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Flashcards in surgical abdomen Deck (49):
1

Sudden/rapid onset and escalation

1. Vascular -

hemorrhage, ischemia

2

Sudden/rapid onset and escalation
Perforation

hollow viscous, ulcer/tumor erosion

3

meds that matter with a surgical abdomen

Steroids
coumadin

NSAID’s
Pepto Bismal
anticholenergics
CAM
current/recent antibiotics

4

Sudden/rapid onset and escalation

1. Vascular - hemorrhage, ischemia

2. Perforation - hollow viscous, ulcer/tumor erosion

3. Rupture - appy, ectopic pregnancy, ovarian etiology

4. Obstruction - bowel, gallbladder, ureter

5. Trauma

5

PMH you want to consider in a surgical abdomen

GI, DM, atherosclerosis, cardiac, renal, CA, Sickle Cell, HIV

6

Elderly - pain out of proportion to exam

Think mesenteric ischemia

7

Stimulants w/ abdominal pain (stimulants are vasoconstrictors)

Think mesenteric ischemia

8

Abd pain, hypotension, tachy, pale, syncope

think

hemorrhagic
AAA
Massive GI bleeds
hemorrhagic pancreatitis
eroding tumors
massive bleeding in pregnancy

9

Testicular torsion

Testicle pain, abd/flank pain (referred)
Doppler ULS

refer to a urologist

10

ddx for all female pelvic pain

i. In DDx for all female pelvic pain
ii. +/- Ovarian cyst hx
iii. Formal ULS for flow, upreg

11

Ischemic colitis - General Surgeon

Hx Crohn’s, ulcerative colitis
ii. Fever, WBC’s/lactate up, +/- peritoneal; CT for dx

12

incarcerated vs strangulate

Can’t reduce incarcerated

skin over the hernia is hot, red, and hurts to the touch, fever; WBC’s, lactate up

13

Mesenteric ischemia

can be

SMA or IMA

14

mesenteric ischemia presentation

Pain out of proportion to exam – severe tenderness but soft abd, non-peritoneal
N/V/D, bloody BM, hx pain after eating

15

labs seen with mesenteric ischemia

Metabolic acidosis, high WBC’s, lactic acid, amylase; hypotension, tachycardia

16

dx mesenteric ischemia

CT angiography for dx



IV fluids, antibiotics, surgical consult
Time to surgery predictor of survival

17

different presentation with elderly

Mesenteric Ischemia
AAA
Appendicitis
Acute Cholecystitis
Perforated Peptic Ulcer


20-40% of elderly w/ abdominal pain will require surgery!

>60yo + Abd Pain = High Risk patient

18

Small Bowel Obstruction

Intermittent, crampy, periumbilical
Rapid, not sudden onset - hours

Intermittent, crampy, periumbilical
Rapid, not sudden onset - hours

Distention, diffusely tender, “tinkling” bowel sounds

Dehydration, low grade temp, tachy/tachy, +/- hypotension

19

Intermittent, crampy, periumbilical
Rapid, not sudden onset - hours

first orders and second orders

IV fluids, pain control, antiemetic, belly labs, lactic acid, EKG, CXR-KUB


Dehydration, low grade temp, tachy/tachy, +/- hypotension

20

Bowel Obstruction

functional

Ileus - adynamic/paralytic; bowel stops functioning due to infection, irritation, inflammation -->
Search for the cause and fix it
Distention both large/small bowel
“Sentinal Loop” can be seen in both

21

Mechanical

Obstruction, compression, rotation

Usually needs surgical intervention

22

sentinal loops

is a sign seen on a radiograph that indicates localized ileus from nearby inflammation.

functional;

23

MCC of LBO

CA

24

Labs that would indicate necrosis in a pt owth LBO

Fever, toxic, WBC’s or high lactate = worrisome for necrosis

25

Ogilvie’s Syndrome)

Distended large bowel but not obstructed

Think tricyclics, anticholenergic agents

in old people

26

Elderly, bedridden, psych, anticholinergics
Same presentation as LBO

Elderly, bedridden, psych, anticholinergics
Same presentation as LBO

think

volvulus

27

MC site of a volvulus

Sigmoid (most common)

cecal


CT AP IV contrast for dx and for location
Antibiotics, surgical consult

28

Pneumoperitoneum

Perforated viscous: air, bowel contents escape – air rises, see it under diaphragm
Rapid onset, constant, epigastric then generalized pain
Vomiting; fever 50%; tachy/tachy

29

RF for pneumoperitoneum

Hx PUD/gastritis, NSAIDS, steroids. CXR negative in 50%! Get CT

30

51yo male, epigastric pain

WBC 17k,
Lactate 3.0

31

Cholecystitis labs seen with

LFT’s: AST 95 (nl ~5-35), ALT 112 (nl ~10-40), Alk Phos 180 (nl ~40-140), T.Bili 2.2 (nl ~0.3-2.0)

32

charcots triad what is it and what is it for

RUQ pain, fever, jaundice

Plus - shock, altered mental status


reynolds

cholangitis

33

unlikely alvardo

5 unlikely

34

possible alverado

5-6 possible

35

probably appy alvarado

7-8 prob,

36

probably alvarado

>9 very prob

37

how would retrocecal appy present

(flank/genital pain),

38

pelvic appy sxs

(rectal/pelvic pain: less abd pain

39

psitive psoas, obturator, rebound, Rovsings seen when

9. Positive psoas, obturator, rebound, Rovsings
a. ONLY if peritoneal irritation – late signs, usually perf’ed

40

presentations of appy in elderly

No RLQ pain in 25%, no migration of pain in 50%

UTI, kidney stone, AGE all common misdiagnoses

41

story of TOA

a. Late progression/complication of PID
b. Low abd pain, n/v, fever, +CMT
c. Hypotensive? Sepsis if ruptures

42

TOA workup

Endovaginal US first, then CT for extent

43

Sudden unilateral pain, n/v, usually afebrile

d. Endovaginal US w/ doppler for flow, cysts
e. Gyn consult, admit


12-24 hr

44

Sudden unilateral pain, +/- n/v

Transabd US for fluid, endovag US for DDx

45

MCC of 1st trimester bleeding

Pregnancy MAY progress or ABORTION MAY follow **MC of 1st Trimester BLEEDING

NO POC expelled from Uterus

closed

46

threatened picture

5wks - gestational sac with fetal cardiac activity

Supportive: Rest @ HOME Return to ER if SX. Persist of PASAGE of POC.
*Serial B-hCG to se if Doubling

47

• Os closed
• +/- abd pain, no passage of POC’s
• No fetal cardiac activity on EVUS

Missed abortion (fetal death <20wks)

48

Septic abortion

• EVUS: thickened, irregular endometrium, no clear sac

• Os open or closed
• Abd pain, fever, + CMT, foul smelling d/c, may be peritoneal

49

what do you do for a packer.

Go-Lytely (they will poop it all out) if stable, not obstructed

Plain KUB, CT if need surgery to remove