Podcast
Questions and Answers
What is the primary cause of acute pancreatitis in most cases?
What is the primary cause of acute pancreatitis in most cases?
Which condition is least likely to result in high-output heart failure?
Which condition is least likely to result in high-output heart failure?
In the case of diverticulitis, which imaging is not typically performed immediately after diagnosis?
In the case of diverticulitis, which imaging is not typically performed immediately after diagnosis?
Which imaging finding is characteristic of sigmoid volvulus?
Which imaging finding is characteristic of sigmoid volvulus?
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What treatment is recommended for Ogilvie syndrome after 48 hours of conservative management?
What treatment is recommended for Ogilvie syndrome after 48 hours of conservative management?
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Which symptom would most likely indicate a colovesical fistula?
Which symptom would most likely indicate a colovesical fistula?
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What is the most common cause of small bowel obstruction?
What is the most common cause of small bowel obstruction?
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Which of the following conditions is associated with electrolyte abnormalities leading to colonic pseudo-obstruction?
Which of the following conditions is associated with electrolyte abnormalities leading to colonic pseudo-obstruction?
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What is the next best step in management (NBSIM) for a patient with blunt trauma to the abdomen who is unstable?
What is the next best step in management (NBSIM) for a patient with blunt trauma to the abdomen who is unstable?
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In case of a patient with urinary retention after an MVC with suprapubic tenderness, what is the next best step in management?
In case of a patient with urinary retention after an MVC with suprapubic tenderness, what is the next best step in management?
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What complication arises in a patient with a liver laceration accompanied by diaphragmatic rupture and right shoulder pain?
What complication arises in a patient with a liver laceration accompanied by diaphragmatic rupture and right shoulder pain?
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What is the NBSIM for an intraperitoneal rupture of the bladder with signs of peritonitis?
What is the NBSIM for an intraperitoneal rupture of the bladder with signs of peritonitis?
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What is the appropriate management for a recent abdominal surgery patient presenting with fever and abdominal pain?
What is the appropriate management for a recent abdominal surgery patient presenting with fever and abdominal pain?
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If a patient has a peptic ulcer disease and presents with sudden hypotension and severe abdominal pain, what condition is most likely?
If a patient has a peptic ulcer disease and presents with sudden hypotension and severe abdominal pain, what condition is most likely?
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A child presents with epigastric pain after a handlebar injury and elevated amylase/lipase levels. What is the likely diagnosis?
A child presents with epigastric pain after a handlebar injury and elevated amylase/lipase levels. What is the likely diagnosis?
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What is the immediate management for a massive GI bleed?
What is the immediate management for a massive GI bleed?
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What is the first-line treatment for perforated appendicitis?
What is the first-line treatment for perforated appendicitis?
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Which imaging technique is recommended for diagnosing a psoas abscess?
Which imaging technique is recommended for diagnosing a psoas abscess?
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What is the most appropriate initial management for a patient diagnosed with acute mesenteric ischemia?
What is the most appropriate initial management for a patient diagnosed with acute mesenteric ischemia?
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What condition is characterized by severe abdominal pain with rebound tenderness and guarding in a patient with a history of ulcerative colitis?
What condition is characterized by severe abdominal pain with rebound tenderness and guarding in a patient with a history of ulcerative colitis?
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In which situation is percutaneous cholecystostomy indicated rather than cholecystectomy?
In which situation is percutaneous cholecystostomy indicated rather than cholecystectomy?
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What is the most common risk factor for an abdominal aortic aneurysm (AAA)?
What is the most common risk factor for an abdominal aortic aneurysm (AAA)?
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What should be the next step if a patient with a new finding of a 5.5 cm AAA on imaging is identified?
What should be the next step if a patient with a new finding of a 5.5 cm AAA on imaging is identified?
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What is the most likely diagnosis for a young female presenting with sudden-onset abdominal pain and a history of a cyst found on imaging?
What is the most likely diagnosis for a young female presenting with sudden-onset abdominal pain and a history of a cyst found on imaging?
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What should be done for a patient with blunt abdominal trauma suspected to have kidney injury?
What should be done for a patient with blunt abdominal trauma suspected to have kidney injury?
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What treatment is indicated for a patient with spontaneous bacterial peritonitis?
What treatment is indicated for a patient with spontaneous bacterial peritonitis?
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What is the next best step in management for appendicitis in a patient when imaging is indicated?
What is the next best step in management for appendicitis in a patient when imaging is indicated?
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What is the optimal treatment for pelvic inflammatory disease?
What is the optimal treatment for pelvic inflammatory disease?
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Study Notes
Abdominal Trauma & Injuries
- Blunt abdominal trauma: Stable patients with no rebound tenderness or guarding undergo CT abdomen; unstable patients receive FAST scan followed by diagnostic peritoneal lavage (if FAST is inconclusive).
- Penetrating abdominal trauma: Patients require exploratory laparotomy (ex lap).
- Retroperitoneal Hematoma: Patients with back pain, hypotension, and instability after cardiac catheterization may have retroperitoneal hematoma/hemorrhage. Immediate embolization angiography is indicated.
- MVC related abdominal injuries: Patients with minimal urine output, suprapubic tenderness, or fullness can have urinary retention or cauda equina syndrome. Urinary catheterization is the initial management.
- Spleen rupture: MVC patients with left shoulder pain and Kehr sign (referred pain) might have a spleen injury, requiring vaccination against SHiN organisms.
- Liver laceration: Patients with right shoulder pain after blunt trauma to the abdomen may have a liver laceration potentially with a diaphragmatic (left side) rupture.
- Subphrenic abscess: Post-abdominal surgery patients presenting with fever and abdominal pain for days may have a subphrenic abscess.
Other Abdominal Conditions
- Diaphragmatic hernia: Newborns with abdominal contents in the thoracic cavity are at risk for diaphragmatic hernia, arising from the pleural peritoneum membrane.
- Traumatic pancreatitis: Epigastric/back pain along with increased amylase/lipase levels (after a handlebar injury and/or MVC) indicate potential traumatic pancreatitis.
- Duodenal hematoma: Children and adults with handlebar injuries, epigastric or back pain, a pulsatile mass, hematemesis, and low hemoglobin are prone to duodenal hematoma.
- Gastroduodenal artery laceration Perforation of peptic ulcer disease with sudden hypotension, low hemoglobin, and severe abdominal pain commonly involves a gastroduodenal artery laceration, requiring urgent endoscopy (EGD).
- Massive GI bleeds: Immediate management includes large-bore IV catheters, fluids, and blood products, with surgical intervention if necessary.
- Appendicitis: Patients with RLQ pain, fever, leukocytosis (increased white blood cells), and positive psoas, obturator, or Rovsing signs likely have acute appendicitis. Immediate surgical intervention (ex lap or laparoscopic appendectomy) is standard in acute appendicitis. Perforated appendicitis warrants rapid appendectomy. Appendiceal abscess treatment involves antibiotics and drainage followed by appendectomy.
- Psoas abscess: Gradually worsening RLQ pain, fever, and leukocytosis over days suggest a psoas abscess requiring CT and antibiotic treatment (ciprofloxacin + metronidazole or cefazolin). Note the difference in presentation from acute appendicitis, which is more acute.
- Ruptured ectopic pregnancy: Young adult females presenting with RLQ pain, fever, leukocytosis, and a positive B-hCG are likely suffering from a ruptured ectopic pregnancy.
- Acute mesenteric ischemia: Patients with a history of recent MI and irregular heart rhythms might have acute mesenteric ischemia (superior mesenteric artery is compromised); angiography is crucial, with possible bowel resection.
- Chronic mesenteric ischemia: LUQ pain, weight loss, and systemic hypotension suggest chronic mesenteric ischemia.
- Toxic megacolon: Patients with ulcerative colitis experiencing severe abdominal pain, rebound tenderness, guarding, abdominal distention, and colon dilation are expected to be treated initially with intravenous steroids (hydrocortisone or dexamethasone); surgery may be needed for unresponsive cases.
- Pelvic Inflammatory Disease (PID): Severe lower abdominal pain and bilateral adnexal tenderness point towards PID. Treatment involves ceftriaxone and doxycycline/azithromycin.
- Fitz-Hugh-Curtis syndrome: Patients with a history of PID and recent RUQ pain suspect Peri-hepatitis (Fitz-Hugh-Curtis syndrome), requiring no specific diagnostic procedure.
- Ovarian torsion: Acute-onset abdominal pain in a female, potentially with a pre-existing pelvic cyst, indicates possible ovarian torsion. Immediate surgery is generally required. Ovarian torsion can be distinguished from ruptured ovarian cyst presentation by the presence or absence of free fluid in the peritoneum.
- Strangulated hernia: Long-term presence of a non-reducible abdominal mass with severe abdominal pain indicates a strangulated hernia that needs surgical repair.
- Acute cholecystitis: RUQ pain, fever, leukocytosis (elevated white blood cells), suggest acute cholecystitis. Treatment normally starts with ultrasound (US) and HIDA scan if results are indeterminate. Laparoscopic cholecystectomy and antibiotics are the typical procedures. Acalculous cholecystitis, especially in elderly or critically ill patients, typically warrants a percutaneous cholecystostomy procedure instead of cholecystectomy.
- Mirizzi syndrome: RUQ pain, fever, leukocytosis, jaundice, and hypotension suggest ascending cholangitis (including Mirizzi syndrome). Treatment often involves emergency ERCP (diagnostic and therapeutic procedure). Choledocholithiasis (stones in the common bile duct), a less severe variant, is identified by RUQ US or MRCP; the patient is usually not as critically ill as those with ascending cholangitis.
- Kidney trauma (blunt): With kidney trauma, non-operative management is typical for the stable patient.
- Spontaneous bacterial peritonitis: Patients with a history of peritoneal dialysis, mild fever, altered mental status (AMS), and low-grade abdominal pain may be experiencing spontaneous bacterial peritonitis requiring an initial paracentesis to evaluate PMNs (polymorphonuclear leukocytes/neutrophils above 250). Treatment is antibiotics (ceftriaxone or cefotaxime). Patients with ascites but without fever require prophylactic fluoroquinolones.
- High output heart failure: Patients with a recent AV fistula placement for hemodialysis presenting with chest pain, hypotension, and lung crackles suggest high-output heart failure. Possible causes include AV fistulas, anemia, and Paget's disease of bone.
- Acute pancreatitis: Treatment includes NPO (nothing by mouth) status, intravenous fluids, and pain control. The leading causes are alcoholic pancreatitis and gallstone pancreatitis (associated with RUQ pain, elevated amylase/lipase, gallstones, and ALT levels ≥ 150).
- Pancreatic pseudocyst: Abdominal pain, epigastric tenderness, and a history of pancreatitis weeks prior indicate possible pancreatic pseudocyst.
- Chronic pancreatitis: Chronic epigastric pain, fat malabsorption, and pancreatic wall white dots on imaging indicate chronic pancreatitis, often due to alcohol abuse.
- Diverticulitis: LLQ pain, fever, leukocytosis in the elderly suggest diverticulitis. A CT scan with contrast is usually the first step in diagnosing diverticulitis. Antibiotics are usually prescribed. Weeks later, a colonoscopy is recommended to rule out colon cancer as a cause for a bleed.
- Colovesical fistula: Diverticulitis patients who have stool or air in their urine likely have a colovesical fistula
- Sigmoid/Cecal volvulus: Severe abdominal pain with the coffee bean sign (oriented to RUQ or LUQ, respectively) may suggest sigmoid or cecal volvulus.
- Ogilvie syndrome: Severe abdominal pain, a distended abdomen, inability to pass stool/gas, but a non-obstructing colon and non-dilated small intestines suggest colonic pseudo-obstruction or Ogilvie syndrome. Treatment includes NPO, nasogastric tube decompression, rectal tube decompression. Severe cases may require neostigmine. Etiologies include electrolyte imbalances (often from diarrhea and diuretic use) and neurological disorders.
- Small bowel obstruction (SBO): Patients with abdominal pain, bilious vomiting, and no passing gas with a history of appendectomy or Cesarean section (C-section) are likely experiencing an SBO. This may occur due to prior surgical adhesions. Other causes include hernias and malignancy.
Vascular Conditions
- Ruptured abdominal aortic aneurysm (AAA): Patients with severe mid-abdominal or back pain, profound hypotension, and a pulsatile abdominal mass are suspicious for ruptured AAA. A calcified structure should be sought in a pre- or post-surgical radiographic analysis. Immediate surgery is essential.
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AAA complications:
- Aorto-enteric fistula: Microcytic anemia weeks to months after AAA repair, with a fistula between aorta and the GI tract causing a slow leak of blood into the GI tract.
- Anterior spinal artery syndrome: Multiple episodes of profound hypotension during surgery, leading to paraplegia, cauda equina symptoms, or urinary retention after surgery; ischemia of the Artery of Adamkiewicz damages anterior 2/3 of the spinal cord.
- Acute tubular necrosis (ATN)/Prerenal AKI: Rising serum creatinine (sCr) after AAA repair due to kidney ischemia during surgery.
- Endoleak: Ongoing slow microcytic anemia with contrast beyond excluded aneurysm margins on a CT angiogram suggests a potential endoleak.
Risk Factors & Screening
- AAA risk factors: Smoking is the primary risk factor for AAA. Screening is recommended for male smokers aged 65-75, and for those older than 50 with a smoking history or having a first-degree relative with AAA rupture.
- AAA screening criteria: Aneurysms > 5.5 cm or showing growth of more than 0.5 cm per six months require prompt repair. Smaller aneurysms warrant periodic ultrasounds and follow-up.
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Description
This quiz covers essential concepts regarding abdominal trauma and injuries, including management protocols for blunt and penetrating trauma, identifying signs of retroperitoneal hematomas, and specific injuries related to motor vehicle collisions. It is designed to test your understanding of clinical procedures and patient assessments in emergency medicine.
