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Abdominal Pain Flashcards

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1
Q

what is the number 1 complaint in the ED

A

acute abdominal pain

*accounts for 10% of all ED visits

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2
Q

ED approach to acute abdominal pain ddx

A
  1. is pt critically ill? (rapid onset? abnormal VS?)
  2. constellation of sx that fit a known disease pattern?
  3. special conditions or risk factors that would make it difficult to identify the critical illness or known disease process?
  4. is surgical consult required?
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3
Q

what type of abdominal pain presentations require surgery consult?

A
  1. Acute abdomen,
  2. a pulsatile abdominal mass,
  3. shock,
  4. hemodynamic instability,
  5. rigid abdomen,
  6. GI bleeding
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4
Q

different approaches to abdominal pain ddx

A
  1. out –> in (skin–> fat–> fascia–> muscle–> peritoneum)
  2. by region
  3. by symptomology and time course
  4. risk factors, special populations
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5
Q

GI causes of acute abdominal pain

A
  1. Appendicitis
  2. Biliary tract disease
  3. SBO/LBO
  4. Pancreatitis
  5. Diverticulitis
  6. IBD
  7. IBS
  8. PUD
  9. Perforated viscus
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6
Q

GU causes of acute abdominal pain

A
  1. Acute scrotum
  2. Renal colic, nephrolithiasis
  3. Urinary retention
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7
Q

Gyn causes of acute abdominal pain

A
  1. Ectopic pregnancy
  2. PID
  3. Ruptured ovarian cyst
  4. Ovarian torsion/abscess
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8
Q

vascular causes of acute abdominal pain

A
  1. AAA
  2. Mesenteric ischemia
  3. Ischemic colitis
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9
Q

extra-abdominal causes of acute abdominal pain

A
  1. Cardiac
  2. Pneumonia
  3. Hernias
  4. Abdominal wall strain
  5. Infections
  6. Poisonings
  7. Metabolic
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10
Q

ddx of abdominal pain in the periumbilical region

A
  1. IBD
  2. bowel obstruction or ischemia
  3. appendicitis
  4. AAA
  5. IBS, DKA
  6. gastroenteritis
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11
Q

ddx of abdominal pain in the epigastric region

A
  1. MI
  2. PUD
  3. pancreatitis
  4. biliary disease
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12
Q

common causes of abdominal pain in people less than 60 y/o

A
  1. Abdominal pain, nonspecific
  2. Appendicitis, acute
  3. Urologic
  4. Intestinal obstruction
  5. Biliary Disease
  6. Trauma, abdominal
  7. PUD, perforated viscus
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13
Q

common causes of abdominal pain in people older than 60 y/o

A
  1. Biliary Disease
  2. Intestinal obstruction
  3. Abdominal pain, nonspecific
  4. Diverticulitis
  5. Appendicitis
  6. PUD, perforated viscus
  7. Malignancy
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14
Q

life-threatening conditions that present with abdominal pain

A
  1. Abdominal aortic aneurysm*
  2. Thoracoabdominal aortic dissection*
  3. Mesenteric ischemia
  4. Perforation of gastrointestinal tract
    - peptic ulcer, bowel, esophagus, or appendix
  5. Acute bowel obstruction
  6. Volvulus
  7. Splenic rupture
  8. Incarcerated hernia
  9. Ectopic pregnancy*
  10. Placental abruption
  11. Myocardial infarction
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15
Q

types of abdominal pain

A
  1. visceral pain
  2. parietal (somatic) pain
  3. referred pain
  4. misleading pain
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16
Q

describe visceral pain

A
  • Usually dull, achy, poorly localized, protracted
  • Direct irritation of the inner layer (visceral peritoneum) of HOLLOW VISCERA and CAPSULES OF SOLID ORGANS. (Distension, inflammation, or ischemia)
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17
Q

describe parietal (somatic) pain

A

-Usually steady, sharp, better localized

  • Peritoneal pain signs: guarding, rebound, rigidity
  • Direct irritation of PARIETAL PERITONEUM of the abdominal wall by gastric juice, pus, bile, urine, succus entericus, feces

visercal pain–> localized peritonitis–> pertonitis

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18
Q

describe referred abdominal pain

ex?

A
  • Pain felt at a location distant from the diseased organ/primary stimulus
    ex. AAA to lower back, gallbladder to shoulder, Ureter to groin, pancreatitis to back, perforated ulcer to RLQ
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19
Q

describe misleading abdominal pain

ex?

A

Abdominal pain from “extra-abdominal” source

Examples: Intrathoracic diseaseto upper abdomen, uremia

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20
Q

describe why abdominal pain in the elderly is more concerning

A
  1. Have more serious illness and disease is more advanced at time of diagnosis
  2. Tend to underreport symptoms
  3. Surgical emergencies are more common
  4. Don’t mount the same immune response

*Fever is not a reliable marker

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21
Q
  • Usually sicker than they look

- Low threshold for a bigger workup and to admit

A

elderly w/ abdominal pain

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22
Q

ED approach to the patient with abdominal pain

A
  1. general survey and VS
  2. H and PE
  3. diagnostic workup (labs/images)
  4. reexamine
  5. diposition/admit
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23
Q

how to take a history for abdominal pain

A

OPPQRST

  1. onset
  2. provacative/palliative factors
  3. quality of pain
  4. region and radiation
  5. severity of pain
  6. temporal factors
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24
Q

key associated GI sx

A
  1. N/V
  2. Anorexia
  3. Diarrhea, constipation, obstipation
  4. Acholic stool, hematochezia, melena, BRBPR
  5. Dyspepsia, dysphagia
  6. Time and content of last meal
  7. Time and character of last BM
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25
key associated GU sx
- Time and character of LMP or irregular bleeding | - Dark urine, hematuria
26
bluish flank discoloration
Grey turner's sign | -seen in acute pancreatitis or AAA hemorrhage
27
bluish periumbilical discoloration
Cullen's sign -seen in acute pancreatitis, ectopic pregnancy, or AAA hemorrhage
28
visible dilated abdominal venous vasculature
caput medusa - in patients suffering from cirrhosis of the liver.
29
high-pitched/tinkling or hypeactive BS-- | decreased or absent BS--
high-pitched/tinkling or hypeactive BS-- obstruction | decreased or absent BS-- ileus, narcotic use, mesenteric ischcemia, LBO
30
guarding is ___, | rigidity is __
Voluntary involuntary contraction of abdomen wall
31
Rigidity, referred tenderness, rebound tenderness--> pain w/ release NOT pushing down
peritoneal irritation
32
when are rectal exams useful?
1. . if patient is hypotensive and suspect bleed 2. Anal lesions, tenderness, masses 3. Detection of grossly bloody or melanotic stools, Guaiac for occult blood 4. Fecal impaction
33
what labs MUST you get with abdominal pain
CBC, BMP, LFTs, Lipase/Amylase, UA, urine pregnancy *could also get coags, cardiac enzymes, venous lactate, ABG
34
``` when would the following imaging studies best be indicated? plain film US CT A/P Angiography (CTA) ECG ```
1. plain film-- suspect obstruction or perforation 2. US- RUQ, hernias 3. CT A/P- study of choice except for stones** 4. Angiography (CTA)- mesenteric ischemia, AAA (if they have time) 5. ECG- all pts w/ upper abdominal pain
35
supplemental studies - UGI: - HIDA: - MRCP: - ERCP:
- UGI: can help resolve SBO - HIDA: used to diagnose problems of the liver, gallbladder and bile ducts - MRCP: looks at ducts - ERCP: through mouth into duodenum and takes out stones in BD
36
what antibiotics would you use for actue abdomen
Broad Spectrum, coverage for Gram-negative rods, anaerobes, and enterococci
37
- One of the most common surgical emergencies - Most common age group is 10-30 years of age - Misdiagnosis remains as a leading cause of malpractice suits
appendicitis
38
causes of appendicitis
1. Obstruction by lymphoid hyperplasia or fecalith (most common cause) 2. Tumor (carcinoid - most common tumor) 3. Infection (parasitic)
39
clinical presentation: - Poorly localized periumbilical pain initially ⟹ migrates and localizes to RLQ pain - Visceral pain that progresses to parietal pain - Anorexia, nausea, +/- vomiting, low-grade temp - Onset of pain before GI symptoms - Low-grade temp, mildly uncomfortable ⟹ fever, ill-appearing - Periumbilical tenderness ⟹ RLQ tenderness and guarding
appendicitis *McBurney's point tenderness (pathognomonic)
40
how does pain present w/ perforated appendicitis and pregnancy?
- Pain free interval and peritoneal signs/sx suggest perforation - Pain may be displaced from RLQ to RUQ in pregnancy
41
special maneuvers for appendicitis
1. Rovsing’s sign - RLQ tenderness with LLQ palpation (Rovsing's= Referred pain) 2. Psoas sign - pain with RLE active hip extension 3. Obturator sign - pain with RLE passive hip flexion and internal/external rotation (A positive psoas sign or obturator test → an inflammatory process adjacent to these respective structures)
42
labs suggestive of appendicits
1. Leukocytosis range 10-20,000 usually with left shift (over 75% neutrophils) 2. UA may be normal or have few RBC and WBC 2ndary to local inflammation
43
imaging findings of appendicitis
CT A/P + IV contrast** and Ultrasound (US)- in pregnancy and children -Typical CT findings: edematous, dilated appendix (over 6mm)-- thickened enhanced walll of appendix-- with periappendiceal fat stranding (representing inflammation) - US is operator dependent and visualizes only one area, reserved for pregnancy and children * abcess, pheglmon, free air= perforated appendix
44
management of appendicitis
1. surgical consult and admission 2. preop management: hydration w/ IVF, NPO, IV analgesics, IV abx 3. Definitive tx is appendectomy (laparoscopic or open technique)
45
what people w/ RLQ pain can go home?
RLQ pain or tenderness with normal labs and imaging, clinically stable, pain well controlled on PO meds, able to return if symptoms get worse, and plan OK’d with surgery
46
risk factors for biliary tract disease
Female, Fertile, Forty, Fluffy, Fair -Primarily related to gallstone disease and complications from gallstone obstruction
47
pathophysiology of biliary tract disease
Obstruction or impaired gallbladder contraction → cholestasis → inflammation → infection *gallstones remain asymptomatic in 80% of cases
48
what is: - choleithiasis: - biliary colic: - Cholecystitis: - Choledocholithiasis: - Cholangitis:
- choleithiasis: GB stones - biliary colic: Intermittent obstruction of the biliary tree by stones (can go home) - Cholecystitis: GB wall inflammation often caused by GS blocking cystic duct - Choledocholithiasis: CBD obstruction from stone - Cholangitis: ascending biliary tract infection of CBD due to CBD obstruction
49
describe the difference btwn acute, chronic, acalculous, and emphysematous cholecystitis
- Acute- obstructed cystic duct most common - Chronic– thickening of GB wall (2/2 fibrosis), NO infection - Acalculous- (no evidence of GS or cystic duct obstruction) geriatrics, critically ill, trauma, TPN, postpartum - Emphysematous (gas w/in GB wall) high risk of gangrene, perforation, mortality
50
tx of choledocholithiasis
remove w/ ERCP
51
what is charots triad and Reynold pentad
Charcot's triad: fever, RUQ abdominal pain, and jaundice Reynolds pentad: Charcot’s triad + AMS and shock *suggest cholangitis-Ascending biliary tract infection of common bile duct due to CBD obstruction
52
clinical presentation: - Acute RUQ pain (pts often say epigstric pain) occasionally referred to the R scapula or epigastrium - Crampy, colicky pain vs moderate to severe, unremitting pain - Postprandial pain (triggered by fatty foods) - Anorexia, nausea, vomiting, +/- fever
biliary tract disease
53
-No fever w/ what type of biliary tract disease
cholelithiasis
54
Dark urine, light stools, jaundice/pruritus suggest what biliary tract disease
CBD obstruction (cholecystitis, cholangitis)
55
Jaundice, fever, shock, AMS suggests what biliary tract disease
cholangitis
56
what labs should you order w/ biliary tract disease and what would expect them to be?
CBC - normal or elevated WBC C/(B)MP- normal or elevated LFTs, ALP, T. bili Lipase- elevated Lipase (GS pancreatitis)
57
what imaging studies could you get for biliary tract disease?
1. US Abdomen diagnostic study of choice* 2. CT A/P if GS pancreatitis or CBD stone obstruction is suspected.* 3. HIDA (Biliary Radionuclide Scanning) = functional evaluation of the GB, sensitive/specific for acute cholecystitis - Acalculous cholecysitis, biliary leak - Good for post-op and worry about biliary leak 4. ERCP diagnostic and therapeutic for CBD stones 5. MRCP diagnostic only, evaluates biliary tree and pancreatic ducts
58
what labs are associated w/ Cholelithiasis | Biliary Colic
Normal
59
what labs are associated w/ | cholecystitis
↑ WBC* ↑ AST/ALT (mild) ↑ ALP (mild) Normal T. bili*
60
what labs are associated w/ choledoncholithiasis
↑ AST/ALT, ↑ T.bili* | ↑ Lipase (GS pancreatitis)
61
what labs are associated w/ cholangitis
↑ WBC (very high), bacteremia | ↑ AST/ALT, ↑ T.bili*
62
US findings: | Gallstones, dilated gallbladder, dilated cystic duct. No GB wall thickening*
Cholelithiasis | Biliary Colic
63
US findings: | Pericholecystic fluid*, distended GB, GB wall thickening*, intra/extrahepatic ductal dilatation, +/- gallstones
Cholecystitis
64
US findings: | Dilated CBD over 6mm*, stone in common bile ducts, distended gallbladder
choledocholithasis
65
US findings: | Dilated, obstructed intrahepatic biliary ducts, dilated CBD, gallstones
Cholangitis
66
management of biliary tract disease
1. pain control- IV fentanyl or diluadid (avoid morphine- causes constriction of sphincter of oddi) 2. IV abx- broad spectrum to cover Gram +, -, and anaerobes 3. IVF, IV antiemetics 4. surgery consult +/- admit to hospital - Cholecystectomy (laparoscopic vs open) - ERCP for choledocholithiasis, cholangitis - HIDA for acalculous cholecystitis
67
what is: Diverticula diverticulosis Diverticulitis
Diverticula: small herniations through the wall of the colon. Diverticulosis: multiple diverticula Diverticulitis: inflamed or infected diverticula Usually involves the sigmoid colon
68
-Common in Western cultures Incidence increases with age -15% to 25% of patients will develop -2/3 of patients have uncomplicated disease (treat with high fiber diet)
diverticular disease
69
what is the pathophysiology of: diverticulosis diverticulitis
Diverticulosis: ↑ intraluminal pressures in the colon + weakening of the colon wall → diverticula Diverticulitis: Thickened fecal material → erosion of the diverticular wall → inflammation and microperforation → diverticulitis
70
complications of diverticulitis
macroperforation, abscess, fistula, peritonitis, sepsis
71
clinical presentation: -Intermittent or constant LLQ abdominal pain, FEVER, +/- diarrhea, constipation, n/v, anorexia -LLQ tenderness, tender palpable mass RLQ or suprapubic pain → redundant sigmoid colon -Peritonitis (rebound and guarding) → perforation
diverticulitis *dverticulosis is typically asymptomatic
72
what labs should you order for diverticular disease
CBC – Leukocytosis BMP, LFTs, Lipase, UA pregnancy test To r/o other causes, assess hydration status
73
what imaging could you order for diverticular disease and what would you see
CT A/P +IV and/or PO contrast (Gastrografin) - Inflammation, colonic diverticula, bowel wall thickening - Phlegmon, pericolic fluid collections (abscess) - Contained microperforation, free air - PO done more w/ inpatient (3 hr study) *Barium will cause peritonitis if there is a perforation
74
CT reveals: Multiple outpouchings seen from sigmoid colon, surrounded by fat stranding with local inflammation affecting an adjacent small bowel loop. 
diverticulitis
75
management of uncomplicated diverticular disease
- Bowel rest (liquid diet) - PO Abx x 7-14 days - Levo/Flagyl or Augmentin - Colonoscopy after episode subsided - Outpatient f/u with surgery if recurrent episodes
76
management of complicated diverticular disease
-Admit -Bowel rest (liquid diet) -NPO if obstructed (fistula, abscess) -IV Abx (broad spectrum) -Abscess – IR/CT guided drainage -Perforation – Surgical consult OR for exploration
77
describe what a mechanical obstruction, simple obstruction and strangulated obstruction
- Mechanical Obstruction: implies a physical barrier, may be complete or partial. (generally requires definitive intervention) - Simple obstruction: Blockage of intestinal lumen only, usually one point of blockage - Strangulated obstruction: Blockage of lumen and blood supply, usually two points of blockage (closed loop)
78
what is adynamic ileus (paralytic ileus)
Neurogenic failure of peristalsis → Decreased bowel motility and muscular tone more common, usually self-limited--> surgical interventino uncommon
79
what is Intestinal pseudo-obstruction (Ogilvie syndrome):
- Colonic dilatation without evidence of a mechanical obstruction - more common in elderly than young pts
80
what is the number 1 cause of SBO
adhesions -if no hx of surgery, increased concern about mass/CA
81
causes of SBO
1. Hernias (groin, abdominal wall, internal) 2. Intussusception (Neoplasm is #1 cause in adults) 3. IBD 4. Foreign bodies 5. Large Bowel Obstruction 6. adhesions
82
causes of LBO
1. Neoplasm (#1) - Almost never caused by hernia or surgical adhesions 2. Fecal impaction 3. Diverticulitis 4. Volvulus (cecal, sigmoid) 5. Stricture 6. Pseudo-obstruction
83
causes of ileus (mechanical obstruction)
1. Opiates* 2. Manipulation of the bowel during surgery* 3. Spinal cord trauma 4. Ischemic bowel
84
clinical presentation: - INTERMITTENT, poorly localized, crampy abdominal pain - N/V, abdominal distension, decreased bowel movements and/or flatus - The more proximal the obstruction, the mores severe the symptoms - Abdominal distension and diffuse tenderness - Abnormal bowel sounds
intestinal obstruction High pitched/tinkling bowel sounds, peristaltic rushes → SBO Diminished or absent bowel sounds → Ileus
85
peritoneal signs (+ bed bump sign, + cough sign) indicate:
perforation/ischemia | intestinal obstruction
86
labs for intestinal obstructions
-CBC, BMP, venous lactate - Normal in early obstruction - Leukocytosis with a left shift - ↑H/H, ↑BUN and Cr, abnormal lytes (vomiting, dehydration) - ↑ venous lactate (strangulation)
87
imaging for intestinal obstructions
1. abdominal plain film (KUB and upright abdominal films) 2. CT A/P w/ PO and IV contrast (Complete vs partial obstruction, strangulated vs simple) 3. upper GI series w/ SB follow through
88
abdominal plain film reveals: Dilated loops of bowel, air-fluid levels, constipation, free air Ileus: dilated, fluid filled loops of bowel
intestinal obstruction *gas may not be present in cases of a closed-loop obstruction
89
abdominal CT A/P with PO and IV contrast shows: - Pneumatosis intestinalis (gas in the bowel wall), portal venous gas, circumferential wall thickening, fat stranding--> ___ - Pneumoperitoneum → ____ - “whirl sign” →___ - small air bubbles along cecum wall--> __
(intestinal obstruction) strangulated bowel perforation volvulus Pneumatosis intestinalis
90
Hugely dilated sigmoid that almost fills the entire abdomen. Note the “coffee bean sign” also known as “bent tire tube sign”, extending from the pelvis to the diaphragm. Complete loss of haustral pattern
sigmoid volvulus
91
management of intestinal obstruction
1. Admit to hospital, consult Surgery 2. IVF, IV pain control, NPO 3. NG tube to intermittent suction (if vomiting) - Can save someone from going to the OR 4. IV Abx (broad spectrum)
92
intestinal obstruction surgical emergencies
Closed-loop obstruction, bowel necrosis, or cecal volvulus - Ileus: NPO, NGT if vomiting, d/c narcotics, ambulate - Sigmoid volvulus: GI consult for endoscopic detorsion
93
a protrusion of any viscus from its surrounding tissue walls (i.e. through a fascial defect in abdominal wall)
hernia
94
anatomical types of hernias
1. groin (most common 75%) - inguinal (indirect more common than direct) - femoral- more prone to strangulation and incarceration;more common in women 2. anterior abdominal wall hernia- Incisional, ventral, umbilical, epigastric, etc.
95
what is the difference btwn an indirect and direct hernia
direct- near the opening of the inguinal canal -abdominal cavity → through the posterior inguinal canal wall → inguinal canal indirect- at the opening of the inguinal canal -abdominal cavity → through internal inguinal ring → inguinal canal → into the scrotum
96
types of hernias
1. Reducible: hernia contents can be displaced back to their usual position - Hernia sac is soft 2. Incarcerated: non-reducible by direct pressure - hernia sac is firm, contents should not be tense - Incarcerated tissue may be bowel, omentum, or other abdominal contents 3. Strangulated: incarcerated with resulting ischemia - Hernia sac is hard, tender, indurated, red/purple skin changes - Surgical emergency
97
clinical presentation: - First symptom is usually a lump or swelling at hernia site - Increase size in lump or swelling during exertion (straining or lifting) - May be painful/tender
hernia
98
signs and sx of strangulated hernia
``` abdominal pain/tenderness N/V fever -Severe, exquisite pain at the hernia site, - skin changes overlying the hernia sac +/- signs of intestinal obstruction, - peritoneal signs, -sepsis ```
99
labs to order for hernias
Normal unless strangulated bowel is present (↑WBC, ↑VL)
100
imaging for hernias
*Imaging not always necessary 1. US will identify hernia, Doppler useful to exclude strangulation - Decreased BP in strangulation 2. CT A/P if concerned about incarceration and/or strangulation - Strangulated loops of bowel w/ signs of obstruction (dilated loops of bowel), ischemia
101
CT findings show: Ventral hernia containing loops of small bowel and omentum. Bowel wall thickening, mesenteric gas and pneumatosis, mesenteric fat stranding suggestive of strangulated hernia with bowel ischemia. Dilation of the proximal loops of bowel and collapse of the distal loops
strangulated hernia w/ bowel ischemia
102
management of hernias
reducible if possible== may be reduced manually under sedation in trandelenburg position *surgical repair for definitive tx
103
how to manage an incarcerated hernia
Try to reduce 1-2 times, then observe the patient in the ED for a period of time for serial abdominal examinations If unable to reduce → consult Surgery
104
how to manage a strangulated hernia
1. Surgical consult for emergent repair 2. Do not try to reduce if you suspect strangulation 3. May need bowel resection if ischemic bowel is present from strangulation 4. IVF, NPO, IV abx, IV pain control
105
what is the difference btwn mesenteric ischemia and ischemic colitis
MI-Often leads to bowel necrosis (ischemic colitis does not) Usually involves the SMA → SMALL BOWEL IC-Variant of mesenteric ischemia Usually involves the IMA → COLON (splenic flexture)
106
s/sx: | Sudden onset of severe abd pain out of proportion to exam, soft abdomen?, ill appearing
mesenteric ischemia
107
s/sx: | LLQ pain and tenderness, mild/crampy abd pain, bloody diarrhea
ischemic colitis
108
tx of mesenteric ischemia and ischemic colitis
MI: Surgical emergency, admit, treat shock IC: Sigmoidoscopy Usually transient, 20% need surgical intervention
109
Small bowel intestinal ischemia 2ndary to occlusion of mesenteric vessel(s)
mesenteric ischemia *SMA is the most common
110
causes of mesenteric ischemia
Embolic arterial occlusion >> thrombotic arterial occlusion >> thrombotic venous occlusion
111
Small bowel has a ___hour viability window after ischemia
2-3
112
risk factors for mesenteric ischemia
``` age over 60 Afib CHF hemodialysis hypercoagulable states ```
113
clinical presentation: -Sudden onset of severe, diffuse, mid to lower abdominal pain -Postprandial pain, gradual onset → thrombotic arterial occlusion +/- Nausea, vomiting, diarrhea, bloody stool * Pain out of proportion to exam - Abdominal distension, absent BS, peritoneal signs, ill appearing
mesenteric ischemia
114
labs for mesenteric ischemia
- CBC, BMP, venous lactate, ABG, coags | - ↑↑WBC, ARF, ↑lactate, metabolic acidosis
115
imaging studies for mesenteric ischemia
1. Angiography (CTA or MRA) is diagnostic study of choice 2. CT A/P + IV contrast to identify additional findings - Bowel wall thickening, pneumatosis intestinalis, organ infarction
116
management of mesenteric ischemia
1. Immediate Surgical consult -OR for exploratory surgery 2 Admit to hospital, stabilize patient -IVF, IV pain control, IV Abx 4. Often there is a poor prognosis - survival of 50% if diagnosed within 24 hours
117
risk factors for AAA
1. M:F 4:1 2. age over 65 90% are infrarenal
118
Infrarenal aortic diameter Normal: __ Aneurysmal: __ Need repair: __
Normal: 2 cm Aneurysmal: over 3cm Need repair: over 5cm
119
clinical presentation: - Severe, abrupt onset of abdominal or back pain, hypotension, syncope, AMS (lack of cerebral profusion)→ Leaking or ruptured - signs of shock, unstable hypotension - Palpable midline abdominal pulsation or mass - Tender --> leaking or ruptured
AAA *most AAA are asymptomatic
120
what should you do with someone who presents w/ suspected AAA
get plain film and take to OR
121
Periumbilical ecchymosis (Cullen sign) or flank ecchymosis (Grey Turner sign)
sign for AAA *massive hemorrhage
122
labs for AAA
CBC, BMP, Type and Cross, coags, VL | PRBC, Platelets, FFP
123
imaging for AAA
1. plain film (CXR, AbXR)-- calcifed and buling aortic contour 2. abdominal US- over 90% sensitive (good for those who are unstable and cannot have CT) 3. CT A/P wwo IV contrast- Anatomic details of the aneurysm and associated hemorrhage
124
management of AAA
1. ALL PATIENTS with the clinical triad of abdominal and/or back pain, a pulsatile abdominal mass, and hypotension → emergent eval by a Vascular surgeon 2. IV access (2 large-bore IV’s), cardiac monitoring, supplemental O2 3. IVF, +/- blood products, control of VS - target HR 60-80, targe BP 100-120 (permissive hypotension) 4. surgical repair
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5 W's of post surgical complications
1. Wind- atelectasis or pneumonia 2. Water- urinary tract infection 3. Wound- infection 4. Walking- DVT 5. Wonder drugs- drug fever, thrombophlebitis, C.diff colitis
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When do these top 10 causes of post-op fever occur? 1. Atelectasis 2. transfusion rxn 3. PNA 4. UTI 5. infection 6. Skin/soft tissue infection 7. thrombophlebitis 8. DVT and PE 9. Intra-abdominal abscess or peritonitis 10. Pseudomembranous colitis
first 24 hrs: atelectasis or transfusion rxn 3-7 days: pneumonia 2-5 days: UTI 5-10 days: Skin/soft tissue infection** less than 3 days: thrombophlebitis 4-6 days: DVT 4-21 days: intra-abdominal abscess or peritonitis** anytime: pseudomembranous colitis or PE*** If you are worried about an abscess and you are only a couple days out, r/o other things --> it takes a while to show up on scan
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common post surgical abdominal pain, GI compliants
1. Intestinal obstruction - Adhesions (few weeks to develop) - Ileus 2. Intraabdominal abscess 3. Anastomotic leaks 4. Bowel injury
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post surgical wound complications
1. Hematomas – pain, pressure, swelling of the wound, bloody wound drainage - Call their surgeon 2. Seromas – painless swelling below the wound 3. Infection – increasing pain, erythema, swelling, drainage, tenderness at incision site, systemic s/sx of infection - Smells funny, have surgeon look at 3. Wound dehiscence – wound ruptures along a surgical suture.
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cholecystectomy surgical complications
Bile leak, bowel injury, pancreatitis, retained CBD stones, abscess
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laparoscopic surgery complications
- Atelectasis, ptx, GI tract injuries, bowel injury | - Get CT of abdomen to r/o bowel perforation and free air
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colonoscopy surgery complications
Hemorrhage, perforation, retroperitoneal abscess, volvulus
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10 most common causes of post-op fever
1. Atelectasis 2. transfusion rxn 3. PNA 4. UTI 5. infection 6. Skin/soft tissue infection 7. thrombophlebitis 8. DVT and PE 9. Intra-abdominal abscess or peritonitis 10. Pseudomembranous colitis

Emergency Medicine (22 decks)

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