Acute Surgical Abdomen - Sasek Flashcards Preview

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Flashcards in Acute Surgical Abdomen - Sasek Deck (45):
1

Causes of Pain by Location:

Suprapubic

  • UTI
  • Bladder Cancer
  • Uterine Fibroids
  • Bacterial Vaginosis
  • Cervicitis
  • Advanced Pregnancy

1

Peritonitis

inflammation of the peritoneum

signs:

  • distended or rigid abdomen
  • fever and chills
  • fluid in abdomen
  • passing few or no stools or gas
  • excessive fatigue
  • low urine output
  • nausea and vomiting

2

Character: Colicky or Crampy

distension or stretching

3

Diarrhea

watery: gastroenteritis  - medical conditions

blood: inflammatory bowel (Chron's; UC)

4

Mesenteric Intestinal Ischemia

 

  • Cause
  • Signs
  • Risk Factors
  • Diagnosis
  • Treatment

abrupt onset of pain out of proportion to examination

CAUSE

  • emboli/thrombi

SIGNS

  • nuaea and vomiting common
  • acidosis common

RISK FACTORS:

  • > 50
  • A FIB
  • Atherosclerotic Disease
  • Hypercoagulability

DIAGNOSIS:

  • CT - CTA or MRA
  • Angiography ** Gold Standard **
  • Elevated Serum lactate
  • Heme positive stool
  • Early surgical consult

TREATMENT:

  • IV fluids
  • surgical removal 
  • IV ABX 
  • Pain control

4

Pancreatitis

  • acute upper abdominal pain
  • band-like radiation to the back
  • alcohol, gallstones
  • nausea, vomiting
  • toxic apearing - febrile
  • patient is restless
  • elevated: serum lipase and amylase

4

Appendicitis

  • pain begins at umbilicus, shifts to right lower quadrant
  • anorexia
  • may have vomiting
  • tenderness at McBurney's point
  • rebound tenderness
  • + obturator
  • + iliospsoas

diagnostics

  • CT with contrast
  • Ultrasound can rule in or rule out

5

Causes of pain by location:

Left Lower Quadrant

 

  • Diverticulitis
  • Ovarian Cyst
  • Ectopic Pregnancy
  • PID
  • Renal Stones (L flank)
  • Ovarian Torsion
  • Inguinal Hernia
  • Referred Hip Pain

6

Immediately Life Threatening Abdomen Conditions

  • AAA
  • Mesenteric Ischemia
  • Perforation GI tract
  • Acute bowel obstruction
  • Volvulus
  • Ectopic Pregnancy
  • Placental Abruption
  • MI
  • Splenic Rupture

7

Character: Burning

ulcer

8

define: Acute Abdomen

sudden, spontanoues non-traumatic disorder whose chief manifestation is in the abdominal area and for which urgent operation may be necessary

delay in tx will adversly affect outcomes

25% discharged vs. 35-40% admitted

elderly - higher mortality rates

kids - 2/3 surgical appendectomy

9

Obstipation

absence of both stool AND flatus 

indicative of mechanical bowel obstruction

10

Abdomen Imaging

Plain Film - low yield
Ultrasound - AAA, gallbladder, female GU
CT - acute abdomen
Angiography - mesenteric ischemia, AAA

11

Ruptured Ectopic Pregnancy

TRIAD

  1. Amenorrhea
  2. Crampy, unilateral abdominal pain
  3. Vaginal bleeding

Need transvaginal US or serial HCG - pelvic exam is non-diagnostic

12

Diagnostic Clues for Abdominal Disorders

  • CXR - free air = perforation
  • ABD XR - multiple air-fluid levels = obstruction
  • CT scan - determine cause and site of obstruction more accurately

12

Bowel Obstruction

 

  • Signs
  • Risks

most often the small bowel

SIGNS:

  • crampy/peristaltic pain
  • distension
  • vomiting
  • absence of flatus

RISKS:

  • pervious surgery
  • elderly
  • Chron's

12

Acute Paralytic Ileus

Neurogenic failure or loss of peristalsis

common in hospitalizated patients

DX: CT & ABD films - gas filled loops

TX - treat primary cause

13

Acute Cholecysitis

5F predisposition

RUQ pain with nausea and vomiting

RUQ tenderness; guadring; + Murphy's sign

14

Abdominal Pain by Location:

Diffuse

  • Ulcerative Colitis/Crohn's Disease
  • Endometriosis
  • Gastroenteritis
  • Peritonitis
  • Constipation
  • Mesenteric Ischemia
  • Diabetic Ketoacidosis
  • Porphyria
  • Malaria

16

Abdomen Physical Exam: Inspection

1. Insepction

  • essentially well or globally ill
  • writhing or motionless
  • distension
  • scars

 

17

Volvulus

anatomic obstruction; malrotation is common in pediatrics

SIGNS:

  • gradual lower abdominal cramping pain
  • chronic pain in kids
  • distension

DIAGNOSIS:

  • barium enema
  • plain film
  • sigmoidoscopy
  • US

19

severe uncontrollable retching

pancreatitis

20

Abdomen Physical Exam: Percussion

3. Perucssion

  • tenderess on percussion
  • rebound tenderness
  • tympany midline: distended bowel loops
  • shifting dullness = free peritoneal fluid
     

20

GI Perforation

causes: peptic ulcer, NSAIDS

signs & symptoms:

  • abrupt onset of severe, diffuse abdominal pain
  • board rigid abdomen
  • free air under the diaphrgam
  • quiet bowel sounds

21

Abdomen Physical Exam: Auscultation

2. Auscultation

  • hyperactive - gastroenteritis, dysentery, cholera
  • hypoactive - constipation
  • high pitched - bowel obstruction
  • absent - peritonitis, end stage obstruction, mesenteric ischemia

 

23

bilious vomit

lesion in proximal small bowel

24

Causes of pain by location:

Periumbilical

  • Early appendicitis
  • Small bowel obstruction
  • Colitis
  • Umbilical Hernia

25

Toxic Appearing Child

  • pale or cyanotic
  • lethargic or inconsolably irritable
  • tachypnea
  • tachycardia
  • poor capillary refill

26

Diverticulitis

  • pain for several days
  • change in bowel habits common
  • tenderness, mass may be felt
  • more common > 50
  • fever and malaise
  • may be constipated
  • low grade leukocytosis

27

Abdomen Physical Exam

other locations to check out

Digital Rectal Exam

  • frank blood or occult blood
  • lesions, masses, level of bleeding
  • hemorrhoids
  • prostate enlargment

Female Pelvic Exam

  • PID vs. ovarian cyst, abscess or appendicitis

Male GU

  • testicular/ scrotal/ hernia exam

EXTRA-ABDOMINAL

  • Heart & Lungs
  • CVA tenderness
  • Eyes - Icterus
  • Skin
  • Musculoskeletal (hip pain)

29

Causes of Pain by Location

Left Upper Quadrant

  • Splenic infarct/rupture
  • Myocardial infarction
  • Pericarditis
  • Pneumonia
  • Diverticulitis (occassionally)
  • Pyelonephritis (L flank)
  • Renal stones (L flank)

30

Testicular Torsion

  • sudden onset of severe, unilateral scrotal pain
  • typically follows vigorous activity
  • school age and adolescents
  • exam
    • high-riding, transversley oreinted testis, loss of cremasteric reflex
  • SURGICAL EMERGENCY

32

Abdomen Physical Exam: Palpation

4. Palpation

  • "board rigid" patient is dying
  • start light and away from pain
  • check for masses and organomegaly

33

Causes of Pain by Location:

Right Upper Quadrant

  • cholecystitis
  • cholelithiasis
  • liver abscess
  • hepatitis
  • cancer of liver or gallbladder
  • pnemonia
  • pyelonephritis
  • renal stones

35

Causes of Pain by Location:

Epigastrium

  • GERD
  • Myocardial Infarction
  • Gastritis
  • Gastric Ulcer or Peptic Ulcer
  • Pancreatitis
  • Pancreatic Cancer
  • Abdominal or Thoracic Aortic Aneurysm/Dissection

36

Abdomen Diagnostic Studies

  • CBC
  • Pregnancy Test
  • Liver Panel
  • Amylase & Lipase
  • Glucose
  • UA

37

Shock

(Toxic Adults)

  • Anxiety or agitation
  • Hypotension
  • Cool, clammy skin
  • Confusion
  • Decreased or no urine output
  • General weakness
  • Pale skin color (pallor)
  • Tachypnea
  • Unconsciousness

38

Intussception

telescoping of bowel segments - segment of intestine invaginates into the adjoining intestinal lumen, causing bowel obstruction
 
common: ILIEOCECAL Valve
 
TRIAD of Symptoms
  1. Vomiting
  2. Abdominal Pain
  3. Blood in Stool

Pain - colicky every 15-20 minutes

39

Abdominal Aortic Aneurysm

 

  • Risk Factors
  • Evaluation

focal dilation of at least 50% compared to normal or > 3 cm

abdominal, back or flank pain

rupture = unstable hypotension

RISK FACTORS

  • Males
  • > 60
  • COPD
  • PVD
  • HTN
  • smoking
  • family hx

EVALUATION

  • Abdominal Ultrasound
  • CT when planning repair
  • surgery if > 5.5 cm
  • routine for follow up depends on size/growth

40

HepatoBiliary Disease

  • localized RUQ pain - radiation to right shoulder/back
  • nausea, vomiting and anorexia

41

Right Lower Quadrant

  • Appendicitis (usually later)
  • Ovarian Cyst
  • Ectopic Pregnancy
  • PID
  • Renal Stones (R flank)
  • Ovarian Torsion
  • Inguinal Hernia
  • Referred Hip Pain

42

Pain 1st >> Vomit 2nd

vs.

Vomit 1st >> Pain 2nd

Pain 1st >> Vomit 2nd (surgical)

vs.

Vomit 1st >> Pain 2nd (medical)

lesion indicated by vomiting character 

 

43

Spleen

  • LUQ pain
  • consider signs and symptoms of infectious mononucleosis

44

Evaluation of Acute Abdomen

History

  • pain: type, location, onset, progression
  • associated symptoms
  • other: GYN, social, travel, surgical, family

Exam

  • inspect
  • auscultation
  • percussion
  • palpation

Diagnostic Test

Management

45

Differential Diagnosis Pediatrics Acute Abdomen

Most Common

  • Appendicitis
  • Infectious Gastroenteritis
  • Colic

Less Common

  • Pancreatitis
  • Gallbladder Disease
  • Lymphoma