The Acute Abdomen and Peritonitis

Question 1

How long should you hold analgesics for an acute abdomen?

Answer 1

Until after initial surgical evaluation is done

Question 2

What is visceral pain?

Answer 2

Slow in onset, dull, poorly localized, protracted

Question 3

What are the primary signals for visceral pain?

Answer 3

Distension and stretch

Question 4

What types of nerves is visceral pain mediated by?

Answer 4

Autonomic (sympathetic and parasympathetic)

Question 5

Where are receptors for visceral pain located?

Answer 5

Mucosa or muscularis on hollow viscera and the visceral peritoneum

Question 6

What is parietal pain?

Answer 6

Intense, acute, sharp, better localized

Question 7

What type of nerves is parietal pain mediated by?

Answer 7

Somatic

Question 8

What causes precisely localized parietal pain?

Answer 8

Direct irritation of parietal peritoneum by pus, bile, urine, and GI secretions

Question 9

What is referred pain?

Answer 9

Noxious sensations perceived at a site distant from that of a strong primary stimulus

Question 10

What does referred pain feel like?

Answer 10

Arises from a deep structure. The pain is superficial, sharp, localized, and persistent

Question 11

What times should be asked about when taking the history of the pain?

Answer 11

At onset and at presentation

Question 12

What is explosive pain?

Answer 12

Pain that develops within seconds

Question 13

What is Rapidly Progressive pain?

Answer 13

Pain that develops over 1-2 hours

Question 14

What is gradual pain?

Answer 14

Pain that develops over several hours

Question 15

What is important to ask about N/V and pain?

Answer 15

Which came first, the pain or vomiting

Question 16

What organs should you specifically ask if the pt still has intact?

Answer 16

Gallbladder, appendix, uterus, ovaries

Question 17

How much of the abdomen should you expose?

Answer 17

from the nipples to below inguinal region

Question 18

What are the stages of the abdominal exam?

Answer 18

inspection
Auscultation
percussion
palpation

Question 19

What should you ask the patient to do and then point to area of maximal pain?

Answer 19

cough

Question 20

What does involuntary guarding on palpation indicate?

Answer 20

Peritoneal inflammation

Question 21

What does rebound tenderness indicate?

Answer 21

peritoneal inflammation

Question 22

What are some methods to elicit peritoneal pain?

Answer 22

Push with stethoscope
Bump bed
Shake pelvis

Question 23

What is rigidity a sign of?

Answer 23

Peritonitis

Question 24

What imaging should be ordered for an acute abdomen?

Answer 24

Abdominal xrays flat and upright with pa upright cxr
Abdominal us
Pelvic US
CT of abdomen and pelvis

Question 25

What is the ddx for right upper quadrant pain?

Answer 25

``` Biliary Colon Hepatic Pulmonary Renal ```

Question 26

What is the ddx for epigastric pain?

Answer 26

``` Biliary Cardiac Gastric Pancreatic Esophagus Vascular ```

Question 27

What is the ddx for left upper quadrant pain?

Answer 27

``` Cardiac Gastric Colon Pancreatic Renal Vascular Splenic Pulmonary ```

Question 28

What is the ddx for RLQ pain?

Answer 28

``` Colonic GYN renal Rectus sheath Hematoma ```

Question 29

What is the ddx for umbilical pain?

Answer 29

Colonic Gastric Vascular

Question 30

What is the ddx for LLQ pain?

Answer 30

``` Colonic GYN Renal Rectus sheath Hematoma ```

Question 31

What is the ddx for suprapubic pain?

Answer 31

Colonic GYN Renal

Question 32

What is the ddx for pain whose onset is minutes?

Answer 32

Perforated viscera, testicular or ovarian torsion, ruptured AAA, ectopic pregnancy, pancreatitis, mesenteric ischemia

Question 33

What is the ddx for pain whose onset is hours?

Answer 33

Biliary, appendicitis, diverticulitis, SBO, PUD

Question 34

What is the ddx for pain whose onset is days?

Answer 34

IBD

Question 35

What are the PE findings that indicated a surgical consult?

Answer 35

Peritonitis incarcerated hernia Tender abdomen with a high fever or hypotension Suspected ischemia

Question 36

What should be done after initial assessment ?

Answer 36

``` Resuscitation Pain meds Abx NGT Foley ```

Question 37

What is peritonitis?

Answer 37

Inflammation or suppurative response of the peritoneal lining to direct irritant

Question 38

What are the local findings of peritonitis?

Answer 38

``` Acute abdomen Abdominal tenderness Rebound tenderness guarding rigidity distention Diminished bowel sounds Free air ```

Question 39

What are the systemic findings of peritonitis?

Answer 39

``` Fever/chills/rigors tachycardia Diaphoresis tachypnea restlessness dehydration/oliguria disorientation shock ```

Question 40

What is secondary peritonitis?

Answer 40

Occurs after perforation, inflammation, infection, or ischemic injuries

Question 41

What bacteria are responsible for peritonitis from PUD?

Answer 41

Usually no bacteria for first 12 hrs (peritonitis from chemical irritation) >12 hrs then gram + and - w/ or w/o fungus

Question 42

Fecal spoilage can be associated with what bacteria?

Answer 42

Gram - and anaerobic bacteria | Most common= ecoli, strep proteus, enterobacter-klebsiella groups, anaerobes, bacteroides fragilis, cocci and clostridia

Question 43

What is the preop treatment for secondary peritonitis?

Answer 43

``` IVF Central venous catheter Cardiovascular agents Mechanical vent A-line ABX (broad spectrum) ```

Question 44

How long should abx be continued post op for peritonitis?

Answer 44

Until pt has remained afebrile with normal WBC

Question 45

What is primary peritonitis?

Answer 45

Occurs in absence of GI perforation | Hematogenous spread

Question 46

What diseases is primary peritonitis associated with?

Answer 46

Cirrhosis, liver disease, nephrotic syndrome, SLE

Question 47

How is primary peritonitis diagnosed?

Answer 47

peritoneal fluid analysis for c&s

Question 48

What does imaging show for primary peritonitis?

Answer 48

free fluid without free air

Question 49

What is the treatment for primary peritonitis?

Answer 49

Abx. No surgery