Gut Instincts
The 6 You Can’t Miss : The 6 critical causes of abdo pain CorePendium tell you to consider.
What are (1) aortic dissection (2) AAA (3) mesenteric ischemia (4) intestinal obstruction (5) perforated viscus (6) ectopic pregnancy
This is the classic pain progression in appendicitis.
What is periumbilical pain that migrates to the RLQ, typically over 12-24 hours.
The most common cause of SBO in adults.
What is Adhesions? (hernias follow)
58yo M w T2DM presents with epigastric discomfort and nausea. Abdomen is soft and nontender.
This is your next move (can’t-miss test)
EKG
What is CT (preferably with IV contrast when evaluating for ischemia)?
A 65yo w AFib develops abrupt, severe, generalized abdominal pain. She is distressed due to pain but her abdomen is surprisingly nontender, nonrigid…. You’re now considering this diagnosis.
What is Acute mesenteric ischemia?
Fewer than this % of patients with acute appendicitis present with the classic combination of RLQ pain, anorexia, n/v.
50%
T/F : a patient who is still having bowel movements cannot have an SBO.
What is False
Continued defecation, including diarrhea can occur in early bowel obstruction.
29yo F with 10wk confirmed IUP, HDS has RLQ abdominal pain and appendicitis is high on your differential.
This is your next move with respect to imaging.
Ultrasound or MRI if necessary (as opposed to CT) should be considered in pregnancy
This is the significance of the phrase ‘surgery begets surgery’ in the setting of abdominal pain history.
Success! You have completed an appropriate evaluation for an undifferentiated abdominal pain patient - these are 4 things CorePendium wants before you send the patient home.
What are (1) benign serial abdominal exams (2) normal vital signs (3) well controlled pain (4) ability to tolerate PO fluids (5) clear return precautions (6) f/u ideally within 12-24 hours.
This percentage of patients with acute appendicitis may have leukocytes on urinalysis (potentially misleading a clinician to make a urinary diagnosis…)
You’re ordering CT for suspected SBO. You specify this on the order for contrast.
What is IV contrast? Oral contrast is generally not necessary and IV helps to evaluate for potential bowel ischemia.
A 12yo M with RLQ tenderness gets a formal ultrasound of his appendix. The report states that the report is ‘nondiagnostic’.
This is your next move.Appendicitis has not been ruled out. Continue your evaluation, serial abdominal examination and consider surgical consult
Your patient with known SBO has now developed fever, tachycardia, guarding, rigidity and pain out of proportion to exam - these two concerning complications are now on your mind…
What are (1) bowel strangulation and/or (2) peritonitis?
These three abdominal emergencies (excluding UTI/pyelonephritis) may present with hematuria on urinalysis.
What are (1) kidney stones (2) appendicitis (3) AAA
In suspected appendicitis, this findings distinguishes a negative imaging study from a non-diagnostic imaging study.
What is visualization of a normal appendix?
A 67yo M w prior abdo surgery presents with vomiting, distention and abdo pain. CT shows a segment of dilated small bowel obstructed at two adjacent points. Lactate is normal and the patient has no peritoneal signs. This is the diagnosis.
What is closed-loop small bowel obstruction - still warrants emergency operative management.
78yo F has significant new abdominal pain. She’s well appearing and her labs are WNL…. You haven’t found a diagnosis :( You’re considering sending her home without imaging…
This is your next move.Strongly reconsider imaging and/or observe with serial exams.
*Patients 65 or older often present atypically
These 3 clinical features should raise your suspicion for perforated or complicated appendicitis (list 3 of 5 possibilities)
What are : (1) ill appearance (2) Fever >39.4C / 102.9 F (3) electrolyte abnormalities (4) dehydration (5) symptoms >24 hrs
This percentage of blood volume (range) may be lost from intra-abdominal hemorrhage before a patient become hypotensive.
Tachycardia may also be a late finding
Modified Alvarado Score (and cutoff value), go!
What is (1) migratory RLQ pain (2) anorexia (3) n/v (4) RLQ tenderness (5) rebound tenderness (6) fever (7) leukocytosis
0-3 appendicitis is unlikely
4-6 further eval indicated, possible appendicitis
>probable, further eval indicated
68yo F with SBO becomes febrile, tachycardia and develops peritoneal signs concerning for bowel ischemia and perforation. In addition to emergency surgical consultation this antibiotic regimen is appropriate.
What is Piperacillin-tazobactam (Zosyn) 3.375g IV q6h - enteric gram negative and anaerobic coverage
(Or ceftriaxone 2g IV q24h + metronidazole 500mg IV q8h) - metronidazole provides added anaerobic coverage
70M arrives hypotensive and diaphoretic with abdo/back pain. He’s unstable. CT scanner is available.
This is your next move.Bedside POCUS (!) for AAA and immediate surgical consult.
These are the key ED management and dispo steps for a stable pt with confirmed bowel obstruction (no peritonitis, no indication for emergent surgery)
What are: make pt NPO, supportive care/ IV fluids, analgesia/antiemetics, surgical consult, consider NG tube decompression, admission