the acute abdomen, peritonitis

Question 1

sudden onset, severe abdominal pain

Answer 1

acute abdomen

Question 2

when should you hold analgesics until w/ an acute abdomen

Answer 2

until after initial eval

Question 3

if a patient doesn’t go to the ER w/ an acute abdomen what should happen?

Answer 3

serial exams by the same provider

Question 4

what is the “policeman” of the abdomen

Answer 4

omentum- likes to clean up the mess and wall off any infection

Question 5

what drug should you not give someone w/ an acute abdomen because it could make it so they can’t give an accurate history?

Answer 5

promethazine (Phenergan)

Question 6

what is visceral pain?

Answer 6

generalized

cause by stretching/ ischemia

Question 7

what mediates visceral pain?

Answer 7

autonomic nerves (sympathetic and parasympathetic)

Question 8

where are receptors for vsiceral pain located?

Answer 8

mucosa or muscularis on hollow visceral and the visceral peritoneum

Question 9

location of visceral pain depends on what?

Answer 9

dermatones of the organ involves

Question 10

what is parietal pain?

Answer 10

more intense, acute

sharp and better localized

Question 11

what mediates parietal pain?

Answer 11

somatic nerves

Question 12

what leads to more precisely localized pain?

Answer 12

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

Question 13

Visceral pain shifting to parietal pain indicates

Answer 13

extension of the underlying process

Question 14

where does referred pain usually arise from?

Answer 14

deep structure

Question 15

why would a patient have pain in the shoulder after a laparoscopic surgery?

Answer 15

air under the diaphragm

Question 16

if a patient has shoulder pain a week after surgery what should you consider?

Answer 16

abscess

Question 17

for duration of pain what should you get?

Answer 17

rate on onset and progression of pain (explosive, rapidly progressive, gradual)

Question 18

with N/V what should you ask about?

Answer 18

what came first, pain or vomiting?

Question 19

women on oral contraceptives for a long time who look shocky what should you think of?

Answer 19

hepatic adenomas

Question 20

what do steroids blunt?

Answer 20

inflammation and wound healing

Question 21

individual on steroids may present how?

Answer 21

have less pain due to lack of inflammation

Question 22

what should you ask a person with an acute abdomen about?

Answer 22

gallbaldder
appendix
uterus
ovaries

Question 23

does a hx of appendectomy entirely rule out appendicitis?

Answer 23

no - can have a stump of appendix left

Question 24

does a hx of cholecystectomy rule out CBD stones?

Answer 24

no - can have common bile duct stones

Question 25

what family hx is important?

Answer 25

IBD sickle cell AAA colon cancer

Question 26

for an acute abdomen what should you do for an HEENT exam?

Answer 26

lymph nodes | sclera color- yellow

Question 27

if a person has post prandial abdominal pain and you hear bruits what should you consider?

Answer 27

clots in the messenteric arteries

Question 28

what does involuntary guarding and rebound tenderness indicate?

Answer 28

peritoneal inflammation

Question 29

what is Rovsing's sign?

Answer 29

pain at McBurney’s point with palpation of LLQ

Question 30

iliopsoas sign

Answer 30

pain when hip passively extended or actively flexed against resistance indicates inflammation on the psoas muscle retrosecal appendix

Question 31

obturator sign

Answer 31

pain with internal rotation of the flexed thigh | one long appendix onto obturator

Question 32

what does costovertebral angle tenderness indicatie

Answer 32

pyelonephritis

Question 33

Murphy's sign

Answer 33

Pain at RUQ with inspiration – ceases inspiration

Question 34

when would you do a CT scan?

Answer 34

appendicitis

Question 35

for trauma do you need contrast

Answer 35

yes, (IV) need to see bleeding

Question 36

to figure out an abscess what can you do with contrast ?

Answer 36

PO and IV need PO to see intestines IV for blood

Question 37

what type contrast do you use for suspected appendicitis?

Answer 37

PO contrast

Question 38

what does an upper endoscopy look at (EGD)?

Answer 38

esophagus stomach duodenum

Question 39

What is an ERCP

Answer 39

endoscopic retrograde coloangial pancreatography

Question 40

what is an ERCP used for?

Answer 40

bile duct etiology

Question 41

what can you see w/ colonoscopy?

Answer 41

colon | terminal ileum

Question 42

used to identify mesentaric ischemia and to identify and possibly stop bleeding

Answer 42

angiography

Question 43

what else could upper quadrant pain present as?

Answer 43

pneumonia

Question 44

Ddx for RUQ pain

Answer 44

hepatitis Gallbladder pneumonia diverticulitis

Question 45

epigastic DDx

Answer 45

``` pancreatitis cardiac GERD PUD biliary vascular ```

Question 46

DDx for LUQ

Answer 46

spleen

Question 47

DDx for RLQ

Answer 47

``` appendicitis ectopic ovarian cyst PID ovarian torsion rectus sheath hematoma ```

Question 48

Ddx for LLQ

Answer 48

sigmoid divericulus

Question 49

suprapubic DDx

Answer 49

bladder colonic gynecology

Question 50

pain onset w/i minutes think of...

Answer 50

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

Question 51

pain onset w/i hours think of...

Answer 51

Biliary disease, appendicitis, diverticulitis, SBO, PUD

Question 52

pain onset w/i days think of...

Answer 52

IBD

Question 53

when do consult a surgeon....

Answer 53

Peritonitis Incarcerated hernia Tender abdomen with high fever or hypotension Suspected ischemia

Question 54

if you suspect chronic cholecystitis what should you get before sending them to the surgeon?

Answer 54

US and LFTs

Question 55

if vomitting a lot/ distended what can you place?

Answer 55

NG tube

Question 56

well-vascularized, pliable, mobile double fold of peritoneum and fat that is involved in control of peritoneal inflammation and leaking viscus or area of infection

Answer 56

omentum

Question 57

– inflammation or suppurative response of the peritoneal lining to direct irritant

Answer 57

peritonitis

Question 58

local findings of peritonitis

Answer 58

``` “Acute abdomen” Abdominal tenderness Rebound tenderness Guarding Rigidity Distention Diminished bowel signs Free air ```

Question 59

systemic findings of peritonitis

Answer 59

``` Fever Chills Rigors Tachycardia Diaphoresis Tachypnea Restlessness Dehydration Oliguria Disorientation Shock ```

Question 60

Labs to get w/ peritonitis

Answer 60

``` CBC w/ diff cross-match ABGs electrolytes BUN and creatinine blood clotting profile lifer and renal function tests blood and urine cultures pre-abx peritoneal fluid pre-abx if possible ```

Question 61

Can occur after perforation, inflammatory, infectious or ischemic injuries of the GI or GU systems

Answer 61

secondary peritonitis

Question 62

what are examples of secondary peritonitis

Answer 62

``` Appendicitis Perforated gastroduodenal ulcers Acute salpingitis Diverticulitis Bowel perforation Trauma Ischemic bowel Acute necrotizing pancreatitis ```

Question 63

Tx for 2ndary peritonitis

Answer 63

``` IV fluids consider central venous cath may need cardiovascular agents mechanical ventilation consider A-line (arterial line for beat by beat BP) ABX- broad spectrum ```

Question 64

how long do you continue abx w/ 2ndary periotnitis?

Answer 64

patient is afebrile w/ normal WBC

Question 65

peritonitis that occurs in the absence of GI perforation

Answer 65

primary peritonitis

Question 66

what mainly causes primary peritonitis

Answer 66

hematogenous spread | occasionally transluminal or direct bacterial invasion

Question 67

what is primary peritonitis associated w/?

Answer 67

cirrhosis advanced liver dz nephrotic syndrome SLE

Question 68

will you see free air w/ primary periotnitis

Answer 68

no

Question 69

patient w/ cirrhosis, no free air but has free fluid what do you suspect?

Answer 69

primary peritonitis

Question 70

>90% of primary peritonitis are _______- microbial infection

Answer 70

mono

Question 71

Tx for primary peritonitis

Answer 71

abx- not surgery

Question 72

tx for secondary peritonitis

Answer 72

surgery