Acute Abdomen
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| What is an acute abdomen? | acute abdomen refers to a sudden, severe abdominal pain that is less than 24 hours in duration in previously well pts
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| Most common causes of acute abdomen (13) | AABCDE, GIM NPPP: Abscess (tubo-ovarian), Append, Bowel Obst, Bil colic, Cholecys, Divert (inc Meckel's), Ectopic preg, Gastroent, IBD, Mes ischemia, Nephrolith/Uterolith, Ov torsion, rupture/cyst, Pancr, Peritonitis, Perf (gastr/duod ulcer), Salpingitis
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| DDx for RUQ pain (17) | Abscess (subphrenic/perinephric most common), Cholangitis, Cholecystitis, Choledocholithiasis, Congestive Hepatopathy, Diverticulitis, Hepatitis, Herpes Zoster, IBD, Muscular strain, Neoplasm, Nephrolithiasis, PUD, PNA, Pneumothorax, PE, Pyelonephritis
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| DDx for RLQ pain (12) | Abscess (subphrenic/perinephric most common), Cholangitis, Cholecystitis, Choledocholithiasis, Congestive Hepatopathy, Diverticulitis, Hepatitis, Herpes Zoster, IBD, Muscular strain, Neoplasm, Nephrolithiasis, PUD, PNA, Pneumothorax, PE, Pyelonephritis
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| DDx for LLQ pain (10) | Abscess, Diverticulitis, Ectopic pregnancy, Gastroenteritis, Hernia, IBD, Neoplasm, Ovarian torsion/cyst, PID, Pyelonephritis
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| DDx for LUQ pain (10) | Abscess (subphrenic/perinephric most common), Neoplasm (pancreatic, splenic, renal), Nephrolithiasis, Pancreatitis, PUD, PNA, Pneumothorax, PE, Pyelonephritis, Splenic infarct/rupture
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| What should you expect on physical exam of pt with acute abdomen? | 1. peritoneal signs (irritation/pain with even slight jarring), 2. lie very still (to keep from irritation peritoneum), 3. Ask them to point to pain with one finger (helps in ddx)
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| Pain from stomach refers to where? | epigastric region/substernal
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| Pain from pancreas refers to where? | epigastric region
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| Pain from small intestine refers to where? | periumbilical
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| Pain from colon refers to where? | lower abdomen/suprapubic
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| Pain from gallbladder felt where? | RUQ
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| Characterization of pain - things you want to ask about when investigating acute abdomen | CLaSP: character, location, severity, pattern
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| Temporal sequence of pain - things you want to ask about when investigating acute abdomen | onset, frequency, progression, duration (ProDuFreOn)
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| alleviating/exacerbating factors - things you want to ask about when investigating acute abdomen | position, food, activity, medications
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| associated signs/symptoms - things you want to ask about when investigating acute abdomen | nausea vomiting, fever, chills, anorexia, wt. loss, cough, dysphagia, dysuria/frequency altered bowel function (diarrhea, constipation, obstipation, hematochezia, melena
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| PMH | prior surgery or illness, associated conditions (pregnancy, menstrual cycle, diabetes, atrial fibrillation or cardiovascular disease, immunosuppression)
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| Meds | anticoagulation, steroids
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| Visceral Pain: characterize, location, types of nerve fibers, nerve system, describe pt | diffuse, ill-defined, usually colicky; typically midline, frequently referred; carried on visceral efferent fibers; may cause para/sympathetic response, typically colicky or ischemic pain; pt writhing in pain
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| Parietal Pain: etiology, types of nerve fibers, Characterize, describe pts | secondary to peritoneal irritation, typically from inflammatory causes; carried on segmental somatic fibers; usually dull, steady ache though better localized; pts do not move or want to be moved
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| Peritoneal signs | 1. extreme tenderness, 2. Rebound tenderness 3. Motion pain 4. Voluntary guarding 5. Involuntary guarding & rigidity
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| Places Where Fluid, Blood, or Pus can Collect | 1. Pelvis 2. Paracolic gutters 3. Morrison’s pouch (subhepatic) 4. Interloop (between loops of bowel) 5. Subphrenic
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| Signs of Appendicitis | 1. iliopsoas, 2. Rovsing’s, 3. Obturator, 4. McBurney's
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| Iliopsoas Sign | pain on passive extension of hip (retrocecal appendix)
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| Rovsing’s Sign | pain in RLQ when press on LLQ
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| Obturator Sign | pain on flexion & internal rotation of hip
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| McBurney’s Sign | pain at McBurney’s Point
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| Murphy’s Sign | inspiratory arrest when palpating under R costal margin (acute cholecystitis)
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| Boas’s Sign | referred R subscapular pain of biliary colic (cholelithiasis)
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| Signs of peritoneal irritation | a. Cough Tenderness b. Heel Tap: pain transmitted up muscles beneath peritoneal cavity
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| Cervical Motion Tenderness | classic sign of PID
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| Signs of Hemorrhagic Pancreatitis | a. Cullen’s Sign: bluish discoloration of periumbilical area b. Fox’s Sign: ecchymosis of inguinal ligament c. Grey Turner’s Sign: flank ecchymosis
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| Cullen’s Sign | bluish discoloration of periumbilical area, Sign of Hemorrhagic Pancreatitis
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| Fox’s Sign | ecchymosis of inguinal ligament, Sign of Hemorrhagic Pancreatitis
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| Grey Turner’s Sign | flank ecchymosis, Sign of Hemorrhagic Pancreatitis
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| Charcot’s Triad | fever, jaundice, RUQ pain (cholangitis)
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| Raynaud's pentad | fever, jaundice, RUQ pain + AMS and hypotension/sepsis/shock; harbinger of worsening, ascending cholangitis
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| Signs of Splenic Injury & Rupture | a. Kehr’s Sign: pain referred to tip of L shoulder b. Ballance’s Sign: dullness to percussion over the flanks (coag blood on L, fluid blood on R)
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| Kehr’s Sign | pain referred to tip of L shoulder
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| Ballance’s Sign | dullness to percussion in the left flank LUQ and shifting dullness to percussion in the right flank seen with splenic rupture/hematoma. The dullness in the left flank is due to coagulated blood, the shifting dullness on the right due to fluid blood.
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| Pt who is slightly febrile, with anorexia, N/V (pain before vomiting), pain is periumbilical then RLQ. What is the diagnosis? What do you diagnose with? What is the initial tx? | Acute Appendicitis, diagnose w CT, IVF rehydration, pre-op Abx (cefoxitin)
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| Pt with post-prandial biliary colic; N/V, fever, Murphy’s Sign; pain in RUQ, with referred pain to R subscapular area. What is the diagnosis? What do you diagnose with? What is the initial tx? | Gallbladder dz; diagnose w U/S; IVF, cholecystectomy. Abx, ERCP to decompress
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| Pt w N/V, absent bowel sounds, +/-fever, dehydration, shock; pain is epigastric/LUQ, radiates to back. What is the diagnosis? What do you diagnose with? What is the initial tx? | Pancreatitis; ddx w Amylase & lipase levels; AXR (sentinel loops), CT (fat stranding); NPO, NGT, IVF, TPN, H2 blocker, analgesia
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| what is the purpose of Ranson's criteria | 11 prognostic Sx to identify high risk in pts w. pancreatitis
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| Ranson's criteria on admission | GA LAW: Glucose > 200 mg/dL, Age>55yr, LDH > 350 IU/dL, AST > 250 IU/dL, WBC > 16,000 cell/mm3
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| Ranson's criteria after 48h | C HOBBS: Ca++ < 8 mg/dL, Hematocrit decrease > 10%, arterial pO2 < 60 mmHg, BUN increase > 5 mg/dL, Base deficit > 4 mEq/L, fluid Sequestration > 6 L
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| Ranson's criteria mortality | 1. If<3 signs, 1%; 2. 3-4 signs, 15%; 3. 5-6 signs, 50%; 4. 7+ signs, approximately 100%
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| Pt w Epigastric tenderness radiating to back, diffuse abd pain, N/V, dec bowel sounds, shock/dehydration, +/-fever | pancreatitis
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| Causes of pancreatitis | I GET SMASHED: Idiopathic, Gallstone, EtOH, Trauma, Steroids, Mumps and other viruses (EBV/CMV), Autoimmune (SLE, PAN), scorpion/snake, Hyper -ca -lipid Hypo-thermia, ERCP, Duod ulcer & Drugs (SAND - steroids/sulfonamides, azathioprine, NSAIDs, diuretics)
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| Pt w N/V, anorexia, blood in stool; Epigastric, radiates to back; What is the diagnosis? What do you diagnose with? What is the initial tx? | PUD; Guaiac+, EGD, UGI series; Abx vs. H. pylori, H2 blocker, antacids, sucralfate, omeprazole
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| Pt w dec Bowel sounds, tympany over liver; pain epigastric, radiates to back. What is the diagnosis? What do you diagnose with? What is the initial tx? | Perforated Ulcer; dx with CXR (free air); NGT, IVF, Foley, Abx, surgery
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| Pt w Heartburn, resp Sx from aspiration, regurgitation; epigastric pain. What is the diagnosis? What do you diagnose with? What is the initial tx? | GERD; dx with EGD, UGI contrast study, pH probe, manometry; H2 blockers, omeprazole, cisapride, elevate while sleeping
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| Pt with NGT blood; painless, or with epigastric pain. What is the diagnosis? What do you diagnose with? What is the initial tx? | Gastritis/Duodenitis, dx with EGD, initial tx with H2 blockers, antacids, sucralfate
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| pt with Fever, diarrhea, anorexia, mass, N/V, dysuria, LLQ or RLQ pain. What is the diagnosis? What do you diagnose with? What is the initial tx? | Diverticulitis; ddx with Abd CT, colonoscopy; tx w IVF, NPO, Abx, NG suction
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| Pt with Bloody Diarrhea, fever, weight loss; pain in hypogastric area. What is the diagnosis? What do you diagnose with? What is the initial tx? | Ulcerative colitis; Colonoscopy w. biopsy, barium enema, UGI, stool cultures; Sulfasalazine, steroids, metronidazole
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| Pt with Diarrhea, fever, weight loss; pain in hypogastric area; has anal disease. What is the diagnosis? What do you diagnose with? What is the initial tx? | Crohn's; Colonoscopy w. biopsy, barium enema, UGI, stool cultures; Sulfasalazine, steroids, metronidazole
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| N/V/D; pain after vomiting; diffuse abd pain. What is the diagnosis? What do you diagnose with? What is the initial tx? | Enterocolitis, Use hx to diagnose, abx and ivf to tx
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| Frequent vomiting, abd distention, high-pitched bowel sounds; pain is Hypogastric, Periumbilical. What is the diagnosis? What do you diagnose with? What is the initial tx? | SBO; AXR (air-fluid levels), CT; NGT, IVF, Foley
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| Abd distention, anorexia, obstipation, N/V, hypogastric pain. What is the diagnosis? What do you diagnose with? What is the initial tx? | Colon Obstruction; AXR, sigmoidoscopy, gastrografin enema; Colonoscopic reduction, enema, colonic tube
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| Hemoperitoneum, LUQ mass, pain in LUQ, referred to tip of L shoulder. What is the diagnosis? What do you diagnose with? What is the initial tx? | Splenic disease; Abd CT, DPL; Ex lap
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| Diffuse abd pain out of proportion to exam; N/V, hyperdefecation +/-heme stools, h/o AFib or heart dz. What is the diagnosis? What do you diagnose with? What is the initial tx? | Mesenteric Ischemia; Mesenteric A- gram, plain film shows “thumb- printing” ; Embolectomy, papaverine vasodilator; resect necrotic tissue
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| Hypotension w. pulsatile abd mass, diffuse epigastric pain. What is the diagnosis? What do you diagnose with? What is the initial tx? | Ruptured AAA; If not ruptured, U/S & CT; OR immediately
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| pain from any quadrant radiates from flank to testicles; What is the diagnosis? What do you diagnose with? | Nephrolithiasis; KUB, U/A, U/S.
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| What could thrombocytopenia indicate? | Sepsis
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| ABG showing metabolic acidosis | ischemia - possible bowel ischemia
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| Sentinel loop on KUB. What is it and what does it indicate? | pancreatitis; dilation of a segment of large or small intestine, indicative of localized ileus from nearby inflammation.
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| What study do you do for nonacute GI bleed or nonacute epigastric pain? | EGD
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| Describe acute appendicitis in elderly. What happens to the mortality rate? | more subtle Sx (less abd pain, fever & CBC unreliable); high rate of rupture --> high rate of mortality;
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| Describe acute appendicitis in infants. | high rate of rupture, faster progression of illness, inability to complain or give Hx, bowel wall inefficient at walling off perforation␣infection spreads
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| Describe acute appendicitis in pregnant women. Does it occur with increased frequency? What trimesters? | most common extrauterine surgical emergency in pregnant women – but occurs w. same frequency as nonpregnant women; usually in 1st 2 trimesters
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| Acute appendicitis in pregnant women. What about it makes the diagnosis more difficult? | appendix laterally & superiorly displaced - Dx more difficult; also “Sx of pregnancy” like N/V confused for appendicitis Sx; may compromise fetus
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