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147 Cards in this Set
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Definition of acute abdomen
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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. |
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How often in cases of acute abdomen, is the abdomen the source of the problem?
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85-90%
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Acute abdomen and malpractice?
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10% of all malpractice claims.
Recovery rates decrease w/ increase in delay of dx |
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MCC non-surgical abdominal pain?
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Gastroenteritis
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MCC of surgical abdomen?
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Appendicitis
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MCCs (2) abdominal pain in pts >60?
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Biliary dz and
Intestinal obstructions |
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In kids, 32% of admission for abd pain is?
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Acute appendicitis
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Define Intraperitoneal?
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Having a mesentery:
Stomach, Jejunum, Ileum, Transverse colon, Liver, GB |
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Definte Retroperitoneal?
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Organs w/out a mesentery and assoc w/ posterior body wall:
Aorta, IVC, Kidneys, Suprarenal glands |
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Define Secondarily Retroperitoneal?
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Organs that once had a mesentery but was lost during devlopment:
Pancreas, Duodenum, Ascending colon Descending colon |
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Be sure to ask about these 6 associated sx in an acute abodmen:
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Distention,
Pain, Nausea, Vomiting, Anorexia, Bowel function |
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Usual suspects of acute abdomen in elderly?
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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. |
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Usual suspects of acute abd in kids?
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Appendicitis.
Also remember intussusception (currant jelly stool) in younger kids. |
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Usual suspects of acute abd in adults?
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Pancreatitis at any age, but espec in adults.
Gallstones/ Alcohol |
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Usual suspects of acute abd in women?
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Gyn causes, espec ectopics
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Define visceral or splanchnic pain?
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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. |
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Where is visceral or splanchnic pain usually located?
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Localized in one of three midline zones of abd:
Epigastric, Midabdominal, Lower abdominal |
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Characteristics of midline zone pain in visceral/ splanchnic pain?
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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. |
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Define Somatic (Parietal) pain?
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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) |
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Define Generalized pain (peritonitis)?
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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 |
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What pain progression might indicate involvement of parietal peritoneum?
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Progressing from dull, aching, poorly localized pain to sharp, constant and better localized pain.
See slide 21 for types and locations of pain |
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Common causes of sudden onset abdominal pain?
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Perf of GI tract or rupture of intra-abd source:
gastric or duodenal ulcer, ruptured diverticulum, Ruptured ectopic, Mesenteric infarction, Ruptures aortic aneurysm |
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What is rapid onset abd pain?
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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. |
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Common causes of rapid onset abd pain?
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Biliary colic,
Pancreatitis, Intestinal obstruction, Volvulus, Diverticulitis, Appendicitis, Renal colic, Intussusception |
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What is gradual onset pain?
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Slowly becomes more severe only after a number of hours or days have elapsed.
Memory as to onset is vague. |
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Common causes of gradual onset pain?
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Neoplasms,
Large bowel obstruction, Chronic inflammatory processes. Hard to make dx from hx alone w/ this type of pain. |
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What is Cramping or Colicky abd pain?
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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 |
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What is constant dull or aching abd pain?
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Causes by distention of a hollow organ, such as GB when cystic duct is obstructed.
Examples: distention of capsule of liver and spleen. |
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What is Kehr's sign?
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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 |
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What is the Howship-Romberg sign?
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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. |
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Where might duodenum, pancreatic pain be referred to?
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Umbilical region
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Where might cardiac pain be referred to?
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Epigastrum,
Jaw, Shoulder, Substernal |
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Where might gallbladder pain be referred to?
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Epigastric pain to right scapula
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Where might appendix pain be referred to?
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Periumbilical
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Where might ureteral pain be referred to?
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Hypogastrium,
Groin, Inner thigh |
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Where might pelvic pathology associated pain be referred to?
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Sacrum
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What type of referral can geintofemoral nerve irritation from retroperitoneal inflammatory processes (retrocecal appendicitis) cause?
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Pain in labia or testicle on ipsilateral side (same side)
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3 main causes of vomiting?
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Perf,
Obstruction, Toxins |
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Loose rule of thumb regarding relationship of vomiting and abd pain?
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Pain usually precedes vomiting when abd pain is from surgically correctable causes.
Reverse is true for medical causes, like gastroenteritis |
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4 conditions in which vomiting is very prominent?
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Mallory-Weiss syndrome.
Boerhaave syndrome (trans-mural), Acute gastritis, Acute pancreatitis |
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4 common causes of nausea withOUT vomiting?
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Hepatocellular dz,
Preg, Metastatic dz, Meniere's dz |
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Most diarrhea with pain is mainly medical (as opposed to surgical). What are 4 exceptions?
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Galllstone ileu,
Superior Mesenteric vascular occlusion, Intestinal obstruction assoc w/ pelvic abscess, Diarrhea in chronic fecal impaction |
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4 things to think about in constipation?
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Progressive intestinal obstruction from cancer or IBD,
Paralytic ileus, Post op, Obstructed groin hernia. |
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Define hematochezia?
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BRBPR
|
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2 common causes of urinary symptoms w/ abd pain?
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Ureteric colic,
Cystitis |
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What happens with Rigors/ chills?
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Rigors more extreme chills.
Caused by cytokine and prostaglandin release. Immune response. Hypothalamic increase in body temp "set point" |
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What you should think of when fever/ rigors accompany abd pain?
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Liver abscess,
Peri-nephric abscess, Intra-abd abcess or infection |
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What medications can interfere with dx process of abd pain?
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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. |
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Ask yourself: is this patient very sick and maybe going to die immed? If so....?
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CALL SOMEONE!!!
Get help!! Load the boat!! |
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If the patient is sick but prob stable for next cpl hours, what should you do?
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Start workup,
Alert proper authorities, Develop differential. Start inital tx and management. |
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Rule of thumb for assessing first outward appearance?
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Pt is pale, clammy, looks close to death, probably is.
Pt sitting up, joking, looking well, probably is.... UNLESS they are on steroids. |
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2 things that can cause a LOW grade fever?
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Appendicitis,
Acute cholecystitis |
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2 things that can cause a HIGH grade fever?
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Salpingitis,
Abscess |
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3 things that can cause a VERY HIGH grade fever?
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Septic shock,
Peritonitis, Acute cholangitis |
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What is Fox's sign?
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Bruising over inguinal ligament - acute retroperitoneal bleeding, usually acute hemorrhagic pancreatitis,
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What might general visible peristalsis indicate?
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Obstruction
Coincides w/ peristaltic pain and borborygmi caused by contents pushing up againts obstruction |
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What is borborygmi?
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Hyperperistalsis
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What can loss of liver dullness be due to?
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Free air - due to perf
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What is percussion tenderness a sign of?
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Peritoneal irritation
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What is Murphy's sign?
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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) |
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What is McBurney's Point?
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1/3 from ASIS to umbilicus. Tenderness in this area can be a sign of appendicitis
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What is Psoas sign?
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Bring hip into extension. Pain can be indicative of appendicitis when appendix is retrocaecal in orientation
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What is Obturator sign?
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Flexion and internal rotation of the hip.
Pain indicative of appendicitis. |
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What is Rovsing's sign?
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Palpation of lower left quadrant increases pain in lower right quadrant.
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What is Blumberg's Sign?
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Rebound tenderness.
Pressing on abd wall deeply and suddenly releasing causes pain in peritonitis. |
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What is peritonitis?
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MAJOR FEATURE OF ACUTE ABD DZ!
Inflammation of peritoneum from variety of causes. Inflammation results in increased blood supply --> edema. |
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MCC of peritonitis in surgical setting?
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Perf of hollow organ
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Implications of amylase, lipase and LFTs in the acute abd?
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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. |
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What can be determined using an abdomen flat and upright, left lat decub xray?
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Air-fluid levels,
Calcifications, "sentinel loop" Eggshell calcification in AAA, Air in biliary tree |
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What is the concern about doing a BE?
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If perforation or acute inflammatory process, can be deadly!!!
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What imaging is best for mesenteric ischemia?
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Angiography
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Patients will be in one of 3 categories: admit and observe, immed intervention, or discharge.
What should you do if you admit and observe? |
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!!! |
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If you immediately intervene, what do you do?
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Determine timing and type of surg,
Consider alternative dx (always have a differential!!), Base preop prep on what your working dx is |
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6 categories of causes of the acute abd?
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Inflammatory (bacterial, chem),
Mechanical, Neoplastic, Vascular, Congenital defects, Traumatic |
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Example of chemical causes of acute abdomen?
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Perf of peptic ulcer, splliage of acid gastric contents --> intense peritoneal reaction
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Average length of appendix?
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8-20 cm
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MCC of acute abdomen?
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Appendicitis!!!
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General characteristics of appendicitis?
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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. |
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Pathophys of appendicitis?
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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. |
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How does fiber help prevent appendicitis?
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Decreases viscosity of feces,
Decreases bowel transit time, Discourages formation of fecaliths |
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What are 6 things that can cause luminal obstruction of appendix?
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Fecaliths,
Lymphoid follicle hyperplasia, Foreign body, Carcinoid tumor, Parasites, Barium |
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What are fecaliths?
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Formed from calcium salts and fecal material in appendix
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What is lymphoid hyperplasia?
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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 |
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MC Primary tumor of appendix?
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Carcinoid tumors.
Some present w/ carcinoid syndorme - caused by seritonin secreted by tumor. |
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2 parasites that cause appendicitis?
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Schistosomes species,
Strongyloides species (S. stercoralis) |
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3 causes of a variation in presentation of appendicitis?
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Variations of appendiceal position,
Pt age, Degree of inflammation |
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Different appendiceal positions?
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Retrocecal in 64%.
Close to ovary or ureter. Deep in pelvis if long. Posterior to ascending colon (retrocolic). |
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Progression of pain with appendicitis?
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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!!!!!!! |
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N/V, bowels w/ appendicits?
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Anorexia and nausea after pain.
Vomiting after pain. May have very little change in bowels. |
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Urinary sx in appendicitis?
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If appendix is near bladder or ureter, can -->
Dysuria/ freq, Hematuria or pyuria, *Males rarely have cystitis. If male w/ UTI sx, consider appendicitis! |
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What is Markle sign?
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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 |
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Rectal exams in appendicitis?
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Inconsistent as to whether it's helpful.
BUT!!!!! Freq sited in successful malpractice claims!! |
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What is Typhlitis (Neutropenic Colitis)?
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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** |
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What is mesenteric adenitis?
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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. |
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Bacterial causes of mesenteric adenitis?
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Yersinia enterocolitica,
Helicobacter jejuni, Campy jejuni, Salmonella, Shigella |
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What is Meckel's Diverticulum?
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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 |
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Meckel's Rule of 2s?
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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 |
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What is Littre's Hernia?
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Hernia sac containing a meckel's diverticulum
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Labs in appendicitis?
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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 |
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Advantages of using CT to dx appy?
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Sensitive,
Accurate, Available, Noninvasive, Can see entire abd |
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Disadvantages of using CT to dx appy?
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Radiation,
Possible contrast rxn, Can take hours to admin oral contrast, Rectal contrast uncomfortable |
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What is the MANTRELS score?
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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. |
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Tx for non-perfed appy?
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NPO,
IVF, Abx: broad spectru, gram neg, enterococcal and anaerobic. SURGERY! Primary intention closure. Continue postop abx 24 hrs |
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Tx for perfed appy?
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NPO,
Fluid resuscitation, Open appy usually, Drain and culture pus, Peritoneal irrigation, Wound left to heal by secondary intention, Abx 5-7 days |
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What should you look for if you do an appy and it's negative?
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Examine terminal ileum for Crohns,
Look for Meckels, intussucetpion, and gyn causes |
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What should you do in a perfed appendix w/ abscess?
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Drain abscess and delay appy until 6-8 weeks later.
Interval appendectomy |
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Complications of appendicitis/ appendectomy?
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Intra-abd abscess formation,
Liver abscess, Wound infection, Bleeding, Perf, Pylephlebitis: suppurative thrombosis of portal vein. |
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What changes about presentation of appendicitis during pregnancy?
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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. |
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Differentiating appendicitis from other possibilities in non-preg women of childbearing age?
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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. |
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Classic presentation of acute cholecystitis?
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5 Fs: Female, Fertile, Forty, Flatulent, Fatty Food Intolerance.
RUQ pain/ epigastric pain w/ radiation to shoulder. + Murphy's sign. |
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Complications of acute cholecystitis?
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Cholangitis,
Perf, Peritonitis |
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Presentation of Peritoneal irritation secondary to perfed viscus gastric or duodenal ulcer?
Inflammatory cause of acute abd |
Free air under diaphragm,
Board like abdomen. |
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3 causes of Perforated bowel?
Inflammatory cause of acute abd |
Diverticulum,
Appy, Traumatic small bowel perf |
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Causes of peritonitis?
Inflammatory cause of acute abd |
Spont bacterial peritonitis in cirrhotics,
tuberculosis, gram neg and pos organisms |
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Presentation of acute sigmoid diverticulitis?
Inflammatory cause of acute abd |
LLQ pain,
Fever, Mass, Older population >50 |
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Other inflammatory causes of acute abd?
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Perf gb/ cholecysitis,
Acute pancreatitis, Gastroentertitis (viral, bact), IBD, Hep, Peritonitis, Mesenteric lymphadenitis, Gyn causes |
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6 gyn causes of acute abd?
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PID,
Fitz-Curtis disease ("violin strings"), TSS, Ruptured ovarian cyst, Tubo-ovarian abscess, Endometritis |
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What is Fitz-Hugh-Curtis disease ("Violin strings")
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Gonococcal perihepatitis
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MCC large bowel mechanical obstruction?
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Carcinoma of colon
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MCC of SBO?
Next two? |
Adhesive bands from prior surg.
Followed by hernia and tumors |
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Lesions extrinsic to bowel that cause obstruction?
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Adhesive bands,
Hernias, Volvulus, Neoplasms, Ovarian torsion |
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Inadequate propulsion causes of obstruction?
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Toxins,
Toxic megacolon, Paralytic ileus, NM conditions |
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What phys exam should you do on ALL patients w/ SBO???
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HERNIA EXAM!!!
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Signs/ sx of SBO?
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Look for surg scars,
Hx bloating, abd distention, n/v, peristaltic pain, Lack of flatus or feces, Large fluid losses and lyte abn |
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Tx of SBO?
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Decrompress w/ NG tube,
Fluid replacement!!! Surgery!! |
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Complications of SBO?
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Perf w/ peritonitis and ischemic bowel
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What is paralytic ileus aka?
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Adynamic ileus
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What might you see on flat plate xray in ileus?
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"sentinel loop"
Dilation of segment of large or small intestine, indicative of localized ileus from nearby inflammation. |
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Causes of ileus?
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Meds,
Postop, Immobility, Spinal fractures, Sepsis, MI, Pneumonia, Head injury |
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Causes of AAA?
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Males, 40+
Arteriosclerosis, Trauma, Connect tissue dz (Marfans, Ehlers'Danlos), Inflam conditions of aorta, Syph |
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Characteristics of AAA?
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Often incidental finding,
Most below renal arteries, Pulsatile abd mass and hypotension = surgery!!! |
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Complications of AAA?
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Death,
Renal failure, Bowel ischemia, MI, Paraplegia |
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Presentation of mesenteric ischemia?
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Pain out of proportion to PE.
Vasculopaths, AFib, Metabolic acidosis, Elevated lactate |
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Respiratory thing that mimic acute abd?
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Pneumonia: RUQ or LUQ pain if lower lobes involved
|
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Cardiac things that mimic acute abd?
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Angina,
MI: epigastric pain, Heartburn |
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Musculoskeletal things that mimic acute abd?
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Compression fx of spine,
Hip fx, Abd wall hematoma seen in gymnasts and swimmers |
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Genitourinary thing that mimics acute abd?
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Cystitis: suprapubic pain, nephrolithiasis
|
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What is testicular torsion?
|
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! |
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Acute abdominal pearls:
Women of child-bearing age? |
Preg test and include ruptured ectopic on differential!
|
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Acute abdominal pearls:
Elderly |
Have a low threshold for admitting!
|
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Acute abdominal pearls:
Amylase |
Measure in all
|
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Acute abdominal pearls:
Vital signs |
Trends are important!
Obtain early and often. |
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Acute abdominal pearls:
Afib |
Afib w/ abd pain is mesenteric ischemia until proven otherwise!!
|
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Acute abdomen pearls:
2 MCC missed dx |
Appendicitis
SBO |
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Acute abdomen pearls:
Hernia |
Intestinal obstructions may vary in presentation!
Look for hernias! Small strangulated femoral hernia in elderly woman easily missed unless you look for it! |
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Acute abdomen pearls:
Vascular |
Don't miss vascular causes like aortic aneurysms!
In elderly: back pain and collapse, espec man > 65 dx ruptured AAA until proven otherwise. |
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Acute abdomen pearls:
Fluids |
Perf viscus or acute pancreatitis - need lots of fluids!!
Monitor by trends in vitals, UOP, central venous pressure |