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176 Cards in this Set
- Front
- Back
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What are you saying when you say a pt has a positive psoas sign?
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the pt flexed the right leg at the hip against resistance that you applied and experienced and increase in abdominal pain. Suggestive of appendicitis.
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What does it mean to have a positive obturator sign?
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with the pts right leg bent at the hip and knee, internal rotation at the knee joint caused increased abdominal pain. suggestive of appendicitis.
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What laboratory tests should be performed with adult abdominal pain?
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-U/A
-CBC -HCG -additional depending on what you need to rule out ie: amylase, lipase, LFTs |
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What diagnostic studies are used to work up adult abdominal pain?
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plain X-ray (flat plate)
contrast studies- barium (upper and lower GI series) ultrasound CT scanning endoscopy sigmoidoscopy colonoscopy |
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What are the common acute pain syndromes in adult abdominal pain?
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1. appendicitis
2. acute diverticulitis 3. cholecystitis 4. pancreatitis 5. perforation of an ulcer 6. intestinal obstruction 7. ruptures AAA 8. pelvic disorders |
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What is appendicitis?
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an inflammatory disease of wall of the appendix
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What is the diagnosis of appendicitis based on?
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history and physical
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Describe the classic sequence of symptoms that suggest appendicitis
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1. abdominal pain- begins in epigastrum or periumbilical area-, anorexia, nausea, or vomiting
2. PAIN BEFORE THE N/V 3. followed by pain over appendix and low grade fever |
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In the typical appendicitis presentation, does the patient experience nause and vomiting then pain? or is it pain then nausea and vomiting?
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Pain THEN n/v
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What findings on PE of adult abdominal pain suggest appendicitis?
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low grade fever
McBurney's point rebound tenderness guarding +psoas sign |
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List 3 mimics of appendicitis
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1. right sided diverticulitis
2. mesenteric adenitits 3. crohn's disease |
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What is mesenteric adenitis?
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a self-limited inflammatory process that affects the mesenteric lymph nodes in the right lower quadrant
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What results from obstruction of the cystic or common bile duct by large gallstones?
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cholecystitis
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Which ducts may be obstructed by gallstones to cause cholecystitis?
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cystic duct
common bile ducts |
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Describe the pain that accompanies cholecystitis
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colicky pain with progression to constant pain in RUQ that may radiate to the RIGHT scapula
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What a the physical findings that suggest cholecystitis?
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-tender to palpation or percussion in the RUQ
-GB may be palpable |
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What lab tests are included in your diagnosis of cholecystitis?
imaging possiblities? |
CBC
LFTs (bilirubin, alk phos) serum pancreatic enzymes plain abdominal film ultrasound |
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What would a plain x-ray suggestive of cholecystitis show?
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biliary air, hepatomegaly, and maybe gallstones
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How often is an ultrasound considered to have accurate test results in cholecystitis?
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about 95%
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What is managment for cholecystitis?
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admission to the hospital
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What is this?
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And abdominal X-ray showing cholecystitis
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What is this?
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cholecystitis on an US
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What is this demonstrating?
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cholecystitis
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What is this showing?
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mesenteric adenitis
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What is shown in this CT show?
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Right sided diverticulitis
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What's the anatomy? Notice all the places where stones are lodged!
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What is ascending cholangitis?
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"when infection spreads through the biliary tree"
bacterial infection superimposed on an obstruction of the biliary tree most commonly from a gallstone, but it may be associated with neoplasm or stricture |
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What are the symptoms of ascending cholangitis?
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jaundice
fever RUQ pain |
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What is acalculous cholecystitis?
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cholecystitis with NO stones
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DNTK
What would you see on imaging of acalculous cholecystitis? |
DNTK
a distended acalculous gallbladder with thickened walls (>3-4 mm) with or without pericholecystic fluid |
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What causes acalculous cholecystitis?
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it is usually a complication of another process
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Who tends to get acalculous cholecystitis?
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diabetics and the elderly
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What is there a risk of with acalculous cholecystitis?
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GB perforation
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Patients with ascending cholangitis are _______________________
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critically ill
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What history items suggest pancreatitis?
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hx of cholelithiasis and alcohol abuse
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Describe the symptoms of pancreatitis
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pain is steading and boring, unrelieved by position change (this is what D. Satonik wrote, mistake?), LUQ with radiation to back
nausea and vomiting diaphoretic |
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What will you find on PE of an individual that suggests pancreatitis?
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acutely ill with abdominal distention
decreased bowel sounds diffuse rebound upper abd may show muscle rigidity |
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What lab tests are often ordered as a diagnostic test with suspected pancreatitis?
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amylase and lipase
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__________ raises 2-12 hours after onset of pancreatitis and returns to normal in _______ days
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amylase
2-3 |
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________ is elevated __________ of pancreatitis
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lipase
several days after an attack |
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Which is more speciic to pancreatitis? An elevated lipase or an elevated amylase?
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Lipase
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What is the management for pancreatitis?
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admission to the hospital
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What is Ranson's criteria used for?
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a clinical prediction rule for predicting the severity of acute pancreatitis
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List Ranson's criteria on admission
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-age >55
-glucose >200 -WBC >16k -AST >250 -LDH >350 |
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List ranson's criteria at 48 hours
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- decreased in HCT >10%
- increase in BUN >5 mg/dL - [Ca] <8 - PaO2<60 - base defecit >4 need for >6 liters of IVF |
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small bowel distention results in ___________ absorption and _________ secretions leading to ________________________-
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decreased
increased further distention and fluid/electrolyte balance |
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describe the pain in a small bowel obastruction
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sudden onset of crampy pain usually in the umbilical area of epigastrum
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Does vomiting occur late or early in a small bowel obstruction?
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early
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When does vomiting occur in a large bowel obastruction?
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late
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What are the PE findings with a small bowel obstruction?
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-hyperactive, high-pitched bowel sounds
-fecal mass may be palpable - abdominal distention - empty rectum on digital exam |
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What labs should you order when you suspect a small bowel obstruction?
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- CBC
- serum amylase - stool for occult blood - type and crossmatch - abdominal x-ray |
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What is the management for a small bowel obstruction?
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hospitalization
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small bowel obstruction (mechanical)
1. etiology 2. pain 3. abdominal distention |
1. prior surgery hx
2. colicky 3. prominent |
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small bowel obstruction (mechanical)
1. bowel sounds are? 2. small bowel distention is? 3. large bowel dilatation is? |
1. increased
2. present 3. absent |
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small bowel ileus
1. etiology 2. pain 3. abdominal distention |
1. recent post-op
2. minimal 3. minimal |
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small bowel ileus
1. bowel sounds are? 2. small bowel distention is? 3. large bowel dilatation is? |
1. absent
2. present 3. present |
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Whey is there large bowel dilatation present in small bowel ileus?
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i don't know, I need to remember to ask Dr. Lee
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#1 cause of large bowel obstruction
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cancer!
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List 2 causes besides cancer that cause a large bowel obstruction
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volvulus
diverticular disease |
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How can you tell the difference between the colon and the small intestine in X-rays?
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in the colon, the haustral markings do NOT traverse the entire bowel width
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What is this?
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sigmoid volvulus
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What is this?
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cecal volvulus
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What does this picture demonstrate?
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a cecal volvulus
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What patient is more likely to have a sigmoid volvulus?
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elderly, chronic constipation
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What do you see on an X-ray showing a sigmoid volvulus?
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inverted U of "bent inner tube"
orients to RUQ |
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How do you fix a sigmoid volvulus?
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with sigmoidoscopy- you decompress and detorse it
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What patient is more likely to get a cecal volvulus?
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younger (20-40 y/o)
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Is the onset of a cecal volvulus insiduous or acute?
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acute
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What leads to a cecal volvulus?
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a conginitally mobile cecum
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What do X-rays of a cecal volvulus show?
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kidney shaped loop in LUQ
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How do you treat a cecal volvulus
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surgery!
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"abdominal angina" refers to
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mesenteric ischemia
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What are the symptoms of mesenteric ischemia?
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sudden onset of pain out of proportion to exam findings
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What will labs show in mesenteric ischemia?
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increased WBC
increased lactic acid increased phosphorus and amylase |
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What are the risk factors for mesenteric ischemia?
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Afib
CHF (low flow) mural thrombus vascular disease |
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What are the two type of causes of mesenteric ischemia?
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embolic and thrombotic
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What artery is most commonly involved in mesenteric ischemia?
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SMA
(superior mesenteric artery) |
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What is a AAA?
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an abnormal dilatation of the abdominal aorta forming an aneurysm that may rupture and cause exsanguination into the peritoneum
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Are AAA more common in younger or older pts?
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the elderly
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What are they symptoms of a ruptured AA?
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sudden onset of excrutiating pain may be felt in chest or abdomen and may radiate to legs and back
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What are the physical findings in an AAA rupture?
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vitals reflect impending shock
deficit or difference in femoral pulses |
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How is an AAA/ruptured AAA diagnosed?
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ultrasound
CT if stable enough |
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An AAA is a ________ _________!
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surgical emergency!
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What is this?
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a small (~3.8 cm) stable AAA
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What is this?
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a leaking AAA
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What is this?
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AAA with thrombus and free blood (could be switched with leaking one)
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Where does the esophagus narrow and what level of the spine do these correspond to?
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cricopharyngeus muscle- C6
aortic arch- T4 tracheal bifrucation- T6 GE ( gastroesophageal) junction- T11 |
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How can you tell if a coin is in a child's esophagus or trachea based on X-rays?
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transverse- in the esophagus (face on)
AP: in the trachea, must drop through the slot of hte vocal cords (edge on) |
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What level of the spine is the cricopharyngeus muscle at?
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C6
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What level of the spine is the aortic arch at?
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T4
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What level of the spine is the tracheal bifrucation at?
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T6
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What level of the spine is the GE (gastroesophageal) junction at?
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T11
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What happens when a child swallows a button battery?
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rapid burns with perforation in 6 hours
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What type of batteries have the worst outcomes when swallowed?
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lithium batteries
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When do button batteries not need to be removed?
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non-esophagel location (i assume this means they are not in the lungs either?)
passed the pylorus within 48 hours |
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When will most esophageal FBs pass the pylorus?
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in 48-72 hours
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Most patients with an esophageal food impaction have _______ ____________.
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underlying pathology
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What are the removal options for an esophageal food impaction?
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endoscopy
foley glucagon and nifedipine (relax LES) |
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What should you avoid with esophagel food impactions?
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meat tenderizers
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Where is this FB?
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in the esophagus
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Where is the FB?
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in the trachea
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What causes most esophageal ruptures?
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iatrogenic! so you, hooker.
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Where do most iatrogenic esophagel ruptures occur?
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at the GE junction
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What is a common cause of upper gastrointestinal bleeding?
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a mallory-weiss tear
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What is a mallory-weiss tear?
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a partial thickness tear of the esophagus at the GE junction
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What preceeds the bleeding in a mallory weiss tear?
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vomiting
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Are mallory-weiss tears constant bleeders or often self limited?
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usually self-limited
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What is Boerhaave's syndrome?
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full thickness tear of the esophagus
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Where is the esophageal tear in Boerhaave's syndrome typically located?
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Left, posterior, distal
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Who typically gets Boerhaave's syndrome?
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males 40-60
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How do you locate the tear in Boerhaave's syndrome?
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a water soluble contrast study to locate the tear
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explain the course of Boerhaave's syndrome
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(full thickness tear to to the esophagus)
associated with vomiting SEVERE acute chest pain chemical, then bacterial mediastinitis |
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11 day old male presents with 3 day history of irritability and poor feeding. Today mother states she found bloody diarrhea in her baby’s diaper.
PE: T: 100.4 P: 100 R: 25 BP: 70/45 Pt is very lethargic , abdomen is greatly distended. What is going on? |
necrotizing enterocolitis
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what does this x-ray show?
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necrotizing enterocolitis
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What is the MC GI emergency in neonates?
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necrotizing enterocolitis
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Who is necrotizing enterocolitis most commonly found in?
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premature infants
only 5-25% of NEC infants are term |
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What is the classica clinical triad of necrotizing enterocolitis?
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abdominal distention
bloody stools pneumatosis intestinali |
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What history items suggest necrotizing enterocolitis?
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vomiting
diarrhea feeding intolerance high gastric residuals following feedings |
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What is found on the abdominal exam in necrotizing enterocolitis?
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-abdominal distention
-frank or occult blood in the stools -abdominal tenderness, abdominal wall edema -erythrema, crepitus, or palpable bowel loops |
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What is found on PE of necrotizing enterocolitis?
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apnea
bradycardia lethargy labile body temp hypoglycemia shock |
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What can be seen on X-ray with necrotizing enterocolitis?
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penumatosis intestinali,
portal venous gas, & pneumoperitoneum |
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What does portal venous gas on X-ray suggest?
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bowel necrosis
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What findings on X-ray are diagnostic of necrotizing enterocolitis with the appropriate clinical picture?
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pneumatosis intestinali
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2 week old male presents with 5 day history of “spitting up” after feedings which has become projectile in nature today. Dad states “The last time he puked it looked like coffee so we thought we should bring him in”
PE: T: 99.0 P: 120 R: 40 BP: 80/50 Pt appears slightly dehydrated, otherwise normal exam What is going on? |
pyloric stenosis
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What is the MCC of bowel obstruction in infancy?
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pyloric stenosis
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What is pyloric stenosis?
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a functional gastric outlet obstruction
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Who is pyloric stenosis more common in?
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first born white males (30%) ages 3-12 weeks and those whose parents had the disease (7%)
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What is the imaging modality of choice for suspected pyloric stenosis?
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ultrasound
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What is the sensitivity and specificity of ultrasound for pyloric stenosis
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sensitivity 99%
specificity 100% |
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What is the criteria for diagnosis of pyloric stenosis?
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pylorus muscle thickness >4 mm
and/or pylorus length >1.4 cm |
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What is this showing?
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pyloric stenosis- they are measuring the muscle thickness
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What is this?
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pyloric stenosis, showing the pyloric length
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What are the classic presenting signs of pyloric stenosis?
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palpable olive (often talked about but rarely felt)
visible peristaltic waves |
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Why are visible peristaltic waves occurring less frequently as a sign of pyloric stenosis?
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because the disease is being diagnosed earlier
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What is the treatment for pyloric stenosis?
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-NPO
-obtain IV access and correct dehydration and electrolyte imbalances -ramstedt pyloromyotomy is definitive tx |
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What should a pt with pyloric stenosis with normal labs receive?
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1.5-2x maintenance with D5 1/4 or 1/3 NS
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21 day old male presents with 1 day history of bilious vomiting and obstipation. “He just won’t stop crying!”
PE: T: 99.4 P: 160 R: 60 BP: 60/40 Abdomen distended, very tender What is going on? |
malrotation with volvulus
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What is malrotation?
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failure of the normal rotation of the gut as it re-enters the abdomen in utero
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What does volvulus lead to?
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life threatening bowel obstruction usually within the first year of life
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What are the classis S&S of malrotation with volvulus?
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bilious emesis and severe abdominal pain- but can be intermittent and may appear "well" with an unremarkable PE
-may have distention depending on timing and location of volvulus |
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4 month old female presents with 12 hour history of diarrhea and colic. “She’s crying off and on all night!”
PE: T: 98.6 P: 170 R: 50 BP: 80/50 Abdomen soft Rectal: Gross blood these are the X-rays- what is it? |
intussescption
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What does this show?
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intussescption
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Who does intussesception most commonly occur in?
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children 3 months- 2 years
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What is the MCC of bowel obstruction in young children?
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intussesception
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What is intussesception?
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telescoping of a segment of bowel
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Because the majority of intussesceptions are ____________ you should look for a _________ mass
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ileocolic
RUQ |
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What does intussesception require in order to occur?
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some sort of lead point, for example tumor, peyer's patch, lymphoma
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What is the classic triad of intussesception?
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colicky abdominal pain
current jelly stools vomiting <20% |
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What are the most common signs of intussescption?
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lethargy and drawing up of the legs
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What do the plain abdominal radiographs show in intussescption?
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most often are normal!
may show: signs of obstruction avdanced cases- free air |
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With suspected intussesception, what should be performed right away? why?
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an air or barium enema
it is diagnostic and therapeutic! |
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When shouldn't a barium or air enema be performed with suspected intussesception?
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when there are signs of perforation or peritonitis
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3 year old female presents with BRBPR first noticed 15 minutes ago by patients mother after waking her from a nap.
PE: T: 98.0 P: 100 R: 20 BP: 90/50 Diaper contains large amount of maroon blood What is going on? |
she has meckel diverticulum
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What is the most common congenital abnormality of the small intestine?
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meckel diverticulum
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What is the problem with meckel diverticulum?
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nothing, by itself it is NOT medically significant (50%)
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When is meckel diverticulum a problem?
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- when contains ectopic mucosal tissue (31% gastric)
- when it acts as a lead point for intussesception (often does in children) |
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What is the most common presentation of meckel diverticulum in children?
in adults? |
bleeding
obstruction |
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4 month old male presents with 1 day history of “colic” and poor feeding. Over the last six hours the infant has become inconsolable.
PE: T: 98.6 P: 120 R: 40 BP: 80/55 Abdomen soft, large firm mass in right scrotum, very tender to palpation, both testicles palpable. What is going on? |
an incarcerated hernia!
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know what pictures of a hernia look like in babies
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know it
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What is going on here?
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an incarcerated hernia!
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who are incarcerated hernias more common in? (peds)
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preterm males (up to 18%)
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If a kid has a hernia, are males or females more likely to have it incarcerate?
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females
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an incarcerated hernia can result in ____________________
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severe complications and death
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What are signs of toxicity with an incarcerated hernia?
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leukocytosis
severe tachycardia abdominal distention bilious vomiting |
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How should you treat an incarcerated hernia is there are no signs of toxicity?
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attempt to reduce it manually
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How shoudl you treat an incarcerated hernia if the patient appears toxic?
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fluid resuscitation, antibiotics
to the OR immediately |
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5 year old female presents with 1 day history of “tummy ache”. 4 hours ago began vomiting. Also complains “I can’t pee”
PE: T: 99.0 P: 80 R: 25 BP: 90/65 Lying very still on her side, begins to cry when asked to roll to her back Abd: TTP diffusely, extremely tender RLQ and suprapubic Bladder scan shows large amount of urine what do you suspect? |
appendicitis
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appendicitis occurs in ____ of the population
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7%
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Appendiceal perforation _______ <18 and >50 because of _________________
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increases
delays in seeking treatment |
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Where it the appendix?
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it can be ANYWHERE!
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What symptoms can an inflamed appendix near a ureter or the bladder cause?
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urinary symptoms such as dysuria, pyuria, or urinary retention
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What are the classic symptoms of appendicitis?
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anorexia and periumbilical pain followed by nausea, RLQ pain, and vomiting (50%)
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What sign has the greatest sensitivity and specificity in detecting appendicitis and what are the values?
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migration of pain from periumbilical to RLQ
sens and spef of 80% |
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you hear: pain then vomiting
you think: _______ |
appendicitis
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you hear: vomiting then pain
you think: __________ |
obstruction
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What is classic presentation for appendicitis?
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a gift! aka not gonna happen all that often
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