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Emergency Medicine > Lecture 11: Abdominal Pain Readings > Flashcards

Lecture 11: Abdominal Pain Readings Flashcards

1
Q

When does an AAA require repair?

A
  • Symptomatic
  • >= 5.0cm
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2
Q

Classic presentation of ruptured AAA

A
  1. Older male smoker
  2. hx of atherosclerosis
  3. Sudden back/abd pain, hypotension, pulsatile abd mass
  4. Onset of pain is both severe and abrupt.
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3
Q

What hx might predispose aortoenteric fistulas?

A

Prior aortic grafting

Duodenum MC location

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4
Q

When do you really start monitoring an AAA?

A

Once it hits 3cm, refer to vascular to monitor

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5
Q

What is the MC initial misdiagnosis for an AAA?

A

Renal colic

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6
Q

What bedside study is helpful in identifying unclear AAA?

A

Bedside abdominal US

Measures diameter only!

You really need a CTA

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7
Q

Goal SBP for ruptured AAA

A

90 SBP

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8
Q

What two layers is blood pouring between for an aortic dissection?

A

Between the intima and adventitia

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9
Q

Classic demographic of Aortic Dissection

A
  • Older male (>50y) using cocaine
  • Hx of HTN
  • CT disorders (EDS, Marfan’s, or CHD)
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10
Q

Stanford classification and Debakey of aortic dissections

A
  • Stanford is just Type A = Ascending, B = descending
  • DeBakey is type 1 = both, type 2 = ascending, type 3 = descending.
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11
Q

What kind of murmur can be heard during aortic dissection?

A

Diastolic murmur of aortic insufficiency

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12
Q

MC XR findings for aortic dissection

A
  1. Abnormal aortic contour + widening of mediastinum
  2. Tracheal deviation
  3. Displacement of aortic intimal calcifications
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13
Q

Imaging modality of choice for aortic dissection

A

CT Scan with IV contrast (altho im pretty sure its CTA)

Alternate is TEE

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14
Q

How do we manage HTN initially in aortic dissection?

A
  • Esmolol
  • Labetolol

Goals: 100-120 SBP, 60-70 HR

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15
Q

If SBP of 100-120 is not met after BB usage in aortic dissection, what can we use?

A
  • Nitroprusside
  • Nicardipine
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16
Q

In elderly patients, what hx is important besides the abdominal pain hx?

A
  • Hx of MI
  • Dysrhythmias
  • Coagulopathies
  • Vasculopathies
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17
Q

What is the most important part in the physical exam for abdominal pain?

A

Palpation

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18
Q

What combination is pretty confirmatory for peritonitis?

A
  1. Rigidity
  2. Referred tenderness
  3. Cough pain

Also use a Carnett test!

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19
Q

Who gets a pelvic exam in evaluation for abdominal pain?

A

Any post-pubertal female

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20
Q

In a patient older than 50 showing pain out of proportion to the PE, what is an important DDx to consider?

A

Mesenteric ischemia

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21
Q

Generally, what does plain XR look for in abdominal pain?

A
  • Obstruction
  • Perforation
  • Free air
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22
Q

Generally, what does US look for in abdominal pain?

A
  • Stones
  • Fluid build-up
  • AAA
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23
Q

What is the MC need for abdominal pain that needs resuscitation?

A

IV fluids (NS/LR)

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24
Q

If we accidentaly give too much morphine, how can we undo it?

A

Naloxone

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25
Q

Generally, what is considered an “acute/surgical abdomen”?

A
  1. Pain
  2. Guarding (involuntary)
  3. Rebound
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26
Q

Overall, what is the purpose of analgesics and antiemetics for abdominal pain?

A

Making it easier to workup/evaluate the patient

So you can get their PE findings more accurately.

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27
Q

Top 2 RFs for PUD

A
  1. H. Pylori infection
  2. NSAIDs (chronic)
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28
Q

Classic description of PUD

A
  • Burning epigastric pain
  • Relieved by ingestion of food/milk/anatacids
  • Recurrent pain that awakens patient up at NIGHT
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29
Q

What change in someone with PUD suggests perforation?

A

Abrupt onset of severe pain

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30
Q

What epigastric pain description is most indicative of GERD?

A
  • Radiating into chest
  • Belching
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31
Q

In what population is epigastric pain more suspicious and what condition?

A

Elderly; it could be an atypical MI

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32
Q

Gold standard for diagnosis of PUD

A

EGD showing an ulcer

Definitive diagnosis of PUD

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33
Q

What are the alarm features for possible cancer with upper GI bleeding?

A
  • Older than 55
  • Unexplained Wt loss
  • Early satiety/anorexia
  • Persistent vomiting
  • Dysphagia
  • Anemia
  • Abd Mass
  • Jaundice
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34
Q

Main 3 drugs used to aid in acid decrease for PUD?

A
  • PPIs (-prazoles)
  • H2RAs (-tidines)
  • Liquid Antacids
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35
Q

Triple therapy H. pylori eradication

A
  1. Omeprazole 20mg BID
  2. Amoxicillin 1g BID
  3. Clarithomycin 500mg BID
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36
Q

Quadruple eradication therapy H. pylori

A
  1. PPI BID
  2. Metronidazole QID
  3. Tetracycline QID
  4. Bismuth QID
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37
Q

How long is eradication therapy for H. pylori?

A

14 days

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38
Q

How do you definitively diagnose PUD?

A

Endoscopy

Anyone with a presumptive dx or alarm features

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39
Q

Mainstay of tx for stable, uncomplicated PUD?

A

PPI or H2RA w/ liquid antacid for breakthrough.

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40
Q

2 MCC of Acute pancreatitis

A
  • Cholelithiasis
  • Alcohol Abuse
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41
Q

What condition can result in secondary pancreatitis?

A

Severe hyperlipidemia

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42
Q

Classic acute pancreatitis

A
  • Mid-epigastric pain that is constant
  • Radiates to the back
  • Worse when supine
43
Q

What 3 features of the H&P make acute pancreatitis highly likely?

2 out of 3 is very sus

A
  1. H&P consistent with acute pancreatitis
  2. Lipase or amylase 2-3x ULN
  3. Imaging showing pancreatic inflammation
44
Q

Preferred lab test for acute pancreatitis

A

Lipase

45
Q

What CBC findings are seen in acute pancreatitis?

A

Leukocytosis or anemia

46
Q

What lab findings suggest complicated pancreatitis?

A
  • Persistent hypocalcemia < 7
  • Hypoxia
  • Increasing BUN
  • Metabolic acidosis
47
Q

Preferred imaging modality for acute pancreatitis

A

Abdominal CT

48
Q

Initial tx of pancreatitis

A

Fluids

49
Q

When are ABX used for pancreatitis and what are they?

A

Infected pseudocyst, abscess, infected fluid

  • Imipenem-cilastatin
  • Meropenem
  • Cipro + metro
50
Q

What procedure is used for Gallstone pancreatitis?

A

ERCP + Sphincterotomy

51
Q

4 MC biliary tract emergencies caused by gallstones

A
  1. Biliary colic
  2. Cholecystitis
  3. Gallstone pancreatitis
  4. Ascending cholangitis
52
Q

Top RFs for gallstones

A
  1. Old
  2. Female
  3. Obese
  4. Rapid wt loss/fasting
  5. Asians
  6. Sickle cell disease
53
Q

Classic description of biliary colic

A
  • RUQ
  • Colicky to constant pain
  • N/V
  • Episodic
  • Referred pain to R shoulder or left upper back
54
Q

If biliary colic pain persists longer than 5 hours, what is it probably?

A

Acute cholecystitis

55
Q

Most sensitive physical test for cholecystitis

A

Murphy’s sign

56
Q

Which version of cholecystitis has the worst prognosis?

A

Acalculous cholecystitis

DM, elderly, trauma, post-sx

57
Q

What is ascending cholangitis?

A
  • Complete biliary obstruction
  • Bacterial superinfection
  • Charcot triad may be present: Fever, Jaundice, RUQ Pain

Emergency!!!

58
Q

Elevation of what 2 labs may suggest choledocholithiasis or ascending cholangitis?

A
  • Serum bilirubin
  • ALP (stasis)
59
Q

Initial imaging modality for suspected biliary colic or cholecystitis?

A

US of the hepatobiliary tract

Can also do sonographic Murphy’s

Chole = murphy’s and murphy’s has a sonographic version so US is preferred imaging

60
Q

What US finding suggests choledocholithiasis?

A

Bile duct diameter > 5cm

61
Q

If US seems inconclusive for suspected cholecystitis, what is the 2nd imaging modality we should consider?

A

Radionuclide scan (HIDA scan)

62
Q

First step in managing cholecystitis

A

Fluids

63
Q

What is the empiric ABX for uncomplicated cholecystitis?

Anyone with suspected chole gets this

A

Cefotaxime/ceftriaxone + Metronidazole

64
Q

What is the empiric ABX for Complicated cholecystitis or ascending cholangitis?

A
  1. Ampicillin
  2. Gentamicin
  3. Clindamycin

Triple coverage

Clint the gentle amp

65
Q

Which chole conditions require ERCP + Sphincterotomy?

A
  1. Choledocholithiasis
  2. Gallstone pancreatitis
  3. Ascending Cholangitis

Other conditions need surgery

66
Q

When can you discharge someone with uncomplicated biliary colic?

A
  • Symptoms abate with tx in 4-6 hrs
  • PO tolerable
67
Q

Most reliable symptom of appendicitis

A

Abdominal pain (Classically in the RLQ at Mcburney’s)

68
Q

Where exactly is McBurney’s point?

A

2/3 Between Umbilicus and ASIS

More laterally

69
Q

What 3 physical exam tests can be done to check for appendicitis?

A
  1. Rovsing’s (roving from LLQ to RLQ)
  2. Psoas (Left lateral decubitus, Stretch SOAS)
  3. Obturator (Flex R Hip + Knee + Internal rotation)
70
Q

Why does appendicitis pain location vary?

A

Your appendix can move around (pelvic, retrocecal, etc)

71
Q

Although a late finding, what is the most useful sign suggestive of appendicitis?

A

Fever

Rebound tenderness, then pain localizing to RLQ.

72
Q

Highest sensitivity S/S for appendicitis

A
  1. Fever
  2. RLQ pain
  3. Pain before vomiting
  4. Absence of prior similar pain
73
Q

What transition in pain is considered highly predictive of appendicitis?

A

Migration to the RLQ

Starts more diffusely

74
Q

What is the imaging study of choice for establishing the diagnosis of appendicitis?

A

CT (non-con is pretty accurate)

DO NOT USE RADIOGRAPHS

Thin patients might be false negative

75
Q

In children and pregnant patient, we prefer a different imaging modality over CT for acute appendicitis. What is it?

A

Graded compression US

76
Q

Which imaging modality works for appendicitis and is not reliant on operator skill?

A

MRI

No ionizing radiation, no contrast needed

77
Q

What is the MC surgical emergency in pregnant patients?

A

Acute appendicitis

78
Q

Mainstay of tx for acute appendicitis

A

Appendectomy

79
Q

Empiric abx prior to appendectomy

A
  • PiptaZo (Zosyn)
  • AmpSul (UnaSyn)
80
Q

What populations are you probably not sure of acute appendicitis in?

A
  • Pediatric
  • Geriatric
  • Pregnant
  • Immunocompromised

Admit for serial exams + monitoring

81
Q

Classic diverticulitis

A
  • LLQ pain (Steady & deep)
  • Fever
  • Leukocytosis
82
Q

What RFs cause diverticulitis to present in the R quadrant?

A
  • Redundant sigmoid
  • Asian
  • Right-sided disease
83
Q

How is diverticulitis diagnosed?

A

Clinically/Imaging

Only need imaging if fail conservative tx or unclear or SUS

Generally, only a person with hx of diverticulitis does not need imaging if presentation is similar to previous.
Any systemic S/S or inability to undergo conservative tx = CT abd pelvis w/ IV con

84
Q

Preferred imaging modality to evaluate diverticulitis (r/o ddx)

A

CT w/ con (extremely high spec and sens)

85
Q

ABX of uncomplicated diverticulitis (oral, outpatient)

A
  • Metronidazole plus
  • Cipro or levofloxacin or Bactrim

Augmentin or Moxifloxacin alternate

Cipro + Metro

86
Q

ABX of moderate diverticulitis (inpatient, IV)

A
  • Metro plus
  • Cipro or levofloxacin or aztreonam or rocephin

Cipro + metro, just switch to IV for Inpatient

87
Q

ABX for severe diverticulitis

A
  • Ampicillin plus
  • Metronidazole plus
  • Cipro or amikacin/gentamicin/tobramycin

Cipro + Metro + Amp because you need to amplify the regimen for severe from inpatient.

88
Q

How soon do you f/u with GI if you’re being treated for diverticulitis OP?

A

6 weeks if you show improvement

I think for a colonoscopy

89
Q

Top RFs for SBO

A
  1. Previous bowel surgery
  2. Incarcerated hernias
  3. Inflammatory diseases
90
Q

Who is sigmoid volvulus MC in?

A

Elderly taking an anticholinergic

Think benadryl, hydroxyzine, oxybutynin

91
Q

Who is cecal volvulvus MC in?

A

Gravid patient

92
Q

Who is Ogilvie syndrome/intestinal pseudo-obstruction MC in?

A

Bedridden elderly on anticholinergics or TCAs

Mimics large bowel obstruction

93
Q

What does bilious vomiting suggest?

A

Proximal obstruction

94
Q

What does feculent vomiting suggest?

A

Distal obstruction

95
Q

In mechanical SBO, when are high-pitched bowel sounds heard?

A

Early

96
Q

How is ileus treated vs SBO?

A
  • Ileus: Observe and hydrate
  • SBO: NG tube +/- surgery
97
Q

Diagnostic imaging modality of choice in the ED for bowel obstruction

A

CT scan (w/ contrast when possible)

Helps differentiate partial vs complete vs ileus vs strangulated.

98
Q

If leukocytosis > 20k is noted with bowel obstruction, what are we concerned about?

A
  • Abscess
  • Gangrene
  • Peritonitis
99
Q

What does elevated hematocrit suggest for bowel obstruction?

A

Dehydration

100
Q

Initial tx for managing bowel obstruction

A

NG tube

101
Q

Pre-op abx for mechanical SBO requiring surgery?

A
  • Zosyn
  • Tircarcillin-clavulanate (discontinued in the US in 2015)
  • Unasyn
  • Cefotaxmine/rocephin + clinda/metro/carbapenem
102
Q

In patients with Ogilvie/pseudo-obstruction, what is the dx and tx?

A

Colonoscopy

103
Q

For an unclear bowel obstruction that is non-surgical, what is the mainstay of tx?

A
  • NG Tube
  • IV fluids
  • Observation

Emergency Medicine (29 decks)

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