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Flashcards in Abdomen - General Deck (19):
1

Be able to define and differentiate visceral, parietal, and referred pain when evaluating a patient for abdominal pain.

  • Visceral pain is usually dull and poorly localized. It is typically the result of distention of a hollow viscus. An example is early-stage appendicitis. 
  • Parietal pain is usually sharp and is localized more easily. It is the result of irritation of nerve roots to the peritoneum. Eg late-stage appendicitis.
  • Referred pain is pain felt at a site distant from the source of painful stimuli. For example, liver pathology can present as right shoulder pain as a result of diaphragmatic irritation.

2

Be able to use patient age, gender, and comorbidities to guide the creation of an appropriate differential diagnosis for abdominal pain. 

AGE

  • Causes of abdominal pain in pediatric patients include intussusception, gastroenteritis, appendicitis, and hemolytic uremic syndrome. 
  • Causes of abdominal pain in older patients include bowel obstruction, mesenteric ischemia, diverticulitis, and aneurysmal disease.

3

Be able to use patient age, gender, and comorbidities to guide the creation of an appropriate differential diagnosis for abdominal pain.

GENDER

Women may have abdominal pain due to gynecologic sources such as ectopic pregnancy, pelvic inflammatory disease, ovarian torsion, or endometriosis, in addition to the many other causes of abdominal pain that are seen in men.

4

Be able to use patient age, gender, and comorbidities to guide the creation of an appropriate differential diagnosis for abdominal pain.

COMORBIDITIES/MEDICATIONS

Comorbidities: 

  • Atrial fibrillation - mesenteric ischemia 
  • HIV-infected patients - opportunistic infections.
  • Sickle cell anemia - dehydration - abd pain/pain crisis
  • Recent abdominal surgery - postoperative causes like leaks or injuries
  • Multiple abdominal surgeries - adhesions

Medications:

  • Narcotics - obstipation and obstruction, mask sx.
  • NSAIDs - ulceration and perforation.
  • Anticoagulants - rectus sheath/retroperitoneal hematomas  GI bleeding.
  • Immunosuppressants - mask symptoms.
  • Cocaine and methamphetamine  - low flow intestinal ischemia.

5

Be able to obtain a detailed clinical history when evaluating a patient with abdominal pain. In addition, be able to perform an appropriate physical examination, including rectal, genital, and pelvic examinations.

  • Obtain a complete and thorough history, include PMHx, PSHx, meds.
  • HPI should include the location, quality, duration, timing, and frequency of the pain; factors that worsen or relieve the pain; associated symptoms.
  • Gynecologic hx for female pts should be obtained.
  • Weight loss may raise suspicion for malignancy
  • Diarrhea may suggest IBD or an infectious etiology.
  • Meds - inc risk of abdominal pain (NSAIDs) and mask sx (nacotics, immunosuppressants) of a more serious problem (esp elderly).
  • Consider nonabdominal etiology: MI, LL PNA

6

When evaluating a patient with abdominal pain, be able to establish a relevant differential diagnosis.

Location and characterization of pain can assist in diagnosis.

  • RUQ: hepatitis, cholecystitis, cholangitis, biliary colic
  • LUQ: splenic abscess, gastritis, gastric ulcer, pancreatitis
  • RLQ: appendicitis, nephrolithiasis, IBD, inguinal hernia, ectopic pregnancy
  • LLQ: diverticulitis, nephrolithiasis, IBD, inguinal hernia, ectopic pregnancy
  • Epigastric: PUD, GERD, gastritis, pancreatitis, MI, ruptured AAA
  • Periumbilical: early appendicitis, gastroenteritis, bowel obstruction
  • Diffuse: gastroenteritis, mesenteric ischemia, bowel obsx, peritonitis, IBS
  • Referred pain: pain in the R shoulder - liver, GB

The nature of the pain may also provide diagnostic information.

  • Burning pain is consistent with PUD.
  • Tearing pain can be seen with aortic dissection.
  • Colicky/crampy pain - distention of a tube (kidney stones or cholelithiasis).
  • Sharp pain develops with inflammation or when noxious stimuli like blood or bowel contents come in contact with parietal peritoneum.

7

Given a patient with abdominal pain, be able to order relevant laboratory and imaging studies.

Labs:

  • CBC, BMP, LFTs, UA
  • can add amylase, lipase
  • urine B-HCG level if young female

Imaging:

  • XR: initial if can't do CT - pneumoperitonx, obsx, volvulus
  • US: initial for RUQ pain or pediatric patients
  • CT: gold standard for many dx

8

Based on a working diagnosis for acute or chronic abdominal pain, be able to determine the need for emergent, urgent, or elective operation if surgery is indicated. Be able to select nonoperative treatment when appropriate.

  • Peritoneal signs or pneumoperitoneum suggest the need for emergent or urgent surgical intervention.
  • Diagnostic laparoscopy can be a useful adjunct when the diagnosis is uncertain.
  • Reducible hernias may be repaired electively. However, nonreducible hernias with signs of strangulation must be repaired emergently.

9

When caring for a patient with either acute or chronic abdominal pain, be able to identify the patient better served immediately with nonsurgical therapy. Also, be able to manage a patient in the preoperative period and prepare a patient for surgery should he or she need it.

  • Serial exams - critical in nonoperative, changes in PE - changes in tx
  • NGT - decompress the stomach and prevent vomiting if obsx
  • Correct electrolyte abnormalities - hypokalemia and acidosis, monitor
  • Foley - monitor fluid resusc
  • Some require abx against gram-negative enterics and anaerobes
    • ​zosyn
    • cipro/flagyl

10

A 30-year-old woman presents to clinic with complaints of chronic lower abdominal pain radiating into the groin. What is your approach to evaluating this patient and developing a differential diagnosis?

  • H&P including a pelvic and bimanual rectal examination.
    • ​HPI: location, intensity, characteristics, better/worse, episodes
    • ROS: N/V, diarrhea/constipx, GI bleed; RUQ ask jaundice, stool/urine color
    • GYN: menstrual hx, vaginal d/c or bleed, dyspareunia, dysmenorhea
    • PMHx; a-fib, DM, PVD; NSAIDs, immunomod/narcotics
    • ​PSHx: abd surgeries, scopes, c-section and deliveries
    • PE: R/o peritonitis, hernias, look for scars
  • Order appropriate testing
    • ​CBC, BMP, UA, LFTs, amylase/lipase; B-HCG
    • US: RUQ or gyn
    • XR: perf or obsx
    • CT: if not pregnant or kidney problems

11

A 55-year-old man is brought to the emergency department. He is diaphoretic, hypotensive, and complaining of severe midepigastric pain. What tests do you obtain in this emergency situation?

  • ABCs: r/o need for intubx, O2, IV access; good monitoring
  • FAST: RUQ, aorta, free fluid, peicardium, IVC, kidneys
  • EKG: r/o MI, arrhythmia 
  • XRs: r/o obstruction, perforation, PNA
  • Labs: CBC, chem 10, lactate, amylase/lipase, LFTs, UA; type and screen
  • DDx: many organ systems can cause this unstable epigastric pain picture
    • CV: AAA, aortic dissection, MI, mesenteric ischemia
    • GI: bowel obsx, duodenal/gastric perf d/t ulcers, volvulus, hernia, abscess
    • HPB: cholecystitis, cholangitis, pancreatitis
    • Other: splenic abscess, pyelonephritis 
  • Quick dx: be able to recognize this and move quickly
    • ​If septic, get cultures, start abx, and find source
    • If able to stabilize, go to CT
    • If perforated/peritonitic on initial workup, go to OR

12

A 25-year-old woman who is 8 weeks pregnant presents with a 5-hour history of right lower quadrant pain. What is your approach to evaluating this patient and developing a differential diagnosis?

  • Get US, emergency obs eval, CBC, UA, LFTs, amylase/lipase
  • vaginal bleeding, GA, HTN, vomiting, fetal HR, obstx hx, amniotic leakage, cervix/uterus status
    • ​vaginal bleeding: < or > 20 wks GA?
      • ​< 20 wks - ectopic, miscarriage
      • > 20 wks - placental abruption, uterine rupture, labor 
    • no ​vaginal bleeding: < or > 20 wks GA?
      • > 20 - HTN? 
        • ​yes - Preeclampsia, HELLP, fatty liver
        • no - uterine rupture, amniotic infection, labor
  • Discuss how pregnancy can alter the presentation of surgical illnesses.
    • ​nausea, vomiting (pre 20 wks), discomfort, constipation can all be normal
    • expandinf uterus changes location of intra-abdominal organs
    • hydronephrosis, light-headedness/syncope if supine are nl
    • WBC can be high as 14, Hgb can be low as 10.5, mild tachycardia 
    • rebound tenderness and guarding are never normal

13

A 28-year-old woman presents to clinic with complaints of diffuse, nonlocalized abdominal pain, especially after eating certain foods. She also experiences bloating and changes in stool consistency and has relief with bowel activity. What is your approach to evaluating this patient and developing a differential diagnosis?

  • Take a thorough history, including dietary habits and correlation with symptoms.
  • Develop a differential diagnosis that includes functional causes of chronic abdominal pain.
    • ​female: endometriosis, leiomyoma, adenomyosis, cysts, PID, adhesive dz; hypothyroid
  • Appropriately identify functional causes of chronic abdominal pain (lactose intolerance, irritable bowel syndrome, food allergy) and develop a plan to address these diagnoses.
    • ​routine labs, iron studies (serum lvl, TIBC, ferritin)
    • IBS - lidestyle, diet changes; can add symptomatic meds if fails more conservative
    • lactose intol - dec lactose, add lactase supps

14

A 54-year-old obese woman presents with abdominal pain that has been increasing in severity over the past 3 days. She has a history of multiple abdominal surgeries and reports that she has had previous episodes of similar pain. What is your approach to evaluating this patient?

  • Understand the importance of taking a thorough history and characterizing the pain.
  • Discuss which diagnostic tests may be indicated and why (eg, laboratory studies, imaging).
  • Identify the prior abdominal surgery as a potential cause (adhesion, hernia).
  • Discuss nonoperative management of partial small bowel obstruction and how to determine when operative intervention is necessary.
    • ​SBFT if partial obsx and stable pt
    • OR if complete obsx, fail SBFT, sepsis, shock, perforation, peritonitis 

15

A 65-year-old, 100 kg patient is in the intensive care unit, intubated, after being admitted with sepsis. He has received a large volume of intravenous fluid resuscitation, and his intra-abdominal pressure, as measured via the bladder, is 18 mmHg. He has a normal urine output and peak airway pressures. Describe the most appropriate management of this patient?

Reduce fluid administration and minimize enteral feedings.

Normal abdominal pressure is 5-7 mmHg; however, obese patients may have abdominal pressures 9-15 mmHg at baseline. Abdominal hypertension is classified into four grades: grade I (12-15 mmHg), grade II (16-20 mmHg), grade III (21-25 mmHg), and grade IV (>25 mmHg). In general, grade I and II can be managed medically. Nonsurgical management includes ensuring adequate analgesia and sedation, minimizing enteral feedings, gut decompression with a nasogastric tube, judicious use of intravenous fluids, and aspiration of ascites, if present. Grade III and IV HTN often require surgical decompression via laparotomy.

16

A 25-year-old, 220-kg female presents to the emergency department with three hours of acute-onset right lower quadrant pain. She describes the pain as mild and reports persistent nausea and vomiting. There is moderate diffuse tenderness on exam. Laboratory studies reveal a white blood cell count of 17,000 and a negative urine hCG. She is too heavy to fit onto the CT table. Which diagnostic test would be most helpful in finding the cause of this patient’s abdominal pain?

Diagnostic laparoscopy

The obese patient can present a diagnostic challenge to practitioners, as obesity compromises imaging quality. In patients who cannot be imaged using standard imaging techniques, diagnostic laparoscopy is a valuable tool. The largest standard film cassette measures 14 x 17 inches, so an abdominal plain film will require several images. Due to inadequate penetration of x-ray beams, plain films often have a suboptimal signal-to-noise ratio. Fat attenuation diminishes ultrasound quality. In addition, the footprint, or the area that is imaged, will be smaller in the obese patient. Diagnostic peritoneal lavage is typically used in trauma patients to confirm the presence of hemoperitoneum.

17

A 70-year-old male presents to the emergency department with an hour of acute-onset epigastric pain. He has a history of diabetes, hypertension, and alcoholism. He has had persistent nausea and is tachycardic. Initial laboratory studies included a complete blood count, basic metabolic panel, and lipase, all of which were normal. Of the following tests, which should be ordered next to explain the etiology of his abdominal pain?

EKG and chest x-ray

Remember that abdominal pain may have nonsurgical causes, especially in older patients. Pathology of the heart and lung may cause referred pain to the upper abdomen. Pulmonary pathology that can cause abdominal pain include pneumonia, especially of the lower lobes, and pulmonary embolism. Cardiac causes can include pericarditis, cardiac tamponade, or myocardial infarction. Additionally, there are many endocrine, metabolic, and hematologic causes of abdominal pain, including diabetic ketoacidosis, sickle cell crisis, and narcotic withdrawal. Focusing exclusively on abdominal pathology in patients presenting with abdominal pain may lead to misdiagnosis or delay of care.

18

Which of the following abdominal illnesses has been associated with cardiopulmonary bypass?

A. Mesenteric ischemia

B. Ogilvie's syndrome

C. Acute pancreatitis

Cardiopulmonary bypass has been associated with the development of mesenteric ischemia, Ogilvie’s syndrome, acute pancreatitis, acute acalculous cholecystitis, ileus, and stress ulcers. These conditions are linked to the low-flow state induced by being placed on cardiopulmonary bypass. Similar conditions can be seen with the use of vasoactive medications.

19

A 65-year-old woman has left lower abdominal pain, fever, and elevated WBC count. Forty-eight hours later, symptoms persist and she has not improved in spite of antibiotic therapy. The diagnostic evaluation most helpful in this setting is:

CT- highly specific, sensitive, noninvasive, low risk

  • Dx of uncomplicated acute diverticulitis usually made clinically.
  • If psx is unusual, complications such as abscess or fistulization occur
  • Abdominal x-rays are inexpensive but usually normal
  • Sigmoid/colonoscopy is usually abnormal but nonspecific, risk perforation
  • Contrast studies - ID narrow/fixed segments, fistula, obsx, displacement, local perf
    • Defer until after the acute d/t risk of perforation.