Acute Abdomen Lecture

Question 1

Esophageal perforation
PUD/gastritis
Mallor-Weiss

..will all present with pain where?

Answer 1

Epigastric pain

Question 2

Associated with high mortality rate

MC type= iatrogenic (50-60%)

Other causes:
Boerhaave’s Syndrome
Trauma
Foreign body ingestion

Answer 2

Esophageal perforation

Question 3

A full thickness perforation of the esophagus after a sudden rise in the intraesophageal pressure, often due to forceful emesis

*usually associated with alcohol

Answer 3

Boerhaave’s Syndrome

Question 4

Acute, severe unrelenting and diffuse pain in chest, neck and abdomen

swallowing exacerbates pain
tachypnea, tachycardia

Abrupt onset, usually preceded by violent emesis
Mediastinal (sub Q) emphysema can be seen (but takes time to develop)

Answer 4

Esophageal perforation

Question 5

A finding caused by air in the mediastinum being moved by the beating heart, can sometimes be ausculated

Answer 5

Hammon’s crunch

(seen with esophageal perforation)

Question 6

Pleural effusions happen in about ____% of pts with intrathoracic perforations

Answer 6

50%

Question 7

Diagnosis of esophageal perforation

Answer 7

CXR will suggest
CT confirms

Question 8

Related to NSAIDs and H Pylori

dyspepsia= continuous or recurrent upper abdominal pain or discomfort +/- associated symptoms

must consider with heavy NSAID, ASA, ETOH and smoking use

Answer 8

PUD, gastritis

Question 9

H pylori is present in about…

____% of duodenal ulcers
____% gastric ulcers

Answer 9

95% duodenal ulcers

70% gastric ulcers

Question 10

Burning epigastric pain that is relieved with food, milk or antacids

recurs at night as stomach empties

EPIGASTRIC TENDERNESS on exam

Answer 10

PUD

Question 11

Gold standard dx of PUD

Answer 11

Upper GI endoscopy

Question 12

Partial thickness tear of esophogeal-gastric junction

Hematemesis after vomiting, CP, coughing

CXR to R/O free air/pneumomediastinum

Answer 12

Mallory Weiss Tear

Question 13

gall stones

often found incidentally (asymptomatic)
**pain ususally after fatty meal (may radiate to chest, R shoulder or scapula)

Answer 13

Cholelithiasis

Question 14

Highest risk= women age 30-80 yo

Usually gallstone obstructing cystic duct
Fever, chills, vomiting, severe pain (often post prandial)

positive murphy’s sign

Answer 14

Acute cholecystitis

Question 15

Gallstone in common bile duct

pain radiating to middle of back and epigastric tenderness
may be jaundiced

*can produce sepsis, pancreatitis, obstructive jaundice

Answer 15

Choledocholithasis

Question 16

Bacterial infection of biliary tree as a result of obstruction

Answer 16

Cholangitis

Question 17

Top 2 causes of acute pancreatitis

Answer 17

1. ETOH abuse
2. cholelithasis

Question 18

A central cause of pancreatitis is intracellular activation of..

Answer 18

trypsin

Question 19

Nausea, vomiting, epigastric pain
May localize to R or L UQ or radiate to back
Usually begins abruptly and lasts for days
Epigastric tenderness
Bowel sounds may be decreased
+ Cullen or Turner sign in SEVERE cases
May have guarding on exam

Pain worse when lying down, better when leaning forward

Answer 19

Pancreatitis

Question 20

What 2 labs will be elevated in pancreatitis?

Answer 20

Lipase (3x norm; nearly 100% sensitive and specific)

ALT (3x norm; nearly 95% predictive value for biliary pancreatitis)

Question 21

Age >55
WBC >16,000
Glucose >200
LDH >350
ALT >250

Answer 21

Ranson’s criteria for Pancreatitis Admission

Question 22

Pain and nausea control
Hydration
Bowel rest

..mainstay tx for?

Answer 22

acute pancreatitis

Question 23

MC abdominal surgical emergency

Answer 23

Appendicitis

Question 24

Develops from obstruction of appendiceal lumen

Increased luminal pressure leads to vascular compromise, bacterial invasion, inflammatory response and resultant tissue necrosis with possible perforation and peritoneal contamination

pain from periumbilical area to the RLQ

Answer 24

Appendicitis

Question 25

MC ages 10-40 VERY rare in kids under 5 bacterial overgrowth by E. Coli occurs in 80% **Rosvings Heel Strike Obturator Sign Psoas Sign Guarding**

Answer 25

Appendicitis

Question 26

After the onset of vague abdominal pain, the classic triad of symptoms in appendicitis are: 1. 2. 3.

Answer 26

1. anorexia 2. nausea 3. vomiting

Question 27

What is the most reliable sign for appendicitis in kids?

Answer 27

Guarding

Question 28

Is fever an early or late sign of appendicitis?

Answer 28

Late

Question 29

Dx of appendicitis is

Answer 29

most are diagnosed **clinically** \*but, image of choice = **CT scan!**

Question 30

90% occur in **sigmoid colon** (LLQ pain) generally in \>50 yo results from high colonic pressures, resulting in erosion and microperforation of the diverticular wall, leading to inflammation of the pericolonic tissue

Answer 30

Diverticulitis

Question 31

Image of choice for diverticulitis?

Answer 31

CT scan

Question 32

Flagyl + Cipro = DOC for?

Answer 32

Diverticulitis

Question 33

Most pts \>60 Males HTN Family history Marfan's Syndrome, smoking, hyperlipidemia, diabetes

Answer 33

AAA

Question 34

Thinning of the media of the aorta with a reduction in elastic, collagen and fibromellar units results in a decrease in tensile wall strength **as the aorta dilates, the force on the aortic wall increases, causing further aortic dilation** \*on avg, can grown 0.25 cm to 0.5 cm a year

Answer 34

AAA

Question 35

For a AAA, those larger than \_\_\_\_\_cm are at risk of rupture

Answer 35

5 cm

Question 36

Classically older males with severe back or abdominal pain who presents with syncope or hypotension **"tearing" or "ripping" pain** Often complain of **unilateral flank or groin pain, hip pain or abdominal pain localized to a specific quadrant**

Answer 36

AAA

Question 37

Retroperitoneal hemorrhage on periumbilical

Answer 37

Cullen's sign **AAA**

Question 38

What is the Grey-Turner sign that can be seen with a AAA?

Answer 38

Flank ecchymosis

Question 39

Image of choice for AAA

Answer 39

CT scan (but if pt is really unstable, can do a bedside ultrasound)

Question 40

Asymmetric femoral pulses can be seen with....

Answer 40

AAA

Question 41

**Periumbilical pain out of proportion to exam** often seen in pts with a fib, hypercoagulable conditions, vasculitis, sickle cell

Answer 41

Ischemic bowel (usually occurs at: splenic flexure, rectosigmoid jxn, ascending colon)

Question 42

Inflammation of mesenteric lymph nodes (usually RLQ)

Answer 42

Mesenteric Adenitis

Question 43

What is more common, large or small bowel obstruction?

Answer 43

Small bowel obstruction

Question 44

MC cause of small bowel obstruction

Answer 44

Adhesions following surgery

Question 45

Adhesions Incarcerated inguinal hernias Intussusception Lymphoma Strictures ..all cause?

Answer 45

Small bowel obstruction

Question 46

Carcinoma Fecal impaction Ulcerative colitis Volvulus Diverticulitis Intussception Psuedo-obstruction ...all can cause?

Answer 46

Large bowel obstruction (neoplasm = MC cause)

Question 47

Vomiting Abdominal distention Pain Past hx of abdominal surgery or hernia

Answer 47

Bowel obstruction

Question 48

What are the bowel sounds like in a person with an obstruction?

Answer 48

Initially..hyperactive Later, diminished/absent