Acute Abdomenand GI Emergencies - GI Flashcards
(26 cards)
Peritonitis
- Inflammation of the peritoneum
- May be localized or generalized
- Caused by infection, trauma, or inflammation of underlying organs, or leakage of blood/bile/urine/gastric juice into the abd. cavity
- Symptoms: abd. pain, fever, nausea/vomiting
- Exam: fever, abd. tenderness/rigidity, rebound and guarding
- An “acute abdomen”
- Often represents a surgical emergency
Acute Appendicitis
-Affects all ages, 10-30 most common
-Most difficult to dx. in the very young, elderly, and immunocompromised
-The greater the delay in treatment, the greater the risk of rupture
Complications of rupture:
-Intra-abdominal abscess
-Adhesions/future Small Bowel Obstruction – scar tissue formation
-Infertility in women
-Death (3-5%)
Acute Appendicitis: Symptoms
- Starts out vague
- Anorexia
- Nausea +/- vomiting
- Low-grade fever
- Abdominal pain
- Gradual onset: subtle
- Migration from periumbilical to RLQ
Acute Appendicitis: Exam
- RLQ tenderness (McBurney’s point), often with rebound and guarding
- Psoas sign: RLQ pain with right thigh extension (pt. lying on left side)
- Obturator sign: RLQ pain with internal rotation of flexed right thigh
- Rovsing’s sign: palpation of LLQ causes RLQ pain
Acute Appendicitis: Lab
- WBC elevated in 86% of cases (but not always!)
- Plain abd. films worthless
- CT abdomen with oral contrast: The best diagnostic study, Very high sensitivity/specificity (both about 95%)
- Ultrasound: Not as good as CT: 75-90% sensitive, No radiation: consider in pregnant pt., kids
- Treatment: Appendectomy
Cholelithiasis/Cholecystitis
-Cholelithiasis: presence of gallstones
-Cholecystitis: gallstones + inflammation of gallbladder (due to GB outlet obstruction)
Risk factors
-Obesity
-Female
-Parity
-50-80% of pts. with gallstones have no sx.
-Symptomatic pts. often give hx. of recurrent attacks
Cholelithiasis/Cholecystitis:Symptoms/exam
-GB contracts in response to fats in small intestine
-Symptoms occur when gallstones migrate to GB neck, cystic duct, or common bile duct
-If obstruction persists, cholecystitis may occur
Symptoms:
-Often occur 30-60 min. after meal usually fatty foods
-RUQ pain – doubled over, comes on suddenly
-Nausea/vomiting
-Fever, toxic appearance suggest cholecystitis
-RUQ tenderness
Murphy’s sign
-Palpate RUQ beneath costal margin
-Have pt. take deep breath
-Pt. has inspiratory arrest due to pain
Cholelithiasis/Cholecystitis: Lab
- WBC, alk. phosphatase, AST/ALT: Usually normal in cholelithiasis, Often elevated in cholecystitis
- Lipase/amylase: If elevated, suggests common bile duct obstruction distal to pancreatic duct: “gallstone pancreatitis”
- RUQ ultrasound: Study of choice, accurately shows gallstones, Thickened GB wall, GB distention suggest cholecystitis
- HIDA scan: radionuclide study - IV isotope given, taken up by normal GB but not in cholecystitis. Almost 100% sensitivity
Cholelithiasis/Cholecystitis:Treatment
Uncomplicated cholelithiasis
- NSAID or narcotic analgesia
- Avoid fatty foods
- If recurrent: elective cholecystectomy
Acute cholecystitis
- IV fluids, pain control
- Antibx.
- Admit
- Surgery, usually 24-72 hrs. later, after GB “cooled down”
Perforated Gastric/Duodenal Ulcer
-Typically have hx. of PUD, antacid use
Risk factors:
- Tobacco
- ETOH
- NSAID use
- Steroids
Perforated Ulcer: h & p
Typical history
- Sudden, severe abd. pain, usually epigastric, often radiating straight to back – release of gastric acids/juices
- Often vomiting
Exam
- Severe distress, looks sick
- Marked abd. tenderness (epigastric or generalized), often rigid
- Bowel sounds possibly absent
- Often tachycardia/hypotension
Perforated Ulcer: lab and treatment
Lab
- Abdominal flat/upright x-ray: shows free air (outside stomach and intestine, shouldnt be there) in 60-70%
- CBC, electrolytes
- CT abdomen may be necessary if plain films fail to show dx.
Treatment
- Vigorous IV fluid resuscitation
- NG tube – hook up to suction to empty out stomach/acids
- Broad-spectrum antibx.
- Emergency laparotomy
Acute Pancreatitis
Usual causes:
- ETOH
- Gallstones: block pancreatic duct
- Familial hyperlipidemia
Symptoms
- Upper abd. Pain
- Nausea/vomiting
Exam
- Epigastric, upper quadrant tenderness
- Possibly abd. distention
- Severe cases: may see hypotension, shock
Acute Pancreatitis: lab
- Elevated amylase/lipase – how make dx, got your dx if its elevated
- CBC: usually leukocytosis, may see anemia if hemorrhagic pancreatitis
- Calcium: may see hypocalcemia
- Ultrasound/CT: show edema of pancreas, possibly pseudocyst or abscess
Acute Pancreatitis:treatment
- IV fluids
- NPO – pancreas needs to rest
- IV analgesia
- Antibx. generally not indicated
- If obstructing stone present: ERCP to remove stone
- Drainage of pseudocyst or abscess, if present
Bowel Obstruction: etiology
Small bowel obstruction
- Adhesions (scar tissue formation) from prior abd. surgery by far most common etiology
- Incarcerated hernia: second most common
- Cancer or polyps much less common
Large bowel obstruction
- Colon CA by far most common etiology
- Other causes: diverticulitis, volvulus (colon flips over on itself)
Bowel Obstruction: h & p
Symptoms: VODKA
- Vomiting
- Obstipation (not passing stool or gas)
- Distention
- Krampy Abdominal pain
Exam
- Diffuse abd. tenderness
- Tympany to percussion
- Bowel sounds: May be high-pitched (“tinkling”), coming in rushes, if late presentation, bowel sounds may be absent
Bowel Obstruction: lab & treatment
Lab
-Flat/upright abd. X-rays
Air-fluid levels, Distended bowel loops
-CBC, lytes, BUN/Cr, others as indicated
Treatment
- NG tube to suction for decompression
- IV fluid resuscitation
- NPO
- Admit
- If no resolution, surgery indicated
Diverticulitis
- 1/3 have diverticuli by age 45, 2/3 by 85
- Usually occurs in sigmoid colon, but may also occur in cecum/ascending colon
Pathogenesis
- Inflammation of diverticuli
- Fecal material trapped, leading to bacterial proliferation
- This inflammation usually walls off
- Rarely may perforate into peritoneal cavity
Diverticulitis: h&p
Symptoms
- Pain
- Change in bowel habits (diarrhea or constipation)
- Straining with BM’s
- Possibly fevers, nausea/vomiting, signs of bowel obstruction
Exam
- Low-grade fever
- Localized abd. tenderness (maybe rebound/ guarding)
- Tender rectal exam
- If perforated, toxic with diffuse abd. tenderness
Diverticulitis: lab & treatment
Lab
- WBC often elevated
- Dx. confirmed by CT: thickened bowel walls with localized inflammatory changes
Treatment
- If localized and pt. appears well, may treat as outpt.: Broad-spectrum antibx., Bowel rest, clear liquids for 48 hrs.
- If pt. appears ill, admit: IV antibx., IV fluids, If perforated: surgery
Ischemic Bowel
- Usually seen in elderly and those with severe peripheral vascular disease
- A true life-threatening emergency
Symptoms
- Severe diffuse abd. pain (out of proportion to tenderness on exam)
- Fever
- Often nausea/vomiting
Exam
- Fever, toxicity
- Diffuse abd. tenderness
Ischemic Bowel:lab & treatment
Lab
- Elevated WBC
- Acidosis, elevated lactate (metabolic acidosis)
- Plain abd. X-rays may show bowel wall thickening: “thumb printing”
- CT usually confirms bowel wall edema, possibly free air, if perforation
Treatment
- Aggressive IV fluids
- IV antibx.
- Immediate surgical consultation to resect infarcted bowel
Ruptured Abdominal Aortic Aneurysm (AAA)
Risk factors
- Elderly
- HTN
- DM
- Peripheral vascular disease
- AAA may be asymptomatic until rupture
- Aneurysms > 5 cm. at significant risk for rupture
