Approach to the Acute Abdomen -- SD

Question 1

When would we get an MRI for an abdominal complaint?

Answer 1

Pregnant woman with abdominal pain – especially in 1st trimester

Question 2

Women of child-bearing age presenting with abdominal pain, what must we do on PE?

Answer 2

Pelvic exam

Question 3

1 month old presenting with nonbilious vomiting – what’s on your DDx?

Answer 3

GERD, hypertrophic pyloric stenosis

Question 4

2 month old presenting with bilious vomiting – whats on your DDx?

Answer 4

malrotation, volvulus, Hirschsprung’s disease, hernias, meningitis, sepsis

Question 5

2 year old presenting with abdominal pain – DDx?

Answer 5

Intussusception, Wilm’s tumor

Question 6

Most common ages to present with appendicitis?

Answer 6

6-18

Question 7

What is the most common cause of abdominal pain in children?

Answer 7

Constipation

Question 8

Severe, explosive pain should make you think of?

Answer 8

Perforation of hollow viscous

Question 9

Progressive, severe pain?

Answer 9

Worsening disease – ischemic necrosis

Question 10

Localized, then generalized pain?

Answer 10

Perforation

Question 11

Crampy, crescendo-descrescendo pain?

Answer 11

Obstruction

Question 12

Pain radiating to the low back?

Answer 12

Salpingitis or cystitis

Question 13

Pain radiating to the mid-back?

Answer 13

Pancreatitis, ulcer, or cholecystitis

Question 14

When does pain radiate to the shoulder?

Answer 14

Diaphragmatic irritation

Question 15

Can you give pain medication to someone with acute abdominal pain before a surgical consult?

Answer 15

Yes!

Question 16

Localized, unrelieved epigastric pain that increases with swallowing

Answer 16

Esophageal perforation

Question 17

What is an esophageal perforation typically preceded by?

Answer 17

Violent emesis

Question 18

What is the main cause of an esophageal perforation?

Answer 18

50-60% iatrogenic

15% Borhaave’s

Question 19

What populations are at risk for gastric ulcers?

Answer 19

Males and older folks

Those with heavy NSAID and ASA use

EtOH and smoking

Question 20

Periodic pain, awakens patient at night, may be better or worse with food

Answer 20

Gastric ulcers

Question 21

What is a Mallory-Weiss tear?

Answer 21

A partial thickness tear of esophagogastric junction

Question 22

Hematemesis after repetitive vomiting, chest pain, and coughing should make you think of?

Answer 22

Mallory-Weiss tear

Question 23

How do we treat gastric ulcers?

Answer 23

GI cocktail – IV PPI/H2 blocker

Question 24

How do we diagnose a Mallory-Weiss tear?

Answer 24

Need EGD but not emergently

Chest x-ray to rule out free air/pneumomediastinum

Question 25

How do we treat a Mallory-Weiss tear?

Answer 25

Conservatively

Question 26

What are the most common type of gallstones?

Answer 26

Cholesterol stones

Question 27

What do we call the presence of stones in the gallbladder?

Answer 27

Cholelithiasis

Question 28

What are risk factors for developing gallstones? Hint** 5 F's

Answer 28

Female, fat, forty, fair, and fertile

Question 29

These people will often have pain after a fatty meal in the RUQ -- may radiate to chest, right shoulder or scapula

Answer 29

Cholelithiasis

Question 30

What is the best diagnostic test for diagnosing cholelithiasis?

Answer 30

Ultrasound

Question 31

Should you see gallbladder thickening on ultrasound for someone with cholelithiasis?

Answer 31

No

Question 32

How do we treat cholelithiasis?

Answer 32

Toradol, morphine, zofran for symptom control

Question 33

Patients will present with fever, chills, vomiting, and severe pain that is often postprandial

Answer 33

Cholecystitis

Question 34

What is murphy's sign?

Answer 34

When you push on the RUQ, patient will stop taking breath in due to pain

Question 35

What's going on with Cholecystitis?

Answer 35

gallstone obstructing the cystic duct

Question 36

Who is at greatest risk for developing cholecystitis?

Answer 36

Women ages 30-80

Question 37

If cholelithiasis is left untreated, what can develop?

Answer 37

Empyema, gangenous gallbladder, perforation

Question 38

How do we treat cholecystitis?

Answer 38

Surgery is definitive!

Question 39

This will present with intermittent, colicky pain that may radiate to the back. Patient may be jaundiced.

Answer 39

Choledocholithiasis

Question 40

Where is the blockage occurring in choledocholithiasis?

Answer 40

Common bile duct

Question 41

Choledocholithiasis is a common cause of?

Answer 41

Pancreatitis

Question 42

How do we treat choledocholithiasis?

Answer 42

Emergency surgery consult IV abx necessary because likely have associated cholecystitis

Question 43

What is the most common cause of pancreatitis?

Answer 43

Alcoholism

Question 44

What presents with severe, unrelenting pain that radiates to the back? Nausea and vomiting are also very common.

Answer 44

pancreatitis

Question 45

True or false patients with pancreatitis often feel better if they are lying down

Answer 45

False! Pain is worse when lying down -- feel better if slumped forward

Question 46

Do patients with pancreatitis typically exhibit both guarding and rebound tenderness?

Answer 46

Guarding, yes. Usually no rebound tenderness.

Question 47

What will a patient's vitals look like with pancreatitis?

Answer 47

Fever, tachycardia, may be hypotensive

Question 48

True or False patient's with pancreatitis will have hypoactive bowel sounds?

Answer 48

True! Decreased to no bowel sounds.

Question 49

This lab value three times its normal value has greater than 95% positive predictive value for biliary pancreatitis

Answer 49

ALT

Question 50

What criteria do we use for prognosis for pancreatitis?

Answer 50

Ranson's

Question 51

What lab value three times its normal has nearly 100% sensitivity and specificity for pancreatitis?

Answer 51

Lipase

Question 52

How do we treat pancreatitis?

Answer 52

IV hydration with large amounts of fluid. IV nausea and pain meds.

Question 53

Elderly person with back pain is treated as a _________ until prover otherwise

Answer 53

AAA

Question 54

Sudden onset of pain, mid abdomen, radiating to back or groin think of?

Answer 54

AAA

Question 55

When will you find asymmetric femoral pulses?

Answer 55

AAA

Question 56

What do vitals signs look like when someone is experiencing a AAA?

Answer 56

Vital signs are initially normal and then tank rapidly

Question 57

What is the only treatment for unstable patient with known leaking AAA?

Answer 57

Emergent surgery

Question 58

What population does mesenteric adenitis usually present in?

Answer 58

Children and young adults

Question 59

Appendicitis in this population is very difficult to diagnose.

Answer 59

Pregnant women

Question 60

How does pain for appendicitis classically present?

Answer 60

Starts in periumbilical region and migrates to RLQ

Question 61

Appendicitis is most common between these ages

Answer 61

10-40

Question 62

Appendicitis in children less than ______ years old is very rare

Answer 62

Five

Question 63

What are four signs we can look for on physical exam to test for appendicitis?

Answer 63

Rovsing's, Heel strike, Obturator, and Psoas

Question 64

90% of diverticulitis occurs in what part of the colon?

Answer 64

Sigmoid

Question 65

What are symptoms of diverticulitis?

Answer 65

Constant pain, fever, constipation, and anorexia

Question 66

How do we diagnose diverticulitis in the ED setting?

Answer 66

CT scan with PO and IV contrast X-rays not helpful unless looking for obstruction

Question 67

These patients will present with abdominal pain, nausea/vomiting, diarrhea, pencil-like stools, or no bowel movement

Answer 67

Bowel obstruction

Question 68

For bowel obstructions -- Abdomen will be distended or non-distended? Have hypo or hyperactive bowel sounds? Be tender or non-tender?

Answer 68

Abdomen is distended, hyperactive bowel sounds, and diffusely tender

Question 69

How do we diagnose a bowel obstruction?

Answer 69

KUB with upright abdomen CT if indicated

Question 70

How do we treat a bowel obstruction?

Answer 70

NPO, NG tube to wall suction, pain medications, surgery consult

Question 71

Painless rectal bleeding with blood/mucus is associated with crohn's or ulcerative colitis?

Answer 71

Ulcerative colitis