The Abdomen Flashcards
(221 cards)
1
Q
What is the most common cause of abdominal injury?
A
Blunt abdominal trauma: MVC is the most common
2
Q
What physical exam finding is highly correlative to abdominal trauma?
A
Seatbelt sign
3
Q
What is your initial assessment for abdominal Trauma?
A
ABCDE
4
Q
What do you do after ABCDE for abdominal trauma?
A
FAST exam
5
Q
If FAST is (+) what do you do next?
A
Laparatomy
6
Q
If Fast is Nondiagnostic what do you do next?
A
Diagnostic Peritoneal lavage –> Laparotomy
7
Q
If Fast is (-) what do you assess next?
A
Bleeding outside the abdomen
8
Q
If Fast is (-) and there is bleeding outside the abdomen what do you do next?
A
Stabilize according to the location of bleed
9
Q
If fast is (-) and there is no bleeding outside the abdomen what do you do next?
A
Stabilize the patient
10
Q
What is the most accurate test for abdominal trauma?
A
CT of the Retroperitoneum
11
Q
What is the best test for hemodynamically unstable patients with abdominal trauma?
A
Exploratory Laparotomy (ex-lap)
12
Q
What are indications for immediate Laparotomy in cases of penetrating trauma?
A
Hemodynamic instability
Peritonitis
Evisceration
Impalement
Evidence of peritoneal penetration and significant organ injury based on imaging or local exploration
13
Q
A
14
Q
What is Cullen sign?
A
Bruising around the umbilicus
15
Q
What are common causes of Cullen Sign?
A
Hemorrhagic Pancreatitis
Ruptured AAA
16
Q
What is Grey Turner Sign?
A
Bruising in the flank
17
Q
What is a common cause of Grey Turner Sign?
A
Retroperitoneal Hemorrhage
18
Q
What is Kerh sign?
A
Pain in the left shoulder
19
Q
What is a common cause of Kehr sign?
A
Splenic Rupture
20
Q
What is Balance sign?
A
Dull percussion on the left and shifting dullness on the right
21
Q
What is a common cause of Balance sign?
A
Splenic Rupture
22
Q
What is Seatbelt sign?
A
Bruising along the path of the seatbelt
23
Q
What is a common cause of seatbelt sign?
A
Deceleration injury
24
Q
What are common causes of RUQ pain?
A
Cholecystitis
Biliary Colic
Cholangitis
Perforated Duodenal Ulcer
25
What are common causes of RLQ pain?
Appendicitis
Ovarian torsion
Ectopic pregnancy
Cecal Diverticulitis
26
What are common causes of LUQ pain?
Splenic Rupture
IBS: Splenic flexure syndrome
27
What are common causes of LLQ pain?
Sigmoid Volvulus
Sigmoid diverticulitis
OVarian torsian
Ectopic Pregnancy
28
What are common causes of midepigastrium pain?
Pancreatitis
Aortic Dissection
Peptic ulcer disease
29
What approach must you take in a female of childbearing age with RLQ pain?
Proceed as though patient is pregnant and r/o ectopic
-get b-hCG and pelvic US
-If US shows ectopic: emergent surgery indicated
30
What should you suspect in a patient >60 with RLQ pain?
Cecal Diverticulitis
31
What is your management for suspected Cecal Diverticulitis?
NPO, place NG tube
Abdominal Abx
32
What should you suspect for RLQ pain in a male patient <60?
Appendicitis
33
What is your management for appendicitis?
Emergent Lap Appy
34
What should you order in a Female patient <60 with RLQ pain?
B-hCG and Pelvic US
35
If your female patient <60 with RLQ pain has a normal b-hCG and US what should you suspect?
Appendicits or Ovarian torsion
36
What is your management for suspected ovarian torsion?
Doppler US to diagnose followed by lap surgery
36
If your female patient <60 with RLQ pain has elevated or abnormal b-hCG what should you suspect?
Ectopic Pregnancy
37
How would you manage the ectopic pregnancy?
Emergent Surgery
38
What is considered Severe abdominal pain?
"Out of proportion to physical findings"
10/10 pain
soft abdomen
no guarding
no rebound tenderness
39
Where does an MI refer pain to?
Left chest, jaw and left arm
40
Where does Cold food refer pain to?
"Brain freeze"
41
Where does the GB refer pain to?
Right shoulder/scapula
42
Where does the pancreas refer pain to?
The back
43
Where does the pharynx refer pain to?
The ears
44
Where does the prostate refer pain to?
Tip of penis/perineum
45
Where does the appendix refer pain to?
RLQ
46
Where does the esophagus refer pain to?
Substernal chest pain
47
Where do Pyelonephritis and Nephrolithiasis refer pain to?
The Costovertebral angle (CVA)
48
What inflammatory abdominal conditions have the greatest potential to require surgical intervention?
Acute Cholecystitis
Acute Pancreatitis
Appendicitis
Diverticulitis
49
What is the etiology of Cholecystitis?
Gallstones occluding the lumen of the cystic duct: causes inflammed GB
50
What are S/S of Cholecystitis?
Fever, Sever RUQ tenderness, Murphy sign , N/V
51
What are diagnostic tests for Cholecystitis?
US: pericholecystic fluid, GB wall thickening and stones in the GB
52
What is the moat accurate test for Cholecystitis?
HIDA scan
53
How do you treat Cholecystitis?
Laparoscopic stugery
54
What is the etiology of acute pancreatitis?
Alcohol of gallstone obstruction of the duct causing inflammation
55
What are S/S of Acute pancreatitis?
Fever, severe midabdominal pain radiating to the back N/V
56
What is the best test for acute pancreatitis?
CT scan
57
What lab values can be used in diagnosing acute pancreatitis?
Amylase is sensitive, Lipase is specific
58
How do you treat acute pancreatitis?
Aggressive IV fluids and NPO
Cholecystectomy if caused by gallstones
59
What is the etiology of appendicitis?
Fecalith obstructing the appendiceal orifice, causing inflammation
60
What are S/S of appendicitis?
Anorexia, Fever, periumbilical pain with RLQ tenderness, Elevated WBC count and left shift
61
What is the most accurate diagnostic test for Appendicitis?
CT scan
62
How do you treat appendicitis?
Laparoscopic surgery
63
What is the etiology of Diverticulitis?
Fecal impaction into Pseudodiverticular causing inflammation
64
What are S/S of Diverticulitis?
Fever, nausea, LLQ pain, peritonitis
65
What is the best and most accurate test for Diverticuitis?
CT scan
66
How do you treat Diverticulitis?
Abx : surgical resection for recurrance or perforation
67
What is Rovsing Sign for appendicitis?
RLQ pain with LLQ palpation
68
What is the Psoas sign for appendicitis?
Pain with hip extension
69
What is the Obturator sign for appendicitis?
Pain with internal rotation of the right thigh
70
What do Abdominal abscesses commonly occur?
After invasive procedures, inflammatory conditions and traumatic events
71
How do you diagnose abdominal abscesses?
CT
72
How do you treat abdominal abscesses?
Incision and drainage: can be percutaneous via US or CT
Abx to prevent bacteremia
73
What is the most common pathogen in an abdominal abscess?
Staph Aureus including MRSA
74
How does a splenic abscess present?
LUQ and splenomegaly
75
What is the most accurate test for splenic abscess?
CT
76
How do you treat a splenic abscess?
Abx and Splenectomy
77
What is bowel obstruction?
Mechanical of functional obstruction of the intestines
78
What is the most common cause of SBO?
Previous abdominal surgery
79
What happens in partial bowel obstruction?
A small amount of GI contents can pass
80
What happens in complete bowel obstruction?
No GI contents can pass
81
What are common symptoms of Bowel Obstruction?
Severe waves of intermittent crampy abdominal pain
N/V
Fever
Hyperactive bowel sounds
High pitched "tinkling" sound: intestinal fluid and air under high pressure
Hypovolemia from 3rd spacing
82
What are common etiologies of bowel obstruction?
Adhesions from previous surgery
Hernia
Crohn Disease
Neoplasms
Intussusception
Volvulus
Foreign bodies
Intestinal atresia
Carcinoid
83
What is the best initial test for bowel obstruction?
Abdominal x-ray: multiple air-fluid levels with dilated loops of small bowel
84
What is the most accurate test for bowel obstruction?
CT scan of the abdomen: transition zone from dlated loops of bowel with contrast to an area with no contrast
85
How do you treat Bowel Obstruction?
NPO
NG Tube with suction: lowers bowel pressure
IV fluids: replace fluid lost to third spacing
Surgical decompression if no response
86
What causes Celiac Artery Compression Syndrome (CACS)?
External compression of the celiac trunk by the median arcuate ligament
87
What are common symptoms of CACS?
Severe postprandial abdominal pain, nausea and weight loss
88
How do you confirm CACS?
Duplex US to measure blood flow through the celiac artery
89
How do you treat CACS?
Surgical decompression
90
What is the #1 cause of Esophageal perforation?
Iatrogenic: most commonly Upper endoscopy
91
What are common symptoms of Esophageal perforation?
Severe, acute onset excruciating retrosternal chest pain
Odynophagia
Hamman sign: crunching sign heard upon palpation of the thorax from subcutaneous emphysema
Pain that can radiate to the left shoulder
92
What is The most accurate test for Esophageal Perforation?
Esophagram: uses sodium solution as a contrast
93
How do you treat esophageal Perforation?
Surgical exploration with debridement of the mediastinum and closure of the perforation
94
What is Boerhaave syndrome?
Full-thickness tear of the esophagus secondary to extreme retching and vomiting
95
What is Mallory-weiss syndrome?
Mucosal tear of the esophagus due to vomiting: most common at the Gatroesophageal junction
96
What is gastric perforation most commonly associated with?
Ulcer Disease
97
What are risk factors for gastric perforation?
H. Pylori infection, NSAIDs, burns, head injury, trauma, cancer
98
What can occur if an ulcer is located on the posterior part of the stomach?
Pancreatitis
99
What are common symptoms of gastric perforation?
Acute abdominal pain: progressively worsens and radiates to the right should from acid irritating the phrenic nerve
Guarding, rebound tenderness and abdominal rigidity
100
What is the best initial test for gastric perforation?
Upright CXR: free air under the diaphragm
101
What is the most accurate test for gastric perforation?
CT
102
How do you treat gastric perforation?
NPO
NG tube
IV Abx and IVF
Emergent surgery
103
What IV Abx are used in gastric perforation?
Piperacillin-Tazobactam
Ampicillin-Sulbactam
Carbapenems
Ciprofloxacin and Metronidazole
104
How do you manage Asymptomatic Gallstones?
monitor and observe
105
How does Biliary Colic classically present?
Abdominal pain in the RUQ; radiating to the right shoulder and back
Often triggered by fatty food due to gallstones
106
What is the best initial test for Biliary colic?
US: shows acoustic shadowing
107
How do you treat biliary colic?
Elective Cholecystectomy
108
What causes post-cholecystectomy diarrhea?
Bile acids overwhelm the terminal ileum and irritate the colonic mucosa
109
How do you treat post-cholecystectomy diarrhea?
Cholestyramine
110
What is Acute Ascending Cholangitis?
Life-threatening emergency caused by obstruction of the Common Bile Duct (CBD): with a gallstone that has escaped the gallbladder
111
What are common symptoms of Acute Ascending Cholangitis?
Jaundice, Fever, RUQ pain, AMS, Hypotension or shock
112
What is the bet initial test for acute ascending cholangitis?
Abdominal US: confirm obstruction with identifying dilated intra and extrahepatic bile ducts + dilated CBD
113
What is the most accurate test for acute ascending cholangitis?
MRCP
114
How do you treat acute ascending cholangitis?
IV Abx followed by ERCP to decompress the CBD and remove the stone: patient must then receive elective cholecystectomy within 72 hours
115
What is Acalculous Cholecystitis?
Inflammatory disease of the GB caused by bile stasis, ischemia and bile salt concentration: no evidence of gallstones or cystic duct obstruction
116
What patient population is more susceptible to Acalculous Cholecystitis?
Critically ill on TPN: CCK-induced GB contraction is suspended in patients not eating
117
What pathogens commonly cause infection in acalculous cholecystitis?
E. Coli, Enterococcus Faecalis, Klebsiella, Pseudomonas, Proteus and Bacteroides Fragilis
118
How do you treat Acalculous Cholecystitis?
Cholecystostomy
119
What is Emphysematous Cholecystitis?
Air fluid in the gallbladder lumen + gas in the gallbladder wall
120
What is a Klatskin tumor (hilar cholangiocarcinoma)?
Cholangiocarcinoma located at the confluence of the Right and Left Hepatic bile ducts
121
What is the most accurate test for Bile leak?
HIDA scan
122
When should you suspect a Bile leak?
Pt after Cholecystectomy with fever, abdominal pain and/or bilious ascites
123
What is the sphincter of Oddi?
Muscle that combines the distal common bile duct and the pancreatic duct as they ender the wall of the duodenum
124
When should you suspect Sphincter of Oddi dysfunction?
Biliary-type pain without other apparent causes
125
What must be present to diagnose Sphincter of Oddi dysfunction?
Pain in the epigastrium and/or RUQ
Episodes lasting at least 30 minutes
Recurrent symptoms at different intervals
Pain builds up to a steady level
Pain severe enough to interrupt daily activities or ED visit
Pain not significantly related to bowel movements
Pain not significantly relieved by postural change or acid suppression
126
What is the most accurate test to diagnose Sphincter of Oddi dysfunction?
Spinchter of Oddi Manometry (SOM)
127
What are the characteristics of Type I SOD?
Biliary-type pain, abnormal liver tests and dilated CBD
128
How do you manage Type I SOD?
Endoscopic Sphincterotomy without preprocedure SOM
129
What are the characteristics of Type II SOD?
Bilary-type pain + abnormal liver tests or Dilated CBD
130
How do you manage Type II SOD?
SOM followed by endoscopic sphincterotomy
131
What are the characteristics of Type III SOD?
Biliary-type pain, normal liver tests, dilated CBD
132
How do you manage Type III SOD?
Medial management: no endoscopic sphincterotomy
133
What 3 cancers involve the pancreas?
Pancreatic cancer
Cholangiocarcinoma
Gallbladder cancer
134
How does Pancreatic cancer present?
Painless jaundice with weight loss
+/- depressive symptoms
Hx of smoking
135
What is the etiology of pancreatic cancer?
90% adenocarcinoma of the head with CBD dilation
136
What is the most accurate test for pancreatic cancer?
CT of the chest, abdomen and pelvic
137
What is used to measure response to therapy in pancreatic cancer?
Ca19-9
138
How do you treat pancreatic cancer?
Whipple Procedure (Pancreaticoduodenectomy)
Palliative CBD Duct stent for metastatic disease
139
How does cholangiocarcinoma present?
Painless jaundice with weight loss in patient with hx of PSC
#1 cancer of the bild duct
Elevated Alk Phos
140
What is the Etiology of cholangiocarcinoma?
Most commonly PSC
SE Asians at increased risk: Clonorchis Sinensis and Opisthorchis Viverrini
141
What is the most accurate test for Cholangiocarcinoma?
MRCP to localize mass
142
How do you biopsy cholangiocarcinoma?
ERCP with brushings or FNA
143
What do you monitor for response to therapy in cholangiocarcinoma?
CA 19-9
144
How do you treat Cholangiocarcinoma?
Surgical resection and chemotherapy
145
How does Gallbladder cancer present?
Constant RUQ pain and jaundice when metastasis occurs
Palpable "Porcelain gallbladder"
146
What is the etiology of Gallbladder cancer?
90% from adenocarcinoma
More common in Female
Associated with chronic typhoid infection of GB
147
What is the best initial test for GB cancer?
US
148
What is the most accurate imaging test for GB cancer?
CT
149
How do you treat GB cancer?
surgical resection if possible and chemotherapy
Extremely poor 1 year prognosis
150
What is the most common type of Visceral Abscess?
Pyogenic Liver abscess
151
What commonly causes a Pyogenic Liver abscess?
Recent abdominal inflammatory process: diverticulitis, Cholangitis
-seeds infection to the liver
152
What portion of the liver is a Pyogenic Liver abscess usually located?
Right lobe: larger and has greater blood supply
153
What are common symptoms of a pyogenic liver abscess?
Fever, abdominal pain
Elevated WBC, AST/ALT
154
What is the next step in management for a pyogenic liver abscess?
Abx to cover gram (-), and anaerobes
155
What antibiotics are commonly used for PYogenic liver abscess (Abdominal abx)?
Piperacillin-tazobactam
Ampicillin-Sulbactam
Carbapenems
Ciprofloxacin and Metronidazole
156
What is the best test to diagnose Pyogenic liver abscesses?
US
157
What is therapeutic for a pyogenic liver abscess?
Percutaneous aspiration
158
What is the most common pathogen found with a pyogenic liver abscess?
Enteric Gram (-) Bacilli
159
What should you do if you find Klebsiella Pneumoniae with a pyogenic liver abscess?
Colonoscopy due to associated with colorectal cancer
160
When is Staph Aureus seen in a pyogenic liver abscess?
After transarterial embolization for HCC
161
What is Candida seen in a pyogenic liver abscess?
During recover of neutrophil counts after neutropenic episode
162
When is Burkholderia Pseudomallei seen with a pyogenic liver abscess?
Recent travel to southeast asia
163
When is Entamoeba Histolytica seen with a pyogenic liver abscess?
Recent travel to central and south America with watery diarrhea
164
What are Gallbladder Polyps?
Outgrowths of the gallbladder mucosal wall
165
How do you treat gallbladder polyps <5mm?
Repeat US at 1 year to confirm size stability
166
How do you treat Gallbladder polyps that are 6-9mm?
Yearly US, remove surgically if it enlarges
167
How do you treat Gallbladder polyps that are 10-20mm?
Remove laparoscopically due to risk of malignancy
168
How do you treat Gallbladder polyps that are >20mm?
Resect surgically do to risk of malignancy
169
How do you treat symptomatic Gallbladder polyps?
Cholecystectomy regardless of polyp size
170
What is Mirizzi Syndrome?
Gallstone lodges in the cystic duct of the GB and compresses the CBD or common hepatic duct causing obstruction and jaundice
171
What labs are seen in Mirizzi Syndrome?
Elevated Bilirubin and Alkaline Phosphatase
172
What is the best initial test for Mirizzi Syndrome?
US
173
What is the most accurate test for Mirizzi Syndrome?
MRCP
174
How do you treat Mirizzi syndrome?
Surgical resection of the GB if simple
If fistula has developed: cholecystectomy and bilioenteric anastomosis
175
What causes Ischemic Colitis?
Lack of blood flow to the bowel: ischemia most damaging to the mucosa
176
What are common symptoms of Ischemic Colitis?
Abdominal pain described as cramping
Bloody diarrhea
177
What is the best initial test for Ischemic colitis?
CT abdomen
178
What is the most accurate test for ischemic colitis?
Angiogram
179
How do you treat Ischemic colitis?
IV normal saline and Antibiotics
180
What is Acute Mesenteric Ischemia?
Acute occlusion of the mesenteric arteries: most commonly SMA
181
What is the #1 risk factor for Acute Mesenteric Ischemia?
A-Fib: emboli occludes the vessel
182
What are common symptoms of Acute mesenteric ischemia?
Excruciating pain out of proportion to the physical exam
183
What labs can be seen in Acute Mesenteric Ischemia?
Increased lactic acid and leukocytosis
184
What is the best initial test for suspected Acute mesenteric ischemia?
Abd x-ray: showing air in the bowel wall
185
What is the most accurate test for acute mesenteric ischemia?
Angiography
186
What is the treatment for acute mesenteric ischemia?
emergent laparotomy with resection of necrotic bowel
187
What causes Chronic Mesenteric ischemia?
Atherosclerotic disease of 2 or more mesenteric vessles
: pain with eating is equivalent of Chest pain with exertion
188
What is the best initial test for chronic mesenteric ischemia?
Angiography to locate the lesions
189
How do you treat chronic mesenteric ischemia?
stent or bypass to reestablish blood flow to allow surgical correction
190
how do you diagnose Splenic Rupture?
FAST or Abdominal CT
191
What is a grade I Splenic Rupture?
Subcapsular hematoma <10% surface area
192
What is a grade II Splenic Rupture?
Subcapsular hematoma 10-50% surface area
193
What is a grade III splenic rupture?
Subcapsular >50% surface area or expanding
194
What is a grade IV splenic rupture?
laceration involving segmental or hilar vessels
195
What is a grade V splenic rupture?
Shattered spleen
196
How do you treat hemodynamically stable Grade I-III splenic ruptures?
Supportive care, monitor Hgb
If patient worsens: Angiographic embolization or surgical exploration
197
How do you treat hemodynamically unstable patient with Positive FAST showing splenic rupture?
Surgical exploration
198
How do you treat High grade IV-V splenic rupture?
Ex-lap for precise staging, repair or removal of the spleen
199
What patients do splenic infarctions tend to occur in?
A-Fib and Hypercoagulable states when the splenic artery becomes occluded by an embolus
Can also be seen in Sickle Cell Disease and Mononucleosis
200
What can be seen on Physical exam in Splenic Infarctions?
acute LUQ pain that radiates to the left shoulder with tenderness and splenomegaly
201
What labs are seen on splenic infarctions?
Elevated LDH
202
How do you treat splenic infarctions?
Treat underlying cause and control pain
Splenectomy for complications such as abscess formation
203
What causes a rectus sheath hematoma?
Ruptured branch of the inferior epigastric artery
204
What are rectus sheath hematomas associated with?
Violent coughing and anticoagulation
205
How does a rectus sheath hematoma present?
Acute onset abdominal pain with a palpable abdominal mass
206
What is the most accurate test for a rectus sheath hematoma?
CT abdomen
207
How do you treat stable patients with a rectus sheath hematoma?
IVF and/or Blood products with reversal of anticoagulation
208
How do you treat patients with an expanding rectus sheath hematoma or those not responsive to blood product?
Angiography with embolization followed by surgery if unresponsive
209
How does Toxic Megacolon present?
diarrhea, colonic dilation, systemic toxicity
210
What are the 2 most common causes of Toxic Megacolon?
IBD and C. Diff Colitis
211
How do you diagnose Toxic Megacolon?
CT abdomen: air-filled colonic distension >6cm
212
What is the next best step for toxic megacolon?
Surgical consult
213
What medical therapies can be used prior to surgery for toxic megacolon?
IBD: Steroids then Infliximab
C. Diff: Vancomycin and metronidazole
214
What is a Volvulus?
Torsion of the bowel leading to obstruction
215
What are the most common sites for a Volvulus to occur?
Sigmoid colon and cecum
216
How do patients present with a volvulus?
Abdominal pain, nausea, abdominal distension and constipation
217
What is the best initial test for Volvulus?
Abd X-ray: U-shaped distended sigmoid colon
218
What is the most accurate test for Volvulus?
CT abdomen: Bird-beak appearance of the colonic segments
219
What is the most effective therapy for perforation or peritonitis in patients with a volvulus?
Surgery
220
what is the nest step in managing volvulus for stable patients?
Endoscopic decompression: if this fails then surgery
