SAEM - Abdominal Pain
A 78 year old female presents to the E.D. with a sensation of left-lower quadrant abdominal pain, accompanied by some irregular bowel movements and loss of appetite. Her abdominal CT (two images) is shown in the Figure. What is the most likely diagnosis? [image] A. diverticulitis B. ovarian cyst C. volvulus D. appendicitis E. gastroenteritis
The answer is A. A patient with this general picture is most likely to have diverticulitis, which is revealed on the CT scan as diverticular disease with inflammation (wall thickening and stranding).
You are treating a 25 year old male with the recent diagnosis of Crohn's disease in the ED. Regarding Crohn's disease, you know that: A. There is a small increased risk of colon cancer B. Small bowel involvement is rare C. Lesions are typically contiguous D. Bleeding is common due to superficial bowel wall inflammation
The answer is A. Although Crohn's disease may involve the entire bowel tract, the rectum is rarely involved. Involved areas are typically non-contiguous (known as "skip lesions") and the inflammation involves all of the layers of the bowel wall--resulting in many of the complications of Crohn's such as abscess and fistula formation, intestinal obstruction, and perforation. The risk of colon cancer is only slightly elevated above baseline. In contrast, Ulcerative colitis begins in the rectum and may spread to the upper parts of the colon but never involves the small intestine. The ulcerations are contiguous and involve only the colonic mucosa. The incidence of colon cancer may be increased up to 30 times over baseline.
A 46 year old woman presents to the emergency department complaining of abrupt onset of intermittent severe pain in the left flank and abdomen that woke her from sleep. She is pacing around the stretcher and appears extremely uncomfortable. She has never experienced this type of pain previously and denies fevers or other symptoms. Renal calculus is suspected. Which of the following is true regarding the diagnosis of renal calculi in this patient? A. Helical CT scan greater than 95% sensitive and specific for renal calculi. B. Urinalysis demonstrating hematuria confirms the diagnosis. C. KUB detects less than 10% of calculi. D. Ultrasound is the study of choice for detecting small ureteral calculi. E. Intravenous pyelogram (IVP) may be used in patients with renal insufficiency.
The answer is A. Helical CT scan has been shown to be both highly sensitive and specific in the diagnosis of renal calculi. It is the preferred modality for evaluation in many centers. Although urinalysis typically demonstrates hematuria in patients with renal calculi, hematuria is not specific enough to confirm the diagnosis, and imaging is warranted in all first-time presenters. KUB detects approximately 60-70% of calculi (though studies addressing this issue are somewhat methodologically flawed). Ultrasound is not reliable for detecting small calculi, but is 85-94% sensitive and 100% specific at demonstrating hydronephrosis. IVP is contraindicated in patients with renal insufficiency due to the dye load necessary to perform the study.
Of the following pain patterns, which is the least likely associated with diagnosis of peptic ulcer disease? A. unrelenting pain over a period of weeks B. pain that awakens a patient in the middle of the night C. relief of abdominal pain with antacids D. pain that is worse preceding a meal E. non-radiating, burning epigastric pain
The answer is A. Pain from peptic ulcer disease typically occurs in periods of exacerbation and remission. Unrelenting pain over weeks or months should suggest an alternative diagnosis. Pain is classically described as non-radiating, burning epigastric pain. Some patients may also complain of chest or back pain. Pain is frequently severe enough to awaken patients from sleep in early morning hours but is often not present upon waking in the morning, as gastric acid secretion peaks around 2 a.m. and nadirs upon awakening.
Working in the ED, you have identified a bony object wedged in the mid-esophagus of a 45 year old patient. Failure to promptly remove a foreign body impacted in the esophagus could result in: A. Esophageal perforation and mediastinitis B. Epiglottal edema and airway obstruction C. The rapid development of xerostomia D. Barrett's esophagitis
The answer is A. The complications of esophageal foreign bodies are rare but serious. They include esophageal erosion and perforation, mediastinitis, esophagus-to-trachea or esophagus-to-vasculature fistula formation, stricture formation, diverticuli formation, and tracheal compression (from both the esophageal foreign body and resultant edema or infection). Air trapping is a sign of a foreign body of the airway. Rarely, airway foreign bodies act as one-way valves that could cause hyperinflation of a lung segment, with resultant bleb rupture and pneumothorax formation.
A 57 year old ill-appearing man presents with fever, chills, abdominal pain, nausea and vomiting. His abdominal CT is shown in the Figure. Which of the following is LEAST correct regarding this patient's condition? [image] A. Emergent percutaneous drainage in the emergency department is indicated. B. CXR may demonstrate a right-sided effusion and elevation of the right hemidiaphragm. C. Treatment with triple coverage antibiotics such as gentamicin, metronidazole and ampicillin should be instituted immediately. D. Elevations of WBC, bilirubin, alkapine phosphatase and serum aminotransferases will be seen on laboratory studies. E. Etiologic agents of this condition include bacteroides, E. coli, Klebsiella, Pseudomonas, Enterococcus, anaerobic Streptococci, and E. histolytica.
The answer is A. The patient has a hepatic abscess, typically caused by gram negatives, anaerobic Streptococci or Entameoba histolytica. Laboratory findings include elevations of WBC, bilirubin, alkaline phosphatase and serum aminotransferases. CXR may demonstrate a right-sided effusion and elevation of the right hemidiaphragm. Treatment with triple coverage antibiotics such as gentamicin, metronidazole and ampicillin should be instituted immediately, however consultation with a general surgeon, interventional radiologist, or gastroenterologist is necessary for definitive treatment, which is drainage of the abscess.
Regarding the diagnosis of acute appendicitis, all the following are true EXCEPT: A. Vital signs are usually abnormal, even early in the course of acute appendicitis. B. Rebound is usually elicited only after the appendix has ruptured or infarcted. C. The psoas sign is pain upon extension of the hip. D. Rovsing's sign is pain in the right lower quadrant upon palpation of the left lower quadrant. E. The obturator sign is pain upon flexion and internal rotation of the hip.
The answer is A. The presentation of acute appendicitis varies tremendously. Early in its course, vital signs including temperature may be normal. Once perforation has occurred, the rate of low-grade fever (<38 C) increases to about 40%. Other variations in presentation include pain in the right upper quadrant, typically from a retrocecal or retroiliac appendix.
A mother brings her 6 week old boy to the emergency room. She states the baby has been vomiting everything she's tried to feed him for the past 12 hours. She states that he usually eats readily and completes an entire feeding, but he is unable to keep anything down. The emesis is non-bloody and non-bilious, however it is projectile in nature. What is the most likely condition in this patient? A. constipation B. pyloric stenosis C. intussusception D. appendicitis E. viral gastroenteritis
The answer is B. Hypertrophic pyloric stenosis typically presents in the second to sixth week of life and is four times more common in males than females. Infants with hypertrophic pyloric stenosis typically are vigorous eaters but shortly afterward regurgitate the entire feeding contents in a projectile fashion. The emesis is non-bilious. The classic finding on exam is an "olive" palpable in the abdomen, and diagnosis is typically via ultrasound. Intussusception typically presents between the ages of 5 and 12 months. Gastroenteritis is characterized by diarrhea as well as vomiting. Neither constipation nor appendicitis typically present with protracted vomiting, though the latter condition tends to present atypically in young children (and elderly adults).
Which of the following pairings of referred pain and causal disease is least likely to be encountered? A. inguinal pain—ureteral colic B. sacral pain—ovarian torsion C. shoulder pain—ruptured spleen D. thoracic back pain—pancreatitis E. epigastric pain—myocardial infarction
The answer is B. Ovarian torsion may cause lower abdominal pain, pelvic pain, adnexal tenderness, and cervical motion tenderness, but it is not known to cause sacral pain.
A 53 year old obese woman presents to the emergency department, accompanied by three of her children, complaining of severe abdominal pain that began this afternoon after lunch. Physical exam reveals marked RUQ tenderness. Likely findings on this patient would include all of the following EXCEPT: A. aminotransferases and bilirubin within normal limits B. marked inguinal lymphadenopathy C. positive sonographic Murphy's sign D. leukocytosis with left shift E. pain in the right scapula
The answer is B. This woman is likely suffering from acute cholecystitis. Predisposing factors include female gender, obesity, increased age and increased parity. Inflammation of the gallbladder causes RUQ pain and sonographic Murphy's sign (inspiratory arrest, due to pain, while the ultrasound probe is positioned over the gallbladder). Pain may radiate to the right scapula. Lab studies usually show leukocytosis with or without a left shift, and aminotransferases and bilirubin are usually within normal limits.
All of the following factors predispose to cecal volvulus EXCEPT: A. age 25-35 B. prior abdominal surgery C. severe chronic constipation D. marathon running E. pregnancy
The answer is C. Cecal volvulus occurs as a result of abnormal fixation of the right colon and increased mobility of the cecum. Depending on the degree of rotation around the mesenteric axis, cecal volvulus can lead to twisting of the mesentery and its blood vessels. Cecal volvulus occurs most commonly in people 25-35 years old and should be suspected in cases of bowel obstruction without known risk factors. Prior abdominal surgery and pregnancy predispose to obstruction or cecal volvulus; however, chronic constipation is not known to predispose to cecal volvulus. Interestingly, marathon runners have been found to have a higher incidence of cecal volvulus, perhaps from having a thin, flexible mesentery that more easily permits rotation of the cecum around the mesenteric pedicle.
In establishing a differential diagnosis of abdominal pain, which of the following is true? A. Diverticulitis tends to cause pain in the right upper quadrant. B. Cervical motion tenderness is a useful physical finding for differentiating women with or without acute appendicitis. C. The onset of pain prior to the occurrence of nausea and vomiting is more often suggestive of a surgical etiology. D. In patients with sickle cell anemia who present with abdominal pain and diarrhea, shigellosis should be a top consideration. E. Radiation of pain to the scapula is suggestive of acute hepatitis.
The answer is C. Pain prior to nausea and vomiting is often suggestive of a surgical etiology of the pain, such as small bowel obstruction. Cervical motion tenderness has been noted in up to 25% of women with acute appendicitis. Patients with sickle cell anemia are prone to Salmonella infections. Radiation of pain to the scapula is classically present in acute choleycystitis. Diverticulitis pain is generally located in the left lower quadrant.
Rosving's sign is described as: A. Pelvic pain upon flexion of the thigh while the patient is supine. B. Pelvic pain upon internal and external rotation of the thigh with the knee flexed. C. Pain in the right lower quadrant when left lower quadrant is palpated. D. Pain that increases with the release of pressure of palpation. E. Tenderness in the right upper quadrant that is worse with inspiration.
The answer is C. Rosving's sign is pain in the right lower quadrant when the left lower quadrant is palpated. Rebound tenderness occurs with the release of pressure. The iliopsoas sign is pain associated with thigh flexion. The obturator sign is pain that occurs with thigh rotation. All of these signs are associated with appendicitis. Murphy's sign is cessation of inspiration during palpation of the right upper quadrant and is associated with acute cholecystitis.
A 57-year-old homeless woman with a history of schizophrenia presents to the emergency department complaining of nausea and severe abdominal pain for 48 hours. The patient is not cooperative with an upright abdominal image, so a flat plate (as shown in the Figure) is obtained. Which of the following is the most likely operative finding in this patient? [image] A. Inflamed appendix B. Rectus sheath hematoma C. Ruptured spleen D. Small bowel obstruction
The answer is D. Dilated loops of small bowel with air-fluid levels (which are not well-seen on a flat plate) indicate small bowel obstruction. KUB is not often useful in the diagnosis of appendicitis, ruptured spleen, gallstone disease, or a rectus sheath hematoma (which is an abdominal wall condition most likely seen in anticoagulated patients with trauma or coughing). Despite this woman's history of schizophrenia and possibly diminished ability to relate a clear story of her pain, her complaint of abdominal pain must be taken seriously with a high suspicion for underlying pathology.
A 50 year old man presents with 1 day of gradually worsening, intermittent, left lower quadrant pain associated with loose stools. He has had no fevers or bloody bowel movements. Similar symptoms in the past were self-limited. All vital signs lie within normal limits. Physical examination shows mild tenderness in the left lower quadrant, normal active bowel sounds and neither masses nor peritoneal signs. His primary-care physician can see him tomorrow in his clinic. What should be done next in the E.D.? A. Discharge home after a single dose of IV antibiotics B. Admit for observation and serial examinations C. Gastroenterology consult for endoscopy D. Discharge home on high-fiber diet, laxatives and stool softeners
The answer is D. This patient has classic diverticulosis (saclike protrusions of colonic mucosa through the muscularis) without signs of acute diverticulitis (inflammation of diverticula). Usually these patients can be managed as outpatients with a high-fiber diet and treatments to decrease intestinal spasm. If the patient develops fever or pain increases he may need further evaluation to rule out abscess formation. Diverticulitis is treated with antibiotics, bowel rest and analgesics.
A 72 year old man with a history of diverticulosis presents with vague abdominal pain for the past day. His physical exam is notable for normal vital signs, left lower quadrant abdominal tenderness without rebound or guarding, and guaiac positive brown stool. Work-up including KUB and abdominal/pelvic CT scan reveals diverticulitis without perforation. Of the following choices, which is the most appropriate management of this patient? A. immediate surgical intervention B. type and cross two units of packed red blood cells C. barium enema to evaluate for carcinoma of the colon D. discharge on oral pain medications E. admission for intravenous antibiotics and fluids
The answer is E. For mild episodes of diverticulitis in which there is no evidence of perforation or peritonitis, there is no indication for immediate surgical intervention. Conservative management with intravenous fluids and antibiotics as well as bowel rest is typically first attempted. Although colon carcinoma may be a precipitating factor in the development of diverticulitis, barium enema should be avoided in the acute period due to high risk of bowel perforation. Although some patients with mild cases of diverticulitis may be discharged home with conservative treatment, the elderly are at higher risk of perforation and should be admitted. Guaiac positive stool in seen in up to 50% of patients with diverticulitis. There is no reason to suspect acute blood loss requiring transfusion in diverticulitis.
Regarding esophageal perforation, which of the following is INCORRECT: A. Iatrogenic perforations of the esophagus usually occur in the proximal esophagus or esophagogastric junction. B. Esophageal perforation has been reported as a complication of nasogastric tube placement, endotracheal intubation, and esophagotracheal Combitube intubation. C. Esophageal perforation may result from forceful vomiting, coughing, childbirth or heavy lifting. D. Over 80% of esophageal perforations are iatrogenic, usually as complications of upper endoscopy, dilation, or sclerotherapy. E. Over 90% of spontaneous esophageal perforations occur in the proximal esophagus.
The answer is E. Over 90% of spontaneous esophageal perforations occur in the distal esophagus, whereas iatrogenic perforations are frequently at the pharyngoesophageal junction or the esophagogastric junction. Foreign body or caustic substance ingestion, severe blunt injury or penetrating trauma, and carcinoma are other causes of esophageal perforation.
A 45 year old woman presents with right upper quadrant pain and fever. The pain is worse after eating. On physical exam she has a Murphy's sign. The most likely diagnosis is: A. Mesenteric Ischemia B. Appendicitis C. Diverticulitis D. Cholelithiasis E. Cholecystitis
The answer is E. Right upper quadrant pain, fever and a Murphy's sign suggests cholecystitis. Cholelithiasis presents with similar pain, but is not associated with fever or a Murphy's sign.
A 25 year old female presents with epigastric pain radiating straight through to the back. Laboratory tests are notable only for markedly elevated amylase and lipase. An abdominal X-ray is taken (see Figure). Regarding this patient's presentation, which of the following is most likely true? [image] A. She probably has an ulcer, since the laboratory results are nonspecific. B. Alcohol use is only associated with pancreatitis in patients older than this woman, and who have been abusing alcohol for years. C. The abdominal X-ray is concerning for early bowel obstruction. D. The X-ray reveals that intrathoracic pathology is likely the cause of the patient's symptoms. E. The most likely explanation for her symptoms is gallstone-related pancreatitis.
The answer is E. The X-ray reveals stones in the gallbladder. These particular stones are not likely the cause of pancreatitis, but the demonstration of gallstone disease raises the likelihood that the patient's pancreatitis is indeed due to gallstones. In the U.S., the most common etiologies of pancreatitis include gallstones (45%) and alcoholism (35%). Alcoholic pancreatitis may occur in young patients as well as in older abusers of alcohol. Many other drugs, infectious agents, and conditions are associated with the development of pancreatitis. A few examples include hypertriglyceridemia, trauma, pregnancy, pancreatic carcinoma, atherosclerotic emboli, and scorpion bites.
A 47 year-old male presents, confused, to the ED. He has limited ability to give a history. On physical examination of the skin, it is noted that there are erythematous changes to both palms. Also, the face and arms are characterized by a number of superficial, tortuous arterioles which fill from the center outwards. The examination of the abdomen reveals violaceous lines radiating from the umbilicus, and there are generally increased venous markings on the abdominal wall (see Figure). What is the most likely diagnosis? [image] A. necrotizing fasciitis B. Rocky Mountain spotted fever C. lymphangitis D. hyperthermia E. liver disease
The answer is E. The patient's palmar erythema, spider angiomata, and caput medusa (due to recanalization of the umbilical vein) are all characteristic of hepatic disease. The figure demonstrates abdominal wall venous engorgement, as well as ascites (another clue to the patient's liver disease).
