Surgery Acute Abdomen

Front 1

Definition of acute abdomen

Back 1

Rapid onset of abdominal pain, w/ or w/out assoc sx such as n/v, in pts who have been previously well.

Stadman's Med dictionary: any serious acute abd condition attended by pain, tenderness and muscular rigidity for which emergency surgery must be considered.

Used synonymously for condition that needs immed surgical intervention.

Front 2

How often in cases of acute abdomen, is the abdomen the source of the problem?

Back 2

85-90%

Front 3

Acute abdomen and malpractice?

Back 3

10% of all malpractice claims.

Recovery rates decrease w/ increase in delay of dx

Front 4

MCC non-surgical abdominal pain?

Back 4

Gastroenteritis

Front 5

MCC of surgical abdomen?

Back 5

Appendicitis

Front 6

MCCs (2) abdominal pain in pts >60?

Back 6

Biliary dz and

Intestinal obstructions

Front 7

In kids, 32% of admission for abd pain is?

Back 7

Acute appendicitis

Front 8

Define Intraperitoneal?

Back 8

Having a mesentery:
Stomach,
Jejunum,
Ileum,
Transverse colon,
Liver,
GB

Front 9

Definte Retroperitoneal?

Back 9

Organs w/out a mesentery and assoc w/ posterior body wall:
Aorta,
IVC,
Kidneys,
Suprarenal glands

Front 10

Define Secondarily Retroperitoneal?

Back 10

Organs that once had a mesentery but was lost during devlopment:
Pancreas,
Duodenum,
Ascending colon
Descending colon

Front 11

Be sure to ask about these 6 associated sx in an acute abodmen:

Back 11

Distention,
Pain,
Nausea,
Vomiting,
Anorexia,
Bowel function

Front 12

Usual suspects of acute abdomen in elderly?

Back 12

Up to 10% sever abd pain: vascular cause (ruptured abd aortic aneurysm, mesenteric ischemia or thrombosis).

Large bowel perf (diverticular dz or carcinoma) more common than appendicitis in elderly.

Front 13

Usual suspects of acute abd in kids?

Back 13

Appendicitis.

Also remember intussusception (currant jelly stool) in younger kids.

Front 14

Usual suspects of acute abd in adults?

Back 14

Pancreatitis at any age, but espec in adults.
Gallstones/ Alcohol

Front 15

Usual suspects of acute abd in women?

Back 15

Gyn causes, espec ectopics

Front 16

Define visceral or splanchnic pain?

Back 16

Diffuse, ill-defined, induced by distention, ischemia, inflammation, spasm or stretch of smooth muscle.

Conducted by afferent visceral nerve fibers in symp and parasymp nervous system.

Often results in referred pain.

Front 17

Where is visceral or splanchnic pain usually located?

Back 17

Localized in one of three midline zones of abd:
Epigastric,
Midabdominal,
Lower abdominal

Front 18

Characteristics of midline zone pain in visceral/ splanchnic pain?

Back 18

Sum of pain from right and left planchnic pathways, poorly localized, covers several body segments and depending on its cause, varies from dull, aching, constant to cramping pain.
Often accomp by autonomic responses: n/v, pallor, sweating, bradycardia, tachycardia, hypotension.

Front 19

Define Somatic (Parietal) pain?

Back 19

Well localized by somatic afferent nerves.
Innervates skeletal muscles and skin.
Localized better than visceral.
Intensified and aggravated by jarring, deep inspiration, movement, coughing or pressure on abd wall (ex. rebound)

Front 20

Define Generalized pain (peritonitis)?

Back 20

Results when abd is suddenly filled w/ pus, blood or enteric contents.
Causes: perfed viscus, bacterial.
Rigid abd, rebound, decreased peristalsis, muscle wall rigidity, fever, leukocytosis, shock

Front 21

What pain progression might indicate involvement of parietal peritoneum?

Back 21

Progressing from dull, aching, poorly localized pain to sharp, constant and better localized pain.

See slide 21 for types and locations of pain

Front 22

Common causes of sudden onset abdominal pain?

Back 22

Perf of GI tract or rupture of intra-abd source:
gastric or duodenal ulcer,
ruptured diverticulum,
Ruptured ectopic,
Mesenteric infarction,
Ruptures aortic aneurysm

Front 23

What is rapid onset abd pain?

Back 23

Pain begins w/ a few seconds and steadily increases in severity over next several minutes.
Pts can recall time of onset in general but w/out precision noted in pain of sudden onset.

Front 24

Common causes of rapid onset abd pain?

Back 24

Biliary colic,
Pancreatitis,
Intestinal obstruction,
Volvulus,
Diverticulitis,
Appendicitis,
Renal colic,
Intussusception

Front 25

What is gradual onset pain?

Back 25

Slowly becomes more severe only after a number of hours or days have elapsed.
Memory as to onset is vague.

Front 26

Common causes of gradual onset pain?

Back 26

Neoplasms,
Large bowel obstruction,
Chronic inflammatory processes.

Hard to make dx from hx alone w/ this type of pain.

Front 27

What is Cramping or Colicky abd pain?

Back 27

Increases in intensity in short waves to max then abruptly ceases for period of complete absence of pain.
Intervals.
Assoc w/ mechanical bowel obstruction, mechanical obstruction.
Examples: gall stones

Front 28

What is constant dull or aching abd pain?

Back 28

Causes by distention of a hollow organ, such as GB when cystic duct is obstructed.

Examples: distention of capsule of liver and spleen.

Front 29

What is Kehr's sign?

Back 29

Diaphragmatic irritation that produces referred pain in the supraclavicular fossa/ left scapular area (Kehr's sign) corresponding to sensory branches of the phrenic nerve (c3-c5).
Example of referred pain

Front 30

What is the Howship-Romberg sign?

Back 30

Obturator nerve irritation from a process in the obturator fossa (MC incarcerated obturator hernia) that produces pain along medial aspect of thigh to knee.
Example of radiation - referred.

Front 31

Where might duodenum, pancreatic pain be referred to?

Back 31

Umbilical region

Front 32

Where might cardiac pain be referred to?

Back 32

Epigastrum,
Jaw,
Shoulder,
Substernal

Front 33

Where might gallbladder pain be referred to?

Back 33

Epigastric pain to right scapula

Front 34

Where might appendix pain be referred to?

Back 34

Periumbilical

Front 35

Where might ureteral pain be referred to?

Back 35

Hypogastrium,
Groin,
Inner thigh

Front 36

Where might pelvic pathology associated pain be referred to?

Back 36

Sacrum

Front 37

What type of referral can geintofemoral nerve irritation from retroperitoneal inflammatory processes (retrocecal appendicitis) cause?

Back 37

Pain in labia or testicle on ipsilateral side (same side)

Front 38

3 main causes of vomiting?

Back 38

Perf,

Obstruction,

Toxins

Front 39

Loose rule of thumb regarding relationship of vomiting and abd pain?

Back 39

Pain usually precedes vomiting when abd pain is from surgically correctable causes.

Reverse is true for medical causes, like gastroenteritis

Front 40

4 conditions in which vomiting is very prominent?

Back 40

Mallory-Weiss syndrome.
Boerhaave syndrome (trans-mural),
Acute gastritis,
Acute pancreatitis

Front 41

4 common causes of nausea withOUT vomiting?

Back 41

Hepatocellular dz,
Preg,
Metastatic dz,
Meniere's dz

Front 42

Most diarrhea with pain is mainly medical (as opposed to surgical). What are 4 exceptions?

Back 42

Galllstone ileu,
Superior Mesenteric vascular occlusion,
Intestinal obstruction assoc w/ pelvic abscess,
Diarrhea in chronic fecal impaction

Front 43

4 things to think about in constipation?

Back 43

Progressive intestinal obstruction from cancer or IBD,
Paralytic ileus,
Post op,
Obstructed groin hernia.

Front 44

Define hematochezia?

Back 44

BRBPR

Front 45

2 common causes of urinary symptoms w/ abd pain?

Back 45

Ureteric colic,

Cystitis

Front 46

What happens with Rigors/ chills?

Back 46

Rigors more extreme chills.

Caused by cytokine and prostaglandin release. Immune response.
Hypothalamic increase in body temp "set point"

Front 47

What you should think of when fever/ rigors accompany abd pain?

Back 47

Liver abscess,
Peri-nephric abscess,
Intra-abd abcess or infection

Front 48

What medications can interfere with dx process of abd pain?

Back 48

STEROIDS!!!! - blunt inflammatory response.
Analgesics: mask pain response.
Antipyretics and abd: mask fever.
Anticoags: can cause gut hematomas.
Pepto: can change stool color.
Beta blockers: may change response to shock.
OCPS: can cause hepatic adenoma rupture.
NSAIDS/ ASA: can cause gastritis and peptic ulcers.

Front 49

Ask yourself: is this patient very sick and maybe going to die immed? If so....?

Back 49

CALL SOMEONE!!!
Get help!!
Load the boat!!

Front 50

If the patient is sick but prob stable for next cpl hours, what should you do?

Back 50

Start workup,
Alert proper authorities,
Develop differential.
Start inital tx and management.

Front 51

Rule of thumb for assessing first outward appearance?

Back 51

Pt is pale, clammy, looks close to death, probably is.

Pt sitting up, joking, looking well, probably is.... UNLESS they are on steroids.

Front 52

2 things that can cause a LOW grade fever?

Back 52

Appendicitis,

Acute cholecystitis

Front 53

2 things that can cause a HIGH grade fever?

Back 53

Salpingitis,

Abscess

Front 54

3 things that can cause a VERY HIGH grade fever?

Back 54

Septic shock,

Peritonitis,

Acute cholangitis

Front 55

What is Fox's sign?

Back 55

Bruising over inguinal ligament - acute retroperitoneal bleeding, usually acute hemorrhagic pancreatitis,

Front 56

What might general visible peristalsis indicate?

Back 56

Obstruction

Coincides w/ peristaltic pain and borborygmi caused by contents pushing up againts obstruction

Front 57

What is borborygmi?

Back 57

Hyperperistalsis

Front 58

What can loss of liver dullness be due to?

Back 58

Free air - due to perf

Front 59

What is percussion tenderness a sign of?

Back 59

Peritoneal irritation

Front 60

What is Murphy's sign?

Back 60

a test for gallbladder disease in which the patient is asked to inhale while the examiner's fingers are hooked under the liver border at the bottom of the rib cage. The inspiration causes the gallbladder to descend onto the fingers, producing pain if the gallbladder is inflamed. Deep inspiration can be very much limited.

Inspiratory arrest upon palpation of RUQ (cholecystitis)

Front 61

What is McBurney's Point?

Back 61

1/3 from ASIS to umbilicus. Tenderness in this area can be a sign of appendicitis

Front 62

What is Psoas sign?

Back 62

Bring hip into extension. Pain can be indicative of appendicitis when appendix is retrocaecal in orientation

Front 63

What is Obturator sign?

Back 63

Flexion and internal rotation of the hip.
Pain indicative of appendicitis.

Front 64

What is Rovsing's sign?

Back 64

Palpation of lower left quadrant increases pain in lower right quadrant.

Front 65

What is Blumberg's Sign?

Back 65

Rebound tenderness.
Pressing on abd wall deeply and suddenly releasing causes pain in peritonitis.

Front 66

What is peritonitis?

Back 66

MAJOR FEATURE OF ACUTE ABD DZ!
Inflammation of peritoneum from variety of causes.
Inflammation results in increased blood supply --> edema.

Front 67

MCC of peritonitis in surgical setting?

Back 67

Perf of hollow organ

Front 68

Implications of amylase, lipase and LFTs in the acute abd?

Back 68

Amylase: elevated in small bowel disease, perf viscus, pancreatitis.
Lipase: more specific for pancreatitis.
LFTs: Check for presence of elevated transaminases, alp, bili indicative of hepatic or biliary dz.

Front 69

What can be determined using an abdomen flat and upright, left lat decub xray?

Back 69

Air-fluid levels,
Calcifications,
"sentinel loop"
Eggshell calcification in AAA,
Air in biliary tree

Front 70

What is the concern about doing a BE?

Back 70

If perforation or acute inflammatory process, can be deadly!!!

Front 71

What imaging is best for mesenteric ischemia?

Back 71

Angiography

Front 72

Patients will be in one of 3 categories: admit and observe, immed intervention, or discharge.
What should you do if you admit and observe?

Back 72

Serial exams q 2 hrs in first 24 hrs of admission.
Judicious use of narcs.
Freq hemodynamic monitoring,
Serial lab work,
Watch like a hawk!!!

Front 73

If you immediately intervene, what do you do?

Back 73

Determine timing and type of surg,
Consider alternative dx (always have a differential!!),
Base preop prep on what your working dx is

Front 74

6 categories of causes of the acute abd?

Back 74

Inflammatory (bacterial, chem),
Mechanical,
Neoplastic,
Vascular,
Congenital defects,
Traumatic

Front 75

Example of chemical causes of acute abdomen?

Back 75

Perf of peptic ulcer, splliage of acid gastric contents --> intense peritoneal reaction

Front 76

Average length of appendix?

Back 76

8-20 cm

Front 77

MCC of acute abdomen?

Back 77

Appendicitis!!!

Front 78

General characteristics of appendicitis?

Back 78

Any age, espec 10-30yo. M>F.
Mortality low.
Infants and elderly higher mortality.
Classic presentation in less than 60%.
In adults, 10% not dx correctly at first.
Failure to dx = leading cause of malpractice.

Front 79

Pathophys of appendicitis?

Back 79

Lumen of appendix gets obstructed --> organ distends d/t edema.
Results in ineffective lymph and venous drainage, hypoxia and mucosal breakdown.
Bacteria invade wall.
Perf can occur --> pus and fecal material in peritoenal cavity.

Front 80

How does fiber help prevent appendicitis?

Back 80

Decreases viscosity of feces,
Decreases bowel transit time,
Discourages formation of fecaliths

Front 81

What are 6 things that can cause luminal obstruction of appendix?

Back 81

Fecaliths,
Lymphoid follicle hyperplasia,
Foreign body,
Carcinoid tumor,
Parasites,
Barium

Front 82

What are fecaliths?

Back 82

Formed from calcium salts and fecal material in appendix

Front 83

What is lymphoid hyperplasia?

Back 83

Assoc w/ variety of inflam and infectious disorders:
- Crohns
- Virus (uri, mono, measles, gastroenteritis),
- Primary or mets cancer,
- Carcinoid syndrome

The follicles get so big they block opening of appendix
More common in kids and young adults

Front 84

MC Primary tumor of appendix?

Back 84

Carcinoid tumors.

Some present w/ carcinoid syndorme - caused by seritonin secreted by tumor.

Front 85

2 parasites that cause appendicitis?

Back 85

Schistosomes species,

Strongyloides species (S. stercoralis)

Front 86

3 causes of a variation in presentation of appendicitis?

Back 86

Variations of appendiceal position,
Pt age,
Degree of inflammation

Front 87

Different appendiceal positions?

Back 87

Retrocecal in 64%.
Close to ovary or ureter.
Deep in pelvis if long.
Posterior to ascending colon (retrocolic).

Front 88

Progression of pain with appendicitis?

Back 88

Steady, severe periumbilical abd pain w/ gradual shift to RLQ (mcBurneys pt) in 1-12 hrs (ave 4-6).

This migration of pain is about 80% sens and spec!!!!!!!

Front 89

N/V, bowels w/ appendicits?

Back 89

Anorexia and nausea after pain.
Vomiting after pain.
May have very little change in bowels.

Front 90

Urinary sx in appendicitis?

Back 90

If appendix is near bladder or ureter, can -->

Dysuria/ freq,
Hematuria or pyuria,

*Males rarely have cystitis. If male w/ UTI sx, consider appendicitis!

Front 91

What is Markle sign?

Back 91

Pain elicited in certain area of abd when standing pt drops from standing on toes to heels w/ jarring landing.

RLQ pain in response to abd percussion, heel-jar and Markle sign suggest periotenal inflammation.

DeGowins Diagnostic Exam says this is very sensitive for localizing true peritonitis

Front 92

Rectal exams in appendicitis?

Back 92

Inconsistent as to whether it's helpful.
BUT!!!!!
Freq sited in successful malpractice claims!!

Front 93

What is Typhlitis (Neutropenic Colitis)?

Back 93

Inflammation and/or necrosis of cecum, appendix and/or ileum.
Neutropenia <1000 - predisposing factor,
Mucosal injury from cytotoxic drugs (chemo).
Cecal distension.

Often confused with appy, BUT these have neutropenia** and usually have been on chemo**

Front 94

What is mesenteric adenitis?

Back 94

Self-limited inflammatory process affecting RLQ mesenteric lymph nodes.
Often mimics appy in young.
Can be caused by virus or bacteria. Could have recent food poisoning. If pt hungry, less likely appy.
Consider in child <15 w/ viral sxns 2 weeks before presentation.

Front 95

Bacterial causes of mesenteric adenitis?

Back 95

Yersinia enterocolitica,
Helicobacter jejuni,
Campy jejuni,
Salmonella,
Shigella

Front 96

What is Meckel's Diverticulum?

Back 96

True intestinal diverticulum.
From failure of vitelline duct (yolk stalk) to obliterate during fetal development.
Contains norm intestinal tissue and ectopic tissue (gastric & pancreatic).
2% population.
Most prevalent congen abnormality of GI tract.
Often confused w/ appy

Front 97

Meckel's Rule of 2s?

Back 97

2% population,
2 in in length,
2 feet from ileocecal valve,
2% sx,
2 types ectopic tissue,
2x > males,
2 yo MC age,
2 MC presentations: bleeding or obstruction/perf

Front 98

What is Littre's Hernia?

Back 98

Hernia sac containing a meckel's diverticulum

Front 99

Labs in appendicitis?

Back 99

Dx is clinical!!! Hx, phys.
Mild left shift and increased wbc,
U/A r/o UTI,
CXR r/o lower lobe pneum & free air.
Abd film: may see fecalith in 5%.
US,
CT

Front 100

Advantages of using CT to dx appy?

Back 100

Sensitive,
Accurate,
Available,
Noninvasive,
Can see entire abd

Front 101

Disadvantages of using CT to dx appy?

Back 101

Radiation,
Possible contrast rxn,
Can take hours to admin oral contrast,
Rectal contrast uncomfortable

Front 102

What is the MANTRELS score?

Back 102

Evaluation of suspicion of acute appy.
Evals:
Migration of pain,
Anorexia,
N/V,
RLQ tenderness,
Rebound tenderness,
Elevated temp,
Leukocytosis,
Left shift

One point for all except 2 pts for RLQ tenderness and Leukocytosis. Total of 10 pts.

Front 103

Tx for non-perfed appy?

Back 103

NPO,
IVF,
Abx: broad spectru, gram neg, enterococcal and anaerobic.
SURGERY!
Primary intention closure.
Continue postop abx 24 hrs

Front 104

Tx for perfed appy?

Back 104

NPO,
Fluid resuscitation,
Open appy usually,
Drain and culture pus,
Peritoneal irrigation,
Wound left to heal by secondary intention,
Abx 5-7 days

Front 105

What should you look for if you do an appy and it's negative?

Back 105

Examine terminal ileum for Crohns,
Look for Meckels, intussucetpion, and gyn causes

Front 106

What should you do in a perfed appendix w/ abscess?

Back 106

Drain abscess and delay appy until 6-8 weeks later.

Interval appendectomy

Front 107

Complications of appendicitis/ appendectomy?

Back 107

Intra-abd abscess formation,
Liver abscess,
Wound infection,
Bleeding,
Perf,
Pylephlebitis: suppurative thrombosis of portal vein.

Front 108

What changes about presentation of appendicitis during pregnancy?

Back 108

Appendix migrates counterclockwise toward right kidney, rising above iliac crest at about 4.5 mos preg.
RLQ pain and tenderness in first trimester.
RUQ or flank pain considered possible sign in latter trimesters.
Aggressively evaluate!! Dx lap suggested for first trimester.

Front 109

Differentiating appendicitis from other possibilities in non-preg women of childbearing age?

Back 109

33% misdiagnosed as PID, UTI and gastroenteritis.
Anorexia and pain >14 days after menses, does NOT suggest PID.
Cervical motion tenderness and abd tenderness outside RLQ support dx of PID.

Front 110

Classic presentation of acute cholecystitis?

Back 110

5 Fs: Female, Fertile, Forty, Flatulent, Fatty Food Intolerance.
RUQ pain/ epigastric pain w/ radiation to shoulder.
+ Murphy's sign.

Front 111

Complications of acute cholecystitis?

Back 111

Cholangitis,
Perf,
Peritonitis

Front 112

Presentation of Peritoneal irritation secondary to perfed viscus gastric or duodenal ulcer?
Inflammatory cause of acute abd

Back 112

Free air under diaphragm,

Board like abdomen.

Front 113

3 causes of Perforated bowel?
Inflammatory cause of acute abd

Back 113

Diverticulum,

Appy,

Traumatic small bowel perf

Front 114

Causes of peritonitis?
Inflammatory cause of acute abd

Back 114

Spont bacterial peritonitis in cirrhotics,
tuberculosis, gram neg and pos organisms

Front 115

Presentation of acute sigmoid diverticulitis?
Inflammatory cause of acute abd

Back 115

LLQ pain,
Fever,
Mass,
Older population >50

Front 116

Other inflammatory causes of acute abd?

Back 116

Perf gb/ cholecysitis,
Acute pancreatitis,
Gastroentertitis (viral, bact),
IBD,
Hep,
Peritonitis,
Mesenteric lymphadenitis,
Gyn causes

Front 117

6 gyn causes of acute abd?

Back 117

PID,
Fitz-Curtis disease ("violin strings"),
TSS,
Ruptured ovarian cyst,
Tubo-ovarian abscess,
Endometritis

Front 118

What is Fitz-Hugh-Curtis disease ("Violin strings")

Back 118

Gonococcal perihepatitis

Front 119

MCC large bowel mechanical obstruction?

Back 119

Carcinoma of colon

Front 120

MCC of SBO?

Next two?

Back 120

Adhesive bands from prior surg.

Followed by hernia and tumors

Front 121

Lesions extrinsic to bowel that cause obstruction?

Back 121

Adhesive bands,
Hernias,
Volvulus,
Neoplasms,
Ovarian torsion

Front 122

Inadequate propulsion causes of obstruction?

Back 122

Toxins,
Toxic megacolon,
Paralytic ileus,
NM conditions

Front 123

What phys exam should you do on ALL patients w/ SBO???

Back 123

HERNIA EXAM!!!

Front 124

Signs/ sx of SBO?

Back 124

Look for surg scars,
Hx bloating, abd distention, n/v, peristaltic pain,
Lack of flatus or feces,
Large fluid losses and lyte abn

Front 125

Tx of SBO?

Back 125

Decrompress w/ NG tube,
Fluid replacement!!!
Surgery!!

Front 126

Complications of SBO?

Back 126

Perf w/ peritonitis and ischemic bowel

Front 127

What is paralytic ileus aka?

Back 127

Adynamic ileus

Front 128

What might you see on flat plate xray in ileus?

Back 128

"sentinel loop"
Dilation of segment of large or small intestine, indicative of localized ileus from nearby inflammation.

Front 129

Causes of ileus?

Back 129

Meds,
Postop,
Immobility,
Spinal fractures,
Sepsis,
MI,
Pneumonia,
Head injury

Front 130

Causes of AAA?

Back 130

Males, 40+
Arteriosclerosis,
Trauma,
Connect tissue dz (Marfans, Ehlers'Danlos),
Inflam conditions of aorta,
Syph

Front 131

Characteristics of AAA?

Back 131

Often incidental finding,
Most below renal arteries,
Pulsatile abd mass and hypotension = surgery!!!

Front 132

Complications of AAA?

Back 132

Death,
Renal failure,
Bowel ischemia,
MI,
Paraplegia

Front 133

Presentation of mesenteric ischemia?

Back 133

Pain out of proportion to PE.

Vasculopaths,
AFib,
Metabolic acidosis,
Elevated lactate

Front 134

Respiratory thing that mimic acute abd?

Back 134

Pneumonia: RUQ or LUQ pain if lower lobes involved

Front 135

Cardiac things that mimic acute abd?

Back 135

Angina,
MI: epigastric pain,
Heartburn

Front 136

Musculoskeletal things that mimic acute abd?

Back 136

Compression fx of spine,
Hip fx,
Abd wall hematoma seen in gymnasts and swimmers

Front 137

Genitourinary thing that mimics acute abd?

Back 137

Cystitis: suprapubic pain, nephrolithiasis

Front 138

What is testicular torsion?

Back 138

Spont twisting of testicle causing ischemia.

Presents w/ acute onset unilateral scrotal pain that might radiate to lower quadrants and mimic acute abd.
10-18 yo.
Time!!! 6 hr window. Surgery!

Front 139

Acute abdominal pearls:
Women of child-bearing age?

Back 139

Preg test and include ruptured ectopic on differential!

Front 140

Acute abdominal pearls:
Elderly

Back 140

Have a low threshold for admitting!

Front 141

Acute abdominal pearls:
Amylase

Back 141

Measure in all

Front 142

Acute abdominal pearls:
Vital signs

Back 142

Trends are important!
Obtain early and often.

Front 143

Acute abdominal pearls:
Afib

Back 143

Afib w/ abd pain is mesenteric ischemia until proven otherwise!!

Front 144

Acute abdomen pearls:
2 MCC missed dx

Back 144

Appendicitis

SBO

Front 145

Acute abdomen pearls:
Hernia

Back 145

Intestinal obstructions may vary in presentation!
Look for hernias!
Small strangulated femoral hernia in elderly woman easily missed unless you look for it!

Front 146

Acute abdomen pearls:
Vascular

Back 146

Don't miss vascular causes like aortic aneurysms!
In elderly: back pain and collapse, espec man > 65 dx ruptured AAA until proven otherwise.

Front 147

Acute abdomen pearls:
Fluids

Back 147

Perf viscus or acute pancreatitis - need lots of fluids!!

Monitor by trends in vitals, UOP, central venous pressure