Acute Abdomen
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Acute Abdomen

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Acute Abdomen Acute Abdomen Presentation Transcript

  • Acute Abdomen Dr.Teresa Galdona PA-C
  • Acute Abdomen Objectives
    • Definition of acute abdomen.
    • To be able to distinguish between a medical or surgical abdomen
    • To be able to obtain a history to facilitate the diagnosis:
    • Immediate Management of Life threatening problems: perform a brief examination, identify candidates for urgent surgery.
    • Further evaluation of patient with acute abdominal pain: H and P/ lab/ x-Rays/ special studies.
  • Acute Abdomen objectives
    • Identify and describe the common localized abdominal masses including umbilical hernia, incisional hernia, epigastric hernia, diastases recti, and lipoma.
    • Describe normal and abnormal bowel sounds and identify increased/decreased bowel sounds, bruits, venous hum, friction rubs and their significance
  • Acute Abdomen objectives
    • Identify the areas commonly auscultated for bruits. i.e., renal artery stenosis
    • Describe the significance of the abdomen in all four quadrants
    • Describe the common abnormalities that can cause irregular percussion notes of the abdomen, i.e. ovarian tumor, pregnant uterus or GI obstruction
  • Acute Abdomen objectives
    • Define and describe the changes associated with light and deep palpation to assess any degree of tenderness, i.e. rebound tenderness, guarding which would indicate a peritoneal irritation or distended viscous.
  • Acute abdomen objectives
    • Recognize and perform the special techniques in examining the abdomen for specific findings: (1) rebound tenderness, (2) shifting dullness in ascites, (3) Fluid wave in ascites, (4) hooking technique for palpating the liver, (5) Murphy's sign for acute cholecystitis, (6) ballottement, and (7) the techniques of assessing possible appendicitis
  • Acute Abdomen
    • Differential Dx. of Acute Abdominal Pain (Understand the anatomic correlation of abdominal pain and types of abdominal pain): causes of abdominal pain by quadrants, parietal pain, visceral pain and referred pain.
  • Acute Abdomen definition
    • It has an acute onset, it can have many potential etiologies and may required immediate medical or surgical intervention, also is mostly accompany by signs of peritoneal irritation (with some exceptions) like: rigidity, tenderness (with or without rebound), involuntary guarding, also may or may not have signs of hypotension and shock.
  • Acute Abdomen
    • 1) H&P: obtain a complete Hx (mnemonic)OPQRST)/ Vital signs (blood pressure, with pt standing or sitting position, pulse, asses peripheral perfusion alertness, skin and extremities temperature).
    • Immediate management of life threatening problems: bleeding, shock, hypotension
  • Acute Abdomen
    • Location of Problem: Chest, abdomen (upper, middle, lower/ sides)
    • Time of Onset: Date, time…?
    • Type of Onset: How: Sudden? Gradual?
    • Original Source: Triggers, what were you doing? (setting at time of occurrence)
    • Severity: Interfere with ADL’S?
    • Time Relationship: How often, when?
    • Duration: How long an episode?
  • Acute Abdomen
    • Course: Getting better, worse?
    • Association: Any other manifestation?
    • Source of Relief: Changes in medication, diet? What makes it better?
    • Source of Aggravation: What makes it worse?
    • Relevant Data & Pertinent Negatives
  • Acute Abdomen
    • Gynecological Hx for females: last menstrual period, pregnancies, STD’s.
    • Associated symptoms: nausea, anorexia, vomiting, change in bowel habits.
  • Acute Abdomen
    • Dyspnea, SOB, pain, wheezing, crackles, orthopnea, (?) Pillows, cough, sputum, emphysema, bronchitis, asthma, URL, chest x-ray
    • Changes in: appetite, weight, N/V. abdominal pain, (?) Diet, digestion, tastes, bowel habits/ stool.
    • Urine: color, polyuria, oliguria, nocturia, dysuria, frequency, urgency, stones…
    • Hx: STD,
  • Acute Abdomen
    • mental status
    • exam abdomen (gently) looking for signs of acute abdomen.(IAPP) Identify and describe the common localized abdominal masses including umbilical hernia, incisional hernia, epigastric hernia, diastases recti, and lipoma.
    • Pelvic(gynecological) exam for females and rectal exam for both male and female (gross blood, asses sphincter tone, and any other evidence of trauma).
    • Check for blood in stools: UC, diverticular ds, diverticulitis, hemorroids
  • Abdominal Assessment Landmarks
    • 1. Xiphoid Process
    • 2. Costal Margin
    • 3. Abdominal Midline
    • 4. Umbilicus
    • 5. Rectus Abdominis Muscle
    • 6.Ant. Sup. Iliac Spine
    • 7. Inguinal Ligament (Poupart’s Ligament)
    • 8. Symphysis Pubis
  • Assessment of the Abdomen Inspection -- Contour
    • Types of abdomen:
    • Flat
    • rounded or convex
    • Scaphoid
    • protuberant
  • Assessment of the Abdomen Inspection -- Contour
    • Flat is normal
    • Large convex abdomen -- 7 F’s
      • Fat Feces
      • Fluid (ascites) Fetus
      • Flatus Fatal growth (malignancy) Fibroid tumor
  • Assessment of the Abdomen Inspection -- Contour
    • Concave or scaphoid abdomen
      • Decreased fat deposits
      • Malnourished state
      • Flaccid muscle tone
    • Convex or protuberant abdomen -- 7 F’s: fat,fluid (ascites), flatus, feces, fetus, fatal growth (malignancy), fibroid tumor
  • Assessment of the Abdomen Inspection -- Symmetry
    • The abdomen should be symmetrical bilateral
    • Asymmetry indicates
      • tumor
      • cysts
      • bowel obstruction
      • enlargement of abdominal organs
      • scoliosis
  • Assessment of the Abdomen Inspection -- Rectus Abdominis Muscle
    • Normal -- no ridge separating the muscles
    • When a ridge is present - diastasis recti abdominus
      • marked obesity
      • past pregnancy
      • increased intra-abdominal pressure
  • Assessment of the Abdomen Respiratory Movement
    • Normally no retractions -- the abdomen rises and falls with each respiration
    • Abnormal due to abdominal disorders
      • appendicitis with local peritonitis
      • pancreatitis
      • biliary colic
      • perforated ulcer
  • Assessment of the Abdomen
    • Masses or nodules -- tumors, metastasis, internal malignancy, or pregnancy
    • Visible Peristalsis -- indicative of obstruction
    • Pulsation -- aortic aneurysm or may occur in aortic regurgitation and in right ventricular hypertrophy
  • Assessment of the Abdomen Umbilicus
    • Umbilical Hernia -- protrusion of the umbilicus secondary to non closure of the ring permitting intestine or omentum to protrude
    • Sister Mary Joseph’s nodule -- nodule in the umbilicus secondary to CA intra-abdominal
    • Intra-abdominal pressure -- protrusion from ascites,masses, or pregnancy
  • Assessment of the Abdomen Auscultation
    • Use diaphragm of stethoscope lightly placed
    • RLQ->RUQ->LUQ->LLQ
    • Bowel sounds 5-30/min
    • High-pitched always heard RLQ-ileocecal area
    • Borborygmi -- “stomach growling” -- normal, hyperactive, gurgling sound
  • Assessment of the Abdomen Auscultation -- Bowel Sounds
    • Absent bowel sounds -- no sound for 4-5 minutes -- late intestinal obstruction
    • Mechanical obstruction -- adhesions, hernias, masses
    • Non-mechanical obstruction -- no intestinal contraction (paralytic ileus) -- physiological, neurogenic, and chemical imbalances
  • Assessment of the Abdomen Auscultation -- Bowel Sounds
    • Hypoactive bowel sounds -- indicates decreased motility
      • peritonitis
      • non-mechanical obstruction
      • inflammation
      • gangrene
      • electrolyte imbalances
      • intraoperative manipulation of the bowel
  • Assessment of the Abdomen Auscultation -- Bowel Sounds
    • Hyperactive bowel sounds -- increased motility of the bowel
      • gastroenteritis
      • diarrhea
      • laxative use
      • subsiding ileus
  • Assessment of the Abdomen Auscultation -- Bowel Sounds
    • High pitched tinkling hyperactive bowel sounds
      • caused by powerful peristaltic action
      • indicative of partial obstruction
      • abdominal cramping
  • Assessment of the Abdomen Auscultation -- Venous hum
    • A continuous pulsing or fibrillary sound
    • If present in the periumbilical area is secondary to portal vein obstruction
      • Portal hypertension caused by cirrhosis
  • Assessment of the Abdomen Auscultation -- Friction Rubs
    • Using the diaphragm of the stethoscope a sound similar to rubbing sandpaper together
    • Sound increases with inspiration
      • Tumors
      • inflammation
      • infarction
  • Assessment of the Abdomen Percussion -- General
    • Visualize all organs as you percuss all quadrants
    • Tympany heard most -- hollow organs. Dull sound over solid organs
      • Dull sound in area where it should be tympanitic -- mass or tumor, pregnancy, ascites
  • Assessment of the Abdomen Percussion -- Liver Span
    • Percuss upward -- midclavicular line above the umbilicus -- typany to dull -- mark
    • Percuss downward -- midclavicular line -- tympany to dull - mark
    • N - 6-12 cm, male 10.5, female 7.0 cm
  • Assessment of the Abdomen Percussion -- Ascites (Shifting Dullness
    • Percuss from above and below from dullness to tympany while patient on their back
    • Place patient on left side and percuss from dullness to tympany
  • Assessment of the Abdomen Percussion -- Ascites
    • The umbilical area percusses dull because the ascitic fluid pools in the dependent area
    • Ascites is present in cirrhosis and other liver diseases
  • Assessment of the Abdomen Fist Percussion -- Kidney
    • Direct fist percussion -- strike the costovertebral angle with one fist
    • Indirect fist percussion -- place palm over costovertebral angle and strike with other hand
    • Pain indicative of infllammatory condition
  • Assessment of the Abdomen Fist Percussion -- Liver
    • Palm down RUQ -- strike with other hand
    • Tenderness can occur with:
      • pyelonephritis
      • cholecystitis
      • hepatitis
  • Assessment of the Abdomen Percussion -- Bladder
    • Percuss from symphasis pubis (urine filled gives dull sound) - if patient unable to empty it is secondary to:
      • neurogenic dysfuntion
      • benign prostatic hypertropy
      • post-op
      • urethral changes
      • some medications
  • Assessment of the Abdomen Palpation
    • Please warm your hands
    • To start avoid known tender areas
    • Have patient take slow deep breaths through mouth
    • Begin with gentle pressure then increase
    • If ticklish or with children palpate through their hand till ticklishness is gone
    • Avoid quick, short jabs
    • Observe patient’s face for expressions of pain
  • Assessment of the Abdomen Palpation -- Light
    • Lightly palpate to note
      • skin temperature
      • tenderness
      • large masses
  • Assessment of the Abdomen Palpation -- Abdominal Muscle Guarding
    • Use both hands -- one on each rectus
    • Check for tensing during expiration
    • When positive it is indicative of peritoneal irritation -- peritonitis
  • Assessment of the Abdomen Palpation -- Deep
    • You can use one or two handed method
    • Two handed method is usually used in obese or very muscular individuals
    • Palpate all quadrants
  • Assessment of the Abdomen Palpation -- Fluid Wave
    • With an assistant placing the ulnar surface of their hand firmly in the midline of the patient
    • You tap from one side to feel the wave on the other side
    • Present with ascites
  • Assessment of the Abdomen Palpation -- Liver -- Bimanuel Method
    • Left hand under patient’s right flank (11th-12th rib) press upward
    • Place right hand at level of dullness -- have patient take a deep breath
    • Push in deeply
    • note -- size, shape, consistency, or masses
  • Assessment of the Abdomen Palpation -- Liver -- Hook Method
    • Place both hands side by side below the level of liver dullness
    • Hook fingers in and up and have the patient take a deep breath in
    • Note the size, shape, consistency, and any masses
    • I prefer to do this in a sitting position
  • Assessment of the Abdomen Palpation -- Liver -- Hepatomegaly
    • Enlarged liver
      • congestive heart failure
      • hepatitis
      • encephalopathy
      • cirrhosis
      • cyst
      • cancer
  • Assessment of the Abdomen Palpation -- Liver -- Murphy’s Sign
    • Palpate the liver margin at the lateral border of the rectus muscle
    • Have the patient take a deep breath
    • If patient exhibits pain and stops inhaling this is a positive Murphy’s Sign present in
      • Cholecystitis
  • Assessment of the Abdomen Palpation -- Spleen -- Bimanuel Technique
    • Pull up with left hand and push in with right hand on inspiration
    • Will only be able to feel if 3 times normal size
    • Splenomegaly
      • inflammation
      • congestive heart failure
      • cancer
      • cirrhosis
  • Assessment of the Abdomen Palpation -- Kidney -- Bimanuel Technique
    • Place one hand on the costovertebral angle of the back and the other hand just below the costal margin
    • Increase pressure during inspiration then have patient hold breath
  • Assessment of the Abdomen Palpation -- Kidney
    • The right kidney maybe difficult to distinguish from an enlarged liver
    • Left kidney enlargement maybe difficult to distinguish from an enlarged spleen
    • Enlarged palpable kidneys are secondary to:
      • hydronephrosis
      • neoplasms
      • polycystic disease
  • Assessment of the Abdomen Palpation -- Aorta
    • Assess the width of the aorta by placing your hands on each side of the aorta just above the umbilicus
    • Abdominal aortic aneurysm -- width greater than 4 cm with lateral pulsations
  • Assessment of the Abdomen Rebound Tenderness
    • Apply firm pressure for several seconds to the abdomen with hand at right angles and fingers extended
    • Quickly release the pressure
    • Test away from site where pain is initially determined
  • Assessment of the Abdomen Rebound Tenderness
    • Pain at site is direct rebound tenderness
    • Pain at another site is referred rebound tenderness
    • Indicative of peritoneal inflammation
    • If in the RLQ think appendicitis (McBurney’s point -- to be discussed later)
  • Assessment of the Abdomen Rovsing’s Sign
    • Press in the LLQ evenly for 5 seconds and note if patient has pain in RLQ - positive
    • Gas is pushed through the ileocecal valve thus distending the cecum
    • In appendicitis pain is noted
  • Assessment of the Abdomen Cutaneous Hypersesitivity
    • Either lift the skin or stimulate the skin with gentle jabbing with a sterile pin
    • Indicates a zone of peritoneal irritation
      • RLQ -- appendicitis
      • Midepigastrium -- peptic ulcer
  • Assessment of the Abdomen Ileopsoas Muscle Test
    • Place your hand over the right thigh and push downward as the patient is trying to raise the leg, flexing the hip
    • Positive RLQ pain associated with a retrocecal or perforated appendicitis
  • Assessment of the Abdomen Obturator Muscle Test
    • Flex the right leg at the hip and knee at a right angle then rotate the leg internally and externally
    • Pain indicative of inflammatory process over obturator muscle
      • ruptured appendix
      • pelvic abscess
  • Appendicitis
  • Assessment of the Abdomen Ballottement
    • Used to displace excess fluid in the abdominal cavity by using stiffened fingers in a jabbing motion
    • Determines a free floating mass
    • If pain is associated with an inflammatory process
  • Assessment of the Abdomen Bladder Palpation
    • Using deep palpation start at the symphasis pubis and palpate up
    • Nodular bladder -- malignancy
    • Asymmetrical bladder
      • tumor in the bladder
      • abdominal tumor causing compression
  • Assessment of the Abdomen
    • Hernia Examination
    • Pelvic Examination
    • Rectal examination
    • Laboratory Examination
    • Diagnostic Imaging
  • Acute Abdomen
    • Associated symptoms.
    • EKG: inferior wall MI may present with epigastric or upper abdominal pain with no clear disorder identified
    • 2) Identify candidates for urgent surgery: hypotension without GI bleeding, aneurysm, rigid abdomen in a pt with abdominal pain,.
  • Acute abdomen
    • Treat shock.
    • Determine shock severity:
    • 1) compensated shock
    • 2) decompensated shock
  • Acute abdomen
    • Understand the anatomic correlation of abdominal pain and types of abdominal pain: causes of abdominal pain by quadrants, parietal pain, visceral pain and referred pain.
    • Most common surgical Causes of abdominal pain by quadrants:
    • RUQ:
    • Perforated duodenal ulcer
    • cholecystitis
  • The Acute Abdomen Rapid Onset of Pain
  • The Acute Abdomen Slow Onset of Pain
  • Acute Cholecystitis
  • Acute Cholecystitis
  • Acute Cholecystitis
  • Acute Cholecystitis -- Gangrene
  • Pneumatobilia
  • Pneumoperitoneum
  • Intestinal Obstruction
  • Intestinal Obstruction
  •  
  •  
  •  
  • Intestinal Obstruction Adhesive Band
  • Intestinal Obstruction
  • Intestinal Obstruction Gallstone Ileus
  • Intestinal Obstruction Incarcerated Strangulating Hernia
  • Intestinal Obstruction Incarcerated Strangulating Hernia
  • Intestinal Obstruction Incarcerated Strangulating Hernia
  • Intestinal Obstruction Incarcerated Strangulating Hernia
  • Acute Abdomen
    • Hepatic abscess
    • Retrocecal appendicitis
    • Appendicitis in pregnant woman
    • RLQ:
    • Appendicitis
    • Cecal diverticulitis
    • Meckel’s diverticulitis
  • Acute abdomen
    • LLQ:
    • Splenic rupture
    • Splenic abscess
    • LUQ:
    • Splenic rupture
    • Splenic abscess
    • Diffuse pain:
    • Bowel obstruction
    • Leaking aneurism
    • Mesenteric isquemia
    • Periumbilical:
    • Early appendicitis
    • Referred pain from small bowel
  • Acute abdomen
    • NonSurgical causes of abdominal pain:
    • RUQ:
    • (RLL) pneumonia
    • Biliary colic
    • Cholangitis
    • Hepatitis
    • Fitz-Hugh-Curtis Syndrome (perihepatitis associated c chlamydial infectionof cervix)
    • Midepigastric:
    • PUD non perforated
    • MI
    • Esophagitis
    • PE
    • Pancreatitis
    • Herpes Zoster
    • Rectus sheat hematoma
  • Acute abdomen
    • RLQ or LLQ:
    • Ureteral calculi
    • Regional enteritis (Crohn’s Ds)
    • Inflammatory bowel Disease (Regional enteritis, UC)
    • PID
    • Endometriosis
    • Prostatitis
    • Mittelschmerz
    • UTI
    • Ruptured ovarian cyst
    • LUQ:
    • LLL pneumonia
    • Gastritis,
    • splenomegaly
  • Acute Abdomen
    • Diffuse:
    • Abdominal wall hematoma
    • Spider bite
    • Lead poisoning
    • Addisonian crisis
    • Sickle cell crisis
    • Diabetic ketoacidosis
    • (DKA)
    • Diabetic gastropathy
    • Opiate withdrawal
  • GI emergencies
    • Appendicitis
    • Ascites
    • Biliary Colic
    • Boerhaave Syndrome
    • Cholangitis
    • Cholecystitis, Acute
    • Cirrhosis
    • Colitis, Ischemic
    • Colitis, Ulcerative
    • Crohn’s Disease
    • Diverticulitis
    • Diverticulosis
    • Gastritis
    • Gastroenteritis
    • Gastroesophageal Reflux Disease
    • Hemorrhoids
    • Hepatic Abscess
    • Hepatic Encephalopathy
    • Hepatitis, Alcoholic
    • Hepatitis, Viral
    • Incarcerated Hernia
    • Intestinal Obstruction
    • Irritable Bowel Syndrome
    • Mallory-Weiss Syndrome
    • Meckel Diverticulum
    • Pancreatitis, Acute
    • Peptic Ulcer Disease
    • Perforated peptic ulcer
    • Variceal Bleeding
  • Acute Abdomen
    • Suprapubic:
    • Ectopic pregnancy
    • Ovarian torsion
    • Tubo-ovarian abscess
    • Incarcerated groin hernia
    • 3. Which of the following is the MOST common cause of painful rectal bleeding?
    • a. internal hemorrhoid
    • b. external hemorrhoid
    • c. diverticulitis
    • d. anal fissure
    • e. rectal foreign body
  • Answer D
    • Anal fissures result from a linear tear of the anal canal beginning at or just below the dentate line and extending distally along the anal canal.
    • Pt’s complain of sharp, cutting pain, most severe during and immediately after a bowel movement.
    • Bleeding is scant and bright red.
    • Anal fissures are especially painful b/c of the rich supply of somatic sensory nerve fibers located in the anoderm
    • All of the following are true regarding acalculous cholecystitis EXCEPT
    • a. it occurs in 5-10% of pt’s with acute cholecystitis
    • b. pt’s are frequently elderly and have a history of DM
    • c. it often occurs as a complication of another process
    • d. diagnosis is difficult due to the subtle clinical presentation
    • e. gallstones are absent
  • Answer D
    • Acalculous cholecystitis occurs in 5-10% of pt’s c cholecystitis.
    • Pts frequently are elderly and have h/o DM
    • There are 2 distinguishing features of acalculous cholecysititis
      • 1. it frequently occurs as a complication of another process
      • 2. pts frequently are gravely ill on initial presentation
    • Which of the following drugs is NOT associated with acute pancreatitis?
    • a. Heparin
    • b. Furosemide
    • c. Rifampin
    • d. Salicylates
    • e. Warfarin
  • Answer A
    • Drugs and toxins are major causes of acute pancreatitis.
    • Some of the meds assoc c the occurrence are OCP’s, glucocorticoids, rifampin, tetracycline, isoniazid, thiazide diuretics, furosemide, salicylates, indomethacin, calcium, warfarin, and acetominophen.
    • Other etiologic factors contributing include infection, collagen vascular ds’s, metabolic disturbances, and trauma
    • In working up a patient with acute abdominal pain, which of the following etiologies is LEAST likely to represent an immediate life threat?
    • a. Myocardial infarction
    • b. Splenic rupture
    • c. Abdominal Aortic Aneurysm
    • d. Perforated duodenal ulcer
    • e. Ruptured ectopic pregnancy
  • Answer D
    • When approaching a pt c acute abd pain, the clinician must consider conditions that can be an immediate threat to the patient’s life.
    • Splenic rupture, ruptured ectopic pregn, and AAA can all be associated with massive bleeding and rapid decline.
    • Extraabdominal conditions that present with abd pain such as MI can also be life threatening.
    • Perforated duodenal ulcer are serious but almost never result in significant hemorrhage, and thus are not usually an immediate threat to life.
    • Which of the following statements is TRUE regarding acute abdominal pain?
    • a. peritonitis causes visceral type of pain and is secondary to peritoneal inflammation from an irritant
    • b. Obstruction of a hollow viscus produces colicky, diffuse visceral pain assoc with N/V
    • c. Intraabdominal causes of pain include bacterial peritonitis, bowel ischemia, and tuboovarian abscess
    • d. referred pain from the abdomen may radiate to the back or groin, but not into the thorax
    • e. Metabolic disorders are rarely a significant source of acute abdominal pain
  • Answer B
    • Three types of pain responses are possible with acute abd pain
      • Peritonitis is a somatic pain and is usually sharper, more constant, and more localized than visceral pain.
      • Obstruction of a hollow viscus is a common cause of visceral pain and is colicky, intermittent, and usually mid-line.
      • Referred pain is often felt in the back, groin, or thighs. Pt’s may also c/o pain in the supraclavicular region especially if the diaphragm is irritated by collections of blood or pus
    • Abd pain can arise from intraabd, extraabd, metabolic, or neurogenic origins.
    • Intrabd origins of pain are divided into 3 categories:
      • Peritoneal inflamm, obstruction of a hollow viscus, and vascular etiologies.
    • Extraabd sources can arise from the abd wall, thorax, or pelvis (as in the case of tubo-ovarian abscess)
    • Metabolic disorders such as DKA and Sickle cell crisis often present with diffuse abd pain
    • All of the following are TRUE regarding the evaluation of a patient with acute abdominal pain EXCEPT
    • a. the onset, location, and severity of pain are useful differentiating factors
    • b. the most important physical examination modality is palpation
    • c. the WBC may be normal even in inflammatory conditions such as appendicitis
    • d. ultrasonography is a valuable imaging tool increasingly available
    • e. analgesic medications should be withheld until a surgeon evaluates the patient because they may obscure the diagnosis.
  • Answer E
    • The evaluation of abd pain should begin with a detailed hx.
    • The onset, severity, location, and character of pain and the presence of associated symptoms guide work-up and tx.
    • Although a complete PE is necessary, palpation of the abd is the most important modality for dx.
    • Lab tests are useful adjuncts, but the limitations of a CBC must be recognized.
    • Helpful imaging modalities include standard XR, U/S, barium contrast studies, and CT
    • IV opiate analgesia is humane and may actually assist in dx by facilitating PE in a pt who could otherwise not tolerate it.
    • Which of the following is the most common cause of upper GI bleeding?
    • a. Esophageal varices
    • b. Mallory-Weiss tear
    • c. PUD
    • d. Erosive gastritis
    • e. Arteriovenous malformations
  • Answer C
    • Upper GI bleeding is defined as bleeding that originates proximal to the ligament of Treitz.
    • PUD, including gastric, duodenal, and stomachal ulcers, is the MC cause of upper GI bleeding (60%)
    • The next MC are erosive gastritis, esophagitis, and duodenitis (15%)
    • Gastric irritants such as ETOH, salicylates, and NSAIDS, predispose pts to upper GI bleeding.
    • Varices (only 6%) from portal HTN in ETOH’ers carry a high mortality rate.
    • Mallory-Weiss syndrome is due to a mucosal tear in the esophagus and is classically assoc c repeated bouts of retching.
    • AV malformations are an uncommon cause of upper GI bleed
    • A pt presents with what appears to be a massive lower GI hemorrhage. Which one of the following is the LEAST likely etiology?
    • a. Diverticulosis
    • b. Angiodysplasia
    • c. Gastric varices
    • d. Duodenal ulcer
    • e. Hemorrhoids
  • Answer E
    • The MC cause of what initially appears to be lower GI bleeding is actually bleeding from an upper GI source.
    • Brisk bleeding from either varices or PUD can be the cause of apparent lower GI hemorrhage.
    • Diverticulosis and angiodysplasia are the MC causes of confirmed lower GI bleed.
    • Both occur more commonly in elderly, are painless, and may be massive.
    • Although hemorrhoids are a common etiology of minor lower GI bleed, usually not significant hemorrhage
    • Other less frequent sources of lower GI bleed include malignancies, IBD, polyps, infectious gastroenteritis, and Meckel’s diverticulum.
    • Which of the following scenarios may represent acute appendicitis?
    • a. a 4 y/o male with vomiting and lethargy
    • b. a 75 y/o female with fever and abdominal pain
    • c. a 26 y/o female who is 32 weeks pregnant with right upper quadrant pain
    • d. a 45 y/o male with AIDS and who has vomiting and diarrhea
    • e. All of the above
  • Answer E
    • Certain groups of pts have atypical presentations and are at risk for delayed dx of acute appendicitis.
    • Children <6 y/o = 57% misdiagnosed; 90% perforation rates
    • Elderly pts, subtle sx, & high perforations
    • Pregnant pts pose difficulty b/c the gravid uterus changes the position of the appendix
    • An U/S can aid in distinguishing pelvic vs abd pathology
    • Immunocompromised are susceptible to delayed dx b/c of their frequent unrelated GI sx.
    • CT is helpful in differentiating surgical from nonsurgical conditions
    • What is the most common cause of large bowel obstruction?
    • a. adhesions
    • b. incarcerated hernia
    • c. Diverticulitis
    • d. Neoplasm
    • e. Sigmoid volvulus
  • Answer D
    • It is important to distinguish between large and small bowel obstruction b/c tx differs
    • The MC cause of colonic obstruction is neoplasm
    • 2 nd MC = diverticulitis, followed by sigmoid volvulus
    • MC SBO = surgical adhesions
    • 2 nd MC SBO = hernias and primary small bowel lesions
    • A 40 y/o female with known gallstones presents with colicky RUQ pain and vomiting. She has a h/o similar episodes that usually resolve after 3-4 hrs. VS: BP 110/60, P 78, R 16, T 98.4*F. PE: mildly tender RUQ without signs of peritonitis. Which of the following would be LEAST appropriate in her ED management?
    • a. IV fluids
    • b. Pain control c opiate analgesics
    • c. pain control c ketorolac
    • d. antiemetic administration
    • e. immediate surgical consultation
  • Answer E
    • Pts with uncomplicated symptomatic cholelithiasis do not require immediate surgical intervention.
    • ED intervention is geared toward pain relief and correction of volume deficits
    • Pain control can be achieved with administration of opiates or ketorolac
    • Antiemetics and gastric decompression with an NGT may be necessary for tx of protracted vomiting.
    • If the pt’s sx resolve within 4-6 hrs and she tolerates oral fluids, D/C home with outpt f/u is appropriate
    • Which of the following is the MOST common presentation of gallstones?
    • a. acute pancreatitis
    • b. acute cholecysitis
    • c. biliary colic
    • d. ascending cholangitis
    • e. gallbladder empyema
  • Answer C
    • Pt’s with gallstones present in a variety of ways, and biliary colic (or symptomatic cholecystitis) is the MC.
    • The pain is colicky in nature, occurs after meals, and typically lasts from 1-6 hrs.
    • Pain lasting longer than 6 hrs that is accompanied by fever or leukocytosis suggests cholecystitis.
    • Biliary colic and acute cholecystitis are by far the MC manifestations of gallstone ds
    • Complications of gallstones may be life threatening.
    • Acute pancreatitis, ascending cholangitis, gallbladder empyema, and emphysematous cholecystitis all require aggressive pt resuscitation and prompt surgical consult
    • What is the MOST common cause of pancreatitis in an urban hospital setting?
    • a. cholelithiasis
    • b. alcoholism
    • c. abdominal trauma
    • d. penetrating peptic ulcer
    • e. salicylate poisoning
  • Answer B
    • Acute pancreatitis is a common cause of abdominal pain.
    • In the US cholelithiasis and alcoholism account for 90%.
    • ETOH related ds is more common in the urban setting, and typically affects males 35-45.
    • Biliary ds is more frequent in the community hospital setting and typically affects females >50.
    • After biliary and ETOH = drugs (1/2 of remaining cases)
    • A 55 y/o female presents to the ED with a fever 4 days after undergoing a laparscopic cholecystectomy. What is the MOST likely cause of the fever?
    • a. Pneumonia
    • b. Thrombophlebitis
    • c. Urinary Tract infection
    • d. Wound infection
    • e. Deep venous thrombosis
  • Answer C
    • Laparoscopic procedures and early postsurgical discharge are becoming increasingly common cost-effective alternatives to laparotomy.
    • As a result, more pts are presenting to the ED with postoperative fever.
    • Fever postop
      • <24 h = atelectasis or necrotizing strept infections
      • 24-72 h = respiratory (pneumonia), IV catheter complications (thrombophlebitis)
      • 3-5 d = UTI’s (MC in female, and pts c cath’s)
      • 7-10 d = wound infections
      • DVT’s can result in fever @ any time, pero usually >5d
    • A pt with suspected cholelithiasis presents to the ED. What is the initial imaging study of choice?
    • a. abdominal plain film
    • b. abdominal ultrasound
    • c. abdominal CT
    • d. Radionuclide scan (HIDA)
    • e. Barium contrast radiography
  • Answer B
    • U/S has emerged as a valuable tool for certain conditions in the ED.
    • It is the initial study of choice for eval of pts with RUQ pain, and can accurately detect cholelithiasis.
    • Plain film is a poor imaging choice to detect gallstones (only 15%), but is useful in evaluating obstruction or suspected perforation.
    • CT is the diagnostic tool of choice for many abdominal conditions including pancreatitis, some trauma, and selected AAA, but is more costly and invasive than U/S for evaluating gallstones.
    • HIDA scan is a useful adjunct if U/S results are inconclusive or acalculous cholecysititis is suspected.
    • Barium studies are useful for imaging in some GI conditions, especially suspected intussusception, but not for eval of GB
    • Which of the following diagnostic study is most useful in the evaluation of a patient in the acute stages of diverticulitis?
    • a. CT scan
    • b. barium enema
    • c. ultrasound of the abdomen
    • d. colonoscopy
    • e. sigmoidoscopy
  • Answer A
    • Both endoscopy and barium enema are contraindicated in pts during acute stages of diverticulitis b/c of risk of perforation.
    • A 28 y/o man has complaints of intermittent, colicky, periumbilical, and lower-quadrant pain for 24 hours. The patient admits to nausea and decreased appetite. He is afebrile. Which of the following is the most likely diagnosis?
    • a. acute appendicitis
    • b. acute pancreatitis
    • c. pyelonephritis
    • d. gastroenteritis
    • e. peptic ulcer disease
  • Answer D
    • The pain pattern is most consistent with a dx of gastroenteritis.
    • Acute appendicitis typically causes periumbilical pain that migrates to the RLQ
    • Acute pancreatitis radiates to the back or shoulder
    • Pyelonephritis is “loin to groin”
    • PUD is typically located in the epigastrum
    • A 7 y/o boy presents with c/o flank pain, fever, frequency, dysuria, and hematuria for 1 day. The UA shows >10 WBC’s per high-powered field, RBC’s, and WBC casts. Of the following, the most likely diagnosis is:
    • a. pyelonephritis
    • b. acute cystitis
    • c. urethritis
    • d. renal calculi
    • e. urinary incontinence
  • Answer A
    • Pyelonephritis is an infection of the renal parenchyma, accompanied by systemic sx such as fever, N/V and assoc with WBC casts in the urine.
    • In pediatric male pt, its occurrence would warrant additional eval to r/o anatomic abnormalities in the urinary tract
    • The most common cause of acute renal failure is:
    • a. prerenal azotemia
    • b. acute parenchymal renal failure
    • c. exogenous nephrotoxins
    • d. obstructive uropathy
    • e. rhabdomyolysis
  • Answer A
    • Prerenal azotemia results from renal hypoperfusion and can be reversed upon restoration of blood flow.
    • It is not associated with structural damage to the kidney and is the most common cause of acute renal failure.
    • A 27 y/o woman with amenorrhea is seen for vaginal bleeding and abdominal pain. An ectopic pregnancy is suspected. Which of the following would support the suspicion?
    • a. enlarged boggy uterus
    • b. ruptured fetal membranes
    • c. adnexal mass
    • d. weak fetal heart beat
    • e. painless profuse bleeding
    • Answer C
    • Classic features of an ectopic pregnancy are abdominal pain, bleeding, and adnexal mass in a pregnant woman.