Acute Abdomen Emergencies Flashcards
(167 cards)
1
Q
Extra-abdominal systems that can cause abdominal pain
A
Cardiac, thoracic, metabolic, hematologic, infections or others
2
Q
What are life threatening causes of abdominal paint that can’t be missed?
A
Abdominal aortic aneurysm and dissection GI perforation Incarcerated hernia Acute bowel obstruction Mesenteric ischemia Ectopic pregnancy Placental abruption Splenic rupture
3
Q
1 cause of abdominal pain in ER
A
Appendicitis
4
Q
Red flags in the history of acute abdominal pain
A
Age >65 Alcoholism Immunocompromised CV disease Comorbidities Prior surgery Recent GI instrumentation Early pregnancy
5
Q
Red flags in the pain characteristics of acute abdominal pain
A
Acute onset
Significant pain at onset
Pain followed by emesis
Constant pain for <2 days
6
Q
Red flags on PE for acute abdominal pain
A
Rigid abdomen
Signs of shock (hypotension and tachycardia)
Involuntary guarding
7
Q
What cause of abdominal pain radiates to right subscapular area?
A
Gallbladder disease
8
Q
What cause of abdominal pain radiates to shoulders
A
Perforated duodenal ulcer
9
Q
What cause of abdominal pain radiates to testicles?
A
Ureteral obstruction
10
Q
What cause of abdominal pain radiates to epigastric area, jaw, neck or UE?
A
MI
11
Q
What cause of abdominal pain radiates to low back?
A
GYN
12
Q
How does visceral abdominal pain present?
A
Dull, aching and colicky
Poorly localized
Distention, ischemia, inflammation or spasm of a hollow organ
13
Q
How does parietal abdominal pain present?
A
Sharp
Well localized
Peritoneal irritation, ischemia, inflammation, stretching of parietal peritoneum
14
Q
What are aggravating and alleviating factors to always ask about with abdominal pain?
A
BM
Eating
Antacids
Exertion
15
Q
What patient is restless and can’t sit still?
A
Renal colic
16
Q
What patient is lying perfectly still and supine?
A
Peritonitis
17
Q
Common causes of hypoactive or absent bowel sounds
A
Peritonitis or small bowel obstruction
18
Q
Common causes of hyperactive bowel sounds
A
Blood or inflammation in the GI tract
19
Q
What must be done with men and women that present with lower quadrant/hypogastric pain?
A
Testicular/pelvic exam
20
Q
Initial diagnostics for abdominal pain
A
CBC with diff BMP/CMP AST, ALT, alk phos, total bilirubin Lipase/amylase Lactic acid UA Urine pregnancy test Stool guaiac
21
Q
What is lactic acid a marker of?
A
Tissue hypoxia
22
Q
What do you use plain films for?
A
Dilated bowel loops, air fluid levels, free air, constipation or foreign body
23
Q
What is a CT without contrast used for?
A
Renal stone or obstruction
24
Q
What is a CT with IV contrast used for?
A
Ischemic bowel, diverticulitis, peritonitis or AAA
25
What is a CT with oral contrast used for?
Really skinny adults or kids
26
When is an u/s used?
Gall bladder, free fluid, renal, ovarian or testicular
27
General management for abdominal pain
```
IV fluids
Anti-emetics
Analgesia
Anti-pyretic
NPO
Abx if indicated
Consults, monitor for sepsis and shock, repeat exa, and vitals
```
28
Reasons for urgent surgical referral
```
Obstruction
Perforation
Peritonitis
Ischemic bowel
Dissection
Rapid sx evolution (increasing TTP/rigidity, pain is severe)
```
29
Who may have atypical presentations related to abdominal pain?
Elderly
Diabetic
Immunocompromised
30
Causes of GI perforation
Spontaneous due to inflammatory changes (gall bladder, appendix)
Bowel obstruction
Trauma
Instrumentation
31
What do the clinical manifestations of GI perforation depend on?
Organ and contents released (air, stool or succus entericus)
32
What is succus entericus?
Various enzymes (lipase, lactase, amylase) and mucus released after perforation of pancreas
33
When is perforation more common?
>50 yr and <10 yr
34
What can perforation be followed by?
Peritonitis
35
Presentation of GI perforation
More diffuse pain after localized tenderness
| Pain can be relieved and then followed by peritonitis
36
Types of pain seen in peritonitis
Localized pain-contained by viscera or omentum
| Generalized pain- gross spillage into cavity
37
Presentation of peritonitis
Pt looks sick (high fever)
Lie still to minimize discomfort
Bloating and full feeling
Rebound tenderness and tender to percussion
Pain with light palpation/bumps
Diminished bowel sounds
N/v, anorexia, low urine output, can't pass stool
38
Who should we suspect spontaneous bacterial peritonitis in?
```
Ascites
Liver cirrhosis (alcoholics)
Fever
AMS
Abdominal pain
Maybe hypotension
```
39
What should you perform and what shouldn't be performed with spontaneous bacterial peritonitis?
DO paracentesis
| DON'T do exploratory laparotomy
40
Tx of spontaneous and secondary bacterial peritonitis
Abx (usually for e coli or klebsiella)-- cefotaxime
41
Who should you suspect secondary bacterial peritonitis in?
```
Possible perf (peptic ulcer, appendicitis) with ascites
Fever
AMS
Abdominal pain
Maybe hypotension
```
42
What must be performed in secondary bacterial peritonitis?
Must do exploratory laparotomy
| and also paracentesis
43
Most common surgical emergency in elderly
Acute cholecystitis
44
Presentation of acute cholecystitis
Severe, constant RUQ pain usually >6 hrs
Can radiate to epigastric or right shoulder
N/v, increase pain with fatty food intake
Guarding, RUQ pain with palpation
Ill appearing and lay still
45
What sign is positive in cholecystitis?
Murphy's (press on and have pt take a deep breath)
46
Labs for acute cholecystitis
Leukocytosis with bands
Elevated CRP
Normal alk phos, transaminases and bilirubin
47
Imaging for acute cholecystitis
```
RUQ U/s:
Gall bladder wall thickening
Sonographic murphy's sign
Gallstones or sludge
Pericholecystic fluid
```
48
Management or acute cholecystitis
IV fluids, analgesia, NPO
Ceftriaxone or Cefuroxime
Consult surgery
49
When do you do operative management with acute cholecystitis?
Lack of noticeable management using non-operative management within 1-2 days
50
Percutaneous drainage in acute cholecystitis
For unstable pts to save surgery until pt is more stable
| Use radiologic guidance
51
What is acute choledocholithiasis?
Gallstones in the common bile duct
52
Most common cause of acute choledocholithiasis
Secondary (passage of stones from gall bladder to common bile duct)
53
Lesser common cause of acute choledocholithiasis
Formation of stones in the common bile duct (maybe CF)
54
Presentation of acute choledocholithiasis
Biliary type pain (colicky-comes and goes) in RUQ that maybe goes epigastric
n/v
Pain can be intermittent with "transient blockage"
Jaundice
55
Positive sign in acute choledocholithiasis
Courvoisier's sign (palpable gall bladder)
56
Labs in acute choledocholithiasis
Elevated bilirubin, alk phos and transaminases (different for cholecysitis)
Also elevated GTT
57
Imaging for acute choledocholithiasis
Transabdominal u/s for presence of stones
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Tx of acute choledocholithiasis
Consult surgery or GI
59
Difference in management for high risk vs low risk pts with acute choledocholithiasis
High risk: ERCP so remove stone by endoscopy or surgery and then elective cholecystectomy
Low risk: cholecystectomy
60
Complications of acute choledocholithiasis
Acute pancreatitis and acute cholangitis
61
What is acute cholangitis?
Ascending bacterial infection due to obstruction of biliary ducts
*medical emergency
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Most common cause of acute cholangitis
Choledocholithiasis
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Other causes of acute cholangitis
Biliary canaliculi, malignancy, benign stenosis
| mostly due to enterococci
64
Presentation of acute cholangitis
Charcot's triad (fever/chills, RUQ abd pain, jaundice)
| Reynold's triad (charcot's + AMS, hypotension)
65
Labs for acute cholangitis
Leukocytosis and neutrophilia
Elevated alk phos, GGT, bilirubin, transaminases
If elevated amylase then pancreatic involvement
66
Imaging for acute cholangitis
```
Depends on severity:
Transabdominal u/s: common bile duct dilatation or stones
Endoscopic u/s
ERCP
MRCP
```
67
Imaging for pregnant pt with acute cholangitis
US usually first and then fetal shielding if need ERCP
68
Management of acute cholangitis
Admit!!
NPO, Iv fluids, analgesia, consult
Empiric abx coverage (ceftriaxone + metronidazole)
Can do biliary drainage (ERCP)
69
Presentation of Hep A
Abrupt onset RUQ abd pain
N/v, anorexia, fever/malaise, dark urine, pale stools, jandice, scleral icterus
Hepatomegaly mostly (can be spleno)
70
Labs for Hep A
Elevated ALT (can be AST), alk phos and bilirubin
71
How long is Hep A pt contagious for?
About 28 day incubation and up to 1 wk following jaundice onset
72
What is pancreatitis?
Acute inflammatory process of pancreas (severe is when there is persistent organ failure)
73
Gallstone pancreatitis
Well localized pain, onset is rapid (stone in common bile duct or pancreatic duct)
74
Other causes of pancreatitis
Less well localized and slower progression
| Alcohol, drugs (amiodarine, antivirals, diuretics etc), severe hyperlipidemia, idiopathic
75
Presentation of pancreatitis
Persistent severe, boring acute epigastric or RUQ pain that can radiate to back
May be relieved leaning forward
Maybe dyspnea if diaphragmatic inflammation
N/v, bloating
76
PE for pancreatitis
Fever, tachypnea, hypotension
Hypoactive bowel sounds
Distension
Scleral icterus or jaundice if due to choledochlithiasis
77
Positive signs of pancreatitis
Cullen's sign (see superficial edema in the subcutaneous in the subQ fatty tissue around umbilicus-periumbilical region)
Grey Turner sign (ecchymotic discoloration due to retroperitoneal bleeding from pancreatic necrosis-flank)
78
Labs to diagnose pancreatitis
Lipase (4-8 hrs) and amylase (6-12) elevated 3x normal
| Also may see leukocytosis and increased CRP
79
What is most sensitive imaging in early pancreatitis?
MRI
80
Criteria to diagnose pancreatitis
Must meet 2:
Acute onset of constant, severe epigastric pain radiating to back
Elevation in serum lipase of amylase to 3x or greater than normal
Characteristic findings on imaging
*if meet first 2, do not need imaging to diagnose
81
Management of pancreatitis
Admit to ICR
NPO, fluids, NG tube, foley catheter, serial labs of amylase and lytes
Analgesia (opiates)
Consult GI when gallstone pancreatitis (ERCP)
82
Risk factors of PUD
NSAID use
H pylori infection
Smoking
Excessive vomiting (gastroparesis, gastroenteritis, anorexia, bulemia
83
Presentation of PUD
Epigastric pain radiating to mid thoracic region
Early satiety, dyspepsia, heartburn, pain with eating
SOB, cough (especially when lie flat)
N/v
Hematemesis
Anorexia
Melena or hematochezia with perf
84
What does a splenic abscess result from?
Endocarditis (typically) or seeding from another site
85
Presentation of splenic abscess
LUQ pain
Maybe splenomegaly or left side pleural effusion
Fever
86
How to diagnose splenic abscess or infarct
CT scan with IV contrast
87
Tx of splenic abscess
Admit
NPO, IV fluids, abx
Maybe splenectomy if consult surgeon
88
Risk factors of splenic infarct
```
Hypercoagulable state (malignancy)
Embolic disease (afib, infective endocarditis)
Sickle cell
Trauma
Complication of mononucleosis
```
89
Presentation of splenic infarct
Acute LUQ pain, fever, n/v
Elevated LDH and leukocytosis
Maybe splenomegaly
90
Tx of uncomplicated splenic infarct
Analgesia and monitor
91
Tx of complicated splenic infarct (abscess, sepsis, hemorrhage)
Surgical eval for splenectomy
92
History that is important for atraumatic splenic rupture
```
Neoplasm (leukemia or lymphoma)
Infection (mononucleosis, CMV, HIV)
Inflammatory disease (acute/chronic pancreatitis)
Drug (anticoagulants)
Mechanical (pregnancy related)
Idiopathic
```
93
Presentation of splenic rupture
Pain and fullness in LUQ maybe referring to left shoulder
Pleuritic pain
Early satiety
94
Diagnosis of splenic rupture
US (gold standard)
| Or can do CT with IV contrast
95
Tx of splenic rupture
NPO, IVF
Transfusion
Immediate surgery (splenectomy)
96
Causes of small bowel obstruction
```
Mostly prior abdominal/pelvic surgery (adhesions)
Abd wall/groin hernia
Intestinal inflammation
Neoplasm
Prior irradiation
FB ingestion
Intussusception or volvulus
```
97
What is intussusception?
Lead pt of bowel is pulled forward by normal peristalsis, telescoping or prolapsing the affected segment of bowel into another segment
98
What is volvulus?
Air filled loop of sigmoid colon twists about the mesentery
99
Presentation of small bowel obstruction
N/v
Cramping abdominal pain-periumbilical (may be more focal if ischemia or necrosis)
Obstipation (inability to pass flatus or stool)
Dehydration
Fever if abscess, ischemia or necrosis
100
Imaging used for small bowel obstruction
Abd x-ray (see dilated loops of bowel with air fluid levels and proximal bowel dilation with distal bowel collapse)
CT (masses, inflammation etc)
101
Tx of small bowel obstruction
Admit
NPO, IV fluids, anti-emetics, NG tube
Consult surgery if not resolved with NG tube and bowel rest
Maybe abx
102
Risks for acute mesenteric ischemia
```
Cardiac arrhythmias
Advanced age
Low CO states
Valvular heart disease
MI
Malignancy
```
103
Presentation of acute mesenteric ischemia due to arterial thrombosis/emboli
```
Rapid onset of severe periumbilical pain out of proportion to PE
N/v
Possible forceful bowel evacuation
Post prandial pain
Maybe hematochezia
```
104
Presentation of acute mesenteric ischemia due to venous thrombosis
More indolent course
| Lower mortality
105
Labs possibly seen in acute mesenteric ischemia
```
Maybe leukocytosis or metabolic acidosis
Hemoconcentration
Increased lactate and LDH
Some have elevated serum amylase
Check d-dimer
```
106
What might be seen on plain abdominal films in acute mesenteric ischemia?
Free air-sign of dead bowel
If yes, laparotomy (embolectomy or colon resection)
If no, then abd CT angiography with IV contrast
107
Management of acute mesenteric ischemia
```
Admit
IV fluids, NPO, foley
Empiric abx (ceftriaxone+metronidazole)
Systemic anticoagulation
Consult
```
108
Most common abdominal emergency
Appendicitis
109
Causes of appendicitis
Blockage of appendix w/ stool
Appendicolith (calcification)
Tumor with secondary infection
110
Pain in appendicitis
RLQ-starts periumbilical and migrates
111
Sign seen with retroceccal appendix
Psoas sign
| back/flank/testicular pain
112
Sign seen with pelvic appendix
Obturator sign
| suprapubic/rectal pain/dysuria/diarrhea more common
113
Presentation of appendicitis
N/v, anorexia
Fever (late)
+ Rovsing's or rebound tenderness
114
Labs for appendicitis
Leukocytosis (bands) and if extreme elevation then perf (normal doesn't r/o)
UA is appendix near bladder
115
Where can pain from appendicitis present in 3rd trimester of pregnancy?
RUQ
116
Imaging for appendicitis
Not needed if clinical appendicitis
117
What kind of imaging is needed for appendicitis if the diagnosis is unclear?
Abd x-ray: free air, + appendicolith (not useful otherwise)
US-limited by obesity and retroceccal appendix
CT (WITH CONTRAST)-shows inflammation, abcesses, fat stranding, fluid collection
MRI (WITH CONTRAST) in pregnant pts
118
Tx of appendicitis
Admit
IV fluids, NPO, analgesia
Abx (cefoxitin or cefazolin+metro)
Surgical consult
119
What is diverticulitis?
Inflammation usually due to microperforation of a diverticulum
120
Presentation of diverticulitis
LLQ pain that is steady, deep constant
Left side pain (tender mass) on rectal exam
N/v, change in bowel habits, urinary sxs
Low fever
Rebound and guarding
Localized tenderness and maybe distension
121
What can result from an acute attack of diverticulitis?
Obstruction or paralytic ileus (edema or compression of colon)
122
Labs for diverticulitis
+ stool guaiac
Mild leukocytosis
UA: pyuria
123
Bowel sounds in diverticulitis
Hyperactive or high pitched in obstruction
| Hypoactive or absent if peritonitis
124
Imaging for diverticulitis
Abd xray is non-specific
US shows abscesses, bowel wall thickening, diverticula, fistulas
CT with contrast is preferred (show thickening, diverticula, abscesses, dilated loops)
125
Tx for diverticulitis
Send home with oral abx (cipro + metro)
| Close f/u within 2 days with GI
126
Tx for complicated diverticulitis
Perf, abcesses, fistula, obstruction
Admit
IV fluids, NPO, abx, consult
127
What does toxic megacolon come from?
Usually complication of IBD (also volvulus, diverticulitis, obstructive colon cancer, secondary to C dif, CMV)
128
Presentation of toxic megacolon
Severe, bloody diarrhea
Toxic appearing pt
AMS, tachycardia, fever, postural hypotension, abd distention and tenderness
129
Imaging for toxic megacolon
Plain abd films: transverse/right colon most dilated up to 15 cm and maybe air fluid levels
130
Criteria for clinical diagnosis of toxic megacolon
```
Enlarged dilated colon on abd imaging
Fever >38 C
HR>120 bpm
Neutrophilic leukocytosis>10,500 microL
PLUS
Dehydration
AMS
Lyte disturbance
Hypotension
```
131
Tx of toxic megacolon
```
Admit
IV fluids, NPO, NG tube
*no antimotility agents or opioids
Broad spectrum IV abx (ampicillin, gentamycin, metro)
IV steroids
```
132
Complications of toxic megacolon
Perf
Massive hemorrhage
Progression of dilatation
133
What is hemorrhoid presentation associated with?
Rectal bleeding, bright red and can be copious
134
Presentation of hemorrhoids
Anal pruritis or prolapse
Acute perianal pain, lump due to thrombosis
Can become strangulated and be gangrenous
135
PE needed for hemorrhoids
Visual inspection
DRE
Anoscopy
136
Tx for internal or external hemorrhoids
Excised by surgeon
| also due fluids or fiber in diet
137
Tx for thrombosed hemorrhoid
Can incise overlying skin and evacuate small clot
| Immediate relief
138
Presentation of perianal abscess
Severe pain in anal area
Fever uncommon unless cellulitis or extension
Area of fluctuance/indurated skin in perianal area
No findings on DRE
139
Tx for perianal abscess
Simple can be drained in ER
Anesthetize area, open wound, evacuate pus and irrigate
Don't pack
Sitz baths at home
Abx if also cellulitis, infection, DM, valvular heart disease, immunosuppressed (augmention, Cipro and Metro)
If extensive then drain surgically
140
Presentation of rectal foreign body
Anorectal or abdominal pain, blood per rectum or mucus discharge hours to days after placement
141
Exam used for rectal foreign body
Can find normal to diffuse peritonitis
Absence of palpable FB on DRE does not exclude
Plain radiograph, flat and upright of abdomen, followed by CT if radio-opaque
142
Management for rectal FB
Removal transanal approach (relax with IV sedation)
Consult surgeon, surgical removal (abdominal palpation, laparoscopy, colotomy)
143
What workup is needed for female pelvic pain
```
CBC with diff
BMP
UA
HCG
NAAT for chlamydia and gonococcus
Gram stain
Pelvic exam and palpate ovaries etc
```
144
Why would you do a US transvaginally?
Suspected ovarian neoplasms, masses
Torsion
Ectopic pregnancy
145
Presentation of ectopic pregnancy
Vaginal bleeding with pain about 6-8 wks after last menses
| Maybe life threatening hemorrhage if ruptured
146
How to diagnose ectopic pregnancy
Transvaginal us, +HCG
147
Tx for ectopic pregnancy
Stable pt and close f/u
| Can use methotrexate
148
When should you not use methotrexate in ectopic pregnancy?
```
High hCG conc
Fetal heart activity noted
Large ectopic size
Renal/liver disease
Breastfeeding
```
149
What to do if suspected tubal rupture or unstable pt with ectopic pregnancy?
Salpingectomy
150
What are most cases of PID related to?
STIs
151
Presentation of PID
Maybe fever/chills
New vaginal discharge (mucopurulent), intermenstrual bleeding
Maybe pelvic organ TTP
Cervical friability
Abundant WBCs on saline microscopy of vaginal fluid
152
Labs for PID
ESR and CRP
Transvaginal US for suspected abscess/free fluis
NAATs for chlamydia or gonorrhea
Gram stain
153
When to hospitalize with PID
Severe clinical illness
Unable to tolerate POs
Complicated PID with abscess
Pregnancy or post-partum
154
Tx for PID
```
IV fluids
Pain control, anti-emetic
Abx (inpt is cefoxiitn + doxy and out is ceftriaxone + doxy)
Consult GYN
Blood cultures x2 if admit
```
155
Most common GYN emergency
Ovarian torsion (increase risk with pregnancy)
156
Presentation of ovarian torsion
Acute onset of pain, n/v and adnexal mass on exam
Maybe abnormal genital tract bleeding
Pain can go to back/flank/groin
Fever if necrotic
157
Imaging for ovarian torsion
US for duplex for BF (transvaginal and transabdominal)
| Direct visualization in surgical eval
158
Tx for ovarian torsion
Pre-menopausal with viable ovary and no malignancy- laparoscopic detorsion
Post menopausal, nonviable ovary or suspected malignancy-salpingo-oophorectomy
159
Presentation of ovarian cancer
```
Adnexal mass, abdominal distention
Bloating, early satiety
Weight loss
Urinary urgency and frequency
Acute presentation can be malignant effusion or SBO
```
160
How to diagnose ovarian cancer
```
US: transvaginal + transabdominal
Tumor markers (CA 125)
```
161
Tx for ovarian cancer
Consult surgery, oncology or GYN
162
What is postpartum endometritis?
Common cause of postpartum febrile mortality caused by infection of endometrium during delivery
163
Presentation of postpartum endometritis
Fever/chills and uterine tenderness
Foul smelling discharge (lochia)
Uterus may be soft, +/- excessive uterine bleeding
164
How to diagnose postpartum endometritis
Clinical and elevated WBC with bands
165
Tx for postpartum endometritis
Admit
IV abx (clinda IV and gentamycin IV)
Consult
166
What must be done with all pts with lower abdominal pain?
Pelvic/rectal exam
167
Concern with pts on chronic steroids and chronic opiates
Can have masking of pain
