after surgery (anesthesia) or irritation of the viscera

Presents c N/V, ABD pain, (-) bowel sounds

Air in stomach, small and large bowel (no flatus being passed)

Contrast does not move through to colon

Question 11

Txt of ileus?

Answer 11

NPO, NG-tube, IV-fluid

AVOID NARCS

Question 12

Prevention of ileus

Answer 12

Good OR technique
Minimize bowel manipulation during surgery
Replete electrolytes

Question 13

What drug is given pre-op as a pro-motility drug to prevent or minimize narcotic-induced ileus?

Answer 13

Alvimopan (Mu blocker)

Question 14

Obstruction presents with:

Answer 14

Pain 
Distention
Present bowel sounds
Fever
Peritoneal signs

Air-fluid levels on upright films

Question 15

What is open-loop obstruction?

Answer 15

Able to decompress (solid mass)

Question 16

What is closed-loop obstruction?

Answer 16

Unable to decompress (volvlus / internal hernia)

Question 17

How is obstruction treated?

Answer 17

NG tube decompression

Close observation

Fluid resuscitation

*higher incidence of surgery compared to ileus

Question 18

Air seen under the right diaphragm on upright films - suspect:

Answer 18

Pneumoperitoneum

Question 19

Air seen under left diaphragm on upright films - suspect:

Answer 19

Pneumoperitoneum OR possibly just a stomach bubble

Question 20

Name some intraabdominal organs that can have either pathologic or benign calcifications:

Answer 20

Gall bladder
Kidney
Ureters
Arteries

Question 21

Before giving any kind of contrast, you wanna order what labs?

Answer 21

BUN/Creatinine to assess kidney function

Question 22

What med do we hold for 48-72 hrs after administration of contrast?

Answer 22

Metformin

Question 23

Describe barium contrast:

Answer 23

Thick, chalky

Coats the walls of hollow organs well

Question 24

Describe Gastrografin:

Answer 24

Thinner, not as caustic if extravasated

Used in suspected perforation

BAD IF ASPIRATED

Question 25

Describe the upper GI tract studies

Answer 25

X-rays Barium swallow (evaluate esophagus) UGI - esophagus, stomach, duodenum UGI with small bowel follow-through (UGI plus add’l timed radiograph to assess small bowel)

Question 26

A barium enema is used to asses:

Answer 26

The lower GI tract (bowel) ACBE - requires prep BE - requires no prep, used to r/o obstruction, can be therapeutic

Question 27

US best for:

Answer 27

Fluid-filled and semi-solid structures Good for detecting free air / fluid in the abdomen

Question 28

US poor for:

Answer 28

Air-filled structures

Question 29

What are the three main areas to divide the abdomen into?

Answer 29

1. GI tract (mouth to anus) 2. Biliary (liver, gall bladder, pancreas) 3. Genito-Urinary-Kidney -> urethra

Question 30

General ROS q’s:

Answer 30

Fever Appetite changes Malaise Trauma

Question 31

GI ROS Q’s:

Answer 31

N/V/D Hematochezia / melena Prior colonoscopy or EGD

Question 32

Biliary ROS Q’s:

Answer 32

Jaundice Hepatitis Gall stones Pancreatitis

Question 33

GU ROS Q’s

Answer 33

``` Hernia LMP OCP’s Gravida/parity STI’s BPH Testicular pain UTI ```

Question 34

Chest ROS Q’s

Answer 34

Cough COPD URI

Question 35

Patient moving vs lying still - differentials:

Answer 35

Lying still - peritonitis Moving/restless - obstructive

Question 36

Name the four general abdominal appearances:

Answer 36

Scaphoid Flat Rounded Protuberant

Question 37

Cullen’s Sign and Grey’s Turner’s Sign - suggestive of:

Answer 37

Acute pancreatitis

Question 38

What is peristalsis:

Answer 38

Segmental contraction and relaxation of the muscles within the GI tract

Question 39

ABD percussion - how do solid organs and fluid sound?

Answer 39

Lower tones

Question 40

ABD percussion - how does free air sound?

Answer 40

Hypertympanic

Question 41

Tenderness to percussion may suggest:

Answer 41

Peritonitis (follow-up with a heel tap to evaluate for rebound tenderness)

Question 42

ABD palpation - pain out of proportion in older CAD patient suggests:

Answer 42

Bowel ischemia - suspect mesenteric ischemia

Question 43

Most ABD complaint patients will get which labs:

Answer 43

``` CBC CMP HCG Amylase/lipase UA ``` (If surgical - PT/INR, aPTT) *if critical, ABG

Question 44

Return criteria for patients with home disposition:

Answer 44

Fever, increased N/V, intractable pain

Question 45

If surgery is likely:

Answer 45

Order consult NPO Start maintenance fluids

Question 46

Interventions for patients admitted for observation:

Answer 46

``` Pain control NG tube Maintenance fluids (mIVF) Labs (repeat) Films (repeat) Vitals (repeat) ```

Question 47

Examples of emergent (do immediately or they die) surgical candidates:

Answer 47

Blunt trauma Penetrating trauma Ruptured AAA Aortic transection

Question 48

Examples of urgent (within 24hrs) surgical candidates

Answer 48

Appendicitis Ectopic pregnancy Incarcerated hernia

Question 49

3 way abd:

Answer 49

Flat Upright CXR

Question 50

Transverse view is AKA:

Answer 50

Axial view (MC view on CT)

Question 51

Why shouldn’t we see air in the small bowel?

Answer 51

Peristalsis is constant, emulsifying the air

Question 52

CVA tenderness - high index of suspicion for:

Answer 52

Pyelonephritis

Question 53

ADC-VAN-DISMEL

Answer 53

Admit (what unit) Diagnosis (and comorbities) Condition (stable, guarded, grave) Vitals (how often to take, usually q4hrs on regular floor) Activity (what they can do, fall risk) Nursing orders (I and O, weights, etc) Diet (NPO, DM, etc) IVF Studies (tests) Meds Allergies Labs

Question 54

Statistically….

Answer 54

9 out of 10 injections are in vein.