exam 1 - abdomen pt 2

Question 1

diverticular disease

Answer 1

-Most patients with DIVERTICULOSIS will be asymptomatic
-5-15% will have painless diverticular bleeding
-4% will develop diverticulitis
-Diverticulitis
-!Abdominal Pain - LLQ
-Can refer to lower back, or cause UTI symptoms
-Localized guarding, rigidity and rebound tenderness
-!± Fever
-± Nausea, vomiting
-!Change in bowel habits (diarrhea or constipation, or altering)
-5% of diverticulitis cases become complicated:
-Perforation, obstruction, abscess formation, fistula
-Dx: !!CT abdomen pelvis with IV contrast may show thickened bowel wall

Question 2

diverticulitis tx

Answer 2

-Acute, uncomplicated diverticulitis in a patient with a history of diverticulitis, or CT-demonstrated first episode of acute, uncomplicated diverticulitis:
-Analgesia
-Stool softeners
-Consider oral antibiotics for 10-14 days:
-Ciprofloxacin (500 mg oral, BID) + Metronidazole (500 mg oral, TID)
-Amoxicillin-Clavulanate (875 mg oral, twice daily)
-Moxifloxacin (400 mg oral, daily)
-Follow up colonoscopy
-A toxic patient with radiographic, or CT evidence of complicated diverticulitis:
-Fluid resuscitation
-Analgesia
-Surgery consult
-IV antibiotics:
-Piperacillin-tazobactam (3.375 – 4.5 g IV q 6h)
-Imipenem-cilastatin (500 mg IV every 6 hours)
-Levofloxacin (500 mg IV every 24 hours) + metronidazole (500 mg IV every 8 hours)
-Ceftriaxone (1 g IV every 24 hours) + metronidazole (500 mg IV every 8 hours)
-Admission to hospital

Question 3

You are working in the emergency room when a patient is brought to your resuscitation room. Per the triage nurse, patient is a 55 year old male who was reporting low back pain and collapsed in triage.
BP 65/40, HR 160, RR 14, O2 sat unknown, Temp 37.1C
Pulse ox ; not reading, poor waveform
Decreased LOC
2 large bore IV with 2L saline
ECG revealed sinus tachycardia
Bedside ultrasound showed 8cm AAA

Call vascular surgery team for likely ruptured AAA
2U PRBCs of O- blood
T&S and 6U blood ordered
Straight to OR

Answer 3

BP 65/40, HR 160, RR 14, O2 sat unknown, Temp 37.1C
Pulse ox ; not reading, poor waveform
Decreased LOC
2 large bore IV with 2L saline
ECG revealed sinus tachycardia
Bedside ultrasound showed 8cm AAA
Call vascular surgery team for likely ruptured AAA
2U PRBCs of O- blood
T&S and 6U blood ordered
Straight to OR

Question 4

AAA

Answer 4

-causes 15,000 deaths in U.S. annually
-Common cause of sudden death men >65 years old
-Mortality rate with ruptured AAA 90%
-Pts with ruptured AAA do not survive to reach the hospital 50%
-Mortality rate elective open operative repair 2-7%
-Frequently missed or delayed dx
-MC misdiagnosed as left sided renal colic, Diverticulitis, MSK pain
-Reasonable indications include all patients >50 years old with unexplained hypotension, dizziness, syncope, cardiac arrest
-Reasonable to consider in all elderly patients with back, flank or groin pain

Question 5

AAA: anatomy

Answer 5

-AAA is a dilation of all 3 layers of the aortic wall to more than 50% normal diameter
-Normal aorta ~2cm diameter
-Abdominal aorta >3cm is considered a AAA
-MC rupture site: retroperitoneum
-MC rupture site: Infra-renal
-Risk of rupture increases once the AAA >5cm
-Can be fusiform in shape (more common) or Saccular (pedunculated)

Question 6

AAA: RF

Answer 6

-Smoking** current smokers have a 7x higher chance to develop AAA
-Male > female
-Increased age >50
-Family history (8x increased risk)
-Secondary causes: obesity, HTN, HLD, atherosclerosis, cardiovascular disease , PVD

Question 7

Which of the following factors does NOT increase the risk for developing an abdominal aortic aneurysm?

Answer 7

Former smoker
Positive family history of aortic aneurysm
Presence of peripheral arterial disease
Being female!!!!!!!!!!!

Question 8

AAA: S&S

Answer 8

-ASYMPTOMATIC > 50% Incidental finding -> Require referral
-MC symptom “PAIN”
-!!!ABDOMEN (80%) BACK & FLANK (60%), OR GROIN (22%)
-Classic Triad (only occurs in <50%)
-!Abdominal/back pain + Hypotension + Pulsatile abdominal mass!!
-Rupture can cause syncope alone (rare)
-Non-specific symptoms -> Lightheadedness or dizziness, Sweating, Clammy skin
-Rarely can find pulse deficit, or lower limb ischemia

Question 9

AAA: workup

Answer 9

-ABCs – especially the circulation!
-Sudden severe blood loss will need transfusion protocol
-Physical exam
-Feel for PALPABLE AORTA
-Sometimes can see retroperitoneal bleeding
-Cullens sign: peri umbilical ecchymosis
-Grey-turner sign: flank ecchymosis
-Ultrasound or other imaging

Question 10

AAA: unstable? -> US

Answer 10

-Dx test of choice in an UNSTABLE patient – CALL SURGERY
-2013 review in Academic EM shows that bedside US for AAA done by EM physicians have a sensitivity of >97.5% and specificity of >94.1%
-Visualize dilated aorta
-!Cannot distinguish if ruptured since blood goes into retroperitoneal space
-!Cannot detect dissection
-Measure from outside wall to outside wall
-This avoids measuring a false lumen d/ intramural thrombus
-Limitations: Obesity or overlying bowel gas

Question 11

AAA: CT

Answer 11

-100% sensitivity
-Can tell you where the rupture is and other vessels involved
-Limitations: Patient must be stable, better w/ IV contrast

Question 12

What is the best imaging modality for the evaluation of a possible abdominal aortic aneurysm in a patient with hemodynamic compromise?

Answer 12

Upright chest film
Non-contrast CT imaging
Contrast CT imaging
Bedside ultrasound
Plain abdominal film

Question 13

AAA screenings

Answer 13

-Normal aorta < 3cm
-AAA = >3 cm
-!!AAAs between 3cm - 5 cm that are asymptomatic
-Usually monitored with serial ultrasound examinations
-!AAAs > 5 cm
-Repaired with open surgery or endovascular repair
-No proven lifestyle changes can decrease the size of AAAs.

Question 14

AAA: tx

Answer 14

-Surgical consultation
-As soon as you suspect it, do not delay
-Cannot fix this in the ER
-Two large bore Ivs
-Type and cross
-Permissive hypotension (SBP>90) may have better outcomes
-EKG and Pre-op labs
-Assess for other causes
-UNRUPTURED:
-3-5 cm are less likely to rupture, outpatient follow up -> Surveillance
->5cm require urgent referral to vascular surgeon within 3-5 days -> Elective repair
-Smoking cessation
-B-blockers
-Antihyperlipid agents
-Low dose ASA
-RUPTURED:
-Resuscitate, resuscitate, resuscitate
-2 large bore IV or a central line
-1-2L crystalloids
-2 units of uncross-matched blood
-(while T&S pending as pt will likely need massive transfusion protocol with FFP, PLT, pRBCs)
-Immediate consult with vascular surgeon for surgery -> Endovascular vs. open repair

Question 15

What is the best initial step for a ruptured AAA?

Answer 15

Transfuse properly typed and cross-matched blood
Hydrate the patient
Immediate surgical consultation!!!!!!!

Question 16

40 year old female G6P6 with no PMH, moderately obese, presents to the ER with 1 day history of constant epigastric and RUQ pain. Rated 7/10. Began after her dinner last night. Also reports pain in her right scapula. She feels nauseous and has vomited twice. She had 2 similar episodes in the last year that self-resolved within an hour. Both times occurred after eating spicy food.
Temp 100.0F | HR 110 | BP 120/80mmHg | RR 18 | SPO2 100%
Exam notable for RUQ tenderness

Answer 16

Temp 100.0F | HR 110 | BP 120/80mmHg | RR 18 | SPO2 100%
Exam notable for RUQ tenderness
WBC 14 (normal 4-10.9)
Total bilirubin 1.0mg/dL (normal 0.1-1.2)
Lipase 30 (normal 7-60)
Troponin <0.1
ECG sinus tachycardia
CXR without lower PNA
U/A negative
HCG negative
+Murphys sign
Fever
Tachycardia
Leukocytosis
Dx…acute cholecystitis!
Why not choledocholithiasis or cholangitis?
Well appearing, normal T bilirubin and ALP makes this less likely
Why not gallstone pancreatitis?
Normal lipase/amylase makes this less

Question 18

cholecystitis

Answer 18

-History/Symptoms
-Fat, female, fertile, forty
-History of postprandial pain in RUQ
->6 hours pain in RUQ
-± Kehr’s sign
-Nausea, vomiting
-Signs/PE findings
-Fever
-RUQ TTP
-Murphy’s sign
-Voluntary guarding

Question 19

what is cholecytitis

Answer 19

Calcification of the gallbladder
Inflammation of the gallbladder
Obstruction of the biliary ductal system
Presence of gallbladder stones
Presence of bile sludge

Question 20

cholecystitis workup

Answer 20

-Pre-op abdominal labs
-CBC for ↑ WBC
-LFTS usually have ↑ ALP
-But normal ALT/bilirubin (unless Mirizzi syndrome)
-Amylase, lipase to assess for evidence of pancreatitis
-U/A for renal pathology
-BHCG for tubo-ovarian pathology
-!!!1st line imaging: Ultrasound
-HIDA if non-diagnostic
-CTAP if complication suspected
-US:
-Gallstone w/ shadowing
-Pericholecystic fluid
-Thickened GB wall >3mm
-Sonographic murphys sign
-GB distension (diameter >5cm, length >10cm)
if dilated CBD, consider choledocholithiasis
-Supportive care:
-IVF, analgesic, anti-emetics, NPO, antibiotics if fever/WBC

Question 21

In evaluating patients with biliary disease using an ultrasound, what classic finding suggests cholelithiasis?

Answer 21

Gallbladder wall thickening
Common bile duct dilatation
Pericholecystic fluid
Echogenic focus with acoustic shadowing
Intrahepatic duct dilatation

Question 22

management of cholelithiasis

Answer 22

-pain and symptom control
-outpatient surgery referral
-admission if unable to control symptoms

Question 23

management of cholecystitis

Answer 23

-pain and symptom control
-bowel rest
-IV antibiotics (pip-tazo)
-surgery- lap cholecystectomy, open chole, or cholecystostomy

Question 24

choledocholithiasis

Answer 24

-Gallstone in the CBD
-Similar symptoms to cholelithiasis:
-RUQ pain, post-prandial, ± radiation, nausea, vomiting
-!!AND Signs of extrahepatic cholestasis:
-Jaundice & pruritis
-Pale stool / dark urine

Question 25

40yoF with 24 hours of RUQ pain and epigastric pain, associated with nausea and vomiting. Report similar pain the past, particularly after eating greasy foods. According to her family, over the last few hours, she had become slightly confused. PMH is negative. Temp 102.5F, HR 110bpm, RR 16/min, BP 90/60mmHg. She is moderately tender in the RUQ to deep palpation. She has slight scleral icterus. She has dark colored urine. WBC 15 (normal 4-10.9) Bilirubin 4 (normal 0.1-1.2) ALP 350 (33-131) AST 300 (5-35) ALT 280 (7-56) GGT 330 (8-88) Amylase 100 (30-110) Lipase 90 (10-140) Urine +bilirubin Ultrasound: - Bile duct dilation without stone Obstructive jaundice! Any condition which causes occlusion of the biliary tree has the potential to cause cholangitis. Cholecystitis, choledocholithiasis, gallstone pancreatitis Viral hepatitis Mirizzi syndrome Liver abscess

Answer 25

Temp 102.5F, HR 110bpm, RR 16/min, BP 90/60mmHg. She is moderately tender in the RUQ to deep palpation. She has slight scleral icterus. She has dark colored urine. WBC 15 (normal 4-10.9) Bilirubin 4 (normal 0.1-1.2) GGT 330 (8-88) Lipase 90 (10-140) Urine +bilirubin Ultrasound: - Bile duct dilation without stone Obstructive jaundice! Cholecystitis, choledocholithiasis, gallstone pancreatitis Viral hepatitis Mirizzi syndrome Liver abscess

Question 26

ascending cholangitis

Answer 26

-MCC: -Gallstones, ERCP, Cholangiocarcinoma -!!Charcots triad -RUQ Pain, fever, jaundice -Reynolds pentad -!!Above + confusion (AMS) and shock (hypotension) -Pre-op abdominal labs should be taken -CBC will have ↑ WBC -LFTs will have ↑ ALP, ALT/AST, GGT, bilirubin -Blood cultures in suspected cases -Initial investigation: U/S with dilated CBD -Low sensitivity initial stages -Low sensitivity for stones -Gold standard: ERCP

Question 27

ascending cholangitis management

Answer 27

-Immediate management -IVF, NPO -Early Broad-spectrum IV Antibiotics -Vasopressors if unstable -Definitive tx: Remove the obstruction -!ERCP (suction vs. stent) -Percutaneous cholecystostomy (PTC) if cannot tolerate ERCP -Call critical care + surgery -Prevent recurrence! -> Delayed cholecystectomy

Question 28

which of the following is NOT a typical laboratory finding in cholangitis

Answer 28

Elevated sodium Elevated alkaline phosphatase Hyperbilirubinemia Elevated transaminases

Question 29

pancreatitis causes

Answer 29

-!!!MC causes: Gallstone, ETOH, ↑ Triglycerides -Post ERCP, trauma -Obstructive biliary sludge or tumors -Drugs: Thiazides, estrogens, salicylates, Tylenol, antibiotics -Metabolic: HLD, hypercalcemia, DKA, uremia -Viral / Autoimmune: Mumps, coxsackie B, hepatitis, EBV, adenovirus -Bacterial: Salmonella, Strep, Myco, legionella -Scorpion stings

Question 30

pancreatitis dx

Answer 30

-Labs -LIPASE is the best -Amylase -Imaging -CT is best -Ranson’s Criteria on admission: -Age >55 -Glucose >200 -WBC>16k -ALT >250 -LDH>350 -3 positives = severe, ICU

Question 31

65-year-old male with history of liver cirrhosis is brought to the ED for AMS. Temp 37.4°C (99.3°F), HR 98, BP 113/72, SpO2 92%, RR 20. He is alert but mildly confused. He has a distended abdomen but denies any tenderness. He has mild asterixis on exam. You wonder if his worsening clinical status could be secondary to hepatic encephalopathy or spontaneous bacterial peritonitis (SBP).

Answer 31

Temp 37.4°C (99.3°F), HR 98, BP 113/72, SpO2 92%, RR 20. He is alert but mildly confused. He has a distended abdomen but denies any tenderness. He has mild asterixis on exam. You wonder if his worsening clinical status could be secondary to hepatic encephalopathy or spontaneous bacterial peritonitis (SBP). cirrhosis -Despite not having the classic triad of SBP, a diagnostic paracentesis was performed Cell count returned at 297 cells/mm3 You ordered 2g cefotaxime IV and admit the patient to the hospital

Question 32

hepatic encephalopathy

Answer 32

-Precipitating factors: “LIVER” -Librium, Infection, Volume loss, Electrolyte d/o, RBCs in gut -Can also be high protein diet or worsening liver function -Early signs are sleep inversion -> sleep during day, awake at night -Asterixis -Hyperammonia levels -Check for hypoglycemia -Treatment: Lactulose, low protein diet

Question 33

spontaneous bacterial peritonitis

Answer 33

-Life threatening infection that occurs in chronic liver dz or !cirrhotic patients! -Portal hypertension -> bowel edema -> transmigration of enteric organisms such as e coli or enterococcus -Classic triad uncommon: -Fever/chills, abd pain, increasing ascites -Consider in any patient with ascites AND hepatic encephalopathy, worsening ascites, abdominal pain, fever, leukocytosis, renal failure -Often generalized abdominal tenderness w/ ascites -“Masked” peritoneal signs -Serum blood tests generally not helpful (CBC, ESR, CRP) -Diagnostic paracentesis* -Neutrophil count >250 cells/mm³ -+ Gram stain -Treatment with 3rd gen cephalosporin (CEFOTAXIME) -Consider adding albumin

Question 34

approach to critical pt with GI bleed

Answer 34

-AIRWAY: -Consider intubation for: airway protection, aspiration risk, AMS, or need for further evaluation such as endoscopy or balloon tamponade device -PPE: Face shield, goggles, mask -Head up position to prevent aspiration -2 suction tip catheters -BREATHING: -avoid positive pressure ventilation prior to intubation (risk of gastric insufflation) -CIRCULATION: -2 large bore Ivs or a large central venous catheter -Maintain MAP > 65 mm Hg -Consider massive transfusion protocol (1:1:1 pRBC:FFP:Platelets) -Consider reversal agents for bleeding if on AC/Anti-platelet -If variceal bleed suspected, administer: -Octreotide and antibiotic (ceftriaxone) -Consider Blakemore tube if endoscopy not immediately available -DISABILITY: -Assess GCS as another reason to intubate (hepatic encephalopathy, hypotension, instability)

Question 35

GI bleed: upper vs lower

Answer 35

-UPPER- proximal to ligament of treitz -HEMATEMESIS -COFFEE GROUND EMESIS -Digested blood, think epistaxis -MELENA-Black tar-like sticky stools that smell bad, black from digestion -BRBPR- If brisk UGIB - bright red blood per rectum -LOWER- distal to ligament of treitz -HEMATOCHEZIA (90% LGIB) -Maroon blood mixed with stool (transverse colon or proximal) -Bright red from anus, rectum, sigmoid -Rarely from rapid UGIB -BRBPR

Question 36

55 year old male with a history of alcoholic liver cirrhosis presents with complaints of weakness, dizziness, syncope, coffee-ground emesis, black tarry stools for two days.

Answer 36

upper GI

Question 37

causes of upper GI bleed

Answer 37

-Proximal- Epistaxis -Esophagus -Esophagitis (common in pregnancy) -!Mallory Weiss tear -!Esophageal varices * highest morbidity -Stomach & duodenum -!Gastritis / GERD -Gastric varices -!Peptic ulcer disease is MC -Duodenitis -Aortoenteric fistula -differentials: nosebleed, hemoptysis, dental bleeding

Question 38

upper GI bleed hx

Answer 38

-Ask how many episodes of bleeding, and how much blood? -Ask about liver cirrhosis, alcohol abuse, hepatitis, peptic ulcers, NSAID use, anticoagulation, recent surgical history (fistulas) -Ask about -Abdominal pain -> PUD perforation? -Vomiting -> Mallory Weiss tear? -PUD -> hx of pain related to eating -Chronic bleeds -> lightheadedness, fatigue, chest pain, DOE, SOB -Dizzy/Syncope -> elderly tend to have pre/syncope or AMS in anemiae

Question 39

eval for UGIB

Answer 39

-Physical exam -Look for jaundice, scleral icterus, abdominal distension, hematemesis, positive stool guaiac or obvious melena on exam -Vitals vitals vitals -Diagnostic tests -CBC for Hgb level (not an assessment of real-time blood loss) -Coagulation panel -CMP: Look for AKI and LFTs -Lactate to guide therapeutic considerations -Type and screen and cross match. -ECG and troponin screening -± Chest x-ray for perforated viscus -± CT angiography for continued bleeding

Question 40

UGIB management

Answer 40

-ABCs -Administer isotonic crystalloid fluids -Administer PPI -Reduces rebleeding and surgical intervention in PUD -Usually, a bolus followed by a continuous infusion -Administer blood products as necessary -Transfusion goal hemoglobin >7g/dL (consider >8 if CAD)

Question 41

esophageal varices

Answer 41

-OCTREOTIDE (somatostatin) -Decreases rate of bleeding and incidence of rebleeding -Decreases portal hypertension -> decreases mortality -50mg/hr for 72 hours -Complications: hypoglycemia, hyperglycemia, thrombocytopenia -PPI and broad spectrum antibiotics -Emergent control of bleeding: -!!BALLOON TAMPONADE: Sengstaken-Blakemore, Minnesota -Complications: sepsis, perforation, 65% rebleed rate -Deferred management: -Endoscopic variceal ligation -TIPS procedure

Question 42

Balloon tamponade devices

Answer 42

-Indication: The uncontrolled hemorrhage from esophageal or gastric variceal bleeding after medical or endoscopic treatment fails, is not available, or is not technically possible -These are temporary measures because of frequent rebleeding after deflation -Contraindications: -Unprotected airway -Esophageal rupture (Boerhaave’s syndrome) -Esophageal stricture -Uncertainty of bleeding site -Well-controlled variceal bleeding

Question 43

A 65-year-old patient presents to the ED with several days of left-lower quadrant abdominal pain and an episode of painless bright red rectal bleeding that occurred 3 hours prior to her presentation. She is currently taking warfarin for a history of paroxysmal atrial fibrillation. She appears pale and is tachycardic on the monitor.

Answer 43

LGIB

Question 44

LGIB causes

Answer 44

-Common causes of LGIB: -DIVERTICULOSIS* MC (30%) -Painless BRBPR -Arteriovenous malformations (AVMs) -Ischemic Colitis -Mesenteric ischemia -Polyps -Malignancy -Hemorrhoids -Aortoenteric fistula (hx of AAA repair) -UGIB is the MC cause of guaiac + stool

Question 45

LGIB diff dx

Answer 45

-upper gi bleed -external hemorrhoids or anal fissure -vaginal bleeding -food: beets, red dyes, iron, pepto-bismol

Question 46

What is the most SERIOUS condition that can cause lower GI bleeding?

Answer 46

Hemorrhoids Diverticulosis Ischemic colitis!!!!!!!!!! - HIGH MORTALITY BUT YOU HAVE MORE TIME Inflammatory bowel disease

Question 47

H&P for LGIB

Answer 47

-similar to UGIB -Ask about signs and symptoms of critical anemia -Chest pain, palpitations, dyspnea, orthostatic symptoms -Ask about painless vs. painful rectal bleeding -External hemorrhoids and anal fissures are typically painful -Ask about recent surgeries, AC use, NSAIDs, bismuth and iron -Rectal exam can assess for hemorrhoids, fissures, and gross finding of blood in stool

Question 48

LGIB workup

Answer 48

-Colonoscopy is the preferred method for diagnosis and treatment but a small subset of patients may benefit from angiographic evaluation and interventional radiology therapy -CT abdomen pelvis can diagnose varices, perforation, gastritis, fistula, colitis, tumor, diverticulis -CT Angiography: Recommended for recent (within 4 hours) or ongoing severe bleeding with any hemodynamic instability. Routine CTA is low yield in those with minor bleeding or if bleeding has stopped. -Endoscopy: within 24 hours for severe bleed -Colonoscopy: needs bowel prep, difficult in massive bleeds

Question 49

LGIB tx

Answer 49

-In many cases of LGIB, the bleeding will stop spontaneously or the source of bleeding can be controlled via endoscopic or angiographic approach. Surgical intervention such as colectomy can be considered if endoscopic and angiographic modalities fail. -Treatment is based on cause -Infectious colitis -> antibiotic -Irritable bowel disease -> bowel rest, IVF, steroids -Ischemia -> bowel rest, antibiotics, surgery depending on cause -Tumor -> surgery if also obstructed or causing massive bleed -Diverticulosis -> IR embolization, surgical resection -Fissures -> nitro/ccb cream -Hemorrhoid -> steroid cream, long term fiber, short term stool softener

Question 50

dispo UGIB/LGIB

Answer 50

-UGIB: -ICU if they have: unstable vital signs, age >75, persistent bleeding, coagulopathy or severe anemia (hematocrit <20%) -Glasgow-Blatchford bleeding score -Indices for discharge with follow-up -LGIB: -Oakland score for lower GI bleeding is a validated score (do not memorize) -Discharge home - Young stable, normal indices, no active bleeding, hemorrhoids or fissures

Question 51

Which blood type is recommended to give a 20 year old female presenting to the ED with massive GI bleeding and unstable vital signs? What is the medication of choice in patients with variceal bleeding? What intervention can be used to temporize an unstable patient with an upper GI bleed due to esophageal varices?

Answer 51

What is the medication of choice in patients with variceal bleeding? What intervention can be used to temporize an unstable patient with an upper GI bleed due to esophageal varices? O neg uncross unmatched octreotide and PPI Blakemore tube