EMed - Abdominal Emergencies

esophageal varices (extremely dilated sub-mucosal vv in the esophagus) d/t portal HTN in presence of cirrhosis or other liver dz

What is the MCC of esophageal hemorrhage?

portal HTN leading to esophageal hemorrhage

A venous hum is most commonly associated with...?

octreotide or somatostatin

What medications should be considered in the case of esophageal hemorrhage to reduce portal venous pressure?

prompt IV access for fluid resuscitation

What is the 1st step in the management of esophageal hemorrhage?

endoscopic sclerotherapy - inject Na+ tetradecyl sulfate or Na+ morrhuate

What endoscopic therapy is done for esophageal hemorrhage?

subcutaneous emphysema palpable in the neck/chest

acute onset of pain usually located in the lower anterior chest or upper abdomen,

classic presentation of spontaneous rupture = severe vomiting or retching followed by acute, severe chest pain or epigastric pain

What is a common presentation of esophageal perforation/rupture?

esophageal perforation

If your patient has fever, pain in neck, upper back, chest, or abdomen, dysphagia, odynophagia, dysphonia, or dyspnea and also has a known ingestion of chemicals or foreign body (FB), what should be suspected?

associated with esophageal perforation

Mackler triad: vomiting, chest pain, subcutaneous emphysema

Hamman sign: raspy, crunching sound heard over the precordium with each heartbeat caused by mediastinal emphysema (often w/ thoracic or abdominal perforation)

What are the Mackler triad and the Hamman sign and with what are they associated?

after a NEG gastrograffin UGI series

When should a barium study for suspicion of esophageal perforation occur?

free air in the mediastinum & abdomen (suggests a large leak)

rupture is spontaneous (watch out for contamination by food debris)

pt is unstable

sepsis

evidence suggests hydropneumothorax or a large pneumothorax

When would you want to perform surgery on a patient with an esophageal perforation?

coins

What is the most common radiopaque object swallowed by children?

70% lodged at thoracic inlet (area on CXR b/w clavicles)

15% mid-esophagus (area on CXR where aortic arch and carina overlap esophagus)

15% LES

What is the most common place of FB complications/impaction?

esophageal FB ingestion

Drooling is a common sx of _______________?

gallstones followed by alcoholism

What is the MCC of acute pancreatitis?

acute pancreatitis

The following are s/sx of...?: abd pain, n/v, possibly guarding/rebound, decreased bowel sounds (ileus), jaundice, steatorrhea (pale, foul-smelling/oily stools)

amylase and lipase (but lipase is more specific)

What labs are good for checking for acute pancreatitis?

Grey Turner's sign: flank ecchymosis

Cullen's sign: umbilical ecchymosis

What PE findings may be seen with acute pancreatitis?

CT scan with contrast

What is the most ordered imaging test to look for pancreatitis?

ERCP (endoscopic retrograde cholangiopancreatography)

Early ____________ (within 24-72 hrs) is known to reduce morbidity and mortality for patients with pancreatitis. It is used to treat bile duct stones, show pancreatic divisum, show sphincter of Oddi dz, and watch of aggravation or induction of pancreatitis, but it is more invasive (watch for bleeding).

pts w/ symptomatic necrotizing pancreatitis

treat mainly with carbapenems (imipenem mainly)

What patients with pancreatitis should get ABX?

early pain often generalized/periumbilical then moves to and localizes @ the RLQ (McBurney's point)

low-grade fever after onset of other sxs

What is the typical presentation of appendicitis?

pregnant females, children, elderly, immunocompromised, DM, obese

With what populations should you have a high level of suspicion of appendicitis?

pt lying down, flexing hips, drawing knees up (reduces movement)

psoas sign

obturator sign

rovsing's sign (palpation/rebound in LLQ produces pain in RLQ)

What are the typical physical exam findings of appendicitis?

CT scan of abd/pelvis with PO contrast

What is the best imaging for appendicitis?

surgery or ABX (zosyn, unasyn)

How do you treat appendicitis?

obstruction of the cystic duct from cholelithiasis (i.e., calculous cholecystitis)

acalculous cholecystitis

What are the 2 major causes of cholecystitis?

upper abdominal pain that radiates to the R scapula

often starts in the epigastric region but then localizes to the RUQ

pain is often colicky at first but then becomes constant

How will a patient with cholecystitis present?

persistence of severe pain for > 6 hrs

How is cholecystitis differentiated from biliary colic?

Murphy's sign (associated with cholecystitis)

tenderness and inspiratory pause with palpation of the RUQ

HIDA scan

What imaging modality for cholecystitis is described by the following?:

- NL exam shows filling of the GB, common bile duct, and small bowel within 30-45 minutes; if the GB does not fill, indicative of cholecystitis; can get EF with use of CCK

gangrene, perforation

What cases of cholecystitis would warrant an immediate cholecystectomy?

sigmoid colon (has the highest intraluminal pressures)

What is the m/c location of diverticula?

diverticulosis

uninflamed diverticula; associated with low-fiber diet, constipation, and obesity

diverticulitis

inflammation of one or more of the diverticula

constipation d/t inflammation, localized abd tenderness (usually in LLQ)

What are common presenting sxs of diverticulitis?

CT scan (will show thickening of bowel wall and fascia, pericolic fat stranding, and local abscess formation)

What is the preferred imaging of choice for suspected diverticulitis?

clear liquid diet

ABX therapy (cipro or bactrim and metronidazole; or can just give augmentin)

How do you treat uncomplicated diverticulitis?

UGIB: b/w pharynx and ligament of Treitz (hematemesis and melena)

LGIB: past ligament of Treitz (BRBPR - bright red blood per rectum (hematochezia))

How do you differentiate a UGIB from a LGIB?

mesenteric ischemia

decreased blood flow that results in ischemia and hypoperfusion @ cellular level; SEVERE abdominal pain that is OUT OF PROPORTION to abd exam findings (pain is poorly localized, and episodes of prior pain after meals may be reported)

1) GI emptying

2) abdominal pain

3) underlying cardiac dz

What is the classic triad of SMA embolism (may be associated with mesenteric ischemia)?

angiography

What is the gold standard for dx of mesenteric ischemia?

peritonitis

All cases of mesenteric ischemia with signs of _________________, regardless of etiology, generally require immediate surgical intervention for the resection of ischemic or necrotic intestines.

dx: peptid ulcer dz (PUD)

etiologies: H. pylori infxn, NSAID use

ulcerations in the gastric or duodenal mucosa that extend through the muscularis mucosa; What is the most likely dx, and what are the m/c etiologies?

True

True or false: Patients with PUD may experience hematemesis/melena and epigastric pain (gnawing/burning sensation, 2-3hrs post-meal, relieved w/ food/antacids, wake up @ night, radiate to back).

melena

Do patients with PUD have melena or hematochezia?

urea breath test OR fecal antigen test... NOT the antibody test

How do you dx an active H. pylori infxn?

if H. pylori --> triple therapy w/ PPI/H2 blocker + ABX

not H. pylori --> PPI or H2 blocker therapy

How do you treat PUD?

perirectal abscess

arises from infxn of the mucus-secreting anal glands which drain into anal crypts; 25-50% form fistulas

with sitting and immediately before defecation

When is the pain from a perirectal abscess the worst?

perianal, perirectal, perirectal abscess

Rectal abscesses --> a tender fluctuant mass may be palpable @ the anal verge (_________ abscess) or on rectal exam (__________ abscess). _____________ may be more involved wiht fistula formation.

True

True or false: Perirectal abscesses need surgical consult.

adhesions then hernias

What is the MCC of a SBO?

SBO

obstruction of the small bowel leads to proximal dilation of the intestines d/t accumulation of GI secretions and swallowed air

early: diarrhea

late: constipation

When are constipation and diarrhea most common for a SBO?

early: hyperactive

late: hypoactive

When are hyperactive vs hypoactive bowel sounds most common for a SBO?

strangulation or malignancy

Rectal blood d/t a SBO may suggest...?

dilated small-bowel loops with air fluid levels

absent or minimal colonic gas

What will be seen on an abdominal series of a SBO?

thrombosed hemorrhoids

swelling of the enlarged, painful vv in the rectum that allows for blood to pool and clot