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What is Visceral Pain?
- Deep, dull, aching pain
- poorly localized
- epigatric or periumbilical
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What is somatic pain?
- sensation conducted via peripheral nerves
- sharp, more intense pain
- moving or coughing aggravates
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What is referred pain?
Pain felt at a distance from its source
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What vital signs are indications of shock?
- Tachycardia
- hypotension
- tachypnea
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What ancillary tests should be ordered for acute abdominal pain?
- UA and HCG(males testicular CA)
- CBC
- LFT - no amylase
- Plain films
- Helical CT
- Ultrasound
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What is Cholelithiasis?
stone which can be found in the hepatic bile canliculi, intra/extrahepatic bile ducts, CBD, and gallbladder
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What is Bile needed for?
- absorption of fats and fat soluble nutrients
- It is produced in the canaliculi
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Things causing enhanced risk of cholesterol stone formation
increased age, female gender, massive obesity, rapid weight loss, cystic fibrosis, parity, drugs, familial tendancies
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Explain BLACK gallstones
- form in the GB
- more common in elderly
- made up of calcium
- associated with disease causing intravascular hemolysis
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Explain BROWN stones
- associated with infection
- form in intra/extrahepatic bile duct
- contains Ca+
- can be seen on Xray
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Clinical features of Cholecystitis
- RUQ pain - referred to right scapula
- N/V
- Prior history of something similar but less severe
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Physical findings of Cholecystitis
- Increased Temp
- tachycardia
- RUQ tenderness/epigastric
- guarding/rebound tenderness
- + Murphys Sign
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Diagnostic stuff for Cholecystitis
- Increased WBC
- LFTs CAN BE elevated (but not always)
- ULTRASOUND * Most usefull
- HIDA scan - most specific
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Aclculous cholecystitis
- Inflammation of the gallbladder without the prescence of stones
- usually elderly
- complication of HIV with infection from CMV
- usually high mortality rate
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What is a porcelain gallbladder?
- Linear/punctuate calcifications within the GB wall
- found in females in their 50s
- high carcinoma rate - most common malignancy
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What is the courvosier sign?
palpable gallbladder
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Acute Pancreatitis - some facts
- Divided in severity based on organ failue or local complications
- Gallstones are most common obstructive cause - 45%
- Chronic ETOH abuse is 2nd common cause
- More common in men, after heavy drinking
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Clinical features of pancreatitis
- epigastric, LUQ, RUQ pain
- rapid onset - minutes
- Pain is constant and severe
- Pain radiates to mid back
- N/V
- Little relief with position change
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Physical exam findings for pancreatitis
- Moderate distress
- rales - pleural effusion possible
- jaundice
- Cullens or Turners sign
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Lab tests for Pancreatitis
- Amylase 70% specific but 100% specific if 3-5x normal
- Lipase 60% specific but 100% specific if 5x normal
- Xray - exclude other things, may show effusions or atelectasis
- CT/US - oral contrast
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Symptoms of Appendicitis
- vague, epigastric pain
- RLQ at McBurneys point
- Pain before vomitting
- no history
- Pt. feels constipated
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Rebound Tenderness
- sign for appendicitis
- Push in at point of pain, pull away after 30 seconds
- Pt. should be in pain
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Rovsings Sign
- push deeply in LLQ
- pull away, pain should be felt in RLQ
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Psoas sign, Obturator sign
- Test for appendicitis
- Psoas-patient supine, pull leg up upon resistance
- Obturator - flexing knee and internal rotate
- *Both cause psoas muscle to rub inflamed appendix
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Inflammatory Markers for appendicitis
- WBC count
- C-Reative Protein
- Interleukin - 6
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Imagine for Appendicitis
- Abdominal plain films
- Barium enema
- Ultrasound
- CT scan
- MRI
- Laproscopy
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Advantages of US
- no radiation, or contrast
- low cost
- widely available
- may find other diagnosis
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Disadvantages of US
- Confounding findings
- Nonvisualization of perforated appendix
- limited view in obese patients
- operator-dependent
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Advantages of CT
- Finds alternative diagnoses
- not-operator dependent
- useful in obese patients
- widely available
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Disadvantages of CT
- Radiation, contrast
- increased cost
- potential false negatives
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Etiology of diverticulitis
fecal matter sequestered in a sac and becomes hard forming a fecolith which compromises the blood supply
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Symptoms of Diverticulitis
- depends on amount of decontamination resulting from perforation
- LLQ
- low grade fever, change in bowel habits
- malaise
- Urinary sx - secondary
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Exam findings of diverticulitis
- LLQ tenderness
- Distention is common
- Rectal bleeding may be seen - more common diverticulosis
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What is the test of choice for Diverticulitis, and what test is used after diagnosis?
- CT scan* test of choice
- Barium enema-excludes other colonic pathology and check for complications
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What will labs show in diverticulitis?
Elevated WBC with bands
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Managagement of diverticulitis
- Most resolve with meds
- Tx of peritonitis, perforation or gas in bowel wall = surgery
- abseccess larger then 5cm = surgery
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What is a simple SBO?
lumen is partially or completely occluded at one or more points, producing distention but no compromise of the blood supply
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What is a Closed Loop SBO?
- bowel obstructed at two sequential sites, usually twisted on an adhesion or hernia opening
- high change of compromising blood flow - strangulation obstruction
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Most common causes for SBO
- ADHESIONS #1
- inflammatory, neoplasm, trauma
- foreign body, gallstones, barium
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What are clinical features of SBO?
- Crampy pain
- recurrent bouts of poorly localized pain
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Explain proximal SBO
- several hours of severe colicky pain
- vomitting
- mild distention
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Explain distal SBO
- A day or two of progressively worsening pain
- more prominent abdominal distention
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What are the 6 clinical indications for high sensitivity of a SBO?
- Age >50
- Previous surgery
- Abdominal distention
- Increased Bowel sounds
- History of Constipation
- Vomitting
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What is the worst things that can happen in relation to SBO?
- Peritoneal signs - pain with cough, shaking or moving
- Tachycardia
- Hypotension
- fever
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Diagnostic tests for SBO
- Plain films - supine and upright
- CT - high accuracy
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Causes of LBO
- Usually elderly
- Carcinoma
- diverticulitis
- volvulus
LBO is less common then SBO
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Clinical features of LBO
- high pitched bowel sounds
- fever
- abdominal tenderness
- possibly peritonitis
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Diagnostic tests for LBO
- Plain films - supine and upright - see dilated bowel
- CT - less helpful in LBO
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AAA epidemiology
- Most below renal arteries
- Most ruptured AAA's have diametes of >5cm
- Most of true aneurysms - involve all three layers
- Men > Women
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Sx of Unruptured AAA
- pain in abdomen, back, or flank
- abdominal mass or fullness
- vague dull, quality, gradual onset of pain
- Most Pt. are Asymptomatic
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Clinical features of RUPTURE AAA
- Pain, Hypotension, Mass
- pain in abdomen, back, flank
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Diagnostic tools for AAA
- plain films, will be seen if large enough
- Cross-table lateral of lumber spine
- *Ultrasound - 100% sensitive
- *CT-100% acurate for diagnosis for stable pt. only
- Pt. with ruptured AAA need to be cross clamped before stable
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