Abdominal pain Flashcards
(141 cards)
1
Q
- MC Older male, smoker, atherosclerosis
- Sudden severe back or abd pain; HoTN; Pulsatile abdominal mass
- Syncope, pain localized to flank, groin, hip or abdomen possible
- Severe + abrupt ripping/tearing pain possible
- Femoral pulsations nml
- Retroperitoneal hemorrhage rarely present w/ external findings (Cullen’s, Grey-Turner’s, scrotal hematoma)
dx?
A
AAA
2
Q
When would an AAA require emergent surgerical repair?
A
Symptomatic aneurysms and ≥ 5.0 cm
3
Q
- GI bleeding - small or life-threatening
- H/o aortic grating at higher risk
- Duodenum MC site
- Hematemesis, melena, hematochezia
- High output cardiac failure with ↓ arterial blood flow distal to fistula
dx?
A
Aortoenteric fistulas
AAA
4
Q
how would a Rupture into retroperitoneum present?
AAA
A
- Fibrosis → chronic contained rupture
- Appear nml, may have pain for long time before dx is made
5
Q
MC incorrect initial dx of AAA? How would this present?
A
renal colic - Back pain, intraabdominal process, testicular torsion , GI bleeding
6
Q
w/u for AAA?
findings?
A
If dx unclear:
-
Bedside abd US - >90% sensitivity
- Aortic rupture/retroperitoneal bleed not reliably identified - CT - delineates where aneurysm and any assoc rupture
- XR - calcified, bulging aortic contour (only in some)
7
Q
- mgmt AAA?
- mgmt if small asx (3-5cm)? large (>5?)
A
- Consult vascular surgeon if rupture / aortoenteric fistula
- Fluids (for HoTN)
- Target SBP: 90 mmHg
- Transfuse PRBC if needed
- Pain control while avoiding HoTN
- Small asx (3-5cm): Refer to vascular surgeon
- Large (>5cm): ↑ risk for spontaneous rupture; close f/u
8
Q
types of nonaortic large-artery aneurysms
A
- popliteal
- SC
- femoral
- femoral pseudoaneurysms
- iliac
- splenic
- hepatic
9
Q
- Old, male, trauma, congenital disorders
- MC peripheral aneurysm
- Discomfort behind knee w/ swelling +/- DVT
dx?
mgmt?
A
- popliteal aneurym
- thrombolysis, ligation, arterial bypass, endovascular repair
10
Q
- RF: Arteriosclerosis, thoracic outlet obstruction
- Pulsatile mass above/below clavicle
- Dysphagia, hoarseness
- Stridor
- chest pain
- UE fatigue / numbness & tingling
- limb ischemic sx
dx?
mgmt?
A
- subclavian aneurym
- surgical repair
11
Q
- RF: Old, male, trauma, congenital disorders
- Pulsatile mass +/- pain
- Limb ischemic sx
- peripheral embolic sx
dx?
mgmt?
A
- femoral aneurym
- thrombolysis, ligation, arterial bypass, endovascular repair
12
Q
- RF: Prior femoral artery cath, trauma, infection
- Pulsatile mass +/- pain
dx?
mgmt?
A
- Femoral pseudoaneurysm
- surgical repair
13
Q
- RF: 40–60 y/o, HTN, fibrodysplasia,
- arteriosclerosis; no gender preference
- Flank pain
- Hematuria
- collecting system obstruction
- shock if ruptured
dx?
mgmt?
A
- renal aneurysm
- surgical repair, Nephrectomy
14
Q
- RF: Old, female, HTN, congenital, arteriosclerosis, liver dz, multiparous; ↑ rupture w/ pregnancy
- Rapid onset;
- epigastric or LUQ pain first, then diffuse abd pain with rupture
- shock
dx?
mgmt?
A
- splenic aneurysms
- surgical repair, splenectomy
15
Q
- RF: Infection, arteriosclerosis, trauma, vasculitis
- Obstructive jaundice
- hemobilia from rupture into CBD
- RUQ pain
- Peritonitis
- Upper GI bleed
dx?
mgmt?
A
- hepatic aneurysm
- surgical ligation, embolization
16
Q
Blood dissects between intimal and adventitial layers of aorta
A
Aortic Dissection
17
Q
RF for Aortic Dissection
A
- MC male, >50y, h/o HTN
- Chronic cocaine use
- h/o cardiac surgery
- Young - CTD, congenital heart dz, pregnancy; Marfan’s syndrome
18
Q
- Acute CP
- Most severe at onset
- Radiates to back/scapula
- Sharp, ripping, tearing pain
- Syncope possible
- Location dependent
- Diastolic murmur of aortic insufficiency possible
- HTN and tachycardia common; HoTN possible
- ↓ pulsation in radial, femoral, or carotid arteries
- Neurologic sequelae
dx?
how do anterior vs abd/back pain differ?
A
aortic dissection
Anterior - ascending aorta
abd/back - descending aorta
19
Q
aortic dissection classification?
A
Stanford Classification
- Type A - Ascending Aorta
- Type B - descending Aorta
20
Q
presentation of Progressed dissection
A
- AV insufficiency
- coronary artery occlusion - MI
- carotid involvement - stroke sx
- occlusion of vertebral blood supply - paraplegia
- cardiac tamponade - shock and JVD
- compression of recurrent laryngeal nerve - hoarseness
- compression of superior cervical sympathetic ganglion - Horner’s syndrome.
21
Q
w/u aortic dissection?
findings?
A
- D-Dimer
- CXR: MC - Abml aortic contour, widening mediastinum
- Deviated trachea, mainstem bronchi, esophagus, apical capping, pleural effusion, displacement of aortic intimal calcifications - Dx: CT w/ contrast; TEE
22
Q
mgmt for aortic dissection
A
- Vascular / thoracic surgeon
- Fluids
- Esmolol/labetalol - Goal HR: 60-70; SBP: 100-120
- SBP >120: nitroprusside/nicardipine
23
Q
3 types of pain
A
- Visceral: poorly localized; stretching of unmyelinated fibers of walls/capsules of organs
-
Parietal: localized; irritation of myelinated fibers of parietal pleura covering peritoneum
- tenderness & guarding → rigidity & rebound tenderness -
Referred: pain felt at a location distant to underlying cause
- MC perceived on ipsilateral side
24
Q
2 classifications/categories
A
- Intra-abdominal: organ infection/inflammation, peritonitis, bowel obstruction, vascular disorders
- Extra-abdominal: Cardiac, thoracic, GU, neuro, metabolic, hematologic, infectious, toxicities - MC: DKA, alc ketoacidosis, PNA, PE, Herpes Zoster
25
pertinent PMHx/SHx
* steroids, abx (C. diff), NSAIDs (gastritis, ulcer/perforation)
* CV/PAD dz, afib, HF (AAA, mesenteric ischemia, atypical MI)
* Immunosupp
* Previous abd surgery
26
pertinent social hx
heavy alc, opiates, smoking
27
gradual onset, think what dx?
inflammatory, infectious/obstructive
27
sudden, severe onset, think what dx?
ischemia, dissection, perforation
28
if abd pain is constant/worsening for >6 hrs, think what dx?
surgical cause
29
pain improves after meals - what dx?
PUD
30
pain worse after meals - what dx
biliary colic
31
pain improves when upright and worse when supine - what dx
pancreatitis
32
pain worse with sudden movements and improves with stillness - what dx?
peritonitis
33
Pain alleviated by constant movement - what dx?
renal colic
34
vomiting occurring after onset of pain = what cause?
surgical cause
35
bilious vomiting - what cause?
obstruction distal to pylorus
36
coffee-ground or hematemesis - what dx?
PUD, varices, aortoenteric fistula (aortic aneurysm repair)
37
loose/watery diarrhea - what dx/cause?
infectious or diverticulitis
38
mucoid diarrhea - what dx?
inflammatory or infectious
39
blood diarrhea - what dx?
mesenteric ischemia or infectious
40
small scant amounts of stool/diarrhea - what dx?
bowel obstruction
41
possible GU sx
* Dysuria, hematuria - UTI, pyelonephritis, nephrolithiasis
* Female: vaginal bleeding or discharge, recent changes in menstruation, dyspareunia - vaginitis, PID, tubo-ovarian abscess, Fitz-Hugh Curtis syndrome, pregnancy
* Males: Penile discharge, scrotal pain/swelling, recent trauma - urethritis, testicular torsion, inguinal hernia
42
low temp w/ abd pain can be seen in what pt demographic?
infectious in elderly & neonates
43
>50y
abd pain out of proportion to physical findings
dx?
Mesenteric ischemia
44
possible Auscultation findings
* Absence - peritonitis, BO
* hyperactive/high-pitched/tinkling - SBO
* hyperactive/medium-pitch - blood/inflammation within GI tract
* Bruit - AAA
45
goals of palpation
tenderness, guarding, masses, organomegaly, hernias
46
goal of light vs deep palpation? findings?
guarding
Voluntary vs involuntary
Involuntary → surgeon ASAP
47
peritoneal testings
* **Rebound tenderness**, rigidity, referred tenderness, cough pain - peritonitis dx; Rebound tenderness alone not the best
* **Heel tap**
* **Jumping**
48
Carnett sign
sit-up test: abd wall pain
Place finger at max abd tenderness found
pain w/ palpation at semisitting position = **(+) abd wall syndrome**
49
what does murphy's sign test for
cholecystitis
50
what does psoas sign test for
retrocecal appendicitis
51
what does obturator sign test for
appendicitis
52
what does rovsing sign test for
appendicitis
53
CVA percussion tests for what
pyelonephritis
54
when abd pain is in the lower 1/2 of abd, do what exam?
pelvic/testicular exam
55
what are you trying to assess for DRE?
tenderness, bleeding, masses
56
other PE findings other than abd exam
* Heart & lungs - afib, PNA
* MSK - hip infections/inflammation can radiate to lower abd
* Skin - Cullen’s & Grey Turner’s - ruptured AAA or hemorrhagic pancreatitis
57
what pt population may fail to show the same abd s/s?
Older pts, MC DM & immunocomp
1. +/- tachycardia if hypovolemic
1. ↓ pain perception, febrile or muscular response to infection/inflammation
1. >50y - Biliary dz, bowel obstruction, diverticulitis, CA, hernia
- Less freq, but still high - Sigoid volvulus, diverticulitis, acute mesenteric ischemia, AAA
58
what lab to order for ALL women of child-bearing age w/ abd pain +/- abnml vaginal bleeding
**hCG (qualitative)**
Blood count not specific/sensitive but MC ordered
59
w/u for abd pain
1. hCG
2. plain abd radiography - low sensitivity
3. US
4. **CT +/- contrast**
60
plain abd radiography would be helpful for what dx
obstruction, perforation, following identified stones in renal colic
61
US may be helpful in what dx?
1. cholelithiasis
1. choledocholithiasis
1. cholecystitis
1. biliary duct dilatation
1. pancreatic masses
1. hydroureter or hydronephrosis
1. intrauterine or ectopic pregnancies
1. ovarian and tubal pathologies
1. free intraperitoneal fluid
1. suspected appendicitis
1. AAA
62
CT would be helpful in what dx
1. mesenteric ischemia
1. pancreatitis
1. AAA
1. appendicitis
1. urolithiasis
IV contrast - lesions, inflammation; not needed for urolithiasis
PO contrast - bowel obstruction
63
mgmt for unstable abd pain
resuscitation, dx clinically w/ emergent surgical consultation
64
general mgmt for abd pain
* Resuscitation - **NS or LR, NPO**
* Analgesics - **morphine, hydromorphone**
* Antiemetics - **ondansetron/metoclopramide**
* Abx if indicated - **gentamicin + metronidazole; pip-taz**
65
morphine/hydromorphone can be reversed with ?
**naloxone** 0.4 to 2 mg SC/IV
66
using NSAIDs or ibuprofen as analgesics for abd pain would be more beneficial for which dx?
renal colic
67
what acute abdominal or pelvic dx requiring immediate intervention
* AAA
* intrabdominal hemorrhage
* perforated viscus
* intestinal obstruction or infarction
* ectopic preg
* gyn emergencies
* “Acute/surgical abdomen” - emergent surgery (pain, guarding, rebound)
68
indications to admit for abd pain
1. Toxic appearance
1. unclear dx in elderly/immunocomp
1. inability to reasonably exclude serious etiologies
1. intractable pain or vomiting
1. AMS
1. inability to follow DC instructions
*Serial examinations otherwise*
69
mgmt for nonspecific abd pain
* **DC and 12-24 f/u**
* return ASAP if incr pain, V, F, or failure of sx to resolve
70
2 components that are key to ulcer development?
1. Acid
1. pepsin
71
MCC of ulcers
1. H pyloir
2. NSAIDs
72
acute or chronic gastric mucosal inflammation and has various causes
gastritis
73
1. **burning epigastric pain - sharp, dull, ache, “empty” or “hungry”**
- **relieved by food, milk, or antacids**
- recurs as gastric contents empty; **awakens pt night**
dx?
PUD
74
Atypical PUD presentations MC in who? findings?
elderly: no pain, not relieved by food, N,V, anorexia, wt loss, and/or bleeding
75
possible changes in pain seen in PUD?
Change in character = complication
* Abrupt onset of severe pain = perforation w/ spillage of gastric/duodenal contents into peritoneal cavity
* Back pain = pancreatitis from posterior perforation
* N/V, early satiety, wt loss = gastric outlet obstruction, CA
* Vomiting blood, melanotic stools +/- hemodynamic instability = bleeding complication
76
PE finding indicative PUD complication
* rigid abdomen - peritonitis in perforation
* abd distention, succussion splash - gastric outlet obstruction
* occult/gross rectal blood, blood in nasogastric aspirate - bleed
77
DDx of epigastric pain
1. GERD - pain, radiating to chest, belching
1. Cholelithiasis/biliary colic - more severe RUQ, radiating around R abd w/ tenderness
1. Pain radiating into back - pancreatitis
- With mass - pseudocyst; Pulsatile - AAA
1. Chronic pain, anorexia, wt loss +/- mass - CA
1. MI - epigastric; considered esp DM & elderly
78
w/u for PUD
* CBC - nml r/o chronic GI bleeding (not acute tho)
* Elevated liver enzyme - hepatitis
* Elevated lipase - pancreatitis
* Trops/ECG - MI
* Upright XR - Free-air (perforation)
* Abd US - cholecystitis, cholelithiasis , AAA
* **Dx: Upper GI endoscopy**
79
tx options for PUD
1. **PPIs** - ↓ acid production (blocks H+ ion secretion; inhibitory effect on H. pylori)
2. **H2RAs** - inhibit acid secretion, OTC
3. **Liquid antacids prn** for pain relief; 1 hr after meals and at bedtime
4. _Tx H. pylori if indicated_ (not started in ED): **PPI + clarithromycin + amoxicillin/metronidazole** x 2 wks
80
mgmt for uncomplicated, stable PUD
DC, PPI/H2RA with liquid antacid, PCP for further eval
81
mgmt for PUD if “Alarm” features, stable enough or DC?
endoscopy
82
mgmt for PUD complications?
consult, admit
* Bleeding
* Perforation - resuscitation, abx, immediate surgical consult
* Gastric outlet obstruction - resuscitation, NG tube
83
pt ed for suspected PUD pts?
Tell pt PUD is **resumptive dx** and **f/u with gastroenterologist for definitive dx with endoscopy**
84
MCC of pancreatitis
1. cholelithiasis
1. alc abuse
85
MCC of pancreatitis if no RF?
2/2 **meds** or **severe hyperlipidemia** if no RF - acetaminophen, carbamazepine, enalapril, estrogens, erythromycin, furosemide, HCTZ, opiates, steroids, tetracycline, and TMP-SMX
86
1. **Midepigastric, constant, boring pain**
- **Radiates to back**
- **Supine worsens**
1. Assoc N/V/abd distention
1. Low-grade F, tachycardia, HoTN
1. Epigastric tenderness
1. Peritonitis (late)
2. Epigastric tenderness - More R/LUQ
1. BS diminished & Abd distention - 2/2 ileus
1. Severe dz: Refractory HoTN shock, renal failure, F, AMS, rsp failure
dx
Pancreatitis
87
for Pancreatitis dx, **2** of the 3 clinical features can make the dx
1. H&P
1. lipase/amylase ≥2-3x ULN
1. imaging consistent w/ pancreatic inflammation
88
w/u for pancreatitis
1. **lipase**/amylase (less specific)
2. CBC - leukocytosis, anemia
3. LFT - assoc biliary involvement
4. **Abd CT**/US
89
Why is CT preferred to dx pancreatitis instead of US?
US can be obscured by **gas**
90
referred CP in pancreatitis - what possible dx?
IHD, pulm, hepatitis, cholecystitis, biliary colic, ascending cholngitis, renal colic, SBO, PUD/gastritis, acute aortic A/D
91
mgmt for pancreatitis
1. Aggressive **fluids** - crystalloids ; Pressors if HoTN and not responsive to fluids
1. **NPO if N/V**
1. Antiemetics - **ondansetron, prochlorperazine**
1. IV analgesia - **morphine**
1. O2 if < 95%
1. MC need **admission**
92
mgmt for Infected pseudocyst, abscess, infected peripancreatic fluid?
| pancreatitis
1. imipenem-cilastatin
1. meropenem
1. cipro + metronidazole
93
mgmt for Severe systemic dz in pancreatitis
* intubation, intensive monitoring, bladder cath, blood transfusion as needed
* Correct symptomatic hypocalcemia
94
mgmgt for hemorrhage/abscess drainage pancreatitis
laparotomy
95
mgmt for gallstone pancreatitis
consult gastroenterology, ERCP, & sphincterotomy
96
poor pronostic signs that require ICU admission:
Decr hgb, poor UO, persistent HoTN, hypoxia, acidosis, hypocalemia
97
what type of pt may be DC with close f/u in pancreatitis?
* Mild, no biliary tract dz, no systemic complications, tolerates PO intakes
* Increase diet as tolerated once nausea is controlled
97
MCC of cholecystitis
* **gallbladder or biliary duct by gallstones**
* MCC biliary tract emergency caused by gallstones: biliary colic, cholecystitis, gallstone pancreatitis, ascending cholangitis
98
cholecystitis can be seen in all age, but MC in who?
DM & elderly
99
T/F: pts presenting with gallstones are MC asx
T
100
RF for choelcystitis
age, female, obesity, rapid wt loss, prolonged fasting, familial tendency, meds, asians, chronic liver dz, hemolytic disorders
101
MCC of ascending cholangitis
CBD stone
life-threatening; Complete biliary obstruction w/ infection
102
* **Epigastric or RUQ pain, constant**
* Intermittent or **colicky**
* N/V
* **Referred to R shoulder or L upper back**
* After eating possible
* Acute - lasts 1-5 hrs
* Circadian pattern - **MC 9pm-4am**
dx?
Biliary colic
103
* Similar to biliary colic but lasts **>5 hrs**
* **F, chills, N, V, anorexia**
* h/o similar attacks or known gallstones
* **Sharp, localized RUQ**
dx?
Acute cholecystitis
104
midline pain, radiating to middle of back
dx?
| Cholecystitis
Choledoncholithiasis
105
1. Jaundice, F, confusion, shock
1. Focal RUQ pain, N
1. **Charcot triad: Fever, jaundice, RUQ pain **
dx?
Ascending Cholangitis
106
w/u for Cholecystitis
1. **WBC**: leukocytosis w/ L shift - Acute cholecystitis, pancreatitis, cholangitis
1. **Serum bilirubin & alkaline phosphatase**: nml/mild elevated - biliary colic, cholecystitis; Elevated - choledocholithiasis, ascending cholangitis
1. **Serum lipase/amylase**
1. **_Hepatobiliary US_**: stones small as 2 mm, signs of cholecystitis
- thickened gallbladder wall (>3-5mm)
- gallbladder distention (>4cm short-axis view)
- pericholecystic fluid
- CBD >5-7 mm = choledocholithiasis
1. Intraabdominal dx → **CT abd**
1. **HIDA** - very specific & sensitive; _used if US fails_
107
heptabiliary US has Better predictive value with ?
sonographic Murphy’s sign and gallstones present
108
general mgmt for Cholecystitis
1. **Fluids** w/ crystalloids; Pressors if HoTN not responsive to fluids
1. **NPO**
1. **ondansetron/prochlorperazine**
1. **morphine, ketorolac**
1. Distended, actively vomiting, or unresponsive to antiemetics → **NG tube low suction**
109
mgmt for Acute biliary obstruction
decompression via endoscopic sphincterotomy of ampulla of Vater
110
mgmt for uncomplicated Suspected cholecystitis/cholangitis
ceftriaxone + flagyl
111
mgmt for Ascending, sepsis, peritonitis Cholecystitis
* triple therapy: **ampicillin + gentamicin + clinda**
* Alt: metronidazole for clinda; 3rd gen cephalo/pip-taz, or FQ for ampicillin
112
mgmt for Acute cholecystitis, gallstone pancreatitis, ascending cholangitis
surgery consult, admit
113
mgmt for choledocholithiasis, gallstone pancr, ascending cholangitis
consult gastroenterology, ERCP + sphincterotomy
114
mgmt for Signs of systemic toxicity/septic cholecystitis
ICU, surgery
115
When to DC Uncomplicated biliary colic
*_relieved with supp within **4-6 hrs** of onset and able to maintain **oral hydration**_*
* DC, PO analgesics x 24-48 hrs, f/u with surgery/PCP
* Return to ED if abd pain worsens, intractable vomiting, another significant attack before f/u
116
* Periumbilical/epigastric pain → **RLQ (McBurney’s point)**
* Anorexia, N/V
* Irritation of bladder and/or colon → dysuria, tenesmus, etc
* **“Bump” sign**
* Fever - late finding
* Maneuvers depends on peritoneum irritation - rouvsing, psoas, obturator
dx?
Acute Appendicitis
117
pt with suspected Acute Appendicitis does the jump test and pain suddenly decreases, what does this indicate
appendiceal perforation
118
w/u for acute appendicitis?
What to use if you want to avoid radiation?
* **clinical dx**
* CBC, CRP - _BOTH nml_ can be used as screening
* UA - pyuria and hematuria in inflamed appendix irritating ureter
* hCG
* **CT w/o contrast - 1st line**: Pericecal inflammation, abscess, periappendiceal phlegmon or fluid collections
* US - good too, but operator dependent
* avoid radiation = MRI - avoid IV gadolinium in pregnant and renal dz
* _plain radiographs are **NOT** helpful!!_
119
high sensitivity s/s that indicate acute appendicitis
* F, RLQ, pain before vomiting, absence of prior similar pain, pain migration
* RL abd rigidity, (+) psoas sign
* Consider if atraumatic R abd, periumbilical or flank pain w/ no h/o appendectomy
120
mgmt for acute appendicitis
1. **surgical consult** _before_ imaging when dx is clear for **_appendectomy_**; transfer if no services
1. **NPO**, IV access & fluids
1. IV **fentanyl, morphine**
1. Abx - **pip/taz** or **Unasyn**
121
* mgmt for unclear presentation of suspected appendicitis?
* what pt demographics would benefit from this?
1. admit to **observe, serial exams, surgical consult**
- Safe for high-risk pts: kids, geriatric, pregnant, immunocomp
122
when can appendicitis be DC?
DC & 12-hr f/u; _avoid strong analgesics_: Stable, nontoxic-appearing with adequate pain control who can tolerate oral hydration have no significant comorbidities, and are able to return in 12 hours
123
1. **LLQ abd pain**, F, leukocytosis
- Higher F if generalized peritonitis or abscess
1. **Changes in bowel habits - D, C**
1. N/V, anorexia
1. **GU sx less common**
1. _Redundant sigmoid colon, Asian, right-sided dz_ → suprapubic or RLQ pain
1. Abd tenderness, obstruction, peritonitis
1. Occult blood in stool possible
dx?
w/u?
* **_Diverticulitis_**
* **clinical dx**; no further eval if stable; imaging if no h/o dx or different presentation (**CT w/ contrast**, compression US, CBC, LFT, UA)
124
mgmt for Diverticulitis
* _Ill-appearing, uncontrolled pain, V, peritoneal signs, systemic infection, comorbidities, immunosupp, complicated_ → **admit & surgical consult**
* _Uncomplicated, do not meet admission criteria_ - **PO abx + liquid diet,** Avoid dairy and red meat
* _Outpatient_ - f/u with gastroenterology for **colonoscopy in 6 wks** if they show improvement
* _Worsening during outpatient tx_ → **admit**
125
abx for outpatient 4-7 d for diverticulitis
1. **Flagyl + FQ/Bactrim**
1. Alt: augmentin; moxifloxacin
126
abx for moderate diverticulitis
1. **Flagyl + FQ (cipro, levaquin)**
2. Alt: rocephin; pip-taz
127
abx for severe, life threatening diverticulitis
1. **pip-taz**
2. alt: aztreonam + flagyl
128
what MC type of intestinal obstruction is self-limiting
Adynamic or paralytic ileus
129
causes of SBO
adhesions d/t surgery, incarcerated hernias, inflammatory dz, IBS, congenital anomalies, FBs
130
causes of LBO
CA, diverticulitis with stricture, sigmoid volvulus, fecal impaction
131
what condition mimics LBO? who is at high risk for this?
Intestinal pseudoobstruction (Ogilvie syndrome)
elderly and bedridden on ACh or TCA
132
Intussusception MC in who
kids
133
Sigmoid volvulus is MC in who?
elderly on ACh
134
cecal volvulus is MC in who?
pregnant ppl
135
1. **Crampy, intermittent, progressive abd pain or no BM or pass gas** - if Partial, can pass gass
1. _Proximal_ - **bilious** V
1. _Distal_ - **feculent** V
1. Localized pain + abd surgical scars, hernia, mass - possible reason
1. **Tympanitic** to percussion
1. **Active, high-pitched BS** if mechanical; Diminished BS with time
1. DRE - impaction, CA, occult blood; Presence of stool does not r/o
1. Pelvic exam
dx?
intestinal obstruction
136
* mild-mod pain
* diffused pain
* mild distention +/- tenderness, decr BS
* dehydration
* nml imaging
dx? mgmt?
ileus
observation, hydration
137
1. moderate to severe pain that can be localized
1. mild distention, tenderness, high-pitched BS
1. leukocytosis
1. abnml imaging
dx? mgmt?
* bowel obstruction
* NG tube, surgery
138
w/u for intestinal obstruction & volvulus
1. _Flat and upright abd radiographs and upright CXR_ - screens for obstruction, confirm severe constipation, or dx hollow viscus perforation with free air
1. **1st line - CT w/ contrast**: delineates partial vs complete obstruction, partial SBO vs ileus, and strangulated vs simple SBO
1. _CBC, lytes, BUN, CR, lactate, coags, type and cross-match_
- _Leukocytosis >20k or left shift_ = abscess, gangrene, peritonitis
- _Elevated hct_ = dehydration
139
mgmt for intestinal obstruction & volvulus
1. **Fluids** with crystalloids, monitor for response, surgical consult
2. **Decompress bowel with NG tube** esp if vomiting or distention
3. Abx
- **Pip/taz; Ticarcillin-clavulanate; unasyn**
- **Cefotaxime**
- **Ceftriaxone + clinda or metronidazole or meropenum**
1. _Dx unclear or adynamic ileus_ - IV fluids, observe
1. _Pseudoobstruction_ - colonoscopy only
