Lecture 9: GI Bleeds and GI/Abdominal Emergencies

Question 1

Herniations or saclike protrusions of the mucosa through the muscularis at points of nutrient artery penetration defines what?

Answer 1

Diverticulosis

Question 2

Periumbilical pain out of proportion to tenderness (i.e., pt is writhing in pain, but PE isn’t impressive) is characteristic of what GI problem?

Answer 2

Acute Mesenteric Ischemia

Question 3

What will abdominal XR show in patient with Acute Mesenteric Ischemia?

Characteristic sign?

Answer 3

• Bowel distention and Air-fluid levels
• Thumb-printing (submucosal edema)

Question 4

What is the diagnostic study of choice for Acute Mesenteric Ischemia?

Early celiac and mesenteric ________ is recommended?

Answer 4

• CT angiography = study of choice
• Early celiac and mesenteric arteriography is recommended

Question 5

Which procedure is indicated in Acute Mesenteric Ischemia to restore intestinal blood flow obstructed by embolus or thrombosis or to resect necrotic bowel?

Answer 5

Laparotomy

Question 6

Ischemic colitis is characterized by what symptoms and signs?

Answer 6

Severe lower abdominal pain followed by rectal bleeding

Question 7

Abdominal XR of ischemic colitis will show what?

Answer 7

• Colonic dilation
• Thumb-printing

Question 8

Differentiate acute mesenteric ischemia from ischemic colitis?

Answer 8

• AMI = periumbilical pain out of proportion to tenderness
• IC = severe LOWER abdominal pain followed by rectal bleeding

Question 9

Although iron-deficiency anemia is associated with occult GI blood loss, why is it also a common finding in pre-menopausal women?

Answer 9

• Menstruation
• Pregnancy-associated iron loss

Question 10

Most common cause of Acute Liver Failure?

Answer 10

Acetaminophen

Question 11

Toxic Megacolon carries a high risk for what complication?

Treated how?

Answer 11

• Perforation
• Treatment w/ surgery

Question 12

Perforated Viscus refers to what?

Significant why?

Answer 12

• Any hollow organ (esophagus, stomach, intestine, uterus, bladder) perforation
• EMERGENCY SURGERY!

Question 13

Perforated viscus is visualized with what imaging modality?

What is seen?

Answer 13

• CT or plain XR
• Free air under diaphragm or air in mediastinum (Pneumoperitoneum = below diaphragm and Pneumomediastinum = above diaphragm)

Question 14

Low grade fever is typical of appendicitis, but what is a high-grade fever or rigors (chills) suggestive of?

Answer 14

• Appendiceal perforation
• Septic thrombophlebitis (pylephlebitis) = rare

Question 15

Psoas sign vs. Obturator sign for Appendicitis?

Answer 15

Psoas sign - pain on passive extension of the right hip

Obturator sign - pain w/ passive flexion and IR of the right hip

Question 16

Moderate ________ with _______ is a common lab finding in appendicitis

Answer 16

Moderate leukocytosis with neutrophilia is a common lab finding in appendicitis

Question 17

What are 2 useful imaging modalities for the diganosis of appendicits?

Answer 17

1. Ultrasound
2. CT

Question 18

What are the most common symptoms/signs of Intestinal Obstruction?

Answer 18

• Colicky abdominal pain
• N/V –> Feculent vomiting (common)
• Abdominal distention
• Absence of flatus or stooling

Question 19

How is the diagnosis of intestinal obstruction made?

Answer 19

Plain radiographs or CT scan

Question 20

What is the treatment for Intestinal Obstruction?

If due to adhesions?

Answer 20

• NG tube decompression and fluid resuscitation
• Urgent laparotomy for lysis of adhesions (LOA) must be performed before bowel ischemia develops

Question 21

In terms of hernias, what does irreducible mean?

Answer 21

Hernia contents cannot be manipulated back into abdominal cavity

Question 22

Patient has abnormal vital signs with a tender, firm, irreducible mass (hernia) this indicates what is occuring to the bowel and what treatment needs to be done?

Answer 22

• Bowel is infarcted/dying
• Needs emergent surgery!

Question 23

Condition in which there is neurogenic failure or loss of peristalsis in the intestine in the absence of any mechanical obstruction describes?

Answer 23

Acute paralytic ileus

Question 24

Direct vs. Indirect Inguinal Hernia?

Answer 24

• Direct = occurs near the opening of the inguinal canal
• Indirect = occurs AT the opening of the inguinal canal

Question 25

What are 5 precipitating factors for Acute Paralytic Ileus?

Answer 25

1. Surgery 2. Peritonitis 3. Electrolyte abnormalities 4. Meds 5. Severe medical illness

Question 26

Acute Colonic Pseudo-obstruction (Ogilvie Syndrome) is characterized by what? Arises when?

Answer 26

- **Severe** abdominal **distention** ---\> **MASSIVE** **dilation** of **CECUM** or **RIGHT** **colon (megacolon****)**w/**no mechanical obstruction** - Arises in **post-op state** or w/ **severe medical illness**

Question 27

The risk of rupture of abdominal aortic aneurysms is related to what?

Answer 27

- **Size** - **\>5cm** = 20-40% chance of rupture

Question 28

AAA's are often asymptomatic and instead discovered how?

Answer 28

- **Routine exam** as a palpable, pulsatile, expansive, and nontender mass - As **incidental finding** via abdominal imaging study for something else

Question 29

What is typically a signal of AAA about to rupture? Is there usually a warning before AAA's rupture?

Answer 29

- Aneurysmal pain - More often, acute rupture occurs **without** prior warning and this complication is **always life threatening**

Question 30

Which signs/symptoms occur with rupture of AAA and this requires?

Answer 30

- Acute pain and hypotension - Emergency operation

Question 31

Who needs to be screened for AAA's and what imaging modality is used?

Answer 31

- Men age 65-75 yo who have **ever** smoked - Abdominal **ultrasound**

Question 32

Most common cause of AAA?

Answer 32

Atherosclerosis

Question 33

Which finding on transvaginal US with serum beta-hCG \>2000 milli-units/mL is indicative of ectopic pregnancy?

Answer 33

No **intrauterine** pregnancy

Question 34

What are 4 conditions that predispose to an ectopic pregnancy?

Answer 34

1. Hx of infertility 2. Pelvic inflammatory diseae 3. Ruptured appendix 4. Prior tubal surgery

Question 35

In the US, what is one of the most common causes of maternal death during the first trimester?

Answer 35

Undetected ectopic pregnancy

Question 36

Which symptom occurs in almost every case of ectopic pregnancy?

Answer 36

**Severe lower quadrant pain** (right- or left- sided) generally 6-8 wks after last period

Question 37

Ovarian torsion is most often due to?

Answer 37

Rupture, bleeding, or torsion of ovarian cysts

Question 38

How serious is an Ovarian Torsion?

Answer 38

**Surgical emergency** requiring prompt diagnosis to preserve ovarian function

Question 39

The majority of ovarian torsions occur on what side?

Answer 39

Right side

Question 40

What is the classic presentation for a patient presenting with an Ovarian Torsion?

Answer 40

- **Sudden-onset**, SEVERE, **unilateral, lower abdominal pain** - May develop after episodes of **exertion** - N/V common

Question 41

What is the primary imaging/diagnostic modality use for suspected Ovarian Torsions? Most commonly shows what?

Answer 41

- Transvaginal US w/ **doppler** - Ovary \>4cm in size due to cyst, tumor, or edema

Question 42

Which finding needs to be considered in males with acute scrotal pain due to it being a urologic emergency?

Answer 42

Testicular torsion

Question 43

Testicular torsion has a bimodal age presentation with peaks occuring during what 2 stages of life?

Answer 43

1. Immediate **neonatal period** 2. Early **puberty**

Question 44

What is the most common age for boys presenting with testicular torsions?

Answer 44

Between **12-18 yo**

Question 45

What is the standard of care for prenatal torsions in neonates? Salvageable?

Answer 45

- Not salvageable - May be taken to OR on a semi-elective basis when infant is a few months of age to decrease the anesthesia risk

Question 46

Which imaging modality is the diagnostic study of choice for Testicular Torsion?

Answer 46

**Doppler US**