L5: Acute Abdominal pain: pt 2 Flashcards
(102 cards)
1
Q
Splenic abscess results from
A
endocarditis
seeding from another site
2
Q
Splenic infarct
A
Splenic artery or sub-branch occluded by embolus, clot, or infection
3
Q
Splenic rupture
A
Traumatic or Atraumatic: Leukemia, lymphoma Mononucleosis, CMV, HIV Acute/chronic pancreatitis Anticoagulants Pregnancy related Idiopathic
4
Q
At risk of splenic infarct
A
Hypercoagulable state (malignancy) Embolic disease (afib, infective endocarditis) Sickle cell disease Trauma Complication of EBV
5
Q
Splenic abscess presentation
A
LUQ pain
Fever
+/- splenomegaly
+/- left side pleural effusion
6
Q
Splenic infarct presentation
A
Acute LUQ pain + Fever N/V Elevated LDH Leukocytosis \+/- splenomegaly
7
Q
How to diagnose splenic abscess or infarct
A
CT scan with IV contrast
8
Q
Splenic rupture presentation
A
LUQ pain, fullness
Referred left shoulder pain
Pleuritic pain
Early satiety
9
Q
How to diagnose splenic rupture
A
Ultrasound→ Gold standard
CT with IV contrast
10
Q
Splenic abscess tx
A
Admit, IV fluids, abx
NPO
Surgeon→ splenectomy
+/- Infectious disease consult
11
Q
Splenic infarct tx
A
Uncomplicated→ analgesia, monitor
Complicated→ abscess, sepsis, hemorrhage→ splenectomy
12
Q
Splenic rupture tx
A
NPO, IV fluids
Type + Cross for transfusion
Emergent Splenectomy
13
Q
At risk for small bowel obstruction
A
Prior abdominal/pelvic surgery→ adhesions Abdominal wall/groin hernia Intestinal inflammation Neoplasm Prior irradiation Foreign body (FB) ingestion *Intussusception/volvulus*
14
Q
Acute mesenteric ischemia
A
Decreased/no perfusion to section of colon
Occlusive, arterial/venous
Embolic, thrombotic, atherosclerotic
15
Q
At risk for acute mesenteric ischemia
A
Cardiac arrhythmias Advanced age Low cardiac output states Valvular heart disease MI Malignancy
16
Q
Small bowel obstruction presentation
A
N/V
Cramping abdominal pain, periumbilical
Ischemia/necrosis→ More focal pain
Obstipation→ inability to pass flatus or stool
+/- dehydration
+/- fever if abscess/ischemia/necrosis
17
Q
Acute mesenteric ischemia presentation if due to thrombosis or emboli
A
Rapid onset, severe periumbilical pain out of proportion N/V \+/- forceful bowel evacuation Postprandial pain (15-30 min) \+/- Hematochezia High mortality
18
Q
Acute mesenteric ischemia presentation if due to venous thrombosis
A
More indolent, lower mortality
19
Q
Abdominal xray of small bowel obstruction
A
Dilated loops of bowel with air-fluid levels
Proximal bowel dilation with distal bowel collapse
20
Q
CT of small bowel obstruction
A
Severity, masses Inflammation Necrosis Perforation Ischemia Non-viable bowel does not enhance with contrast
21
Q
Early labs of acute mesenteric ischemia
A
often nonspecific
22
Q
Labs of acute mesenteric ischemia may include
A
+/- leukocytosis
Hemoconcentration
Increased lactate, LDH
+/- elevated serum amylase (50%)
Check d-dimer
Advanced disease/necrosis→ metabolic acidosis
23
Q
Imaging for acute mesenteric ischemia
A
Xray: Free air, “dead bowel”→ laparotomy
No signs on xray→ abdominal CT angiography IV contrast
24
Q
Small bowel obstruction tx
A
Admit, NP, IV fluids
Antiemetics
NG tube, bowel rest
Consult surgery, GI
Not resolving→ Surgical intervention
Complicated bowel obstruction→ surgery, abx
25
Acute mesenteric ischemia management
Admit, IV fluids, NPO
Foley catheter
Ceftriaxone + Metronidazole (empiric)
+/- systemic anticoagulation
Consult GI, surgery, Vascular/Cardiology
26
Most common abdominal emergency
appendicitis
27
Who has a high risk of perforation with appendicitis?
| In whom is appendicitis usually missed?
perforation <4 years
| missed <12 years
28
Appendicitis presentation
```
N/V/A
Fever (late finding)
Rebound tenderness/ (+) Rovsing’s
+/- rigidity, voluntary guarding, pain on rectal exam
RLQ pain starts periumbilical + migrates
```
29
Retrocecal appendicitis:
Back/flank/testicular pain
| +Psoas sign
30
Pelvic appendicitis:
Suprapubic/rectal pain/ dysuria/diarrhea
| +Obturator sign
31
If your patient has clinical appendicitis
no further imaging is needed, you can go straight to surgical consult
32
Appendicitis labs
Leukocytosis (bands) → if extremely elevated→ perforation
Normal WBC doesn’t rule out appendicitis
UA→ +/- pyuria, bacteria, hematuria (if appendix near bladder/ureter)
33
Appendicitis if the patient is pregnant
Pain in RUQ instead of RLQ
34
Imaging for appendicitis
Abdomen xray→ free air, appendicolith (calcification)
US→ limited by obesity or retrocecal appendix
CT + contrast→ inflammation, abscesses, fat stranding, fluid collection
MRI + contrast→ pregnancy
35
Appendicitis treatment
Admit, IV fluids
NPO, analgesia
Cefoxitin
OR
cefazolin + metronidazole
Surgical consult
36
Diverticulitis
Microperforation of a diverticulum→ Inflammation
LLQ/sigmoid
Risk: age, diverticulosis
37
Diverticulitis presentation
```
Steady, deep, constant pain
N/V, low grade fever
Change in bowel habits
Urinary urgency, frequency, dysuria
Rebound, guarding, localized tenderness
```
38
An acute attack of diverticulitis might present with
edema/compression of colon→ obstruction/paralytic ileus
39
Diverticulitis DRE
left sided tender mass
40
Complications of diverticulitis
Obstruction (hyperactive/ high pitched bowel sounds)
| Peritonitis (hypoactive/ absent bowel sounds)
41
Diverticulitis labs
(+) stool guaiac
+/- mild leukocytosis
UA→ pyuria
42
Diverticulitis imaging
Abdominal xray→ non-specific
US→ abscesses, bowel wall thickening, diverticula, fistulas
*CT with contrast* → localized bowel thickening, colonic diverticula, abscesses, fistulas
Obstruction→ dilated loops of bowel
43
Uncomplicated diverticulitis tx
Ciprofloxacin + metronidazole
Follow up 2 days with GI
44
Complicated diverticulitis is ______ and tx is _____
perforation, abscesses, fistula, obstruction
Admit, IV fluids+abx, NPO
Consult GI +/- surgery
45
Toxic megacolon is a complication of...
```
*IBD*
volvulus
diverticulitis
obstructive colon cancer
C diff
CMV in HIV pts
```
46
Toxic megacolon presentation
```
Severe, bloody diarrhea
Toxic appearing patient
AMS
Tachycardia
Fever
Postural hypotension
```
47
Toxic megacolon complications
perforation
massive hemorrhage
progression of dilatation
48
Diagnostic criteria for toxic megacolon
Xray→ transverse/right colon dilated up to 15 cm +/- air fluid levels
Fever >38 C, HR >120
Neutrophilic leukocytosis >10,500
```
PLUS:
dehydration
AMS
hypotension
electrolyte disturbance
```
49
Toxic megacolon tx
Admit, IV fluids, NPO
NG tube
IV abx→ ampicillin, gentamicin, or metronidazole
IV steroids→ prednisolone or methylprednisolone
Consult surgery, GI
NO antimotility agents or opioids
50
Hemorrhoid presentation
Copious bright red rectal bleeding
Anal pruritus, prolapse
Acute perianal pain
“lump” due to thrombosis
51
Perianal abscess presentation
Severe pain in anal area
Cellulitis or extension→ fever (otherwise rare)
52
Rectal foreign body presentation
Usually long delay→ hours/days
Anorectal or abdominal pain
Blood per rectum
Mucus discharge
53
Thrombosed hemorrhoid complications
prolapse
strangulation
gangrene
54
Hemorrhoid diagnosis
Visual inspection + DRE
Anoscopy, endoscopic procedures
55
Perianal abscess diagnosis
Perianal fluctuance/indurated skin
normal DRE
56
Rectal foreign body diagnosis
Normal to diffuse peritonitis
DRE→ +/- palpable foreign body, can’t rule out
Pain radiograph, flat + upright
If radio-opaque→ CT
57
Hemorrhoids treatment
Increased fluids, fiber
| Excision by surgeon
58
Thrombosed hemorrhoids treatement
incise overlying skin, evacuate small clot→ immediate relief (non-surgical practitioner)
59
Simple anorectal abscess treatment
drain in ER: anesthetize, open wound, evacuate pus, irrigate. (no packing)
Home: sitz baths
60
Anorectal abscess associated with cellulitis, systemic infection, DM, valvular heart disease, immunosuppression treatment
Augmentin
OR
Cipro + Metronidazole
61
Non-superficial anorectal abscess treatment
Non-superficial abscess
CT/MRI→ determine extension
Admit, GI + surgical consult
Surgical drainage
62
Rectal foreign body management
Shape and size of object influences management:
IV sedation + transanal removal
OR
Consult surgeon→ surgical removal:
Abdominal palpation for caudal pressure + stabilization
Laparoscopy
Colotomy with primary closure
63
After a rectal foreign body is removed...
rigid proctoscopy or flexible sigmoidoscopy
64
Pelvic pain exam
Pelvic exam→ cervical motion tenderness, erythema/edema?
Palpate ovaries→ size, pain, masses?
65
Pelvic pain labs
```
CBC with differential
BMP
Urinalysis
HCG→ if (+) get quantitative
Nucleic acid amplification test (NAAT) for chlamydia and
gonococcus
Gram stain, cultures
```
66
Pelvic pain imaging
Transvaginal Ultrasound→ Ovarian neoplasms/masses. Torsion, Ectopic pregnancy
CT→ further evaluation following ultrasound
MRI→ pregnant women
67
Ectopic pregnancy most likely extrauterine location
Fallopian tubes
68
Ectopic pregnancy presentation
Vaginal bleeding + pain
6-8 weeks after LMP
Ruptured→ life threatening hemorrhage
69
PID causes
```
STI related (85%) → N gonorrhoeae, C trachomatis
Involves uterus, fallopian tubes/ovaries, +/- abscesses
```
70
Ovarian torsion
Partial or complete rotation of ovary→
71
Most common GYN emergency
ovarian torsion
72
Risk of ovarian torsion
Pregnancy
73
Ovarian cancer presentation
```
Adnexal mass, abdominal distention
Bloating, early satiety
Weight loss
Urinary urgency, frequency
Acute presentation→ +/- malignant effusion, SBO
```
74
Postpartum endometritis
infection
| of endometrium after delivery→ Postpartum febrile mortality
75
Postpartum endometritis presentation
Fever/chills
Uterine tenderness
Lochia (foul smelling discharge)
+/- soft uterus, excessive uterine bleeding
76
PID presentation
```
Fever, chill
New mucopurulent vaginal discharge
Intermenstrual bleeding
Pelvic TTP
Cervical friability
```
77
Ovarian torsion presentation
```
Acute onset of pain
+/- radiate to back/flank/groin
N/V
Adnexal mass on exam
+/- abnormal genital tract bleeding
+/- fever (marker of necrosis)
```
78
Diagnose ectopic pregnancy
Transvaginal ultrasound
| (+) hCG
79
PID diagnostics
Saline microscopy of vaginal fluid→ abundant WBCs
Transvaginal ultrasound→ +/- abscess, pelvic free fluid
NAATs→ chlamydia, gonorrhea
G stain + cultures
+/- elevated ESR/CRP
80
With ectopic pregnancy, be surer to
Monitor Hgb/Hct
81
Diagnose ovarian torsion
Ultrasound with duplex
Transvaginal + transabdominal
Direct visualization during surgical eval
82
Diagnose ovarian cancer
```
Transvaginal + transabdominal ultrasound
Tumor markers (CA 125)
```
83
Diagnose postpartum endometritis
Clinical diagnosis
| Elevated WBC with bands
84
postpartum endometritis tx
Admit, consult GYN
| IV Clindamycin + Gentamycin
85
Ovarian cancer tx
Consult surgery, oncology, GYN
86
Ovarian torsion tx if premenopausal, viable ovary, no malignancy
Laparoscopic detorsion
87
Ovarian torsion tx if post-menopausal, nonviable ovary or suspected malignancy
Salpingo-oophorectomy
88
Ectopic pregnancy tx if patient is stable and will follow up
Methotrexate
89
Ectopic pregnancy tx if suspected tubal rupture or hemodynamically unstable pt
Salpingectomy
90
When can't methotrexate be used?
```
high hCG
fetal heart activity
large ectopic size
renal/liver disease
breastfeeding
```
91
General tx for PID
Consult GYN
IV fluids, pain control
Antiemetic
+/- syphilis, HIV testing
92
Outpatient tx for PID
Ceftriaxone + doxy
93
Inpatient tx for PID
Cefoxitin + doxy
94
Hospitalize a patient with PID if...
Severe clinical illness
Unable to tolerate PO
Complicated PID with abscess
Pregnancy or post-partum
→ Get blood cultures x 2
95
Can you attribute significant abdominal pain to gastroenteritis?
NO, never
96
Old patient has risk factors + abdominal pain, so you have to rule out
Abdominal aortic aneurysm
97
In surgical cases, which comes first, pain or vomiting?
Pain
98
If a patient's pain wakes them up from sleep...
that's "significant"
99
Can a lack of free air on CXR rule out perforation?
Nope
100
What can mask pain?
Chronic steroids or opiates
101
Who perceives pain less?
The elderly
102
If you're concerned your patient might have a GI bleed and need surgery...
order a blood type/cross
