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Snapshot
  • A 30-year-old G0P0 woman presents to the emergency room for acute onset abdominal pain and nausea. She recently had unprotected sex with 2 different partners. On physical exam, she has involuntary guarding and tenderness to percussion. A urine pregnancy test is positive, and a transvaginal ultrasound shows a ruptured ectopic pregnancy.
Introduction
  • Overview
    • acute abdomen is characterized by acute onset of severe abdominal pain that requires urgent surgical evaluation
      • management depends on etiology
  • Epidemiology
    • incidence
    • etiologies
      • hemorrhage
        • abdominal aortic aneurysm rupture
        • bleeding gastric ulcer
        • ruptured ectopic pregnancy
      • ischemia
        • ischemic bowel disease
      • perforated bowel/peritonitis
        • perforated peptic ulcer
        • bowel obstruction
        • diverticular disease
        • inflammatory bowel disease
        • perforated appendicitis
  • Pathogenesis
    • mechanism
      • hemorrhage will often lead to hypovolemic shock, requiring swift intervention
      • ischemia results in elevated lactate and also requires early intervention
      • perforated bowel causes inflammation of the peritoneum or peritonitis
Presentation
  • Symptoms
    • common symptoms
      • dehydration
      • sudden-onset abdominal pain
      • pain out of proportion to exam
        • ischemic bowel disease
  • Physical exam
    • inspection
      • pallor
      • hypovolemia
      • tachycardia
    • motion
      • rigid abdomen
      • tenderness to percussion
      • involuntary guarding
      • may have reduced or absent bowel sounds
Imaging
  • Chest radiograph
    • indications
      • to look for free air under the diaphragm
    • findings
      • free air under the diaphragm, indicating bowel perforation
  • Abdominal radiograph
    • indications
      • if bowel obstruction is suspected
    • findings
      • dilated loops of bowel
  • Abdominal ultrasound
    • indications
      • if biliary or hepatic etiology is suspected
      • if tubo-ovarian pathology is suspected
      • if appendicitis is suspected
      • if aneurysm is suspected
      • evaluate for hemorrhage
  • CT abdomen and pelvis
    • indications
      • if mesenteric ischemia, diverticulitis, or bowel perforation are suspected
Studies
  • Serum labs
    • lactate
    • arterial blood gas
    • urinalysis
    • pregnancy test
    • blood cultures
      • to rule out infection
    • amylase and lipase
      • if pancreatitis is suspected
    • complete blood count
    • electrolytes
    • liver function panel
Differential
 
Differential by Location of Abdominal Pain
Generalized
  • Bowel obstruction
  • Mesenteric ischemia
Right Upper Quadrant Epigastric Left Upper Quadrant
  • Acute cholecystitis
  • Hepatitis
  • Liver abscess
  • Acute cholangitis
  • Peptic ulcer disease
  • Myocardial infarction
  • Pancreatitis
  • Gastric ulcer
  • Splenic rupture
Right Lower Quadrant Periumbilical Left Lower Quadrant
  • Appendicitis
  • Bowel obstruction
  • Appendicitis
  • Abdominal aortic aneurysm
  • Diverticulitis
Lower Abdomen
  • Inguinal hernia
  • IBD
  • UTI
  • Pelvic inflammatory disease
  • Ectopic pregnancy
  • Testicular torsion
 
Treatment
  • Management approach
    • depends on the etiology of acute abdomen
  • Medical
    • supportive care
      • indications
        • all patients
      • modalities
        • intravenous hydration
        • analgesia
        • anti-emetics
        • nasogastric decompression if necessary
        • bowel rest
        • NPO
        • blood transfusion if necessary
  • Surgical
    • surgical intervention
      • indications
        • irreversible pathologies such as appendicitis, mesenteric ischemia, and perforated bowel
Complications
  • Septic shock
  • Death
 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.GN.1) A 17-year-old woman presents to the emergency department with abdominal and pelvic pain. She states it started 3 days ago and it has been getting gradually worse. She states it is diffuse and is located over her abdomen, pelvis, and inside her vagina. She also endorses vaginal pruritus and a discharge from her vagina. The patient works in an ice cream parlor and is sexually active with multiple different partners. Her temperature is 98.0°F (36.7°C), blood pressure is 122/80 mmHg, pulse is 82/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is notable for a foul smelling vagina with a thin, white discharge. Her abdomen is diffusely tender. The patient is noted to be itching her vagina during the exam. Which of the following is the most appropriate initial step in management? Review Topic

QID: 100511
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Cervical swab and culture

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CT abdomen/pelvis

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KOH prep

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Urine hCG

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Wet mount

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M2

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