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Of the following causes of abdominal pain, which occurs more frequently in patients less than 50 years old compared with older patients?
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C. Appendicitis. Both the patient’s age and gender play an important role in forming the differential diagnosis. As patients age there is a distinct shift in causes of abdominal pain and an increase in surgically treatable etiologies. This has been best documented in the OMGE’s (World Organization of Gastroenterology) survey of worldwide causes of abdominal pain. This survey gathered data on more than 10,000 patients in 17 countries presenting with acute abdominal pain. When the data is segregated by age comparing those less than 50 years of age to those older than 50 years of age there are clear differences. Appendicitis is by far the most common etiology of a surgical abdomen in patients younger than 50. In the older population group cholecystitis is the most common cause with good representation from bowel obstruction, appendicitis, pancreatitis and diverticulitis. In older patients hernias are a more common problem, with up to a third of bowel obstructions being related to hernias. Cancer, vascular disease, and mesenteric ischemia are also more common as we age. While it is more common for a patient in their twenties to present with abdominal pain, a large proportion will have the diagnosis of nonspecific abdominal pain. Patients older than 50 years of age have both a higher likelihood of an operative etiology for their acute abdomen as well as an increased mortality related to their presentation. This mortality is higher still for patients older than 70 years of age.
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Which of the following is correct regarding the role of the abdominal plain films in evaluation of the acute abdomen?
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A. They can exclude serious disease.
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B. They are most useful when intestinal obstruction is part of the differential diagnosis.
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C. They are an important part of the work up in patients presenting to the emergency department with abdominal pain.
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D. They are the most sensitive test for a perforated viscus.
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E. They have a high sensitivity in detecting disease including appendicitis, cholecystitis, renal stones and GI bleeding.
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B. They are most useful when intestinal obstruction is part of the differential diagnosis. Before the advent of the CT scan the acute abdominal series played an important role in the diagnosis of the acute abdomen as diagnostic tools were limited. There are long lists of radiologic findings that may correlate with a wide variety of intra-abdominal pathology. A small percentage of renal and biliary stones may be seen on plain radiograph. In our current practice environment there is a much more limited role for plain films of the abdomen. They can be helpful in locating foreign bodies within the GI tract and they may assist in the diagnosis and evaluation of bowel obstructions. Ultrasound is a more sensitive test for biliary stones. CT scans have increased sensitivity and specificity in almost all causes of intra-abdominal pathology when compared with abdominal plain films. For this reason, in stable patients who are going to undergo CT scan there is little added value in obtaining plain films. Upright chest radiograph is the most sensitive test for intra-abdominal free air from a perforated viscus. It should be obtained as part of the evaluation of the acute abdomen both for identifying free air as well as ruling out a variety of cardiac and pulmonary pathologies.
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A 65-year-old man is brought to the ED with abrupt onset of acute abdominal pain. He appears uncomfortable and moaning. Initial vitals: BP 110/88 mm Hg, HR 125 beats/min and irregular, respiratory rate 24 breaths/min. His abdominal examination is remarkable for a non-distended abdomen with no tenderness elicited on examination. Which of the following would be the most helpful next step?
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A. Admit with observation
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C. Basic labs including CBC, basic metabolic panel, amylase and lipase
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D. Upright plain abdominal x-ray
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E. ABG and Lactate. Given the severity of the patient’s pain and its abrupt presentation it would not be prudent to solely admit this patient without further evaluation. This patient presents with severe acute abdominal pain and a relatively benign abdominal examination, concerning for mesenteric ischemia. Etiologies include arterial or venous occlusion as well as nonocclusive low-flow states such as in critically ill with hypotension. This patient has an irregular heart rate from atrial fibrillation, which puts the patient at risk for an arterial embolic event. The classic presentation of mesenteric ischemia is severe pain out of proportion to physical examination findings. Helpful laboratory data include an arterial blood gas with lactate. An elevated lactate suggests tissue hypoxemia. Ischemic bowel as a result of diminished blood flow will convert to anaerobic metabolism on a cellular level producing lactate. Although not specific to mesenteric ischemia, it can be a helpful laboratory value to predict severity of illness when elevated. A normal lactate does not exclude mesenteric ischemia. If clinically suspected, workup should proceed despite a normal lactate. Radiographic imaging of choice is CT angiography to assess mesenteric vessels. These patients should be kept strict NPO and if mesenteric ischemia is diagnosed, patient should proceed emergently to the operating room for exploratory laparotomy to minimize further bowel ischemia. Amylase is helpful in ruling out other diagnostic possibilities such as pancreatitis. As mentioned earlier plain abdominal films are rarely indicated in evaluation of the acute abdomen.
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A 32-year old woman with 30 week pregnancy arrives to the emergency department complaining of nausea, one episode of emesis and right lower quadrant pain. Ultrasound performed does not visualize the appendix. WBC is 14. The next best step is
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A. Admit with observation
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B. CT scan abdomen/pelvis with PO/IV contrast
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D. Exploratory laparoscopy
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E. Exploratory laparotomy
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C. MRI abdomen/pelvis. Pregnancy presents a diagnostic dilemma when encountering abdominal pain. Ultrasound is the first line imaging modality in pregnant women as it is noninvasive and does not involve radiation; however, ultrasound often will be equivocal or indeterminate in diagnosing appendicitis. If ultrasound is nondiagnostic, MRI is preferred to CT scan for the evaluation of acute appendicitis in pregnancy. MRI avoids ionizing radiation, making it a safer imaging modality for the fetus. Both laparotomy and laparoscopy are considered safe in pregnancy. Early operative intervention in appendicitis during any trimester is warranted as ruptured appendicitis is associated with higher rates of fetal mortality, maternal mortality, and preterm delivery. Given the operative risks of the procedure (fetal loss, early labor) and the risks of delayed diagnosis (ruptured appendicitis, fetal loss) when possible confirmation of diagnosis is preferred before proceeding to the OR and patients are rarely simply observed.
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All of the following are indications for urgent operative intervention EXCEPT
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A. A 49-year-old man with 12 hours of right lower quadrant pain, rebound tenderness and WBC 17.
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B. A 45-year-old diabetic woman with 18 hours of right upper quadrant pain, WBC 12 and ultrasound demonstrating pericholecystic fluid, thickened gallbladder wall and gallstones.
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C. A 52-year-old man with 2 days of bilateral lower quadrant pain and guarding on physical examination, WBC 18 and CT abdomen/pelvis which showing peri-sigmoidal fat stranding and extraluminal air.
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D. A 65-year-old man with 1 day of mild abdominal pain and reports of bright red blood per rectum. Normotensive, but hematocrit on admission 24% (baseline Hct 42%).
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E. A 78-year-old intubated woman, HR 110 beats/min, BP 95/60 mm Hg. Chest x-ray obtained to confirm endotrachial tube placement shows sub-diaphragmatic air.
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D. A 65-year-old man with 1 day of mild abdominal pain and reports of bright red blood per rectum. Normotensive, but hematocrit on admission 24% (baseline Hct 42%). There are several pathways in the management of patients with an acute abdomen. There is a subset of patients who require immediate operative intervention including ruptured abdominal aortic or visceral aneurysms, splenic or hepatic adenoma rupture, ruptured ectopic pregnancy, and major abdominal trauma. These patients may be recognized by their hemodynamic instability. Another cohort of patients will present with urgent operative indications. In this group there is often enough time for diagnostic testing to confirm the diagnosis, but once confirmed the patient should proceed expeditiously to the operating room. Conditions requiring urgent intervention include perforated hollow viscus, acute appendicitis, diverticulitis (perforated), mesenteric ischemia, and strangulated hernias. A third group of patients include those who will need operative intervention on the same admission (12-48 hours) but not urgently. Early intervention would be for patients with uncomplicated cholecystitis, or incarcerated hernias. Several diagnoses should be observed on surgical services but may not require operative intervention. This group includes patients with uncomplicated bowel obstructions, uncomplicated diverticulitis, and symptomatic cholelithiasis. These patients may require operative intervention if they fail to improve with nonoperative management. Lastly diseases such as pancreatitis, inflammatory bowel disease, peptic ulcer disease, endometriosis, and gastritis may cause significant abdominal pain but usually respond to nonoperative therapies and usually do not require operative intervention. The lower GI bleeding is preferentially treated with colonoscopy and resuscitation. It rarely requires urgent operative intervention and only in those patients with hemodynamic instability who have failed conservative management. When the cause of abdominal pain is uncertain despite diagnostic testing a judgment must be made as to whether the patient merits inpatient monitoring or can be further evaluated as an outpatient.