NBME Shelf Review (Part 7) – Abdominal Pain

Hernia * 3 classifications for hernia* Reducible* Able to be reduced (placed back into the abdomen) at bedside* Incarcerated* Cannot be reduced but not severely tender or erythematous* Can occasionally cause bowel obstructions* Strangulated* Cannot be reduced but LOSING BLOOD SUPPLY* Extremely tender and abnormal exam* Needs emergent surgical consult Esophageal Varices * Classic presentation* Hematemesis/Melena* Chronic liver disease (hepatitis, alcoholics)* Treatment* Fluid bolus if hypotensive* Octreotide* Ceftriaxone* Transfuse blood as needed* If hemoglobin <7 transfuse* If patient actively bleeding and level <8 transfuse* Consult GI for endoscopy Hepatic Encephalopathy * Common findings* Altered mental status* Asterixis* Elevated ammonia level * Treat with lactulose or rifamixin Peptic Ulcer Disease * History* Hematemesis or Melena* Epigastric abdominal pain* Chronic NSAIDS or steroids* Treatment* PPI (such as pantoprazole)* Works better than an H2 blocker Cholecystitis * RUQ ultrasound* Thickened gallbladder wall* Distended gallbladder* Pericholecystic fluid* Obvious impacted stone* HIDA scan* Inject radioactive material* Absorbed by hepatocytes* Secreted into biliary tree into small intestine* If gallbladder not visualized* Cystic duct obstruction* If common bile duct cannot be visualized* Choledocolithiasis Ascending Cholangitis * Charcots Triad* Fever* RUQ Pain* Jaundice* Patient requires ERCP (gastroenterology consult)* Give antibiotics Acute Pancreatitis * Diagnosis* Classic description* Epigastric pain radiating to back* Severe vomiting* Lipase* >3x upper limit of normal is diagnostic* CT scan to look for complications of pancreatitis Additional Reading * RUQ Abdominal Pain (EM Clerkship)* Biliary Diseases and Pancreatitis (EM Clerkship)