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Medicine II: Emergency Medicine > Abdominal Emergencies > Flashcards

Flashcards in Abdominal Emergencies Deck (97):

Abdominal complaints are what percent of ED visits? How do we diagnose them?

6% of ED visits. H&P + directed studies = Dx. MUST rule out life-threatening emergencies. Most common diagnosis is NONSPECIFIC.


Why AP is Tricky

Imprecise pain generation and transmission to the CNS.
Comorbid disease.
Extra-abdominal pain


In considering the age of the patient, what diagnoses should we think of in 0-2 yo, 2-12yo, teens/adults, elderly?

0-2- Colic, GE, viral illness, constipation

2-12- Functional, appendicitis, GE, toxins

Teens to adults- Addition of genitourinary problems

Elderly- Beware of everything!


What are the types of Pain?

Visceral, Somatic & Referred


Describe Visceral Pain.

Stretch fibers in capsules or walls of hollow viscus that enter both sides of spinal cord. Crampy, achy, diffuse, poorly localized.



Describe Somatic Pain.

Fibers dermatomally distributed and enter unilaterally in the spinal cord. Sharp, lancinating, well localized



Describe Referred Pain.

Overlap of fibers from other locations. Pain is distant from site of generation. Symptoms, but no signs



What part of the physical exam tends to be the most helpful for abdominal pain?

Palpation; Tenderness versus pain, Start away from painful area. Look for guarding, rebound, masses.


The Physical Exam: Signs

Hop Test


T/F: A rectal exam is one of our most useful tools in diagnosing abdominal pain.

False, A Rectal exam adds very little beyond gross blood or melena.


What is the first step in the management of Abdominal Pain

Always start with ABC’s


What is one Laboratory Test with abdominal pain we have to always use with women?

Pregnancy test in women of child bearing age


Is the CBC helpful in diagnosing abdominal pain?

NO, it lacks sensitivity, and has no specificity. The CBC should not dramatically alter approach (tender is still tender).


How are various imaging procedures used with abdominal pain in the ED?

In Plain films we look for free air, obstruction, air-fluid, FBs

Ultrasound: No radiation exposure, Limited exam. Used as a rapid “yes or no” ED evaluations. May add doppler.

CT: Much more specific (Contrast vs. non-contrast) does have radiation exposure

MRI: Limited use for abd pain, Pregnant patients


Acute Appendicitis Pathophysiology:

Thought to be due a luminal obstruction (food, adhesions, or lymphoid hyperplasia). The obstruction leads to increase in intraluminal pressure. and eventually, the increased pressure leads to arterial stasis and tissue infarction.


Clinical Features of Acute Appendicitis:

#1 symptom is abdominal pain. Classically, patients develop periumbilical pain followed by anorexia, NV, and low grade fever. As the illness progresses, the pain becomes more localized to the the RLQ.


Diagnosing Acute Appendicitis:

*MANTRELS + CT Abdomen and Pelvis w/ oral & IV contrast

Labs: CBC, BMP, UA
Pelvic Exam and/or Rectal Exam


Treatment of Acute Appendicitis

Antibiotics, Surgery or conservative management


Characteristics of Small Bowel Obstruction on Plain Film:

Small intestine is characterized by transverse linear densities that extend completely across the bowel lumen (plicae circulares).


Characteristics of Large Bowel Obstruction on Plain Film

The colon is seen peripherally in the abdomen, is larger in diameter, and contains short, blunt, and thick projections (haustra) that arise from the bowel wall and extend only partially into the lumen.


Small Bowel Obstruction (SBO) Pathophysiology:

ADHESIONS!!!! or Strangulated and incarcerated inguinal hernias.


Clinical Features of SBO:

Diffuse abdominal pain that is often crampy, colicky, intermittent and severe.Followed by vomiting and inability to pass flatus.

PE may show distended abdomen that is diffusely tender with occasional high-pitched bowel sounds on auscultation.


Diagnosis of SBO

3-View Plain Film AXR showing dilated loops of small bowel and AF levels.

Typically followed by CT AP to assess degree and location of obstruction.

Labs: CBC, BMP


Large Bowel Obstruction Pathophysiology:

Neoplasms are by far the most common cause of LBO, followed by diverticular disease then simoid volvulus.


Clinical Features of LBO

Diffuse abdominal pain that is often crampy, colicky, intermittent and severe.Followed by vomiting and inability to pass flatus.

PE may show distended abdomen that is diffusely tender with occasional high-pitched bowel sounds on auscultation.


Diagnosis and Treatment of LBO

Plain Films (may perform barium enema), typically followed by CT AP to evaluate for neoplasm

Labs: CBC, BMP


Bowel Perforation Pathophysiology:

Typically caused by a perforated peptic / duodenal ulcer or perforated diverticulum.


Bowel Perforation Clinical Features

Perf of peptic/duodenal ulcer causes sudden onset, severe upper abdominal pain. The pain may temporarily subside as the gastric contents dilute within the peritoneum.

Perf of diverticulum also causes sudden sharp pain but may be more diffuse and in lower quadrants.


Bowel Perforation Diagnosis:

3-View Plain Film AXR then IMMEDIATE SURGERY CONSULTATION. DO NOT DELAY treatment on CT scan.

Labs: CBC, BMP, Coags, Blood Cx, Type and Screen


What is the pathogenesis of Biliary Colic?

The pathogenesis of biliary colic or symptomatic cholelithiasis typically occurs when a stone moves from the gallbladder to the biliary tract, possibly leading to obstruction.


What are the “F’s” of biliary disease (risk factors)?

o Female
o Forty or Fifty
o Fat
o Fertile


Clinical Features of Biliary Colic

Occurs frequently after ingestion of food. Begins suddenly and may subside gradually over a few hours. Pain is frequently found in the RUQ. May be diffuse upper AP with occasional radiation to the scapula. Accompanied with NV.

The Murphy sign is worsened pain or inspiratory arrest resulting from deep, subcostal palpation on inspiration (97 percent sensitive for acute cholecystitis).

Acute cholecystitis is similar to biliary colic but symptoms become more severe and persistent.


Diagnosis of Biliary Colic

RUQ Ultrasound is the test of choice (Inexpensive, Harmless to patient and/or fetus, Quick, Sensitive and Specific)

Labs: CBC, BMP, LFTs, Lipase

Typical findings of acute cholecystitis on US: GB wall thickening, dilated CBD, pericholecystic fluid and an Ultrasonographic Murphys sign.


Treatment of Biliary Colic

Antibiotics, IVFs, surgical consultation

If symptomatic cholelithiasis, may discharge home with an outpatient follow-up for elective cholecystectomy.


What is Mesenteric Ischemia?

A relatively rare diagnosis and when missed is almost always fatal, therefore you should maintain a high clinical suspicion (especially for patients with a history of diffuse atherosclerotic disease, cardiac dysfunction or recent arterial catheterization.)


Pathophysiology of Mesenteric Ischemia:

May be caused by an embolus, thrombus, vasoconstriction or venous thrombosis.

Chronic ischemia is typically caused by low-flow-limiting lesions such as stenosis or occlusions. The watershed areas that are common locations for colon ischemia (between the SMA and IMA).


Clinical Features of Mesenteric Ischemia:

Patients classically have sudden onset central abdominal pain that is out of proportion to the examination +/- NV.

Weight loss secondary to rapid bowel emptying (an important clue for an acute abdomen). Bloody diarrhea is a late sign.


Diagnosis & Treatment of Mesenteric Ischemia:

Labwork may reveal a marked leukocytosis, azotemia, acidosis, elevated lactic acid

CT angiogram or Mesenteric Angiography (if available)


Clinical Features of Pyelonephritis

Classically characterized by chills, fever, flank pain, and CVA tenderness +/- urinary symptoms such as dysuria, frequency, and urgency. As it progresses, patients may also develop NV.

Occurs most often as a result of untreated or asymptomatic UTI.


Diagnosing Pyelonephritis

Typically a clinical diagnosis based on a thorough H&P and UA findings.

A CT may show perinephric stranding with mild hydronephrosis but is typically non-contributory.


Renal Colic

Urolithiasis is a very common condition. The incidence of stones is highest among whites with a peak incidence between ages 20 and 50 years, and the male to female ratio is 3:1.

75-85% of stones are calcium stones that usually occur in conjunction with oxalate, phosphate or both.


Renal Colic Clinical Presentation:

Patients usually present with sudden onset of unilateral flank pain that may radiate to the ipsilateral LQ, groin, scrotum, or labia. Patients may also develop NV.

Hematuria is present in approximately 90%


Diagnosing Renal Colic:

Obtain CBC, BMP, UA, and uHCG.

**Spiral CT is the test of choice; IV Pyelogram, US, and KUB may also be used (Sensitivity drops with each of these tests respectively.)


Treatment of Pyelonephritis

Uncomplicated pyelonephritis without obstruction can usually be treated with oral antibiotics and discharge.

Indications for admission acute include: extremes of age, intractable NV, pregnancy, male.


T/F: A patient with appendicitis by H&P does not need a CT scan to confirm the diagnosis; they need an operation.



Treatment of Mesenteric Ischemia

Treatment is surgical, with restoration of flow by bypass or embolectomy, resection of nonviable intestine, and liberal use of "second look" laparotomy.


What are the categories when describing the Quality of Pain?

Acute Onset, Gradual Pain, Colicky Pain, Constant Pain


What is Acute Onset Pain indicative of ?

Indicates a vascular etiology (AAA, Mesenteric Thrombosis), a ruptured viscus, or obstruction.


What is Gradual Pain indicative of?

Due to inflammation (Appy, diverticulitis)


What is Colicky Pain indicative of?

Indicates obstruction of a viscus as opposed to a perforation, in which the severe pain persists or worsens


What is Constant Pain indicative of?

Suggests a solid organ process such as hepatitis, pancreatitis, or pyelonephritis


How do we determine which lab studies to order with abdominal pain?

Based on patients reported pain and system based approach.Should change your management depending on result.

CBC, electrolytes, LFT’s, UA, amylase, lipase


What it the typical presentation of Acute pancreatitis?

Dull epigastric pain that radiates to back in classic presentation accompanied with N/V.


What are the causes of Acute pancreatitits?

Alcohol and Gallstones and most important!

Others: Idiopathic, ERCP, Trauma, Infectious, Medications


What goes into the Work-up for acute pancreatitis?

CBC, Chemistry, LFT’s, Lipase

CT Abd/pelvis


What is Gray Turner's Sign?

A bluish-discoloration of the flank


What is Cullen's Sign?

A periumbilical bluish-discoloration


What are Ranson’s Criteria?

On admission: - Age > 55, WBC > 16,000, Glucose >200,
AST > 250, & LDH > 350

At 48 hours: - Calcium < 8, Hematocrit fall > 10%, BUN increase of 1.8, Base deficit > 4, PO2 < 60, Fluid > 6Liters


What is a Pancreatic Pseudocyst?

A cystic collection of fluid with a high content of pancreatic enzymes, lacking a true epithelial lining. Located in the parenchyma of the pancreas or adjacent abdominal spaces


What is the Treatment for a pancreatic pseudocyst?

NPO!, NGT, Pain meds, Bowel rest and IVF


Patient Disposition with a pancreatic pseudocyst:

Discharge it is Mild pancreatitis, the patient is tolerating PO, this is not first episode, they have only a slight lipase elevation, and if the pain is controlled

Admission is the patient is Not able to tolerate PO or it there is Intractable pain


Ruptured Ectopic is a ______________.



How does a patient present with a ruptured ectopic pregnancy?

Presents with the Triad of ABD pain, Amenorrhea and Vaginal bleeding

They can also have sypmtoms of Dizziness, weakness, N/V. This Can present similar to spontaneous abortion.


What are the Physical Exam Findings in a patient with a Ruptured Ectopic Pregnancy?

Lower abd/pelvic pain. We must preform a Pelvic Exam


What work up do we order if we suspect a ruptured ectopic?

HCG!, CBC, Chem, UA



How do we treat a patient with a ruptured ectopic pregnancy?

Surgical if the patient is Hemodynamically unstable → go to OR

Medical is the patient is hemodynamically stable: Methotrexate, control their pain.


Pelvic Inflammatory Disease Pathophysiology:

• Endometritis
• Salpingitis


How does a patient present with Pelvic Inflammatory Disease?

Patient complains of Lower abd pain, Vaginal discharge, Low back pain and Dysuria


What are the Physical Exam Findings in a patient with Pelvic Inflammatory Disease?

Low abd tenderness noted.

During Pelvic Exam: Purulent discharge,

CMT – “Chandelier” sign
Uterine/adnexal TTP


What goes into the Work-up of a patient presenting with Pelvic Inflammatory Disease?

Labs: CBC, Chemistry, Wet Prep, UA, Sed rate and CRP and GC cultures or other detection assays

Imaging: TOA vs. ovarian cyst vs. ovarian torsion


Treatment for PID:

Outpatient: Levaquin or Ofloxacin + Flagyl

Indication for Admission: Pregnancy, Intractable pain, Unable to tolerate PO, Immunodeficient, TOA.

Inpatient meds: Cefotetan or Cefoxitin + Doxycycline OR Clindamycin + Gentamycin


Patient presentation with a Ruptured Ovarian Cyst:

Cysts typically asymptomatic until complicated.

Complications include Hemorrhage, torsion, rupture or infection


What is the most common Ruptured Ovarian Cyst

Follicular cysts


Ovarian Torsion Pathophysiology:

Twisting of a vascular pedicle of ovary leads fallopian tube ischemia which leads to occlusion of lymphatics & venous drainage and thus rapid enlargement of adnexa


Risk Factors for Ovarian Torsion:

Greatest frequency in reproductive age women (Mid 20’s), who have a PMHx of Ovarian cysts, Tumors (Cystadenomas & Teratomas), Pelvic surgery, Tubal ligation, Hysterectomy, or Pregnancy


Treatment of Unstable patients with ovarian torsion:

Initial Stabilization: ABC’s
Then IV- O2- monitor and Volume replacement
+/- Blood Transfusion as indicated
Immediate Gynecologic consultation & admission

Unstable patients or torsion GO TO THE OR


Discharge Criteria of Ovarian Complaints

Stable patients with a ruptured cyst and No evidence of coagulopathy. Along with No evidence of significant hemorrhage.

Ensured close GYN follow-up


What is Peritonitis?

Inflammation of peritoneum, the membrane that lines the abdominal cavity and viscera.


What is the pathophysiology of peritonitis?

Infectious: Perforation of GI tract, Strangulation of intestinal tract, Penetrating/blunt trauma, Ingestion of sharp FB, Endoscopy, Spontaneous bacterial peritonitis, Intra-peritoneal dialysis.

Non-infectious: Leakage of sterile body fluid into abd cavity, Blood, Bile, Urine, Pancreatic enzymes, Post-surgical, Adhesions, Foreign body reaction.


What are the Signs & Symptoms of Peritonitis?

Abd pain with involuntary Guarding (Rigid abdomen
). With accompanying Fever and Tachycardia. Ileus and Nausea and vomiting.


Work-up for peritonitis:

Directed toward determining source of peritoneal irritation. Labs, Imaging.


Treatment for peritonitis:

ABC’s First then IV fluids

Consult surgery early

Broad spectrum IV antibiotics, Pain meds and if needed Surgery


Disposition of a patient with peritonitis:



What is a Retroperitoneal hemorrhage? And what can cause it?

It is a bleeding into retroperitoneal space. Can be caused by Patients being on anti-coagulation, Trauma, AAA complication, Malignancy or a Clotting disorder


What is in the Retroperitoneum?

• Kidneys
• Ureter
• Bladder
• Vena cava
• Aorta
• Part of duodenum
• Part of colon
• Pancreas
- Reproductive organs


Presentation of a Retroperitoneal hemorrhage

Patient often presents with vague and misleading pain. Patient often has a Hx of AAA, recent trauma, anti-coagulation.


Retroperitoneal hemorrhage Symptoms:

Back pain, flank pain, dizziness, weakness, syncope


Physical Exam Findings in a patient with a Retroperitoneal hemorrhage

Grey Turner sign


What goes into the Work-up for a Retroperitoneal hemorrhage?

Labs: CBC, BMP/ABG (Electrolytes), PT/PTT/INR, UA

Imaging: CT


Treatment for a Retroperitoneal hemorrhage:

ABC’s and IV fluids

Correct coagulopathy, Consult appropriate service (General surgery, Urology, Renal/ureter – injury)


Disposition of a patient with a Retroperitoneal hemorrhage

OR! Admit to appropriate service for observation


T/F: Elderly with abdominal pain may have more serious disease and pain out of proportion to exam.



Treatment for SBO:

IVFs, NGT, analgesia, antiemetics

Admission, and possible surgery depending on degree of obstruction.


Treatment of LBO:

IVFs, NGT decompression


What is the Treatment for Bowel Perforation?

Broad spectrum antibiotics covering anaerobic and Gram – organisms


T/F:Cardiac disease can present as upper abd pain



T/F: All patients need full lab/imaging work-up for abdominal pain.

False, Not all patients need full lab/imaging work-up