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EM Abdominal Pain
| Question | Answer |
|---|---|
| Differential Dx can be formed using ___ in presentation of abdominal pain | patient age |
| Pediatrics | Appendicitis,intussusception, gastroenteritis |
| Adults | Biliary tract dz, SBO, PUD, diverticulitis, Pancreatitis, Holiday abdomen |
| Elderly | Bowel obstruction, AAA, Neoplastic Process |
| History of pain | Location, radiation, quality, severity, Palliative or exacerbating, onset/timing |
| RUQ | Biliary colic, Perforated Duodenal Ulcer |
| Pain radiating to the groin | kidney stones |
| Pain radiating to the Back | AAA, Pancreatitis |
| Pain radiating to the Left Arm | Acute coronary syndrome |
| Neck pain | Pain from phrenic irritation |
| Sudden and Sharp pain | Acute vascular lesion, ischemia or infarction, rupture of a hollow viscous |
| Dull or Vague pain | inflammation of viscera |
| Colicky (intermittent) pain | Cholecystitis, Nephrolithiasis, SBO |
| Slow onset pain | think about inflammatory process |
| Causes of Vomiting | Severe irritation of peritoneal or mesenteric nerves, obstruction of an involuntary muscular tube (biliary duct, ureter, intestine, appendix) |
| Specific Diseases to gather hx about with abdominal pain | PUD, IBS, diverticular Dz, Hx of AA or repair of AAA, GB dz, Renal Dz, CAD |
| PE | Irregular heart beat: Afib, emobolus to mesenteric vasculature. Decreased breath sounds: lower lobe pneumonia mimicking abdominal pain. Legs flexed, staying still: peritonitis |
| Involuntary contractions of abdominal muscles indicates that it is | time for a surgery consult |
| High Hct/Hgb may indicate | dehydration, COPD |
| Low Hct/Hgb may indicate | bleeding, anemia |
| Elevated amylase | in pancreatitis, small bowel obstruction, salivary gland infection |
| Elevated LFTs | ALT/AST elevated in hepatitis, biliary/Alk Phos- common bile duct |
| Urinalysis | renal stones, hematuria. No blood does not r/o stones. |
| Imaging of Abdomen | Plain films (CXR, KUB), US, CT, Angiography, Barium Swallows, MR |
| CXR shows | Pneumonia and free air, kidney stones, GB stones (if radiopaque) |
| US is useful in | gallbladder and ovarian dz, hydronephrosis on kidney, pancreas may show dilated duct |
| ___is very sensitive to free air, and may be used for therapeutic procedures (drainage of abscess) | CT |
| Evaluation of Mesenteric Ischemia | Angiography |
| ____ is a dangerous study in perforation | Barium Studies, never place barium above obstruction. |
| Indication for Barium Studies | Volvulus, Colon Cancer, Mucosal detail |
| Common Five F's | Female, Fertile, Forty, Fat, Flatulent |
| Acute Cholecystitis | RUQ pain, hx of biliary colic, N/V, Febrile, Murphy's sign |
| Acute Appendicitis | Hx: Periumbilical pain that migrates to RLQ, Anorexia. PE: Low grade fever, RLQ (McBurney's pt), Obturator sign/psoas sign. Lab: Usually mild leukocytosis, Morbidity related to perforation with >95% perf. rate after 48 hours of sx |
| Mecke's Diverticulitis | Rules of 2: 2% of pop, 2 ft proximal to ileocecal valve, 2 types of mucosa, 2 years of age (50% cases>age 2), 2:1 M:F ratio. Tx is resection |
| Severe egigastric pain radiating to the back, often associated with ETOH, usually elevated amylase, tx is medical | Acute pancreatitis. |
| Ulcer Dz | Gastric or duodenal ulcer, epigastric pain, may present w/ bleeding obstruction or perforation, Free air on CXR, bleeding or ulcer present during endoscopy |
| Small bowel obstruction | Physiology: food or fb stuck in bowel lumen, Peristalsis causes contractions against obstruction, N/V, bilious vomiting, constipation, severely dehydrated,electrolyte abnormalities |
| PE of small bowel obstruction | distended abdomen, surgical scars (previous surgeries), high pitched bowel sounds, tympanic to percussion |
| TX of SBO | Non-operative: NPO, NGT - decompression, IV fluids |
| Large Bowel Obstruction | same physiology as SBO, presents with diffuse pain, constipation, abdomen markedly distendd, most common causes: diverticulitis, cancer, volvulus |
| Diverticulitis commonly seen where? | LLQ. Left colon. Fever. Diagnosis confirmed with CT. Tx: IVF, ABX |
| Mesenteric Ischemia | Sudden onset of abd. pain, N/V, diarrhea, GI bleeding, may have hx of postprandial angina, atherosclerosis, smoking. Pain out of proportion. Dx confirmed by angiograpy |
| Ruptured AAA | tearing sensation to back. Often present in schock. Exam reveals pulsatile abdominal mass, Rapid diagnosis with US. Surgical Emergency. >5cm - high risk. Higher assciation with COPD, diastolic hypertension |
| The most life-threatening gynecologic cause of acute abdomen | ectopic pregnancy. Get a pregnancy test: serum B-HCG |
| PID | ages 15-35, sexually active, prior hx of PID or STD, during or before menstruation, lower diffuse abdominal pain, vaginal discharge |
| PID PE | Fever, Diffuse lower abdominal pain, hyperemic cervix, "Chandelier Sign". Labs: leukocytosis, abnormal wet prep |
Created by:
ltm12