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GI: Clin Med IIA > Abdominal Pain & Acute Abdominal Disorders > Flashcards

Abdominal Pain & Acute Abdominal Disorders Flashcards

1
Q

Evaluation of acute abdominal pain always begins with the assessment of:

A

The mnemonic “OPQRST”

  • O = onset = acute, gradual, or an ongoing chronic problem.
  • P = provocation & palliation = Anything make it better or worse?
  • Q = quality = sharp, dull, crushing, or burning, intermittent, constant, or throbbing.
  • R = region & radiation, meaning the location, or where the pain is on the body, and whether it radiates or extends
  • S = severity, which can be quantified with a score on a scale of 0 to 10 .
  • T = time = how long the condition has been going on and if it has changed over time.
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2
Q

other associated sx of acute abdominal pain

A
  1. other GI sx - nausea, vomiting, constipation, diarrhea, and changes in stool
  2. genitourinary - dysuria, frequency, and hematuria
  3. constitutional sx - fevers, chills, fatigue, weight loss, and anorexia
  4. Cardiopulmonary sx - cough, shortness of breath, orthopnea, and exertional dyspnea.
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3
Q

what conditions could be in the R hypocondriac Q

A

gallstones
stomach ulcers
pancreatitis

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4
Q

what conditions could be in the epigastric region

A

stomach ulcers
heartburn/indigestion
pancreatitis
gallstones
epigastric hernia

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5
Q

what conditions could be in the L hypochondriac Q

A

stomach ulcers
deodenal ulcer
biliary colic
pancreatitis

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6
Q

what conditions could be in the R lumbar Q

A

kidney stones
urine infection
constipation
lumbar hernia

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7
Q

what conditions could be in the umbilical region

A

pancreatitis
early appenditis
somtach ulcer
inflamed bowel
small bowel umbilical hernia

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8
Q

what conditions could be in the L lumbar Q

A

kidney stones
diverticular disease
constipation
inflamatory bowel

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9
Q

what conditions could be in the R iliac region

A

appendicitis
constipation
pelvic pain (gynae)
groin pain (inguinal hernia)

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10
Q

what conditions could be in the hypogastric region

A

urine infection appendicitis
diverticular diseae
inflamed bowel
pelvic pain (gynae)

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11
Q

what conditions could be in the L iliac Q

A

diverticular disease
pelvic pain (gynae)
groin pain (inguinal hernia)

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12
Q

difference between pain from an inflamed viscera (organ pain) and that of localized peritoneal irritation (somatic pain)

A
  • slow-onset, poorly localized, dull discomfort (visceral)
  • sudden, sharp, well-localized, lateralizing pain (somatic/parietal)
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13
Q

what to inspect for during an abdominal PE

A

Patient appearance
Masses
Distention
Pregnancy
Previous surgical scars
Ecchymosis
Board-like abdomen
Stigmata of severe hepatic disease

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14
Q

what to ausculte for in abdominal PE?

A

“Silent Abdomen”
Can signify diffuse peritonitis
High pitched BS
Early bowel obstruction

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15
Q

peristalsis is related to meal intake, it may be necessary to listen for as long as ____ to establish the absence of peristalsis, especially in those who have not eaten.

A

2–3 minutes

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16
Q

what to palpate for during an abdominal PE

A

Examine hernia rings
Elicit cough tenderness
Feel for guarding
Rebound
CVA tenderness
Deep palpation

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17
Q

how is percussion helpful during an abdominal PE?

A
  • Determining size and density of underlying matter
  • Can estimate liver, spleen, bladder, etc.
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18
Q

what is the Carnett Sign

A

A very simple test that can identify whether pain in the abdomen is arising from overlying muscle vs underlying peritoneal cavity.

  1. Ask to tense abdominal wall w/ neck flexion (protecting the abdominal viscera and cavity from the pressure of examiner’s hands), and abdomen is then reexamined
  2. If pt’s discomfort worsens = disorder of the abdominal wall. If it lessens = intra-abdominal process
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19
Q

what is the Murphy’s Sign

A

AKA “inspiratory arrest”

As the pt takes a slow, deep breath, the examiner elicits an abrupt cessation in inspiration by deep palpation of the right upper quadrant. This finding is suggestive of cholecystitis

Good indicator for Gallbladder inflammation

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20
Q

what is Rovsing Sign

A

AKA “indirect tenderness”

RLQ pain elicited by pressure applied on LLQ

Good Indicator of Appendicitis

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21
Q

what is the Psoas Sign

A

The patient flexes the thigh against the resistance of the examiner’s hand.

Appendicitis

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22
Q

what is the Obturator Sign

A

The patient’s thigh is flexed to a right angle and gently rotated, first internally and then externally.

Appendicitis
Diverticulitis
PID

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23
Q

additional PEs you could do with abdominal pain

A

Pelvic Examination - provides essential information not revealed by other maneuvers.

Rectal Examination
1. Examination of stool for gross or occult blood must be considered in patients with abdominal pain.
2. Occult blood may result from:
- intestinal tumors, inflammatory bowel disease, ischemic bowel disease, and lesions of
the upper gastrointestinal tract.

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24
Q

labs for abdominal pain

A
  • CBC
  • CMP
  • UA
  • Amylase/Lipase
  • Lactate (elevated with tissue hypoxia)
  • beta- hCG !
  • EKG/Cardiac Troponins - Older pts, Upper abd or nonspecific sx
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25
Q

imaging for abdominal pain

A

Plain abdominal radiographs, US, CT

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26
Q

management for abdominal pain

A
  • Stabilize
  • NPO
  • IV hydration with NS or LR
  • Analgesics - Morphine / Demerol / Dilaudid; NSAIDS - ketorolac
  • Antiemetics
  • Surgical or GYN consultation
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27
Q

indications for admission for abdominal pain

A
  1. Toxic appearance
  2. Unclear diagnosis in elderly or immunocompromised
  3. Inability to exclude serious etiology
  4. Intractable pain or vomiting
  5. Altered mental status
  6. Inability to follow discharge or F/U instructions
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28
Q

Torsion of a segment of the bowel
An air segment of colon twists about its mesentery
Leads to bowel obstruction

A

Volvulus

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29
Q

main types of Volvulus and which is MC

A

sigmoid (MC)
cecal volvulus

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30
Q

volvulus occcurs in who MC?

A
  • older adults with a mean age of 70 y/o
  • often institutionalized and debilitated d/t underlying neurologic or psychiatric disease and have a hx of constipation
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31
Q

pathophys of volvulus sigmoid

A
  • air-filled loop of sigmoid colon twists about its mesentery
  • Obstruction of intestinal lumen and impairment of vascular perfusion occur when degree of torsion >180 and >360 degrees
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32
Q

RF for sigmoid volvulus

A
  • Anatomic features - long, redundant sigmoid colon with a narrow mesenteric attachment
  • Chronic fecal overloading from constipation may cause elongation and dilation of sigmoid colon
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33
Q

presentation of sigmoid volvulus

A
  1. Insidious onset of slowly progressive abd pain, N/C, abd distention - many present 3-4 days after starting
  2. Vomiting occurs days after onset of pain
  3. ends up continuous and severe, often w/ colicky component during peristalsis
  4. abd distention and tympany
  5. Tenderness to palpation
  6. Fever, tachycardia, hypotension absent in early stages
    - If present = perforation and/or peritonitis
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34
Q

work-up for sigmoid volvulus

A
  1. CBC, CMP, lactate levels, U/A, pregnancy test, amylase/lipase
  2. DX: Abd CT
    - “whirl” pattern, caused by dilated sigmoid around its mesocolon and vessels
    - “Bird-beak” appearance of afferent/efferent colonic segments
  3. alt: abd radiographs - U-shaped, distended sigmoid colon (“bent inner tube”)
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35
Q

management for sigmoid volvulus

A
  1. IV fluids
  2. Endoscopic detorsion w/ rigid sigmoidoscope
    - Straightens sigmoid colon by gentle pressure with minimal insufflation
    - visualization of dilated proximal segment filled with gas /stool or a sudden expulsion of gas/stool indicates successful reduction
    - High risk of recurrence: elective sigmoid colectomy w/ primary anastomosis after detorsion
    - Immediate surgical exploration with gangrene
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36
Q

Rotation/torsion of a mobile cecum and ascending colon
Results from non fixation of the right colon

A

Volvulus - Cecal

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37
Q

Rotation occurs around the ____ vessels, which leads to earlier vascular impairment and can progress to bowel ischemia, necrosis, or perforation

A

ileocolic blood vessels

38
Q

presentation of cecal volvulus

A
  1. Highly variable
    - Most present with gradual onset of steady abd pain accompanied by episodic cramping pain d/t peristalsis
    - N/V and obstipation
    - Duration of sx can last from hours to days
  2. Diffusely distended and tympanitic with tenderness to palpation
  3. Fever and or hypotension with peritonitis
39
Q

work-up for cecal volvulus

A
  1. R/o other causes of abdominal pain
  2. Labs: CBC, electrolytes, lactate, UA
  3. Imaging
    - Plain radiography - “Coffee bean sign;” “Comma Sign”
    - CT: 1st line and confirmatory: locates lvl of obstruction and can assess bowel damage - “Whirlwind” sign: indicating rotation of mesentery
    - Contrasted (Barium) GI series- “bird’s beak” obstruction - Only done if radiographs inconclusive/no access to CT
40
Q

management for cecal volvulus

A
  1. Cecal volvulus can not be detorsed endoscopically
  2. Stable w/o bowel compromise:
    - Open Surgical Detorsion, then ileocecal resection #1
  3. Hemodynamically Unstable w/o bowel compromise or debilitated
    - Cecopexy after detorsion: Anchors to abd wall = reduces mobility of cecum

Should not detorse with bowel compromise, reperfusion injury occurs (bacteremia/sepsis)

  1. Stable w/ bowel compromise
  • Ileocolic resection or R colectomy
  • Ileocolonic anastomosis
    2. Unstable with bowel compromise
  • Resection + end ileostomy
41
Q

Portion of the bowel is telescoped into another segment
One segment becomes drawn into lumen of distal segment of bowel

A

Intussusception

42
Q

Intussusception is MC in who

A

MCC of intestinal obstruction 6 mo - 3 yrs
Male/female ratio of 4:1

43
Q

Intussusception helps MC where

A

ileocolic

44
Q

Pathogenesis of intussusception

A
  1. As intussusception develops, mesentery is dragged into the bowel = venous and lymphatic congestion = edema
    - Can lead to ischemia, perforation, and or peritonitis
  2. MC idiopathic
    - viral triggers may play a role
    - d/t stimulation of lymphatic tissue in intestinal tract
  3. 25% are d/t underlying disorders
    - lead point: lesion/variation in intestines that is trapped by peristalsis
    — Meckel diverticulum, polyp, cyst, tumor
45
Q

presentation of intussusception

A
  1. Previously healthy infant 3-36 mo develops recurring paroxysms of abd pain with screaming and drawing up knees
    - abd pain can be severe - 15-20 min intervals
    - V/D
  2. Bloody mucus-containing stools appears within next 12 hrs - “currant jelly”
  3. Child is characteristically lethargic/febrile between episodes
  4. Abdomen tender and distended - “Sausage-shaped” mass in R side of abdomen
  5. The likelihood of bowel compromise increases with duration of sx
  6. As sx progress, significant lethargy develops
46
Q

work-up for intussusception

A
  1. Ultrasound (#1)
  2. Abdominal x-ray (mainly to exclude perf)
  3. Barium enema - confirmatory
    - “Coiled spring”
    - Frequently curative
47
Q

management for intussusception

A
  • Surgical consult for extremely ill pts - Evidence of bowel perf, or reduction unsuccessful
  • Nonoperative reduction
48
Q

what is Non-operative Reduction

A
  1. hydrostatic/pneumatic pressure by enema - TOC for infant/child who is clinically stable and has no evidence of bowel perforation or shock
  2. Fluoroscopy guided - Pneumatic (air) or hydrostatic (saline or contrast)
  3. Sonography guided
    - Hydrostatic
    — Can only do hydrostatic b/c air would interfere with US
    — Air blocks the sound waves
49
Q

what is fluoroscopy non-operative reduction

A
  • A type of medical imaging that shows a continuous X-ray image on a monitor, much like an X-ray movie
  • The intussusception appears as a filling defect within the bowel lumen
  • Can be pneumatic or hydrostatic
  • Successful reduction is indicated by the free flow of contrast or air into the small bowel
50
Q

what is a sonographic non-operative reduction

A
  • This guidance requires a hydrostatic technique to provide retrograde pressure
  • Only hydrostatic can be used with sonographic guidance
  • Successful reduction include disappearance of the intussusception and the appearance of water bubbles in the terminal ileum
51
Q

which reduction technique has higher success rates and less chance of perforation

Intussusception

A

pneumatic

  1. If perforation - air would do less damage than contrast or saline
  2. Fluoroscopy is used monitor procedure
    - Air is instilled rectally until intussusception is pushed back gently = decreasing the intraluminal pressure
    - Also showing a rush of air now into the ileum and small bowel
52
Q

pathophys of appendicitis

A
  1. Initiated by obstruction of appendix by a fecalith (stone made of feces), inflammation, FB, neoplasm
  2. Obstruction = increased intraluminal pressure, venous congestion, infection
  3. Can progress to gangrene and perforation develops within 36 hours left untreated
53
Q

presentation of appendicitis

A
  1. Vague, colicky, abd pain - most reliable sx
  2. Dull pain originating in periumbilical or epigastric region
    - Localization to RLQ w/n 12 hrs
    - Worsened by walking or coughing
  3. N/V, anorexia, obstipation, low grade fever
  4. sx increase over 24 hrs
  5. PE: localized tenderness + guarding RLQ w/ gentle palpation w/ one finger
    - When cough, pt’s can localize pain = sign of peritoneal inflammation
    - Rebound tenderness, not required for dx
    - McBurney’s point tenderness
    - Rovsing sign
    - Psoas sign
    - Obturator sign
    - Heel slap sign
    - Rebound tenderness
    - abd rigidity or involuntary guarding
    - Tender DRE - pelvic appendix
    - Right flank pain - retrocecal appendix
54
Q

work-up for appendicitis

A

Mostly clinical
* CBC
* UA
* Pregnancy test
* Abdominal x-ray - nonspecific
* Surgical consult
* US - reliable to confirm dx (but not to exclude)
* CT scan - imaging study of choice

55
Q

management for appendicitis

A
  1. Consult surgeon - Laparoscopic appendectomy (TOC)
  2. Preoperative preparation
    - Hydration with IV fluids
    - Correction of electrolyte abnormalities
    - Perioperative abx - Cefoxitin / ampicillin-sulbactam
    — Prevents wound infection and intra-abdominal abscess; G- aerobes and anaerobes
56
Q
  • Potentially lethal complication of inflammatory bowel disease or infectious colitis
  • Total or segmental nonobstructive colonic dilatation of >6 cm systemic toxicity
A

Toxic Megacolon

57
Q

pathophys of Toxic Megacolon

A
  1. Generally seen in IBD, esp Crohn Colitis, the hallmark of toxic megacolon is characterized by severe inflammation extending into the smooth muscle layer
    - Paralyzing colonic smooth muscle = dilation
    - Inflammatory mediators released, inhibiting smooth muscle tone
58
Q

presentation of toxic megacolon

A
  • S&S of colitis resistant to therapy often present for at least 1 wk prior to onset
  • Severe bloody diarrhea - MC presenting sx
  • Malaise
  • Abdominal pain and distention
  • Vomiting
  • Tenesmus
  • Toxic appearing
  • Altered mental status
  • Tachycardia, Fever, Postural hypotension
  • Lower abd pain and tenderness, +/- peritonitis
  • Dehydration - Bowel loses ability to reabsorb water and salt
59
Q

historical factors that would help you suspect toxic megacolon

A

prior hx of IBD attacks
extent of disease
details of therapy
extraintestinal manifestations of IBD
recent travel, antibiotic use
occupational exposure
use of antimotility agents
HIV status

60
Q

work-up for toxic megacolon

A
  1. Abd CT exam diagnostic modality of choice
    - Good at establishing dx and excluding complications (perforation, vascular compromise, obstruction)
  2. Plain abd films for baseline - will most likely be done 1st - Want to do for serial follow up
  3. Stool specimen - C. diff, CBC, ESR, CMP, CBC
61
Q

Criteria for Toxic megacolon Diagnosis

A
  1. Radiographic evidence of colonic distention
  2. at least 3 of the following:
    - Fever >38oC (100.4)
    - HR >120 bpm
    - Neutrophilic leukocytosis >10,500
    - Anemia
  3. at least one of the following:
    - Dehydration
    - Altered mental status
    - Electrolyte disturbances
    - Hypotension
62
Q

which part in toxic megacolon is often most dilated?

A
  • transverse or right colon is usually most dilated, often >6 cm and occasionally up to 15 cm on supine films
  • Multiple air-fluid levels are common and small bowel gas
63
Q

tx for toxic megacolon

A
  1. Serial CBCs, BMPs, and abd radiographs
  2. Complete bowel rest
  3. Tx dehydration/lyte abnormalities
  4. NG tube
  5. DC ALL antimotility agents (opiates, anticholinergics)
  6. Prophylaxis - Gastric stress ulcerations
  7. Enteral feedings once improvement
  8. BID abd radiographs
  9. +/- Abx - Ampicillin-gentamicin-metronidazole OR 3rd-gen cephalo + metronidazole
  10. IV corticosteroids (hydrocortisone 100mg continuous infusion)
    - If >3 d w/ no improvement = infliximab/Remicade
  11. Surgical consult for colectomy with ileorectal anastomosis
64
Q

indications for surgery for toxic megacolon

A
  • colonic perforation
  • necrosis, or full-thickness ischemia
  • intra-abdominal HTN or abdominal compartment syndrome
  • clinical signs of peritonitis or worsening abd exam despite adequate medical therapy
  • end-organ failure
65
Q

Refers to sudden onset of small intestinal hypoperfusion

A

Acute Mesenteric Ischemia

66
Q

Acute Mesenteric Ischemia MC affects which artery?

A

superior mesenteric artery

67
Q

causes of occlusive acute mesenteric ischemia

A

Acute embolism
Thrombosis

68
Q

causes of nonocclusive acute mesenteric ischemia

A

Low-flow state
Low cardiac output
Vasopressors

69
Q

presentation of acute mesenteric ischemia

A
  1. Hx of prior embolic event present in ⅓ of acute embolic cause
  2. abd pain out of proportion to PE findings - Sudden, Severe, Periumbilical, N/V
  3. PE
    - Mild abd distention which grossly progesses
    - BS absent
    - Occult blood in stool
    - Feculent odor to breath
70
Q

work-up for acute mesenteric ischemia

A
  1. Lab studies -Nonspecific
    - Normal labs do not exclude
    - May have leukocytosis with immature WBCs
    - Metabolic acidosis
    - acute abd pain + metabolic acidosis = Acute Mesenteric Ischemia until proven otherwise
  2. Imaging
    - Plain Abdominal films have limited role
    - CT/MRI performed first, but findings nonspecific
    - Diagnosis Mesenteric Arteriography: Shows narrowing/spasming of mesenteric arteries, reduced filling, irregularity of arterial branches
71
Q

tx for acute mesenteric ischemia

A
  1. Pain control parenteral opioids
  2. Hemodynamic support -Broad spectrum abx, NG tube
  3. Anticoagulation to improve mucosal perfusion
  4. Vasodilator infusion - Nitroglycerin
  5. Abdominal exploration d/t intestinal ischemia
    - Intestinal infarction
    - perforation
72
Q

acute upper GI bleed originate where?

A

proximal to the ligament of Treitz
AKA Suspensory Muscle of Duodenum

73
Q

MCC of UGI bleed

A

PUD
* Erosive gastritis and esophagitis
* Esophageal and gastric varices
* Mallory-Weiss syndrome

74
Q

MCC of LGI bleed

A

Diverticulosis
* Diverticular disease
* Arteriovenous malformations
* Inflammatory disease
* Polyps
* Hemorrhoids

75
Q

historical findings of GI bleeding

A
  1. Hematemesis/coffee-ground emesis - Suggests source proximal to R colon
  2. Melena - Upper GI Bleed
  3. Hematochezia - Usually coming from colon/rectum
  4. More subtle presentation - Hypotension, tachycardia, angina, syncope, weakness, confusion
  5. Wt loss and changes in bowel habits - Suggests malignancy
  6. Meds / alcohol use - PUD, gastritis, esophageal varices
  7. Spider angiomata, palmar erythema, jaundice, gynecomastia - underlying liver disease
76
Q

ingestion of what can simulate melena?

A

iron
bismuth

77
Q

ingestion of what can simulate hematochezia

A

beets

78
Q

what meds can cause red stools?

A

cefdinir

79
Q

work-up for GI bleeding

A

Careful ENT exam
Rectal exam
Type and crossmatch
CBC, electrolytes, BUN/Cr, glucose, coagulation studies, LFTs

80
Q

tx for GI bleeding

A

Emergency stabilization

  1. Airway, breathing, circulation
  2. O2, IV, monitor
  3. IV fluids - NS
  4. Blood - based on clinical factors
  5. NG tube - all patients with significant bleeding
  6. Early endoscopy - consult surgeon
81
Q

a protrusion, bulge, or projection of an organ or part of an organ through the body wall that normally contains it

A

hernia

82
Q

In adults, most umbilical hernias are acquired d/t ?

A

increased intra-abdominal pressure

83
Q

Predisposing factors of Umbilical Hernia include:

A
  1. multiple pregnancies with prolonged labor
  2. ascites
  3. obesity
  4. large intra-abdominal tumors
84
Q

presentation of umbilical hernia

A
  1. Increases steadily in size
  2. Umbilical hernia sac usually contain omentum - small and large bowel may be present
  3. Incarceration and strangulation are common → Emergent repair
  4. Umbilical hernias with tight rings are often associated with sharp pain on coughing or straining
  5. Very large umbilical hernias more commonly produce an aching sensation
85
Q

tx for umbilical hernia

A
  1. Surgical repair
    - Open repair for larger hernias
    - Mesh repair laparoscopically

Surgical repair
Open repair for larger hernias
Mesh repair laparoscopically

86
Q

About 10% of abdominal operations result in ?

A

incisional hernias from prior abdominal incisions
Result from a breakdown of the fascial closure

87
Q

RF for incisional hernias

A

multifactorial

  1. Poor surgical technique
  2. Postoperative wound infection
  3. Advanced age
  4. General debility
  5. Obesity
  6. Postoperative pulmonary complications that stress the repair as a result of vigorous coughing
  7. Placement of drains or stomas through the primary operative fascial defect
  8. Failure to close the fascia of laparoscopic trocar sites over 10 mm in size
  9. Defects in collagen
88
Q

tx for ventral hernia

A
  • primary suture-only repairs
  • mesh reinforcement
  • minimally invasive techniques using laparoscopy or robotic technology
  • open techniques
  • abdominal binder or other type of elastic undergarment for compression.
89
Q

Concerning clinical features for strangulation in hernias include?

A

very firm incarcerated hernia
severe tenderness on exam
redness or other discoloration of the overlying skin

90
Q

indications for abdominal binder/compression for hernia tx

A
  1. does not require urgent or emergent surgery,
  2. is unwilling to undergo surgery
  3. is a poor surgical risk

GI: Clin Med IIA (12 decks)

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