| Term | Definition |
|---|
| 4 main causes of acute abdomen | perforation, obstruction, infection/inflammation, ischemia |
| when is sx the answer for acute abdomen | peritonitis (excluding primary); ab pain/tenderness + sepsis; acute intestinal ischemia; pneumoperitoneum |
| what is primary peritonitis | spont inflamm with nephrosis (children) or ascites and mild ab pain (adults) |
| when is med tx the answer for acute abdomen | primary peritonitis, pancreatitis, cholangitis |
| what do you rule out before doing sx on acute abdomen | pancreatitis |
| what things can mimic acute abdomen | urinary stones, lower lobe pneumonia, MI, PE, ruptured ovarian cysts |
| how does perforation presents | acute ab pain sudden severe constant and generalized pain is excruciating with movement |
| most common causes of GI perforation | diverticulitis, perforated peptic ulcer, crohns dz |
| fever and lower ab pain in elderly pt | diverticulitis |
| epigastric pain classically awakes pt at night and refer pain to scalpula | perforated peptic ulcer |
| how to dx a perforation | supine and erect ab xray (free air under diaphragm or falciform lig) |
| mgmt of perforation | NPO, IV fluids and antibiotics (Flagyl & gentamicin; 2ndgen ceph like cefotetan/cefoxitin), emergency sx |
| mcc of esophageal perf | iatrogenic |
| presentation of esophageal perf | pain in chest/upper ab, dysphagia/odynophagia, subq emphysema post endoscopy |
| first study of choice in esophageal perf | gastrograffin contrast esophogram |
| presentation of obstruction | severe colicky pain; absences of flatus/feces; NV, pt constantly movement |
| risk factors for obstruction | prev sx (adhesions), elderly pt c wt loss, anemia or bloody stool (tumor), hx of recurr lower ab pain (diverticulitis), hx hernia (incarcerated hernia), sudden ab pain in elderly pt (volvulus) |
| dx of obstruction | CBC, lactate level, supine & erect ab xray (look for dilated loops of bowel, absence of gas in rectum, bird beak sign for volvulus) |
| mgmt of obstruction | NPO,NG suct, IV fluids, consider gastrograffin study (if perf isnt r/o), if not corrected emergency sx |
| mgmt of volvulus | proctosigmoidoscopt c rigid instrument, leave rectal tube in place |
| mgmt of recurrent volvulus | sigmoid resection |
| mgmt of ab hernia | elective repair for all ab hernias EXCEPT umbilical in pts < 2yo and esophageal sliding hiatal hernia |
| main causes of inflammatory cause of acute ab | acute diverticulitis; acute pancreatitis; acute appendicitis |
| presentation of inflammation in acute ab | grad onset of ab pain that builds up over several hrs, ill define pain that becomes localized to the site of inflammation |
| are peritoneal signs present in pancreatitis | no |
| presentation of acute diverticulitis | LLQ pain, middle/older pt c fever, leukocytosis, peritoneal irritation in LLQ c palpable tender mass |
| dx of acute diverticulitis | Ab CT (looking for abscess and free air) |
| tx of acute diverticulitis (no peritoneal signs) | manage as outpt c antibiotics |
| tx of acute diverticulitis (local peritoneal signs and abscess) | admit pt, NPO, IV fluids, IV antibiotics |
| tx of acute diverticulitis (Gen peritonitis/perf) | perform emergency sx |
| tx of acute diverticulitis (recurrent attacks of diverticulitis) | perform elective sx |
| presentation of acute pancreatitis | upper ab pain rad to back c NV |
| tx of acute pancreatitis | NPO, NG suction, IV fluids |
| complications of pancreatitis | abscess (after 10 days), pseudocyst (after 5wks), chronic damage |
| tx of pseudocysts | <6cm and pres < 6wks: observe; >6cm or present > 6wks: percutaneous drainage or endoscopic drainage |
| how to tx chronic pancreatitis | tx c insulin and pancreatic enzyme supplements |
| presentation of acute appendicitis | anorexia, vague periumbilical pain that moves to RLQ, tenderness, guarding, rebounding in RLQ |
| dx of acute appendicitis | fever and leukocytosis, get u/s or CT scan if dx is unclear |
| tx of actue appendicitis | IV antibiotics/fluids before appendectomy, if perf: cont IV until fever and WBC ct normalizes |
| warning signs for hemorrhagic pancreatitis | lower HCT that cont to falls day after presentation, very high WBC (>18K), glucose and BUN, very low Ca |
| sx conditions for chronic ulc colitis | 20+ yrs, multiple hospitalizations, if pt needs high dose steroids or immunosuppressant, toxic megacolon |
| presentation of toxic megacolon | ab pain, fever, leukocytosis, epigastric tenderness, massively distended t'verse colon on xr cin the wall of the colon |
| mgmt if ischemia is suspected | straight to sx (embolectomy, revasc) or order angiography (vasodilators/thrombolysis) |
| when to consider an intra-ab abscess | hx of prev operation, truama or intra-ab infex/inflamm |
| dx of intra-ab abscess | CBC and CT c contrast of ab/pelvis |
| mgmt of intra-ab abscess | always drain abscess (sx or perq), give ABs to prevent spread of infex (doesnt cure abscess though) |
| dx obstruction due to biliary stones | u/s, can confirm with ERCP |
| what is ERCP | Endoscopic retrograde cholangiopancreatography; flexible camera (endoscope) is inserted through the mouth, down the esophagus, into the stomach, through the pylorus into the duodenum where the ampulla of Vater (the opening of the common bile duct and pancreatic duct) |
| mgmt of obstruction due to biliary stones | sphincterotomy and remove common duct stone, cholecystectomy should follow |
| presentation of obstructive jaundice caused by tumor | progressive symp in preceeding wks and wt loss |
| main type of tumors to consider for obstructive jaundice | adenoca @ head of pancreas, adenoca of ampulla of vater, cholangocarcinoma in common duct |
| dx obstructive jaundice caused by tumor | u/s, CT scan (if tumor seen get percutaneous bx.; if not seen get ERCP) |
| presentation of biliary colic | brief (about 20 mins) colicky pain in RUQ, rad to rt shoulder and back; triggered by fatty foods s peritoneal signs |
| what is biliary colic | temporary occlusion of cystic duct |
| tx of biliary colic | elective cholecystectomy |
| what is acute cholecystitis | persistent occlusion of cystic duct from a stone |
| presentation of acute cholecystitis | constant pain, fever leukocytosis and peritoneal irritation in the RUQ |
| dx of acute cholecystitis | u/s shows gallstones, thickened gall bladder wall, pericholecystic fluid |
| tx of acute cholecysitis | NG suction NPO, IV fluids antibiotics, elective cholecystectomy (6-12wks post d/c) |
| when is emergency cholecystectomy needed | generalized peritonitis or emphysematous cholecystitis (suggests perf or gangrene) |
| what is acute ascending cholangitis | obstruction of common duct causes obs and ascending infex |
| presentation of acute ascending cholangitis | high fever, high WBC, sepsis, EXTREMELY HIGH alk phos |
| tx of acute ascending cholangitis | IV antibiotics, emergency decompression of common duct (by ECRP or PTC via the liver), eventual cholecystectomy |
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