Abdominal Pain & Acute Abdominal Disorders Flashcards

Question

imaging for abdominal pain

Answer 1

Plain abdominal radiographs, US, CT

Answer 2

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

Answer 3

1. Toxic appearance 1. Unclear diagnosis in elderly or immunocompromised 1. Inability to exclude serious etiology 1. Intractable pain or vomiting 1. Altered mental status 1. Inability to follow discharge or F/U instructions

Answer 4

**sigmoid (MC)** cecal volvulus

Answer 5

* 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

Answer 6

* 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

Answer 7

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

Answer 8

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**

Answer 9

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”)

Answer 10

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

Answer 11

Volvulus - Cecal

Answer 12

ileocolic blood vessels

Answer 13

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

Answer 14

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

Answer 15

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**

Answer 16

Intussusception

Answer 17

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

Answer 18

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

Answer 19

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

Answer 20

1. **_Ultrasound_** (#1) 1. Abdominal x-ray (mainly to exclude perf) 1. _Barium enema_ - confirmatory - “Coiled spring” - _Frequently curative_

Answer 21

* Surgical consult for extremely ill pts - Evidence of bowel perf, or reduction unsuccessful * Nonoperative reduction

Answer 22

1. _hydrostatic/pneumatic pressure by enema_ - **TOC for infant/child who is clinically stable and has no evidence of bowel perforation or shock** 3. Fluoroscopy guided - Pneumatic (air) or hydrostatic (saline or contrast) 4. Sonography guided - Hydrostatic --- Can only do hydrostatic b/c air would interfere with US --- Air blocks the sound waves

Answer 23

* 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

Answer 24

* 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

Answer 25

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

Answer 26

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

Answer 27

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

Answer 28

**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**

Answer 29

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

Answer 30

Toxic Megacolon

Answer 31

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

Answer 32

* 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

Answer 33

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

Answer 34

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

Answer 35

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

Answer 36

* **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

Answer 37

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

Answer 38

* 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

Answer 39

Acute Mesenteric Ischemia

Answer 40

superior mesenteric artery

Answer 41

Acute embolism Thrombosis

Answer 42

Low-flow state Low cardiac output Vasopressors

Answer 43

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

Answer 44

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

Answer 45

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

Answer 46

proximal to the ligament of Treitz AKA Suspensory Muscle of Duodenum

Answer 47

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

Answer 48

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

Answer 49

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

Answer 50

iron bismuth

Answer 51

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

Answer 52

Emergency stabilization 1. Airway, breathing, circulation 1. O2, IV, monitor 1. IV fluids - NS 1. Blood - based on clinical factors 1. NG tube - all patients with significant bleeding 1. Early endoscopy - consult surgeon

Answer 53

increased intra-abdominal pressure

Answer 54

1. multiple pregnancies with prolonged labor 1. ascites 1. obesity 1. large intra-abdominal tumors

Answer 55

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

Answer 56

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

Answer 57

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

Answer 58

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

Answer 59

* 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.

Answer 60

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

Answer 61

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

Abdominal Pain & Acute Abdominal Disorders Flashcards

(90 cards)