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Flashcards in ABD Deck (28):
1

Etiologies of the acute abdomen

Inflammatory: bacterial, chemical Mechanical Neoplastic Vascular Congenital Traumatic

2

Visceral anatomy

Helps determine where pain may be referred Epigastric-- foregut Periumbilical-- midgut Lower abdominal-- hindgut

3

Three types of pain

Visceral Somatic Referred (T10-11 dermatome, lower lobe pneumonia)

4

Visceral pain

Results from stretching of autonomic fibers surrounding a hollow or solid viscus Crampy, colicky, gassy Usually intermittent Obstruction is common cause Usually ill-defined, diffuse May not have a point tenderness Pure visceral pain is midline

5

Visceral pain: Dx

Appendicitis Cholecystitis Bowel obstruction Renal colic Any hollow organ can cause visceral pain-- bladder, GB, ureters

6

Somatic pain

Occurs when pain fibers located in parietal peritoneum are irritated by chemical or bacterial inflammation Represents inflammation occurring subsequent to obstruction or visceral pain Generally: sharper, more constant, more precisely localized to area of disease, usually tenderness localized to area of pathology

7

If perforation is suspected....

DO NOT GIVE PO CONTRAST BARIUM Use Gastrografin or VoLumen (iodine)

8

Referred Pain

Pain felt any distance from diseased organ Frequently follows classical patterns GB-- radiates to R scapula Renal colic-- radiates into groin/testes Diaphragmatic irritation-- radiates to subraclavicular region

9

Origins of intra-abdominal pain

Peritoneal inflammation Obstruction of a hollow viscus Vascular disorder

10

Peritoneal inflammation

Somatic pain caused by inflammation of the peritoneum by an irritant Aseptic: gastric juice, pancreatic juice, bile, blood, urine Bacterial: Primary/spontaneous (cirrhosis, ascites) or secondary (disease or trauma to abdomen)

11

Obstruction of a hollow viscus

Obstruction of intesting, ureter, biliary tree produces typical colicky pain Intestinal obstruction leads to N/V Intensity increased with proximal obstruction Common causes: neoplasm, adhesions, volvulus, hernia, intussusception, pyloric stenosis

12

Vascular disorders

Bowel ischemia, infarction and aortic dissection, leakage or rupture are major abdominal vascular emergencies May present with atypical s/sxs Increased incidence with increasing age Almost always catastrophic consequences

13

Abdominal wall pain

Usually secondary to trauma: muscle strain, contusion, hematoma

14

PE of abdominal exam

Visual: Visceral pain-- often doubled over, writhing for comfortable position Peritonitis pain-- lie completely still, even gently tapping stretcher causes severe pain Ominous: diaphoresis, cyanosis, pallor, tachycardia, hypotension, orthostatic changes

15

Cullen's sign

Ecchymosis to peri-umbilical region

16

Grey-turner sign

Ecchymosis to flank or abdomen

17

Imaging studies in abdominal pain

Abdominal x-ray: flat and upright US CT-- most definitive testing

18

Elderly

Higher tolerance for pain results in later presentation Lower abdominal muscle mass results in paucity of findings Less physiologic reserve Paucity of findings results in significant delay in going to OR Delay in going to OR results in significant mortality, morbidity

19

Infants, children

Causes of pain are similar, but may not be able to verbalize More common: acute appendicitis, volvulus, intussusception, pyloric stenosis

20

Top 5 life threats

Abdominal aortic aneurysm Splenic rupture Ectopic pregnancy Acute MI Mesenteric infarction

21

Acute appendicitis

RLQ pain, localizes from periumbilical region N/V, fever, occasionally diarrhea MCC of surgical acute abdomen in patients obstruction --> ischemia

22

Dx of appendicitis

H&P: anorexia, N/V, fever, RLQ abdominal pain, peri-umbilical abdominal pain CBC w/diff: leukocytosis with shift to left UA Amylase/lipase: nonspecific Beta HCG (female) and trans-vag US

23

Imaging for appendicitis

US-- children CT scan-- adults

24

Questions to ask before surgery

NPO status Underlying comorbidities Surgical hx (esp. abdominal procedures) Allergies (to meds, family allergies) Coag (if suspicion)

25

What is the most common surgical procedure in the western hemisphere?

Appendectomy

26

What fluid would be good for management?

LR (unless renal disease)

27

What abx would be good?

Know the hospital protocol Cephalosporin, most likely Cover gram negatives

28

Treatment for appendicitis

Appendectomy Interval appendectomy Laparoscopy vs laparotomy Hydration Antibiotics Acute vs gangrenous vs perforated