Trans Group: Nicanor Ong, E. Edited by: Marianne Sadaya

Subject: Topic: Lecturer: Date:

Surgery 3.1 Evaluation of Acute Abdominal Pain Dr. Alcedo February 3, 2014

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Second Semester A.Y. 2013-2014

CASE 1. A 55 year old male consulted in the ER because of severe pain which suddenly awakened him in the early hours of the morning associated with generalized muscle guarding. He is most likely suffering from which of the following:

A. Small bowel intestinal obstruction B. Acute cholecytitis C. Ureteral colic D. Perforated peptic ulcer disease

Review of Anatomy maximal acid production is during hours in the morning (also experienced by people with hyperacidity) Sudden, generalized pain pouring acid in your GI will cause inflammation of the peritoneal lining Involuntary muscle guarding even if patient is asked to relax, he cannot soften his abdominal wall Question to ask yourself: Is this life threatening? YES

OUTLINE

I. Introduction II. Acute Abdomen III. History IV. Physical Examination V. Evaluation and Diagnosis

A. Laboratory B. Imaging

VI. Categories After Initial Evaluation VII. Algorithms for the Approach to

Patients with Acute Abdominal Pain VIII. Differential Diagnosis IX. Indicators for Urgent Laparotomy X. Laparotomy or Laparoscopy

References: Recording - italicized Sabiston Textbook of Surgery, 19th edition, Chapter 47

I. INTRODUCTION

II. ACUTE ABDOMEN Abdominal pain undiagnosed for less than 7 days (some consider

up to 10 days as acute) Accounts for 1% of all hospital admissions because majority are

discharged after initial examination while some would require immediate surgery

Questions to ask yourself while examining: o Is this a surgical abdomen?

If you miss the diagnosis, its either you manage a surgical patient medically or a medical patient surgically. Either way the consequences are somewhat unacceptable

o If it is, does it require immediate surgery or can it be done a few days after?

Is this case very urgent? Delaying a surgery that is strongly indicated can be lethal for a patient.

III. HISTORY Hollow viscus obstruction insidious onset of diffuse dull aching

pain, associated with nausea and vomiting, unable to lie still, no alleviating factors

Early inflammatory process of solid viscera diffuse dull ache pain

Progression of inflammatory and obstructive process progression in several hours into sharp and stabbing pain, aggravated by movement, coughing, and relieved by lying still

Localized Peritonitis localized tenderness with rebound and muscle guarding

Perforation, strangulation, spontaneous bleeding sudden onset of pain with progression with minutes to a few hours; early sharp localization, progressing to generalized tenderness with rebound and rigidity; referred pain to the shoulder tip and scapula with blood or pus in the sub-phrenic space

USE CLITAA IN TAKING THE HISTORY Characteristic: Somatic vs. Visceral

o Let patient talk and provide his/her own description of the pain before you suggest specific characteristics (e.g. burning, sharp, etc)

Location: Where is it? Where does it radiate? Intensity use the pain score (0 absence of pain; 10 equal to

the pain of labor; If you encounter such a patient, do not force your patient to answer your questions.

Time course: Acute? Intermittent? Sudden vs. Progressive Aggravating and Alleviating Factors Associated Signs and Symptoms Elicited by direct irritation of the parietal peritoneum Mediated by affarent somatic nerve fibers Localized in the dermatome supplied by the segmental nerve

roots innervating the parietal peritoneum Sharp and well-localized

A. Hollow Viscus Perforation (Sudden onset, severe)

When a seemingly healthy patient feels like the pain was suddenly switched on

Can lead to neurogenic shock

Somatic Pain

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CASE 2. Appendicitis 25 year old male complaining of 10 hour history of periumbilical pain which radiated initially to the right upper quadrant and later on localized to the right lower quadrant. Associated with fever, anorexia, vomiting. In PE there is rebound tenderness. If a 2nd yr med student were to evaluate this patient and CBC results are normal, urinalysis showed little RBC and WBCs; will this affect your diagnosis? Clincial findings sometimes contradict the clincial evaluation. Stick to clincal findings if you know its right! CASE 3. Acute Cholecystitis Patient had 4th attack today. Colicky right upper quadrant pain 3 times in the past lasting for about 2-3h. Prenup of ultrasound showed acute cholecyctitis. 26mm. site of initial pain: periumbilical pain bec of distention of the appendix

Sudden onset of excruciating pain suggests intestinal perforation, arterial embolism with ischemia, and other conditions like biliary colic. o Ureteral colic (may be constant) o Perforated ulcer o Ruptured aortic aneurysm

From the lecturer: Perforation of a hollow viscus resolve in the spillage of the sulcus entericus into the the peritoneal cavity; peritoneal signs indications for surgery B. Infectious Process (Gradual progressive pain)

Worsens over time

o Cholecysitis o Hepatitis o Pancreatitis o Appendicitis o Tubo-ovarian abscess or ectopic pregnancy o Diverticulitis at the LLQ, are of sigmoid colon

From the lecturer: pancreatitis some surgical, some medical; Abdominal pain that would present as surgical but actually medical

C. Hollow Viscus Obstruction (Colicky, crampy, intermittent)

o Biliary colic RUQ; aggravated by a fatty meal, where

cholecystokinin stimulates gall bladder contraction and since theres a stone obstructing the cystic duct, the pressure in the gall bladder rises and produces pain

o Ureteral colic/Kidney Stones flank pain that goes down o Small bowel obstruction periumbilical area o Colonic obstruction hypogastric area From the lecturer: However, a patient with acute gastroenteritis or diarrhea may present like this. Thats why its important to diagnose before performing a surgery! Obstruction of a hollow viscous - tumors in the colon can result to obstruction of the sigmoid and if surgery is not done in an acute setting, the bowel will perforate. The first portion that will perforate will be the cecum because it has the largest diameter. Cecum surgery must be done before perforation begins otherwise it will become complicated

Caused by distension of organs

o Poorly localizing because it is innervated by autonomic nerve fibers vague and poorly localized to the midline (epigastrium, periumbilical region or hypogastrium) depending on the origin from the primitive foregut, midgut or hindgut

Solid organ visceral pain in the abdomen is located in the quadrant of the involved organ (e.g. liver pain is across the RUQ)

Small Bowel Obstruction poorly localized periumbilical pain Colonic Pain centered between umbilicus and pubis symphysis Pancreatitis - epigastric pain radiating to the back Renal Colic - colicky pain radiating to the groin

Visceral Pain

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Pain perceived at a site distant from the primary affected organ Due to convergence of afferent fibres from separate areas in the

posterior horn of the spinal cord o RIGHT SHOULDER liver, gall bladder (cholecystitis), right

hemidiaphragm via C3 to C5 nerve roots o LEFT SHOULDER heart, tail of pancreas (pancreatitis),

spleen, left hemidiaphragm o SCROTUM and TESTES ureter via splanchnic nerves of T11-

L1 or hypogastric plexus of S2-S4

Diffuse, mild, dull discomfort Vomiting usually precedes the onset of pain Diffuse, non-specific abdominal tenderness No rebound tenderness and no muscle guarding

Relieved by antacids: Peptic Ulcer Disease o Will not be relieved by Proton-Pump Inhibitors right away

Aggravated by movement: Peritonitis Aggravated by fatty food intake: Biliary Tract Disease o Bile is released from the gallbladder and if there is a stone

obstructing the cystic duct the pressure inside the gallbladder increases and causes a colicky pain in the RUQ.

Eating worsens the pain: pain of bowel obstruction, biliary colic, pancreatitis, diverticulitis, or bowel perforation

Eating relieves the pain: nonperforated peptic ulcer disease or gastritis

NAUSEA, VOMITING, HEMATEMESIS

o Upper abdomen is distended, lower abdomen is scaphoid may be due to gastric outlet obstruction patient will vomit (Vomitus is white due to gastric acid. No staining of bile since the food has not passed through the pylorus since there is an obstruction)

o Patient with pancreatic cancer, large enough to obstruct the duodenum patient will vomit (Vomitus is bile-stained due to secretion of bile by the gall bladder at the second part of the duodenum; Importance: helpful in diagnosis and planning the patients treatment. An obstruction in the duodenum will have a harder surgical procedure - Whipples procedure)

o Relationship to other symptoms Medical Abdomen Vomit FIRST, then PAIN

(Found in conditions like gastroenteritis) Surgical Abdomen PAIN first, then VOMIT

(stimulation of the medullary efferent fibers that are triggered by visceral afferent pain fibers); peritoneal irritation leads to rebound tenderness and muscle guarding; thus, always an indication for surgery!

FEVER - Sign of an inflammatory process (RLQ without fever - Not appendicitis)

From the lecturer: The earlier, the more proximal the lesion: obstruction in the esophagus, once patient swallows, vomit immediately. If obstruction in the pylorus because of peptic ulcer disease, will vomit only when stomach gets filled Not sure of diagnosis? Need more observation this is the time to request for diagnostic tests. However, if patient presents with a history compatible with abdominal aortic anerysm, dont request for a CT scan because patient will die in the CT scan room. Exigent time of abdominal catastrophy BOWEL MOVEMENT

o Change in color of feces (Clay-colored: obstruction of the biliary tree since bile cannot pass through)

o Consistency o Constipation: mechanical obstruction or peristalsis o Diarrhea: infectious enteritis, inflammatory bowel

disease or parasitic contamination o Bloody: as above or due to ischemia o No need to smell

From the lecturer: Patient complains of pencil shaped stools: obstructing lesion is in the descending colon (cecum: liquid stool; rectum: solid stool because of small hole) URINARY SYMPTOMS

o Frequency o Hematuria o Change in color of urine (Tea-colored: beginning

jaundice; ask for RUQ pain) ANOREXIA, WEIGHT LOSS From the lecturer: 70 year old patient presents with colicky abdominal pain (gradually progressive) distending abdomen with moderate to severe weight loss for several weeks. Think of Malignancy: what tests: colonoscopy or CT scan? Not only to diagnose the disease but to help plan the mode of tratement. If surgery, when and what.

GYNECOLOGIC SYMPTOMS Sexual Activity Amenorrhea Vaginal Bleeding Vaginal Dischage Amenorrhea Day of Cycle

Hypertension, Coronary Artery Disease: patient with

subendocardial infarcts usually presents with epigastric pain. The worse thing that you can do is manage patient with peptic ulcer dse instead of infarcts

Atrial fibrillation 10/10 abdominal pain with a soft abdomen; no other physical examination findings (vascular emergency); if bowel develops gangrene develop generalized muscle perforation guarding and distended abdomen (important to diagnose patient with atrial fibrillation: SURGERY!!)

o Infarction atrial fibrillation can throw an embolus into the superior mesenteric artery infartcion of the small bowel (important: past health history and medication history); pulse is regularly irregular, severe pain without obvious peritoneal irritation, think of a vascular problem because this will dictate the tempo of how to manage the patient

Referred Pain

Non-surgical causes of Abdominal Pain

Aggravating and Alleviating Factors

Associated Signs and Symptoms

Menstrual History for women in the Reproductive age group

Medical History

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Pulmonary Disease Previous surgery colicky abdominal pain presenting with

intestinal obstruction; 2-3 times surgery in the past; intestinal obstruction secondary to adhesions

Alcohol history acute liver hepatitis might be mistaken for gallstones

Smoking History Drug Abuse

IV. PHYSICAL EXAMINATION General Examination: Vital signs - will tell you the degree of dehydration of patient

and possible atrial fibrillation. Patient vomiting with tachycardia and hypotension means patient is severely dehydrated.

Look for signs of pallor if suspecting ectopic pregnancy or abdominal aneurysm

Acetone smell- medical emergency not sugrical Examination of chest and heart Abdominal examintaion Patient is agitated nd unable to lie still visceral pain;

suggestive of hollow viscus obstruction and strangulation Patient is lying motionless in bed parietal pain; suggestive of

peritonitis Patient is drowsy with decreased responsiveness suggestive of

hemodynamic instability and/or sepsis Expose from nipple to mid-thigh Check for abdominal distention and/or swelling

Look for scars, fistulae, sinuses Check for istended superficial veins Ecchymosis: Cullens sign hemmorahhguc pancretitis Gray-Turners sign

Figure 5. Ecchymosis

Check for peritoneal irritation Presence of cough tenderness, rebound tenderness (can also be

elicited by percussing), involuntary muscle guarding (for children: tickle and then touch both sides of the abdomen; If left side relaxes and right side remains hard involuntary)

Pinpoint the area of maximal tenderness Check for organomegaly Check for the presence of tympani (presence of gas) Check for shifting dullness

Figure 6. Palpation of the Abdomen

Perform superficial and deep palpation Use the pulp of the fingers and not the tip Examine the most tender area last Perform percussion if possible

Auscultate away from pain just like when you palpate to avoid more pain the area

Watch out for incarcerated hernia (seen in the scrotum) in the elderly with abdominal distention High-pitched tinkling sounds suggestive of intestinal

obstruction Hypoactive bowel sounds enteritis and intstinal ischemia Absent bowel sounds check for 1-2min (dont just multipy;

listen for thw whole 2mins before declaring absent bowel sounds)

V. EVALUATION AND DIAGNOSIS A. Laboratory Studies

Considered routine in evaluation of a patient with an acute abdomen

Help in confirmation of inflammation or infection present Aid in elimination of some of the most common nonsurgical

conditions o Hemoglobin level (CBC) and White blood cell count with

differential valuable because most patients with acute abdomen will

have leukoytosis or bandemia o Electrolyte, BUN, creatinine levels

Assist in evaluating the effect of factors: vomiting or third place fluid losses

May suggest an endocrine or metabolic diagnosis as the cause

o Amlyase and Lipase may suggest pancreatitis but can also be elevated in

disorders, such as small bowel infarction or duodenal ulcer perforation

normal levels do not exclude pancreatitis as a possible diagnosis caused by effects of chronic inflammation on enzyme production and timing factors

o Liver function tests (Total and direct bilirubin, serum aminotransferase, alkaline phosphatase level) for evaluating potential biliary tract causes

Inspection of the Abdomen

Palpation of the Abdomen

Auscultation of the Abdomen

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o Urinalysis In diagnosis of bacterial cystitis, pyelonephritis and certain

endocrine abnormalities (e.g. diabetes, renal parenchymal disease)

Urine culture- confirms suspected UTI and direct antibiotic therapy but cannot be done in time to be helpful in the evaluation of acute abdomen

o Urine human chorionic gonadotropin (HCG) level Suggest pregnancy as a confounding factor in the patients

presentation or aid in decision making on therapy o Occult blood test

Can be helpful in evaluation but nonspecific o Stool test

for ova and parasite evaluation C. difficile culture and toxin assay

Helpful if diarrhea is a component of the patients presentation

Improvements in imaging techniques resulted in more rapid operative correction of the problem, with less morbidity and mortality

No imaging technique can replace a careful history and physical examination

X-Ray

Figure 1.1. Upright chest radiograph depicting moderate sized pneumoperitoneum (Intestinal contents in chest space)consistent with

perforation of abdominal viscus. Detects pneumoperitoneum (free air in peritoneal cavity)

o In upper right chest radiographs as little as 1 ml o In lateral decubitus (left side down) abdominal radiographs

in patients who cannot stand; 5- 10 ml o Air will insinuate in between the liver and diaphragm, let

the patient stay in lateral decubitus for a few minutes so that air can go up

o Helpful in patients suspected of having perforated duodenal ulcer, 75% of these patients will have visible pneumoperitoneum

Show abnormal calcifications o 5% of appendicoliths

o 10% of gallstones o 90% renal stones o Pancreatic calcifications with chronic pancreatitis,

calcification in abdominal aortic aneurysm, visceral artery aneurysm, atherosclerosis in visceral vessels

Identifies gastric outlet obstruction and obstruction of proximal, mid, or distal small bowel in upright and supine abdominal radiographs (step ladder sign airfluid levels- only seen in upright position)

Can also aid in determining if complete or partial small bowel obstruction presence or absence of gas.

Differentiation of colonic gas from small intestinal gas, obstruction of colon presence of haustral markings

Suggest volvulus of the cecum or sigmoid colon o Cecal comma shape, with concavity facing inferiorly

and to the right o Sigmoid bent inner tube, with its apex in the upper

quadrant

Figure 1.2. Upright abdominal x-ray with an obstructing sigmoid adenocarcinoma. Note the haustral markings on the dilated transverse colon that distinguished this from small

intestine

Figure 1.3. Supine abdominal x-ray (air fluid levels are not seen). Patient with intestinal obstruction. Note distended (air

filled) loops of bowel with thickened bowel walls.

B. Imaging Studies

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Figure 1.4. Omega sign () Sigmoid volvulus

Figure 1.5. Upright abdominal x-ray with sigmoid colon volvulus. Note the characteristic appearance of bent inner tube, with its apex in the right upper

quadrant

Ultrasound Accurate for detecting gallstones and assessing gallbladder wall

thickness and presence of fluid around the gallbladder

Determines diameter of extrahepatic and intrahepatic bile ducts but limited to detect common bile stones

Detects intraperitoneal fluid Presence of intestinal air limits the ability to evaluate the

pancreas or other abdominal organs Can differentiate gas from fluid, like for diagnosing abscess

which is a fluid filled cavity with gas, gallbladder is also fluid filled

Indications for Emergency Ultrasound o Detection of Acute Cholecystitis, pancreatitis, liver abscess o Appendicitis, appendicial abscess, diverticular abscess,

mesenteric cyst, tubo-ovarian abscess, pelvic abscess o Useful in pregnant and young patient o Patients with suspected AAA (Abdominal Aortic Aneurysm) o Diagnosis of free intraperitoneal fluid

Figure 1.6. Thick walled, fluid filled appendix with surrounding

inflammation

Figure 1.7. Large appendicular abscess containing gas

Figure 1.8. Pancreatic necrosis lack of gland enhancement following IV contrast administration is diagnostic. Pancreas is hardly visualized

Figure 1.9. Acute pancreatitis enlarged pancreas with indefinite border and

infiltration of the surrounding fat (peri-pancreatic stranding)

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CT scan More widely available and less likely to be hindered by

abdominal air Secondary imaging modality of choice following plain abdominal

radiography Well performed CT using oral, rectal, and IV contrast is highly

accurate for evaluating disease such as appendicitis, while dual contrast CT scanning for small bowel injury following blunt trauma Excellent for differentiating mechanical small bowel

obstruction from paralytic ileus and identify transition point in mechanical obstruction.

Figure 2.0. CT scan with partial small bowel obstruction. Note presence of dilated small bowel and decompressed small bowel.

The decompressed bowel contains air, indicating a partial obstruction

VI. CATEGORIES AFTER INITIAL EVALUATION

Patients with immediate life-threatening conditions Abdominal Crisis abdominal problem is life-threatening to the

patient o Massive Intra-abdominal bleeding (aneurysm, ruptured

ectopic pregnancy, spontaneous rupture of liver or colon) must act immediately, lest patient might die of exsanguination

o Acute intestinal ischemia with hypovolemia with uncontrolled acidosis the longer you wait -> the more extensive formation gangrene -> might lose all of the bowel

o Intra-abdominal sepsis uncontrolled abdominal infection Medical Crisis

o Myocardial infarction o Tension pneumothorax o Diabetic ketoacidosis

Life-threatening conditions needs urgent laparotomy the more you wait, the more peritoneal soilage will happen -> lead to shock and death., so early operation is needed o Perforated hollow viscera o Strangulated bowel o Intra-abdominal abscess with generalised peritonitis

VII. ALGORITHMS FOR ACUTE ABDOMINAL PAIN A. ACUTE ONSET, SEVERE, GENERALIZED PAIN

Figure 2.1: Algorithm for treatment of acute onset, severe, generalized abdominal pain. NG nasogastric tube; NL normal study. Peritoneal signs include: peritonitis, rebound tenderness, involuntary muscle guarding

B. GRADUAL ONSET, SEVERE, GENERALIZED PAIN

Figure 2.2: Algorithm for the treatment of gradual onset, severe, generalized abdominal pain. ERCP endoscopic retrograde cholangiopancreatography;

LFT liver function tests.

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C. RIGHT UPPER QUADRANT PAIN (RUQ PAIN)

Figure 2.3: Algorithm for the treatment of right upper quadrant abdominal

pain. US - ultrasound

Differential diagnoses for RUQ Pain: o Pyelonephritis or nephrolithiasis, hepatic abscess,

pulmonary embolus, pneumonia or musculoskeletal o May include other causes found in the epigastrial region:

cardiac origin, esophageal inflammation or perforation, gastritis, PUD, biliary colic, pancreatitis

D. LEFT UPPER QUADRANT PAIN (LUQ PAIN)

Figure 2.4: Algorithm for the treatment of left upper quadrant pain.

Differential diagnoses for LUQ Pain:

o Ruptured spleen, splenomegaly, gastric ulcer

E. RIGHT LOWER QUADRANT PAIN (RLQ PAIN)

Figure 2.5: Algorithm for the treatment of right lower quadrant pain.

Differential diagnoses for RLQ Pain:

o Meckels diverticulum, Crohns disease, diverticulitis, salpingitis, ectopic pregnancy

F. LEFT LOWER QUADRANT PAIN (LLQ PAIN)

Figure 2.6: Algorithm for the treatment of left lower quadrant abdominal pain.

VIII. DIFFERENTIAL DIAGNOSIS

All patients must be seen, evaluated immediately on presentation and reassessed at frequent intervals for changes in condition.

Requires a comprehensive knowledge of the medical and surgical conditions that create acute abdominal pain.

Peritoneal lavage can provide information that suggests pathology requiring surgical intervention. The lavage can be performed under local anesthesia at the patients bedside. This can provide sensitive evidence of hemorrhage or infection, as well as some types of solid or hollow organ injury.

Patients having emergency or life threatening surgical disease are taken for immediate laparotomy; urgent diagnoses allow time for stabilization, hydration, and preoperative preparation, as needed.

Hospitalized patients who do not go urgently to the OR must be reassessed frequently, preferably by the same examiner, to recognize potentially serious changes in condition that could alter diagnosis or suggest development of complications.

Laboratory and imaging studies should never replace the bedside clinical judgment of an experienced surgeon.

Patients are more likely to be seriously or fatally harmed by delaying surgical treatment to perform confirmatory tests than by misdiagnoses discovered at operation.

IX. INDICATORS FOR URGENT LAPAROTOMY

Increasing severe localized tenderness (e.g supperative appendicitis becomes gangrenous -> lead to rupture)

Progressive tense abdominal distention when there is severe obstruction

Spreading involuntary muscle rigidity peritoneal irritation is spreading due to bowel movement, which will spread the infection

High fever, tachycardia, confusion marked leukocytosis with shift to the left pneumoperitoneum (see figure 1.1)

All of these need urgent laparotomy

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Serious conditions Needs early planned surgery or close monitoring

o acute appendicitis depends on the stage; how long the patient is having pain. Theres a need to hydrate the patient before doing surgeryl for the patients optimal condition.

o diverticulitis, diverticular abscess, tubo-ovarian abscess load the patient with antibiotics and hydrate the patient

o localized intra-abdominal or pelvic abscess o small bowel obstruction o large bowel obstruction

Less serious conditions

which require conservative treatment o biliary colic, renal colic o inflammatory bowel disease o non-specific abdominal pain o gastroenteritis, infective colitis o urinary tract infection o uncomplicated ovarian cyst o ruptured graaffian follicle o uncomplicated diverticular disease o most medical causes of abdominal pain

Some special Cases

Meckels Diverticulum o Presents as lower GI bleeding, sometimes with pain just like

appendicitis o If a patient diagnosed to have appendicitis but when

examined surgically to have a normal looking appendix, you have to examine the distal 2 ft (ileum), especially in a young patient

Volvulus of Meckels Diverticulum

o A gangrenous twisted Meckels diverticulum

Twisted Ovarian Cyst: Gangrenous

Ruptured Ectopic Pregnancy o Massive bleeding; patient will die of insanguination

Sigmoid Volvulus

o Sigmoid becomes gangrenous due to loss of blood supply

Infarcted Bowel o Caused by an embolus in the tributaries o If detected early, might save the bowel by doing an

embolectomy o A progressive gangrenous process

X. SUMMARY

Importance of accurate history taking and complete PE Early decision whether the patient needs urgent surgery More important to detect immediate life threatening

conditions than arriving at the correct diagnosis even if you dont have the correct diagnosis, it is better to have a live patient with an unsure diagnosis rather a dead patient

The diagnosis in an early abdominal pain is difficult. Need to re-examine the patient after adequate resuscitation

Define surgical from non-surgical abdomen Make the patient comfortable and pain-free if possible

give pain relievers

Opioids dont mask physical signs or prevent accurate diagnosis

Think of the more common surgical conditions first not the 1% incidence of abdominal pain. In UERM, most common surgery performed is cholecystectomy which is presented as a RUQ pain.

SAMPLE QUESTIONS

1. This aspect in the physical examination of the abdomen is done last in patients presenting with abdominal pain. a. Auscultation b. Inspection c. Palpation d. Testing fluid wave

C 2. A 33 year old male came in for blood-streaked stools associated with crampy abdominal pain, nausea and diarrhea. He has mild direct and rebound tenderness over the left side of the abdomen. Rectal examination shows blood-streaked mucoid stools in the examining finger. He is most probably suffering from: a. Diverticular disease of the colon b. Amoebic infection of the colon c. Neoplasm of the colon d. Internal hemorrhoidal disease

C 3. A 55-year-old female who is diagnosed to have chronic cholecystitis with lithiasis in the past presents with RUQ pain, jaundice and fever. Which test will help in accurately determining the present problem?

a. Elevated transaminases b. Reduced prothrombin time non responsive to IV Vitamin K c. CBD dilation with intraluminal shadow d. Elevated bilirubin levels

C 3. True of abdominal pain a. Always present in abdominal diseases b. First symptom in abdominal problems that are medical in nature c. Maybe the presenting symptom of myocardial infarct d. Most common symptom seen in patients in emergency room

D 4. Midureteral stones are found in: a. Upper abdominal b. Peri-abdominal c. Lower abdominal d. None of the above

C 6. Somatic type of chain is characterized by which of the following? a. The sensation travels through the ANS. b. It is the type of pain that one experiences when an inflamed appendix

touches the anterior parietal peritoneum. c. It is difficult to localize. d. It usually precedes visceral pain in all inflammatory conditions in the

abdomen. B

7. 45 y/o, male, with a history of exploratory laparoscopy 5 years PTA. Chief complaint is colicky abdominal pain. Which will indicate that he has an infarcted bowel?

a. Hyperactive bowel sounds b. Distended abdomen c. Local area of tenderness d. All of the above

8. A 45 y/o female with sudden crampy epigastric pain with right upper quadrant pain which radiated to the right shoulder, aggravated by deep inspiration. What is the best diagnostic technique for this? a. Auscultation of bowel sounds b. Determination of liver size and calculation of Liver Span c. Eliciting Rovsings Sign d. Eliciting Murphys Sign

C

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9. Which of the following is the MOST common manifestation of Peptic Ulcer Disease (PUD)? a. Early satiety b. Epigastric pain c. Post prandial vomiting d. Gaseousness feeling after a meal

B 10. Which of the following can explain the occurrence of referred pain? a. Stimulation of nerve fibers of the same embryologic origin b. Stimulation of nerve fibers with similar receptors c. Convergence of nerve fibers at the spinal cord d. Stimulation of nerve fibers of an organ adjacent to the diseased organ

C 11. A 55 year old alcoholic diagnosed to have a duodenal ulcer by upper gastrointestinal endoscopy, complains of severe epigastric pain which later becomes generalized. Which among the following findings will help us in the diagnosis? a. Generalized ileus on KUB b. A distended loop of bowel on the RLQ c. Lucency below the left diaphragm above the gastric bubble d. Presence of a distended stomach

C 12. A 50 year old male patient came in because of colicky abdominal pain of several hours duration associated with decrease in passage of flatus. Which of the following clinical findings can help us in the diagnosis of the present condition? a. The presence of a globular abdomen b. Hypoactive bowel sounds c. A midline incision scar d. History of an alcoholic binge the night before

C 13. Visceral type of pain can be characterized by which of the following: a. It can be localized easily by the patient b. It usually is associated with a solid organ involvement c. May be due to muscular contraction d. Is usually accompanied by fever upon presentation

C 14. A 44-year-old female patient was diagnosed to have gallstones in the gallbladder. The pain history of this patient will most likely be characterized as: a. Waves of dull pain associated with vomiting b. Acute wave of constricting pain c. Sharp pain worsened by movement d.Tearing pain

B 15. A 65-year-old male woke up during the early hours of the morning due to

severe epigastric pain. Based on the history alone, which of the following is the most likely cause of his pain?

a. Ureteral colic b. Acute Pancreatitis c. Biliary colic d. Perforated peptic ulcer disease

D 16. A 44-year-old female diagnosed to have gall bladder stones by ultrasound

a year ago came in because of right upper quadrant pain after eating a fatty meal which was later on associated with radiation to the back after several hours. She might be suffering from:

a. Acute cholecystitis b. Choledocholelithiasis c. Biliary pancreatitis d. Acute cholangitis

A 17. A 25 year old male presents with nausea and vomiting and after three hours develops generalized abdominal pain. Based on this history alone, this patient might be suffering from: a. Typhoid ileitis b. Acute appendicitis c. Acute gastroenteritis d. Urinary tract infection

C

18. A In a male patient who comes in for a possible acute appendicitis, which of the following is more specific for acute appendicitis

a. Presence of fever b. Presence of leucosytosis c. Presence of RLQ direct and rebound tenderness with involuntary muscle

guarding d. Presence of generalized ileus seen of plain abdominal x-ray exam

C 19. Right upper quadrant intermittent pain, jaundice and acholic stools

suggest which of the following: a. Viral hepatitis b. Biliary obstruction c. Pancreatitis d. Cholecystitis

B 20. A 53 year old male consults for epigastric pain associated with nausea and

a feeling of gaseous distention relieved by burping after the Christmas holidays. The appropriate approach in the management is:

a. Treat symptomatically and work-up only if the symptoms persist b. Obtain serum amylase and lipase levels c. Request for an abdominal ultrasound d. Do an upper GI endoscopy and barium swallow

A 21. A 65-year-old male woke up during the early hours of the morning due to

severe epigastric pain. Based on the history alone, which of the following is the most likely cause of his pain?

a. Ureteral colic b. Acute Pancreatitis c. Biliary colic d. Perforated peptic ulcer disease

D 22. A 44-year-old female diagnosed to have gall bladder stones by ultrasound

a year ago came in because of right upper quadrant pain after eating a fatty meal which was later on associated with radiation to the back after several hours. She might be suffering from:

a. Acute cholecystitis b.Choledocholelithiasis c. Biliary pancreatitis d. Acute cholangitis

A

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