The document discusses the evaluation and management of acute abdominal pain. It describes how acute abdominal pain can be caused by many different intra-abdominal and extra-abdominal conditions ranging from minor to life-threatening. A thorough history, physical exam, and diagnostic testing are needed to make an accurate diagnosis as the cause is often not apparent initially. Common etiologies of acute abdominal pain discussed include appendicitis, cholecystitis, diverticulitis, pancreatitis, bowel obstruction, renal colic, pelvic inflammatory disease, and ectopic pregnancy.
Approach to Management of Upper Gastrointestinal (GI) BleedingArun Vasireddy
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in altered form in the stool (melena). Depending on the severity of the blood loss, there may be symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal bleeding is considered a medical emergency and typically requires hospital care for urgent diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and some rarer causes such as gastric cancer.
The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid replacement is often required, as well as blood transfusion, before the source of bleeding can be determined by endoscopy of the upper digestive tract with an esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can be applied to reduce rebleeding risk. Specific medical treatments (such as proton pump inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal hemorrhage) may be used. Recurrent or refractory bleeding may lead to need for surgery, although this has become uncommon as a result of improved endoscopic and medical treatment.
Approach to Management of Upper Gastrointestinal (GI) BleedingArun Vasireddy
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in altered form in the stool (melena). Depending on the severity of the blood loss, there may be symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal bleeding is considered a medical emergency and typically requires hospital care for urgent diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and some rarer causes such as gastric cancer.
The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid replacement is often required, as well as blood transfusion, before the source of bleeding can be determined by endoscopy of the upper digestive tract with an esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can be applied to reduce rebleeding risk. Specific medical treatments (such as proton pump inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal hemorrhage) may be used. Recurrent or refractory bleeding may lead to need for surgery, although this has become uncommon as a result of improved endoscopic and medical treatment.
Austin Journal of Gastroenterology is an open access, peer reviewed, scholarly journal dedicated to publish articles related to original and latest advancement of in the field of Gastroenterology.
The aim of this journal is to provide a platform for research scholars and academicians around the globe to promote, share, and discuss various new issues and developments in different fields of Gastroenterology. Austin Journal of Gastroenterology accepts original research articles, review articles, case reports and short communication on all the aspects of Gastroenterology.
Austin Journal of Gastroenterology strongly supports the scientific upgradation and fortification in related scientific research community by enhancing access to peer reviewed scientific literary works. Austin Publishing Group also brings universally peer reviewed journals under one roof thereby promoting knowledge sharing, mutual promotion of multidisciplinary science.
Marketing and the Muslim women community in AsiaInsightAsia
See how InsightAsia can help your marketing team strike up a genuine dialogue with a spectrum of Muslim women in the ASEAN region.
Get in touch with InsightAsia at http://www.insightasia.com/offices
Describes the concept of a surgical abdomen, acute abdominal pain, emergency intervention and approach to management, including the controversial use of analgesic and antibiotics in emergency room.
This presentation explains in detail the definition, pathophysiology, signs & symptoms, management, and prognosis of intestinal obstruction, ileus, and volvulus.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
2. Acute Abdomen
• Challenge to Surgeons
• Most common cause of surgical emergency
admission
• Encompass various conditions ranging from
the trivial to the life-threatening
• Clinical course can vary from minutes to hours,
to weeks
• It can be an acute exacerbation of a chronic
problem e.g. Chronic Pancreatitis, Vascular
Insufficiency
5. ASSESMENT
• A Full history
• Thorough physical examination
Diagnosis can be made most of the time by
a good history and a proper physical
examination.
- An exact diagnosis often impossible to make after the initial
assessment, and often relying on further investigation
6. Types of Abdominal Pain:
• Three types of pain exist:
1. Visceral
2. Parietal
3. Referred
7. 1. Visceral Pain
• Due to stretching of fibers innervating the
walls of hollow or solid organs.
• It occurs early and poorly localized
• It can be due to early ischemia or
inflammation.
8. 2. Parietal Pain
• Caused by irritation of parietal peritoneum
fibers.
• It occurs late and better localized.
• Can be localized to a dermatome superficial to
site of the painful stimulus.
9. 3. Referred Pain
• Pain is felt at a site away from the pathological
organ.
• Pain is usually ipsilateral to the involved organ
and is felt midline if pathology is midline.
• Pattern based on developmental embryology.
12. Acute Abdominal Pain
• Two approaches to evaluate pts with acute
abdominal pain:
1. Classification of abd pain into systems
2. Abdominal Topography (4 quadrants)
13. Classification on Abdominal Pain
• Three main categories of abdominal pain:
1. Intra-abdominal (arising from within the abd
cavity / retroperitoneum) involves:
• GI (Appendicitis, Diverticulitis, etc, etc, etc)
• GU (Renal Colic, etc, etc, etc)
• Gyn (Acute PID, Pregnancy, etc)
• Vascular systems (AAA, Mesenteric Ischemia, etc)
14. Classification on Abdominal Pain
2. Extra-abdominal (less common) involves:
• Cardiopulmonary (AMI, etc)
• Abdominal wall (Hernia, Zoster etc)
• Toxic-metabolic (DKA, OD, lead, etc)
• Neurogenic pain (Zoster, etc)
• Psychic (Anxiety, Depression, etc)
3. Nonspecific Abd pain – not well explained or
described.
16. History (S)
• Duration?
• Nausea, vomiting? Bloody? (Coffee grounds emesis?)
• Change in urinary habits? Urine appearance?
• Change in bowel habits? Melena (Dark, tarry stools?)
• Regular food/water intake?
17. History (S)
• Females
–Last menstrual period?
–Abnormal bleeding?
In females, abdominal pain =
GYN problem until proven otherwise
18. Historical features of Abd Pain
• Location, quality, severity, onset, and duration
of pain, aggravating and alleviating factors
• GI symptoms (N/V/D)
• GU symptoms
• Vascular symptoms (A. fib / AMI / AAA)
• Can overlap i.e. Nausea seen in both GI / GU
pathologies.
19. Historical features of Abd Pain
• PMH
– Recent / current medications
– Past hospitalizations
– Past surgery
– Chronic disease
– Social history
– Occupation / Toxic exposure (CO / lead)
20. Physical Exam (O)
• Palpate each quadrant
– Work toward area
of pain
– Warm hands
– Patient on back,
knee bent (if
possible)
– Note tenderness,
rigidity, guarding,
masses
21. Physical Examination of the Abdomen
• Note pt’s general appearance. Realize that the
intensity of the abdominal pain may have no
relationship to severity of illness.
• One of the initial steps of the PE should be
obtaining and interpreting the vitals.
• Pts with visceral pain are unable to lie still.
• Pts with peritonitis like to stay immobile.
22. Physical Examination of the Abdomen
• INSPECT for distention, scars, masses, rash.
• AUSCULATE for hyperactive, obstructive,
absent, or normal bowel sounds.
• PALPATION to look for guarding, rigidity,
rebound tenderness, organomegally, or
hernias.
• Women should have pelvic exam (check FHR if
pregnant).
• Anyone with a rectum should have rectal
exam.
24. Radiographic Test
• Plain abdominal radiographs or abdominal
series has several limitations and is subject to
reader interpretation.
• CT scan in conjunction with ultrasound is
superior in identifying any abnormality seen
on plain film.
25. Specific Diagnoses
• In patients above fifty years of age the top four reasons for
acute abdominal pain are: Biliary Tract Disease (21%,) NSAP
(16%), Appendicitis(15%), and Bowel Obstruction (12%).
• In patients under fifty years of age the top three reasons for
acute abdominal pain are: NSAP (40%,) Appendicitis (32%,)
and Other (13%.)
26. Appendicitis
• Usually due to
obstruction with
fecalith
• Appendix becomes
swollen, inflamed
gangrene, possible
perforation
27. Appendicitis
• Pain begins periumbilical; moves to RLQ
• Nausea, vomiting, anorexia, fever
• Patient lies on side; right hip, knee flexed
• Pain may not localize to RLQ if appendix in odd
location
• Sudden relief of pain = possible perforation
28. Acute Appendicitis
• “In spite of a large number of algorithms and
decision rules incorporating many different
clinical and laboratory features, an accurate
preoperative diagnosis of appendicitis has
remain elusive for more than a century.”
29. Acute Appendicitis
• Clinical features with some predictive value
include:
• Pain located in the RLQ
• Pain migration from the periumbilical area to the RLQ
• Rigidity
• Pain before vomiting
• Positive psoas sign
• Note: Anorexia is not a useful symptom (33% pts not
anorectic preoperatively.)
30. Acute Appendicitis
• Ultrasound can be used for detection, but CT
is preferred in adults and non-pregnant
women.
• The CT scan can be with and without contrast
(oral & IV.)
• A neg. CT does not exclude diagnosis, but a
positive scan confirms it.
31. Peptic Ulcer Disease
• Steady, well-localized
epigastric or LUQ pain
• Described as a “burning”,
“gnawing”, “aching”
• Increased by coffee,
stress, spicy food,
smoking
• Decreased by alkaline
food, antacids
32. Peptic Ulcer Disease
• Erosion of the lining of the stomach,
duodenum, or esophagus
• May cause massive GI bleed
• Patient lies very still with complaint of intense,
steady pain, rigid abdomen with exam,
suspect perforation
33. Gastroesophageal Reflux
• Also known as GERD
• Signs and symptoms
can mimic cardiac
pain.
• Usually onset after
eating.
• Typically resolved with
medication.
34. Cholecystitis
• Inflammation of gall
bladder
• Commonly associated
with gall stones
• More common in 30 to 50
year old females
• Nausea, vomiting; RUQ
pain, tenderness; fever
• Attacks triggered by
ingestion of fatty foods
35. Biliary Tract Disease
• Most common diagnosis in ED of pts > 50.
– Composed of:
• Acute Cholecystitis (acalculus / calculus)
• Biliary Colic
• Common Duct Obstruction (Ascending Cholangitis –
painful jundice / fever / MSΔ).
• Of those patients found to have acute
cholecystitis, the majority lack fever and 40%
lack leukocytosis.
36. Biliary Tract Disease
• Patients may complain of:
– Diffuse pain in upper half of abdomen
– Generalized tenderness throughout belly
– RUQ or RLQ pain.
37. Biliary Tract Disease
• Sonography (US) is the initial test of choice for patients with
suspected biliary tract disease. More sensitive than CT scan to
detect CBD obstruction.
• CT scan is better in the identification of cholecystitis than in
the detection of CBD obstruction.
• Cholescintigraphy (radionclide / HIDA scan) of the biliary tree
is a more sensitive test than US for the diagnosis of both of
these conditions.
38. Biliary Tract Disease
• MR cholangiography (MRCP)
– Has good specificity and sensitivity in picking up
stones and common duct obstructions.
– Less invasive / less complications than ERCP
(ERCP can induce GI perforation, pancreatitis, biliary duct injury)
39. Bowel Obstruction
• Blockage of inside of intestine
• Interrupts normal flow of contents
• Causes include adhesions, hernias, fecal
impactions, tumors
• Cramping abdominal pain, nausea,
vomiting (often of fecal matter),
abdominal distension
40. Small Bowel Obstruction
• SBO may result from previous abdominal surgeries.
• Patient may present with intermittent, colicky pain,
abdominal distention, and abnormal BS.
• Only 2 historical features (previous abd surgery
and intermittent / colicky pain) and 2 physical
findings (abd distention and abn BS) appear to
have predictive value in diagnosing SBO.
41. Small Bowel Obstruction
• Plain abd films has a large number of
indeterminate readings and can be very
limited due to the following:
• Pt is obese
• Pt is bedridden / contracted (limited lateral decub /
upright view)
• Technical limitations
45. Small Bowel Obstruction
• CT scan is better than plain film in detecting
high grade SBO.
• CT scan can also give more info that might not
be seen on plain film (i.e. ischemic bowel)
• Low grade SBO may require small bowel
follow through.
46. Pancreatitis
• Inflammation of pancreas
• Triggered by ingestion of
EtOH; large amounts of
fatty foods
• Nausea, vomiting;
abdominal tenderness;
pain radiating from upper
abdomen straight through
to back
• Signs, symptoms of
hypovolemic shock
47. Acute Pancreatitis
• 80% of cases are due to ETOH abuse or gallstones.
• Other common causes:
– Drugs ( Valproic acid, Tetracycline, Hydrochlorothiazide, Furosemide)
– Pancreatic cancer
– Abdominal trauma/surgery
– Ulcer with pancreatic involvement
– Familial pancreatitis (Hypertriglycerides / Hypercalcemia)
– Iatrogenic (ERCP)
– In Trinidad, the sting of the scorpion Tityus trinitatis is the most common cause of acute
pancreatitis
• Definition :
– Inflammation of the pancreas
– Associated with edema, pancreatic autodigestion, necrosis and possible
hemorrhage
48. Acute Pancreatitis
• Only a minority number of pts present with
pain and tenderness limited to the anatomic
area of the pancrease in the upper half of the
abdomen.
• 50% of pts present with c/o pain extending
well beyond the upper abd to cause
generalized tenderness.
49. Acute Pancreatitis
• The inflammatory process around the
pancreas may cause other signs and
symptoms such as:
– Pleural effusion
– Grey Turner's sign ( flank discoloration )
– Cullen's sign ( discoloration around the umbilicus )
– Ascites
– Jaundice
50. Acute Pancreatitis
• Lipase testing is preferred in ED.
• Other test to consider: (CBC, Amylase, UA and
CE/trop)
• The height of the pancreatic enzyme
elevations do not have prognostic value
• A double contrast helical CT scan stages
severity and predicts mortality sooner than
Ranson’s Criteria.
51. Acute Pancreatitis
• Should consider ICU admission for pts with
high Ranson’s Criteria.
• When making the diagnosis of Acute
Pancreatitis, it maybe necessary to assess
the pt for the following:
1. Biliary pancreatitis
2. Peripancreatic complications
52. Acute Pancreatitis
Biliary pancreatitis
-Due to CBD obstruction.
-Can lead to Ascending Cholangitis
Clinical findings: May have a fever, jaundice / icterus
Lab findings: ↑AST / ALT, ↑Total Bilirubin
Radiological std:
MRCP - Test of choice to get clear images of the pancrease and CBD.
Double contrast CT - can also be use, may have limited view of the CBD – 2nd most
common test to be ordered in ED
Ultrasound – 1st most common test to be order in ED to evaluate for CBD obstruction.
More sensitive than CT scan to evaluate the CBD. Its use is safer in pregnancy.
53. Acute Pancreatitis
Peripancreatic complications:
• Necrosis (Necrotizing Pancreatitis)
• Hemorrhage (Hemorrhagic Pancreatitis)
• Drainable fluid collections (Ruptured Pancreatic Pseudocyst)
– Clinical findings: May have a distended Abd, appear septic,
Cullen’s sign, and / or Grey Turner’s Sign.
– Lab findings: No definite lab test will help in the diagnosis. May
see decrease Hg or ↑Lactic Acid level.
– Radiological test: of choice to evaluate for the above
complications is a double contrast CT scan.
55. Acute Diverticulitis
• Less than ¼ of pts present with LLQ pain.
• 1/3 of pts present with pain to the lower half of
the abdomen.
• 20% of elderly pts with operatively confirmed
diverticulitis lacked abdominal tenderness.
• Elderly pts are at risk for a severe and often fatal
complication of diverticulitis.
(Free perforation of the colon)
56. Acute Diverticulitis
• CT with contrast:
– Test of choice for Acute Diverticulitis.
– Can identify abscesses, other complications, and
inform surgical management strategies.
• US:
– Relies on identification of an inflamed
diverticulum to make the diagnosis which is often
obscured in pts with complicated diverticulitis.
57. Esophageal Varices
• Dilated veins in
lower part of
esophagus
• Common in EtOH
abusers, patients
with liver disease
• Produce massive
upper GI bleeds
58. Renal Colic
• Pts may present with abrupt, colicky, unilateral flank pain that
radiates to the groin, testicle, or labia.
• Hematuria and plain abd films can be helpful however do not
provide a strong support in the diagnostic evaluation of
suspected renal colic.
• Noncontrast helical CT is standard for the diagnosis. IVP has poor
sensitivity and time consuming in ED setting.
• Must rule out AAA.
59. Kidney Stone
• Mineral deposits form in
kidney, move to ureter
• Often associated with
history of recent UTI
• Severe flank pain
radiates to groin, scrotum
• Nausea, vomiting,
hematuria
• Extreme restlessness
60. Acute Pelvic Inflammatory Disease
• Patient may complain of pain / tenderness in
lower abdomen, adnexal or cervix.
• Most importantly patient may complain of
abnormal vaginal discharge (most common
finding).
• Fever, palpable mass, ↑WBC have been
inconsistently associated with PID.
• The best noninvasive test is transvaginal
ultrasound.
61. Ectopic Pregnancy
• Fertilized egg is
implanted outside the
uterus.
• Growth causes
rupture and can lead
to massive bleeding.
• Patient c/o of severe
RLQ or LLQ pain with
radiation.
62. Ectopic Pregnancy
• Symptoms include abdominal pain (most
common) and vaginal bleeding (maybe the
only complaint).
• Female pts (child bearing age) that present
with these symptoms automatically get a
pregnancy test and HCG quantitative level.
63. Ectopic Pregnancy
• If the pt is pregnant, then order a transvaginal
US to evaluate for ectopic pregnancy.
• Clear view of an IUP in 2 perpendicular views
essentially excludes an ectopic pregnancy.
• If an IUP is not seen, this must be interpreted
in the context of the discriminatory zone (DZ)
of the quantitative HCG.
64. Ectopic Pregnancy
• The DZ (1500 mlU/ml) is the threshold level of
serum HCG, above which a normal IUP should be
seen on sonography.
• Although there is a broad range of normal
variation in HCG, failure of levels to increase by
about 66% within 48 h in 1st trim pregnancy
suggests an abnormal gestation (either a
threatened miscarriage or blighted pregnancy
from an ectopic.)
• If the diagnosis is not made with US and there is
still a high suspicion for ectopic than laparoscopy
is indicated.
65. Pelvic Inflammatory Disease
• Inflammation of the
fallopian tubes and
tissues of the pelvis
• Typically lower
abdominal or pelvic
pain, nausea, vomiting
66. Abdominal Aortic Aneurysm
• Localized weakness of
blood vessel wall with
dilation (like bubble on
tire)
• Pulsating mass in
abdomen
• Can cause lower back pain
• Rupture shock,
exsanguination
67. Abdominal Aortic Aneurysm
• Dissections produce chest or upper back pain
that can migrates to abdomen as the dissection
extend distally.
• AAA rather than dissect, it enlarge, leak, and
rupture.
• <50% of pts with AAA present with hypotension,
abdominal/back pain, and/or pulsatile abd mass.
Can present similar to renal colic.
• Neither the presence or the absence of femoral
pulse or an abdominal bruit are helpful clinically.
68. Abdominal Aortic Aneurysm
• Palpation is an important part of physical exam. Maybe
able to detect an enlarged aorta.
• Any stable pt > 50 yrs old presenting with recent onset of
abd / flank / low back pain should have a CT scan to
exclude AAA from the differential diagnosis.
• Can use bedside ultrasound FAST scan, but this will not
provide information about leakage or rupture.
• MRI is limited in its ability to identify fresh bleeding. It is
not an appropriate emergency procedure.
69. Mesenteric Ischemia (MI)
• Diagnosis can be divided into the following:
1. Arterial insufficiency
• Occlusive – Embolic (A. Fib) / Thrombotic
– Embolic MI has the most abrupt onset.
• Nonocclusive – Low flow state (AMI / Shock)
– Usually has clinical evidence of a low flow state ( acute cardiac
disease)
70. Mesenteric Ischemia (MI)
2. Venous – Mesenteric Venous Thrombosis
• Occurs in hypercoagulable states.
• Usually is found in younger pts.
• Has a lower mortality.
• Can be treated with immediate anticoagulation.
71. Mesenteric Ischemia
• Pt is usually older, has significant co-morbidity,
and with visceral type abdominal pain poorly
localized without tenderness.
• Pt may have a diversion for food or weight loss.
• Elevated Lactate level may help in the diagnosis.
• Abd films may have findings of perforated viscus
and / or obstruction.
• May find pneumotosis intestinalis, free fluid,
dilated bowel consistent with an ileus and / or
obstructive pattern on CT scan.
• Angiography is the diagnostic and initial
therapeutic procedure of choice.
72. Ischemic Colitis
• It is a diagnosis of an older patient.
• Pain described as diffuse, lower abdominal pain
in 80% of pts.
• Can be accompanied by diarrhea often mixed
with blood in 60% of patients.
• Compares to mesenteric ischemia, this is not due
to large vessel occlusive disease.
• Angiography is not indicated. If it is performed it
is often normal.
73. Ischemic Colitis
• Can be seen post – Abd Aorta surgery
• The diagnosis is made by colonoscopy.
• A color doppler ultrasound can also be used.
• In most cases only segmental areas of the
mucosa and submucosa are affected.
• Chronic cases can lead to colonic stricture.
• Treatment may include conservative
management or if bowel necrosis occurs surgery
may be needed for colectomy.
74. Extrabdominal Diagnoses of Acute Abdominal
Pain: Cardiopulmonary
• Pain is usually in upper half of abdomen.
• A chest film should be done to look for pneumonia,
pulmonary infarction, pleura effusion, and / or
pnemothorax.
• A neg. film plus pleuritic pain could mean PE.
• If epigastric pain is present one should inquire about
cardiac history, get and ECG, and consider further
cardiac evaluation .
75. Extrabdominal Diagnoses of Acute Abdominal
Pain: Abdominal Wall
• Carnett’s sign: The examiner finds point of
maximum abdominal tenderness on patient.
Patient asked to sit up half way, and if
palpation produces same or increased
tenderness than test is positive for an
abdominal wall syndrome.
• Abd wall syndrome overlaps with hernia,
neuropathic causes of acute abdominal pain
76. Extrabdominal Diagnoses of Acute Abdominal
Pain: Hernias
• Characterized by a defect through which
intraabdominal contents protrude during
increases in the intraabdominal pressure
• Several types exist: inguinal, incisional,
periumbilical, and femoral (common in Female).
• Uncomplicated hernias can be asymptomatic,
aching / uncomfortable, and reducible on exam.
• Significant pain could mean strangulation (blood
supply is compromised) / incarceration (not
reducible).
77. Inguinal Hernia
• Protrusion of the
intestine through a
tear in the inguinal
canal.
• Usually identified by
abnormal mass in
lower quadrant, with
or without pain.
• Strangulation can lead
to necrosis.
78. Toxic causes for
Acute Abdominal Pain
• Pt may present with symptoms of N/V/D and/or +/- fever to
suggest a gastroenteritis or enterocolitis.
• Most of these infections are confine to the mucosa of the GI
tract, therefore, pts may not present with significant tenderness.
• Other Infectious etiology that can cause abd pain includes: Gp A
Beta Hem. Strep Pharyngitis, Henoch-Schonlein purpura, Rocky
Mountain spotted fever, Scarlet fever, early toxic shock
syndrome.
79. Other Toxic causes for
Acute Abdominal Pain
• Other toxic cause includes poisoning and OD
– Black Widow Spider Abd muscle spasm
– Cocaine induced intestinal ischemia
– Iron poisoning
– Lead toxicity
– Mercury salts
– Electrical injury
– Opoid withdrawal
– Mushroom toxicity
– Isopropranol induced hemorrhagic gastritis
80. Metabolic causes for
Acute Abdominal Pain
• DKA
• AKA (ETOH)
– Note both AKA / DKA can be a cause or a
consequence of acute pancreatitis.
• Adrenal crisis
• Thyroid storm
• Hypo / hypercalcemia
• Sickle cell crisis – consider these causes for pain
splenomegaly / heptomegaly, splenic infarct,
cholecystitis, pancreatitis, Salmonella infect, or
mesenteric venous thrombosis.
81. Neurogenic causes for
Acute Abdominal Pain
• “Hover Sign” – the pt show signs of discomfort
when the examining hand is hovering just
above or is passed very lightly over the area of
dysesthesia.
• Zosteriform Radiculopathy- follows
dermatome distribution and is characterized
by shooting or continuous burning sensation.
• May be due to diabetic neuropathic
involvement of root, plexus, or nerve.
82. NSAP causes for
Acute Abdominal Pain
• A good portion of ER patients will have
nonspecific abdominal pain.
• Patients may have nausea, midepigastric pain,
or RLQ tenderness.
• The lab workup is usually normal.
• WBC may be elevated.
• Diagnosis should be confirm with repeated
exam.
83. Special Considerations
• In pts >50 you must consider mesenteric
ischemia, ischemic colitis, and AAA.
• In an elderly patient symptoms do not manifest
in the same manner as those younger.
• Compared to young pts, only 20% of elderly pts
with abdominal pain will be diagnose with NSAP
• Assume an elderly patient has a surgical cause of
pain unless proven otherwise.
• 40% of those > 65 yrs old that present to ED with
abdominal pain need surgery.
84. HIV/AIDS
• Enterocolitis with diarrhea and dehydration is
most common cause of abdominal pain.
• CMV related large bowel perforation is
possible.
• Watch for obstruction due to Kaposi Sarcoma,
lymphoma, or atypical mycobacteria.
• Watch for biliary tract disease (CMV,
Cryptosporidium.)
85. Treatment of Acute Abdominal Pain
• Hypotension:
– In younger pts probably due to volume depletion
from vomiting, diarrhea, decreased oral intake or
third spacing.
• Treatment would be isotonic crystalloid.
– Younger patients may also have abdominal sepsis
(septic shock).
• Treatment would include isotonic crystalloid,
antibiotics, and vasopressors (levophed or dopamine).
86. Treatment of Acute Abdominal Pain
• Hypotension:
– In older patients CV disease should be added to
the differential.
• If AMI is the diagnosis, a aortic balloon pump may be
needed until angioplasty or bypass is done. If CHF is
diagnosed than dobutamine with isotonic crystalloid
may be used
– Must also consider hemorrhage as a cause:
• Initiate treatment with isotonic crystalloid then
consider blood transfusion
87. Treatment of Acute Abdominal Pain
• Analgesics:
– Though in past ER physicians did not treat acute
abdominal pain with analgesics for fear of altering
or obscuring the diagnosis, current literature
favors the use of opoids judiciously in such
patients.
88. Treatment of Acute Abdominal Pain
• Antibiotics:
– Must be consider when treating suspected
abdominal sepsis or diffuse peritonitis.
– Coverage should be aimed at anaerobes and aerobic
gram negatives.
– If SBP suspected, must cover for gram positive
aerobes.
– Examples of mononotherapy are cefoxitin, cefotetan,
ampicillin-sulbactam, or ticarcillin-clavulanate.
89. Disposition of Acute Abdominal Pain
• Indications for admissions:
– Pts who appear ill.
– Very young / Elderly
– Immunocompromised
– Unclear diagnosis
– Intractable pain, nausea, or vomiting
– Altered mental status
– Those using drugs, alcohol, or that lack social
support.
– Pts with poor follow-up and/or noncompliant.
90. Disposition of Acute Abdominal Pain
• Non-specific abdominal pain
– If this is the working diagnosis, patients must be
re-examined in 24 hours. This may be done in the
outpatient setting.
91. ??? QUESTION #1 ???
• A 45 year-old male patient presents with severe abdominal pain which is
worse with movement. He has fever, tachycardia, tachypnea and a
narrow pulse pressure. There is guarding, and rebound tenderness in the
right lower quadrant. Which of the following is the most likely diagnosis?
A. Perforated appendicitis
B. Acute unperforated appendicitis
C. Perforated gallbladder
D. Ruptured diverticulum
E. Acute cholecystitis
92. ??? QUESTION #2 ???
• A 45 year-old male with peptic ulcer disease (PUD) presents to the ED
with an abrupt onset of severe epigastric pain 1 hour prior to arrival. Abd
exam leads you to suspect an early acute surgical abdomen. Describe the
findings and treatment with this complication of PUD. Physical
examination findings suggestive of perforation include all of the following
except?
A. A reactive pleural effusion is frequent seen with gastric perforation.
B. Tympany may indicate free air, confirmed by upright chest x-ray or
lateral decubitus film
C. Acute pancreatitis may result from posterior perforation.
D. Chemical peritonitis progresses to abdominal rigidity, bacterial
peritonitis and sepsis.
93. ??? QUESTION #3 ???
• Acute pancreatitis may range from mild inflammation to severe
hemorrhagic pancreatitis with extensive necrosis of the gland. Serum
amylase and lipase are elevated. Laboratory findings suggesting a poor
prognosis include all of the following except:
A. Elevated blood glucose
B. Elevated hematocrit (due to dehydration)
C. Elevated LDH
D. Elevated WBC
E. Elevated AST
94. ??? QUESTION #4 ???
• Most hernias are asymptomatic, but signs and symptoms may include all
of the following except:
A. Chronic postprandial pain and belching.
B. Nausea and vomiting with pain, inflammation and toxicity, progressing to
perforation, peritonitis and sepsis with strangulated hernias.
C. Abdominal or focal pain and tenderness, possibly with signs of
obstruction with incarceration. Possibly tachycardia and fever,
leukocytosis and left shift.
D. Local swelling; intermittent "dragging" sensation or minor aching
discomfort.
95. ??? QUESTION #5 ???
• All of the following are true regarding the plain radiographic evaluation of
bowel obstruction except:
A. A stepladder pattern of air-fluid levels suggests obstruction.
B. Gas in the rectum or sigmoid excludes obstruction.
C. A dilated loop may terminate abruptly at the site of obstruction.
D. Obtain an upright chest x-ray to exclude free air in the abdomen.
E. Obtain flat and upright abdominal films or decubitus films to look for
air fluid levels.
F. Dilated loops without stepladder air-fluid levels may be due to ileus.
96. ANSWERS
1. A -These findings are highly suggestive of bacterial peritonitis and
sepsis.
2. A
3. B
4. A
5. A -With complete obstruction, distal gas will usually be absent. Gas may
still be present early in obstruction, however, or may be introduced
during the rectal examination.