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GIM - ABIM

Acute Abdomen

QuestionAnswer
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
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
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
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
DDx for LLQ pain (10) Abscess, Diverticulitis, Ectopic pregnancy, Gastroenteritis, Hernia, IBD, Neoplasm, Ovarian torsion/cyst, PID, Pyelonephritis
DDx for LUQ pain (10) Abscess (subphrenic/perinephric most common), Neoplasm (pancreatic, splenic, renal), Nephrolithiasis, Pancreatitis, PUD, PNA, Pneumothorax, PE, Pyelonephritis, Splenic infarct/rupture
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)
Pain from stomach refers to where? epigastric region/substernal
Pain from pancreas refers to where? epigastric region
Pain from small intestine refers to where? periumbilical
Pain from colon refers to where? lower abdomen/suprapubic
Pain from gallbladder felt where? RUQ
Characterization of pain - things you want to ask about when investigating acute abdomen CLaSP: character, location, severity, pattern
Temporal sequence of pain - things you want to ask about when investigating acute abdomen onset, frequency, progression, duration (ProDuFreOn)
alleviating/exacerbating factors - things you want to ask about when investigating acute abdomen position, food, activity, medications
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
PMH prior surgery or illness, associated conditions (pregnancy, menstrual cycle, diabetes, atrial fibrillation or cardiovascular disease, immunosuppression)
Meds anticoagulation, steroids
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
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
Peritoneal signs 1. extreme tenderness, 2. Rebound tenderness 3. Motion pain 4. Voluntary guarding 5. Involuntary guarding & rigidity
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
Signs of Appendicitis 1. iliopsoas, 2. Rovsing’s, 3. Obturator, 4. McBurney's
Iliopsoas Sign pain on passive extension of hip (retrocecal appendix)
Rovsing’s Sign pain in RLQ when press on LLQ
Obturator Sign pain on flexion & internal rotation of hip
McBurney’s Sign pain at McBurney’s Point
Murphy’s Sign inspiratory arrest when palpating under R costal margin (acute cholecystitis)
Boas’s Sign referred R subscapular pain of biliary colic (cholelithiasis)
Signs of peritoneal irritation a. Cough Tenderness b. Heel Tap: pain transmitted up muscles beneath peritoneal cavity
Cervical Motion Tenderness classic sign of PID
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
Cullen’s Sign bluish discoloration of periumbilical area, Sign of Hemorrhagic Pancreatitis
Fox’s Sign ecchymosis of inguinal ligament, Sign of Hemorrhagic Pancreatitis
Grey Turner’s Sign flank ecchymosis, Sign of Hemorrhagic Pancreatitis
Charcot’s Triad fever, jaundice, RUQ pain (cholangitis)
Raynaud's pentad fever, jaundice, RUQ pain + AMS and hypotension/sepsis/shock; harbinger of worsening, ascending cholangitis
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)
Kehr’s Sign pain referred to tip of L shoulder
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.
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)
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
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
what is the purpose of Ranson's criteria 11 prognostic Sx to identify high risk in pts w. pancreatitis
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
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
Ranson's criteria mortality 1. If<3 signs, 1%; 2. 3-4 signs, 15%; 3. 5-6 signs, 50%; 4. 7+ signs, approximately 100%
Pt w Epigastric tenderness radiating to back, diffuse abd pain, N/V, dec bowel sounds, shock/dehydration, +/-fever pancreatitis
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)
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
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
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
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
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
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
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
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
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
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
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
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
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
pain from any quadrant radiates from flank to testicles; What is the diagnosis? What do you diagnose with? Nephrolithiasis; KUB, U/A, U/S.
What could thrombocytopenia indicate? Sepsis
ABG showing metabolic acidosis ischemia - possible bowel ischemia
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.
What study do you do for nonacute GI bleed or nonacute epigastric pain? EGD
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;
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
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
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
Created by: christinapham