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e Abdominal Pain Flashcards

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1
Q

What are the general characteristics for acute abdominal pain?

A
  1. Evaluation of acute abdominal pain requires rapid assessment of likely causes & early initiation of appropriate Tx
  2. DDx should extend beyond intra-abdominal pathology
    A. Epigastric pain : MI, PE, pneumonia
    B. Abd pain : DKA
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2
Q

What are the ddx an abrupt onset abdominal pain?

A
  1. Perforated viscus
  2. SBO
  3. Ureterocalculus
  4. Acute pancreatitis
  5. Ischemic bowel
  6. Ruptured vessel (portal, AAA)
  7. Acute cholecystitis
  8. Ruptured spleen
  9. Acute urinary retention
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3
Q

What are common RUQ ddx?

A
  1. ACute cholecystitis
  2. Duodenal ulcer
  3. Hepatitis
  4. Congestive hepatomegaly
  5. Pyelonephritis
  6. Appendicitis
  7. Right pneumonia
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4
Q

What are common RLQ ddx?

A
  1. Appendicitis
  2. Salpingitis
  3. Tubo-ovarian abscess
  4. Ruptured ectopic pregnancy
  5. Renal/ureteric stone
  6. Incarcerated hernia
  7. Mesenteric adenitis
  8. Meckle’s Diverticulum
  9. Crohn’s dz
  10. Perforated ceacum
  11. Psoas abscess
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5
Q

What are common LLQ ddx?

A
  1. Intestinal obstruction
  2. Acute pancreatitis
  3. Early appendicitis
  4. Mesenteric thrombosis
  5. Aortic aneurysm
  6. Diverticulitis
  7. Sigmoid diverticulitis
  8. Salpingitis
  9. Tubo-ovarian abscess
  10. Rupured ectopic pregnancy
  11. Perforated colon
  12. Crohn’s dz
  13. Ulcerative colitis
  14. renal/ureteral stone
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6
Q

What are common LUQ ddx?

A
  1. Ruptured spleen
  2. Gastric ulcer
  3. Aortic aneurysm
  4. Perforated COlon
  5. Pyelonephritis
  6. Left pneumonia
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7
Q

What are common epigastric pain ddx?

A
  1. Myocardial infarct
  2. Peptic ulcer
  3. Acute Cholecystitis
  4. Perforated Esophagus
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8
Q

What are common ddx with a gradual onset?

A 
1. Peritoneal inflammation or infection
A. Appendicitis
B. Diverticulitis
C. Gastritis
D. PID
E. Chronic pancreatitis
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9
Q

How is a pt with acute abdominal pain assessed for stability?

A 
1. Determine pt stability
A. Ill or toxic appearing ?
B. Responsiveness?
C. GCS
D. ABC’s?
E. Vital signs?
F. Extremity perfusion?
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10
Q

What is included in the abdominal exam in a pt with acute abdominal pain?

A
  1. Inspection
  2. Auscultation
  3. Percussion
    A. Assess organomegaly, ascitis (fluid wave), obstruction, mass
  4. Palpation
    A. Rebound tenderness, board-like rigidity or guarding, pulsatile mass
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11
Q

What additional exams are required for a pt presenting with abdominal pain?

A
  1. DRE (if appropriate)
    A. Guaiac
  2. Genitalia/Pelvic exam (if appropriate)
    A. Do not do a rectal exam on a cardiac pt or a shock pt
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12
Q

What does a positive Iliopsoas sign indicate?

A

Retrocecal appendicitis

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13
Q

What does a positive Rovsing’s sign indicate?

A

Inflammation, peritonitis

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14
Q

What does a positive Obturator sign indicate?

A
  1. inflammation involving the obturator nerve

A. Appy, diverticulitis, PID

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15
Q

What does a positive Murphy’s sign indicate?

A

cholecystitis

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16
Q

What are the ddx for severe abdominal pain?

A
  1. Renal colic
  2. Biliary colic
  3. Acute pancreatitis
  4. Acute gastritis/ulcer
  5. Perforated viscus
  6. Peritonitis
  7. Vascular pathologies
    A. MI, mesenteric ischemia, AAA dissection
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17
Q

What are the common ddx for dull poorly localized pain?

A
  1. Suggests inflammatory process
    A. Appendicitis
    B. Diverticulitis
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18
Q

What are the common ddx for intermittent pain with cramps?

A
  1. Gastroenteritis

2. SBO

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19
Q

What ddx have pain that radiates to the back?

A
  1. Pancreatitis
  2. Peptic ulcer
  3. Gastritis
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20
Q

What ddx have pain that radiates to the shoulder?

A
  1. From ipsilateral diaphragmatic irritation by air, blood or infection in peritoneal cavity
    A. Cholecystitis
    B. Salpingitis/ ovarian pathology
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21
Q

What ddx presents with periumbilical and epigastric pain?

A

Gradually localizes to RLQ -> appendicitis

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22
Q

What ddx presents with Pain radiating to the flank and groin or genitalia?

A
  1. Ureteral colic

2. Testicular torsion

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23
Q

What asst. sxs may be present with acute abdominal pain?

A
  1. Anorexia
  2. N&V
  3. Fever & rigors
  4. Flank pain
  5. Constipation
  6. Diarrhea
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24
Q

What may fever and rigors asst with abdominal pain indicate?

A
  1. Suppurative cholangitis (pyogenic infection/obstruction)
    A. RUQ pain, fever/chills, jaundice (Charcot’s Triad)
    B. Surgical emergency
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25
What may flank pain asst. with abdominal pain indicate?
1. Pyelonephritis | 2. Renal colic
26
What may constipation asst. with abdominal pain indicate?
Suggests intestinal obstruction, diverticulitis, appy or ileus
27
What may diarrhea asst with abdominal pain indicate?
Suggests gastroenteritis, colitis, (diverticulitis, appendicitis, SBO)
28
What dx studies are indicated for abdominal pain?
1. CBC w/ diff 2. Serum CMP 3. Serum Lipase and Amylase 4. UA w/ micro 5. Urine or serum HCG 6. EKG 7. Bedside/stat USN 8. KUB 9. CXR 10. CT
29
What may the CBC w/ diff show for abdominal pain?
1. Hct ↑ in dehydration 2. Hct ↓ in anemia or acute bleed 3. WBC helpful if significantly elevated A. “L shift” → bacterial infection
30
What may the Serum CMP show in abdominal pain?
``` 1. Hepatic Function Tests A. Suspected hepatitis B. RUQ pain/tenderness C. Jaundice/light colored stools D. Tea colored urine 2. Serum Electrolytes/BUN/Cr A. Evaluate kidney function B. ↑ BUN -Dehydration -GI bleed ```
31
What may the UA w/ micro show for abdominal pain?
1. UTI’s 2. Kidney stones 3. Uncontrolled DM 4. Dehydration a. ↑ SG
32
What may the urine or serum HCG show for abdominal pain?
1. Obtain in all women of child bearing age unless pregnancy is physically impossible A. TAHBSO
33
Who is at a higher risk for an ectopic pregnancy?
1. Hx PID 2. IUD 3. Prior ectopic pregnancy 4. Failed tubal ligation
34
What may an EKG show for abdominal pain?
Obtain in pt w/ epigastric or upper abd pain & unclear etiology
35
Why is a bedside/stat USN ordered for abdominal pain?
R/O free intra-peritoneal fluid (cul-de-sac), ectopic pregnancy, cholecystitis, hydronephrosis, pancreatitis, AAA, IUP, Ovarian cyst
36
Why is a KUB ordered for abdominal pain?
R/O calculus, SBO, colon obstruction, constipation
37
Why is a cxr ordered for ab pain?
R/O free air, pneumonia
38
Why is a CT ordered for ab pain?
R/O appy, tics, pancreatitis, mass, stones, ischemic bowel
39
What ab pain pts get surgery?
1. Acute abdomen A. Appendicitis, ruptured spleen, GI bleed, bowel perforation, intestinal obstruction, peritonitis, ectopic pregnancy, renal obstruction B. Pulsatile abdominal mass C. Shock w/ abd pain 2. If hypotensive or hemodynamically unstable w/abd pain A. R/O life threatening pathology B. STAT Surgical consult
40
How is life threatening abd pain managed?
``` 1. Treat shock A. Oxygen @ rate 2-10 l/min by NC or mask -Keep SaO2 > 95% B. 2 large bore IV’s -Crystalloid sol’t (NS or LR) 2. Obtain labs: A. CBC w/ diff B. Serum CMP, lipase, lactate, HCG C. Fingerstick glucose D. Type & screen E. ABG’s 3. Foley catheter to monitor UO A. Obtain UA (UC if indicated) 4. Rapid IV infusion 5. NG TUbe if indicated 6. IV abx if indicated 7. Pelvic exam 8. DRE ```
41
What is the rapid IV infusion for life threatening abd pain?
1. Titrate rate to stabilize BP 2. Initially 1 liter bolus over 10-20 minutes (adult pts) 3. Caution in pt w/ Hx of CHF
42
Persistent shock despite fluid resuscitation in pt w/ acute abd pain requires what?
Exploratory laparotomy
43
When is a nasogastric tube indicated?
1. Intestinal obstruction 2. Peritonitis 3. Severe ileus 4. GI bleed
44
When are abx indicated for life threatening abd pain?
1. Suspected bacterial peritonitis or perforated viscus : | A. Broad spectrum IV abx after obtaining blood & urine cultures
45
What may be found on a pelvic exam w/ abd pain?
PID, ectopic pregnancy, ovarian cyst, ovarian cancer
46
What may be found on a DRE w/ abd pain?
1. assess for presence/absence of blood in stool/rectum (+) occult blood -> intestinal tumors, IBD, ischemic colitis, bleeding ulcers 2. Allows exam of prostate A. Prostatitis, BPH, prostate nodules
47
What is the common hx for appendicitis?
1. Classically, initial pain is poorly localized (visceral pain) in periumbilical region 2. Later pain shifts to RLQ (somatic pain fibers) 3. Anorexia, N/V, constipation, low grade fever may be present
48
What are common PE findings for appendicitis?
1. Hypoactive or absent BS 2. RLQ tenderness over McBurney’s point A. Check iliopsoas , obturator, & Rovsing signs 3. Guarding, splinting 4. (-) adnexal tenderness on pelvic exam 5. Right sided tenderness on DRE 6. No testicle tenderness /hernia
49
What dx studies are used for appendicitis?
1. CBC A. Leukocytosis w/ left shift 2. UA +/- WBC’s 3. CT abd & pelvis w/ contrast -> Non-visualized appendix or perforated appendix
50
What is the treatment for appendicitis?
1. STAT surgery consult, NPO, analgesia, IV fluids, IV antibiotics
51
What is the common hx for intestinal obstruction?
1. Intermittent poorly localized crampy pain 2. If pain constant & severe, consider possible perforation or bowel ischemia 3. Bilious vomiting
52
What is the common pe findings for intestinal obstruction?
1. Ill appearing, does not move 2. Distended tender abd w/ high pitched bowel sounds 3. Absent bowel sounds w/ ileus 4. Tender throughout 5. Mild-mod guarding 6. (-) stool guaiac
53
What is the common dx studies for intestinal obstruction?
1. KUB -> dilated loops of bowel w/ air fluid levels | 2. CBC, CMP
54
What is the common Rx for intestinal obstruction?
NPO, +/- NG suction, IV crystalloids, surgery consult, close observation
55
What is the common hx for bowel perforation?
1. Sudden onset severe agonizing mid-abd or lower abd pain 2. N/V, fever 3. Hx of diverticulitis is common
56
What is the common pe findings for bowel perforation?
1. Toxic appearing 2. Shock may be present 3. Absent BS 4. Rigid, tender abdomen
57
What is the common lab findings for bowel perforation?
1. CBC, CMP, Blood & urine Cx (If shock -> ABG’s, serum lipase, serum lactate, type & screen) 2. Leukocytosis w/ L shift 3. KUB (or CXR) -> free air under diaphragm
58
What is the common Rx for bowel perforation?
1. NPO, IV crystalloids, oxygen, foley cath, STAT general surgery consult, 2. IV abx after cultures obtained
59
What is the common hx for diverticulitis?
1. Gradual onset lower abd pain 2. Constipation or diarrhea 3. +/- nausea 4. +/- hematochezia
60
What is the common pe findings for diverticulitis?
1. +/- low grade fever 2. Softly distended 3. Hypoactive BS 4. Tenderness LLQ (most common), L mid abd or RLQ w/ guarding 5. +/- palpable abd mass 6. +/- (+) stool guaiac
61
What is the common labs for diverticulitis?
1. UA 2. CBC w/diff, +/- CMP 3. CT Abd & pelvis w/contrast (IV or oral)
62
What is the common Rx for diverticulitis?
1. NPO, IV crystalloids, IV abx (then oral), observation 2. Can be treated as OP if no peritoneal signs 3. F/U colonoscopy may be indicated
63
What is the common hx for gastroenteritis?
1. Severe crampy abd pain that may have come on gradually or abruptly 2. N/V/Diarrhea
64
What is the common pe findings for gastroenteritis?
1. May be orthostatic if dehydrated | 2. Generalized tenderness without guarding
65
What is the common dx studies for gastroenteritis?
1. +/- CBC, BMP 2. UA A. ↑ SG indicates dehydration
66
What is the common Rx for gastroenteritis?
1. Oral hydration (if tolerates po) or IV hydration 2. +/- Antiemetic 3. Severely ill should be hospitalized
67
What is the common hx for IBD?
1. Intermittent abd cramping & intermittent bloody diarrhea 2. Weight loss 3. +/- fevers
68
What is the common pe findings for IBD?
Abd exam variable
69
What is the common dx studies for IBD?
1. CBC, BMP, ESR, CRP 2. UA 3. CT Abd to assess for bowel perforation, obstruction, intraperitoneal abscess
70
What is the common Rx for IBD?
1. If hypotensive or shock: Follow Shock Protocol 2. NPO 3. NG tube suction if vomiting 4. Antiemetics 5. Surgical consult if: Significant hemorrhage, perforation, abscess, or toxic megacolon
71
What is hte Rx for an ambulatory IBD pt?
1. Oral abx 2. Steroids 3. Sulfasalazine
72
What is the common hx for biliary colic?
1. Abrupt onset of pain in upper abd (esp RUQ) after eating 2. Usually resolves after several hours 3. Referred pain to right scapula
73
What is the common pe findings for biliary colic?
1. Afebrile 2. RUQ tenderness & occasionally, palpable gall bladder 3. (+) Murphy’s sign
74
What is the common dx studies for biliary colic?
1. Abd USN -> gallstones, dilated GB or cystic duct 2. OP HIDA scan if (-) USN 3. +/- CBC, CMP if indicated
75
What is the common Rx for biliary colic?
Analgesics, Clear liquids-> fat free diet, elective surgery
76
What is the common hx for acute cholecystitis?
1. RUQ pain 2. Anorexia 3. N/V 4. Fever
77
What is the common pe results for acute cholecystitis?
1. Low grade fever 2. (+) Murphy’s sign 3. May have palpable gall bladder
78
What is the common dx studies for for acute cholecystitis?
1. CBC, CMP if indicated 2. Abd USN 3. Gallstones, dilated intra & extra hepatic bile ducts, thickened GB wall
79
What is the common Rx for for acute cholecystitis?
NPO, NG tube to suction for vomiting, IV crystalloids, parenteral analgesics, surgical consult
80
What is the common hx for ruptured AA?
1. Severe abd pain of sudden onset that often radiates into low back 2. Syncope usually related to blood loss & lack of cerebral perfusion 3. Eventually leads to shock
81
What is the common pe findings for ruptured AA?
1. Pulsatile abd mass | 2. Unequal LE pulses
82
What are the common dx studies for ruptured AA?
STAT bedside abd USN
83
What is the common Rx for ruptured AA?
1. CBC, Type & Cross match 2. STAT vascular surgery consult 3. Follow shock protocol A. IV access B. 2 large bore peripheral caths or central venous catheter C. Treat shock w/ IV crystalloids followed by whole blood D. Oxygen E. Foley cath
84
What is the common hx for ischemic colitis?
1. Abrupt onset of localized or diffuse crampy abd pain & diarrhea 2. Ischemic areas may progress to gangrene if ischemia is severe 3. Hematochezia 4. Elderly
85
What is the common pe findings for ischemic colitis?
1. Hyperactive to hypoactive BS as progresses 2. Softly distended 3. Mild to moderate tenderness to palpation over affected area 4. (+) stool guaiac
86
What is the common dx studies for ischemic colitis?
1. CBC, CMP variable 2. CT abd w/ IV contrast A. Colonoscopy - procedure of choice if CT inconclusive
87
What is the common Rx for ischemic colitis?
``` 1. Supportive- A. NPO B. NG tube if ileus C. IV crystalloids D. Parenteral analgesia E. Oxygen 2. Bowel resection if symptoms increase ```
88
What is the common Hx for mesenteric ischemia?
1. Sudden onset of severe, diffuse abd pain in mid or lower abdomen 2. Pain is out of proportion to exam & not relieved by narcotics 3. N/V/D 4. Hematochezia
89
What is the common pe findings for mesenteric ischemia?
No focal findings initially -> then abd distention
90
What is the common dx studies for mesenteric ischemia?
1. CBC: Leukocytosis 2. CMP A. Azotemia B. Acidosis 3. CT angiogram
91
What is the common Rx for mesenteric ischemia?
Hospitalization & immediate surgical consult
92
What is the common Hx for renal colic?
1. Sudden onset of severe flank pain, often radiates to groin 2. Constant dull ache between episodes may be present 3. N/V, restlessness (pacing floor)
93
What is the common pe findings for renal colic?
1. Severe CVA tenderness | 2. Remainder of exam typically unremarkable
94
What is the common dx studies for renal colic?
1. UA -> RBC’s, WBC’s, crystals 2. KUB may show calculi if radio-opaque 3. Noncontrast CT abd
95
What is the common Rx for renal colic?
1. Analgesia, tamsulosin (Flomax) 2. ↑ fluids 3. Strain urine 4. F/U w/Urologist 5. Small stones (5mm) may require urologic intervention
96
What is the common Hx for pyelonephritis?
1. Flank pain, dysuria, frequency, urgency 2. Fever, rigors 3. N/V
97
What is the common pe findings for pyelonephritis?
1. CVA tenderness | 2. +/- abd tenderness
98
What is the common labs for pyelonephritis?
1. UA 2. Urine C&S 3. Blood cultures 4. CBC, BMP
99
What is the common Rx for pyelonephritis?
1. OP (oral abx & hydration) A. If tolerates po & reliable to return 2. IP (IV abx & IV hydration) A. If severely ill, pregnant, very young, very old, immunocompromised, GU tract abnormality
100
What is the common Hx for acute pancreatitis?
1. Acute onset of severe unrelenting epigastric pain radiating thru to back 2. N/V 3. Shock (severe cases) 4. Predisposing conditions: A. Alcoholism B. Gallstones
101
What is the common pe findings for acute pancreatitis?
1. Hypoactive or absent BS | 2. Tender epigastrium w/guarding
102
What is the common labs for acute pancreatitis?
1. WBC 2. Amylase, Lipase 3. CMP 4. If Dx uncertain: CT abd
103
What is the common Rx for acute pancreatitis?
1. IP -> NPO, NG tube if needed, aggressive crystalloid IVF, analgesia 2. Chronic pancreatitis -> Treat OP if tolerating po & pain controlled w/ oral med
104
What are the risk factors for ectopic pregnancy?
1. Ectopic pregnancy should be considered in all women of child bearing age who presents w/ abd pain 2. Previous ectopic 3. Hx STD’s 4. Smoking 5. IUD
105
What is the common Hx for ruptured ectopic pregnancy?
1. Classic triad: A. Abd pain, amennorhea, vaginal bleeding/spotting 2. Prior to rupture, pain is vague & poorly localized 3. After rupture -> severe unilateral abd/pelvic pain 4. N/V 5. +/- Shoulder pain 6. Postural hypotension -> shock
106
What is the common exam findings for ruptured ectopic pregnancy?
1. Unilateral doughy mass in adnexal area | 2. Tender cervical motion
107
What is the common dx studies for ruptured ectopic pregnancy?
Transvaginal U/S
108
What is the common Rx for ruptured ectopic pregnancy?
1. Treat shock or hypotension w/ IV crystalloids & blood if necessary 2. Emergent surgical intervention
109
What is the common Hx for acute salpingitis (PID)?
1. Gradual onset of pelvic/lower abd pain 2. Vaginal discharge/bleeding 3. +/- N/V 4. Fever 5. Sexually active
110
What is the common exam findings for acute salpingitis (PID)?
1. Normal BS 2. Tender hypogastrium, may localize 3. Cervical motion tenderness 4. Adnexal tenderness or fullness (tubo-ovarian abscess)
111
What is the common dx studies for acute salpingitis (PID)?
1. UA: +/- WBC’s, + RBC’s 2. CBC: Leukocytosis w/L shift 3. Urine or serum HCG 4. GC/Chlamydia Cx, general Cx 5. Pelvic sono -> Thickened fluid filled fallopian tubes, +/- fluid in cul-de-sac A. R/O tubo-ovarian abscess
112
What is the common bacteria for acute salpingitis (PID)?
1. N. gonorrhoeae 2. Chlamydia trachomatis 3. Mycoplasma 4. Staphylococcus 5. Streptococcus
113
What is the common Rx for acute salpingitis (PID)?
1. Empiric antibiotics A. OP B. Ceftriaxone 250 mg IM/IV x 1 dose AND doxycycline 100 mg PO bid x 14 d C. +/- metronidazole (Flagyl) 500 mg PO bid x 14 d
114
When should an acute salpingitis (PID) pt be hospitalized?
1. Uncertain Dx 2. Pregnancy 3. Unable to tolerate po 4. Failed OP treatment 5. Pt unable to follow-up
115
What is the common hx for ovarian torsion?
1. Sudden unilateral lower abd pain/pelvic pain of mod-severe intensity 2. Worse w/ position change 3. Pain may radiate to groin, back, flank 4. N/V 5. Hx ovarian cysts
116
What is the common exam findings for ovarian torsion?
Exquisite tenderness of affected adnexa
117
What is the common dx studies for ovarian torsion?
1. (-) HCG 2. D-Dimer (↑ > 70% of cases) 3. Normal CBC 4. Normal UA/UC 5. Pelvic U/S w/ doppler A. (-) doppler does not R/O torsion B. MRI in highly suspicious case
118
What is the common Rx for ovarian torsion?
Admit for observation & laparoscopy to uncoil
119
What may be found on USN in ovarian torsion?
1. Enlarged ovary 2. Peripherally displaced ovarian follicles 3. Free pelvic fluid > 80% of cases 4. Whirlpool sign of twisted vascular pedicle 5. Underlying ovarian lesion 6. Uterus may be slightly deviated towards the torted ovary
120
What is the standard therapy for suspected bacterial peritonitis?
Cefotaxime 2 gm IV q8h x 5days
121
What abx is used for uncomplicated SBP?
Ofloxacin 400 mg PO bid x 8days
122
What is the abx of choice for nosocomial SBP?
Extended spectrum abx (carbapenems, Zosyn)
123
What is the abx of choice for a pt recieving fluorquinolones or bactrim SBP prohylaxis?
Cefotaxime 2 gm IV q8h x 5days
124
What is the abx of choice for a pt with SBP with a beta lactam hypersensitivity?
Ciprofloxacin 400 mg IV q12h
125
What is the abx of choice for a with SBP and advanced renal failure, creatinine >1mg/dl, BUN>30 or total bili >4?
IV cefotaxime 2 gm IV q8h x 5 days | IV albumin 1.5 g/kg given on day 1 and 1.0g/kg given on day 3

Gen Med: Emergency Med (13 decks)

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