1. abdominal pain Flashcards
adhesions - history
Hx of abdominal or pelvic surgery
intermittent, cramp like abdominal pain
nausea and/or vomiting
constipation
absence of flatus
history of intra-abdominal malignancy (ovarian or colon cancer)
adhesions - examination
high pitched bowel sounds with rushes or absent bowel sounds
distended abdomen
tenderness on palpation
involuntary guarding
pyrexia
tachycardia
tympany on percussion
presence of abdominal scars
adhesions - Ix
CT abdo pelvis with oral and IV contrast - may see dilated loops of proximal bowel with collapsed loops posterior to site of obstruction
abdo x-ray - dilated loops of bowel
Chest X-ray - may see free air under the diaphragm
ABG - normal or metabolic acidosis; elevated lactate
FBC - elevated WBC, may be normal in early obstruction
CRP - may be elevated
incarcerated hernia - Hx
Hx of hernia, intermittent, cramp like abdominal pain, painful bulge, nausea, vomiting, decreased of absent bowel function, absence of flatus, distended abdo
incarcerated hernia - O/E
high pitched bowel sounds with rushes or absent bowel sounds
distended abdomen
tenderness to abdo palpation
tender bulge in abdominal wall our inguinal/femoral region, involuntary guarding, indirect hernia
incarcerated hernia - Ix
ABG - may be normal or metabolic acidosis, elevated lactate
FBC - may be normal in early obstruction, elevated WBC count as bowel infarction develops
CRP - may be elevated
CT abdo pelvis - dilated loops of proximal bowel with collapsed loops posterior to the site of obstruction
US groin - free fluid in hernia sac, bowel wall sickened, fluid within a herniated bowel loop, dilated intra-abdominal bowel loops
cholecystitis - Hx
RUQ pain intense lasting more than 30 minutes
HX of cholelithiasis and biliary colic
exacerbated by eating fatty foods
referred right shoulder pain
fever, nausea and/or vomiting
more common in women
risk factors for cholecystitis
women
obesity
age over 50
pregnancy
use of oestrogen
history of liver disease
cirrhosis
pancreatitis
cholecystitis O/E
fever, tachycardia, rue tenderness
Murphy’s sign - arrest of inhalation during palpation
palpable gallbladder
local guarding
jaundice
cholecystitis Ix
FBC - elevated WBC count
LFTs - may see elevated alkaline phosphatase, bilirubin and aminotransferase
CRP > 30 mg/L
RUQ US: gallstones, thickened gallbladder wall (>4mm), pericholecystic fluid
cholescintigraphy - no contrast filling in gallbladder
cholescintigraphy is cholecystitis
no contrast filling gallbladder
perforated gastric ulcer Hx
recurrent upper abdominal pain - dyspepsia
nausea, vomiting, anorexia
pain exacerbated by food
weight loss
use of NSAIDs
sudden onset severe upper abdo pain with fever, nausea, vomiting, peritoneal signs
referred pain to shoulder secondary to diaphragmatic irritation
perforated gastric ulcer O/E
fever, peritoneal signs with guarding and rebound
perforated gastric ulcer Ix
ABG - may be normal or metabolic acidosis
blood cultures - may detect bacteraemia
FBC - microcytic anaemia, elevated WBC count
serum electrolytes - may show elevated creatinine and urea
CRP - usually elevated
normal serum lipase or amylase
CT abdo pelvis - pneumoperitonism
abdo x-ray - abdominal free air on erect abdominal film
chest x-ray - may see free air under the diaphragm
helicobacter pylori - may be positive
perforated gastric ulcer special tests
Upper GI series with water soluble contrast - extraversion of contrast from stomach
oesophagogastroduodenoscopy with biopsy - may show helicobacter pylori or malignancy on histology
fasting serum gastrin level - hypergastrinaemia in zolliger-ellison syndrome
appendicitis Hx
sudden onset
constant, severe abdo pain often periumbilical with migration to right lower quadrant, usually worse on movement
nausea, vomiting, anorexia, fever, diarrhoea, more common in children than young adults, pain may improve after appendix rupture.
appendicitis O/E
fever, tachycardia, patient may be lying in right lateral decubitus position with hips flexed; no or decreased bowel sounds; pain commonly originates near the umbilicus or the epigastrium; right lower quadrant (McBurney’s point) tenderness with rigid abdomen; guarding and rebound tenderness; Rovsing’s sign (palpation of left lower quadrant elicits pain in the right lower quadrant), psoas sign (right lower quadrant pain with right thigh extension), pain reproduced by coughing or hopping
appendicits Ix
FBC - elevated WBC count
CRP elevated
CT scan of abdomen and pelvis wth intravenous contrast - abnormal appendix (diameter >6mm) identified or calcified appendicolith seen in association with peri-appendiceal inflammation
RLQ US: non-compressible appendix of >7mm in anteroposterior diameter appendicolith, interruption of continuity of the echogenic submucosa, peri appendices fluid or mass
MRI abdo - findings may include diffuse or segmental enlargement of the pancreas with irregular contour and obliteration of the peri pancreatic fat, necrosis or pseudocysts.
ectopic pregnancy Hx
vaginal bleeding with severe, usually unilateral pelvic pain, amenorrhoea or painless vaginal bleeding, history of recent early pregnancy or missed last menstrual period
ectopic pregnancy risk factors
history of ectopic
tubal surgery
PID
infertility treatment and pregnancy with an IUD in situ
ectopic pregnancy O/E
may have palpable adrenal mass with or without tenderness, rigid abdomen, guarding and rebound tenderness with ruptured ectopic leading to haemorperitoneum, tachycardia, and hypotension, vaginal bleeding on speculum examination
ectopic pregnancy Ix
hCG - positive
FBC - possible anaemia
pelvic ultrasound - no intrauterine pregnancy detected, ectopic pregnancy visualised
diagnostic laparoscopy - ectopic pregnancy or complex mass seen
PID Hx
sexually active, unprotected sexual intercourse
prior infection with chlamydia of gonorrhoea; history of PID; use of intrauterine device, lower abdominal or pelvic pain of recent onset or relatively short duration that may have begun after intercourse, abnormal vaginal discharge , fever
PID O/E
abdominal tenderness, abnormal vaginl discharge, cervical motion tenderness and adnexal tenderness will be present, bimanual examination may reveal a tube-ovarian abscess
PID O/E
FBC - elevated WBC count
erythrocyte sedimentation rate/CRP - elevated
wet mount of vaginal secretions - polymorphonuclear cells present
nucleic acid amplification test or culture of vaginal secretions - may confirm infection with chlamydia trichromatic or neisseria gonorrhoea
PID US
tubal wall thickness >5mm, incomplete septa within the tube, fluid in the cup-de-sac, and a cog-wheel appearance on the cross section of the tubal vein, may see complex adnexal mass, which could be indicative off a tubo-ovarian abscess
acute pancreatitis
acute-onset, constant, severe mid-abdominal/epigastric pain that often radiates to the back; nausea, vomiting; anorexia; history of biliary colic, alcohol misuse, use of specific medicines (e.g., sulphonamides, tetracycline, oestrogens, corticosteroids), trauma, or surgery
acute pancreatitis O/E
varying degrees of abdominal tenderness, usually worse in the epigastric region; guarding, abdominal distension, and reduced or absent bowel sounds; ecchymoses in the skin of one or both flanks (Grey-Turner’s sign) and/or the periumbilical area (Cullen’s sign)
acute pancreatitis Ix
serum lipase of amylase - elevated (3x the upper limit)
FBC - elevated WBC
LFTs - normal or elevated ALT
urea and creatinine - normal or elevated
serum glucose - normal or elevated
serum calcium - may be elevated
serum triglycerides - may be elevated
acute pancreatitis imaging
abdo US - ascites, gallstones, dilated common bile duct, enlarged pancreas
CT abdo with oral and IV contrast - may show pancreatic inflammation, peri-pancreatic stranding, calcifications, fluid collections, confirms or excludes gallstones.
magnetic resonance cholangiopancreatography - findings may include stones, diffuse or segmental enlargement of the pancreas with irregular contour and obliteration od the peri pancreatic fat, necrosis or pseudocysts
acute diverticulitis Hx
perisistant LLQ pain, fever, anorexia, nausea, vomtiing, abdominal distension (with ileum), patient may have a history of diverticulosis
acute diverticulitis O/E
fever, LLQ tenderness, frank blood in stool, diffuse tenderness with peritoneal signs (guarding, rebound tenderness, rigid abdomen) with perforation or ruptures abscess
acute diverticulitis Ix
elevated WBC count
acute diverticulitis imaging
water soluble contract enema - may see diverticula along with extraversion of contrast material into an abscess cavity or into the peritoneum
abdo US - may see fluid collections around the colon or a thickened hypoechoic bowell wall
endoscopy - may ee inflamed diverticulum, abscess or perforation
laparoscopy in diverticulitis allows direct visualisation of bowel if diagnosis is unclear
ulcerative colitis Hx
bloody much diarrhoea and/or frank blood, fever, abdominal pain, weight los, growth retardation, back and joint pain and stiffness
UC O/E
abdominal tenderness; fevers; skin rash; episcleritis; pallor; guaiac-positive stools or frank blood on rectal examination
UC labs
FBC:
variable degree of anaemia, leukocytosis, or thrombocytosis
comprehensive metabolic panel (including LFTs):
hypokalaemic metabolic acidosis; elevated sodium and urea; elevated alkaline phosphatase, bilirubin, aspartate aminotransferase, and alanine aminotransferase; hypoalbuminaemia
CRP and erythrocyte sedimentation rate:
elevated
UC stool studies
negative culture, Clostridium difficile toxins A and B negative; WBCs present; elevated faecal calprotectin
UC abdo X ray
dilated loops with air-fluid level secondary to ileus; free air is consistent with perforation; in toxic megacolon, the transverse colon is dilated to ≥6 cm in diameter
UC colonoscopy/sigmoidoscopy
rectal involvement, continuous uniform involvement, loss of vascular marking, diffuse erythema, mucosal granularity, fistulas (rarely seen), normal terminal ileum (or mild ‘backwash’ ileitis in pancolitis)
UC biopsy
continuous distal disease, mucin depletion, basal plasmacytosis, diffuse mucosal atrophy, absence of granulomata, and anal sparing; only mucosal/submucosal involvement
UC in double contrast barium enema
results range from a fine granular appearance of the bowel wall to diffuse ulceration, thumbprinting (due to mucosal oedema), and narrowing and shortening of the bowel, depending on the severity of the disease
UC CT abdo pelvis with oral and IV contrast
may show thickening, inflammation, abscess, fistulisation, obstruction of the bowel; biliary dilation suggests primary sclerosing cholangitis
churns disease Hx
family history of Crohn’s disease; typical age range 15-40 or 60-80 years; fevers, abdominal pain, prolonged intermittent bloody or non-bloody diarrhoea; fatigue; anal discharge and abscess; weight loss; faltering growth in children
churns disease O/E
abdominal tenderness often periumbilical or right lower quadrant if terminal ileum inflamed, mimicking appendicitis; peri-anal disease with fissures, skin tags fistulae, sinuses, and abscesses; aphthous ulcers; blood on rectal examination
churns disease labs
FBC:
anaemia; leukocytosis; may be thrombocytosis
comprehensive metabolic panel:
hypoalbuminaemia, hypocholesterolaemia, hypocalcaemia
CRP and erythrocyte sedimentation rate:
elevated
iron studies:
normal, or may demonstrate changes consistent with iron deficiency
serum vitamin B12:
may be normal or low
serum folate:
may be normal or low
churns disease stool studies
absence of infectious elements seen on microscopy or culture; faecal calprotectin may be elevated
churns disease imaging
abdo x ray:
small bowel or colonic dilation; calcification; sacroiliitis; intra-abdominal abscesses
CT abdomen:
skip lesions, bowel wall thickening, surrounding inflammation, abscess, fistulae
MRI abdomen/pelvis:
skip lesions, bowel wall thickening, surrounding inflammation, abscess, fistulae
abdominal and pelvic ultrasonography:
bowel wall thickening, surrounding inflammation, abscess; tubo-ovarian abscess
colonoscopy:
aphthous ulcers, hyperaemia, oedema, cobblestoning, skip lesions
churns disease tissue biopsy
tissue biopsy:
mucosal bowel biopsies demonstrate transmural involvement with non-caseating granulomas
cholelithiasis Hx
right upper quadrant or epigastric pain (lasting more than 30 minutes) sometimes associated with food
cholelithiasis O/E
right upper quadrant or epigastric tenderness; jaundice
cholelithiasis labs
LFTs:
may be normal or elevated alkaline phosphatase and elevated bilirubin
serum lipase and amylase:
elevated (>3 times upper limit of normal) in acute pancreatitis
cholelithiasis imaging
abdominal ultrasound:
demonstrates stones in the gallbladder
endoscopic ultrasound (EUS):
stones in gallbladder or bile duct
GI malignancy Hx
nausea, vomiting, abdominal pain and distension (especially with distal obstruction); little or no flatus or bowel function; weight loss; black stools
GI malignancy O/E
may have palpable mass, pallor, or cachexia; if obstruction present, distended abdomen, high-pitched (hyperactive) bowel sounds with rushes, or absent bowel sounds; tenderness to abdominal palpation, involuntary guarding; tachycardia
GI malignancy labs
FBC:
variable level of anaemia
renal function:
normal, except if advanced pelvic disease is compressing ureters
LFTs:
normal, except if liver metastases present
faecal occult blood testing:
positive
GI malignancy imaging
CXR:
normal or evidence of metastatic disease
oesophagogastroduodenoscopy with biopsy:
may show upper gastrointestinal ulcer, mass, or mucosal changes and provide histological confirmation
colonoscopy with biopsy:
ulcerating exophytic mucosal lesion that may narrow the bowel lumen; histological confirmation
CT thorax/abdomen/pelvis with oral and intravenous contrast:
hypodense lesions around tumour site or at distant metastatic sites (e.g. liver); colonic wall thickening, enlarged lymph nodes, liver metastases, ascites, lung secondaries; invasion of mesorectal fascia
CT colonography:
appearances similar to conventional colonoscopy, with an ulcerating exophytic mucosal lesion that may narrow the bowel lumen
upper gastrointestinal endoscopic ultrasound:
determines clinical tumour (T) and node (N) stage of upper gastrointestinal tumours
transrectal endoscopic ultrasound:
determines clinical tumour (T) and node (N) stage of rectal tumours
mallory-weiss tear Hx
vomiting or coughing with subsequent haematemesis; retrosternal, epigastric, or back pain; melena; presyncope/syncope; dysphagia, odynophagia
mallory weiss tear O/E
postural/orthostatic hypotension; pallor, tachycardia
mallory weiss tear imaging
erect CXR:
may show free air
oesophagogastroduodenoscopy:
bleeding, adherent clot, or fibrous rind over an area of mucosal split at or near the gastro-oesophageal junction
diabetic ketoacidosis Hx
inadequate or inappropriate insulin therapy, infection (pneumonia and urinary tract infections are the most common), myocardial infarction; anorexia, nausea, vomiting, polyuria, thirst; abdominal pain; fever; dizziness, weakness, mental status change
diabetic ketoacidosis O/E
acetone breath; deep, laboured, gasping breathing (Kussmaul’s breathing); signs of hypovolaemia (tachycardia, hypotension, poor capillary refill, sunken eyes); abdominal tenderness; altered mental status
diabetic ketoacidosis labs
plasma glucose:
elevated
serum electrolytes and urea:
usually sodium low, potassium elevated, chloride low, magnesium low, calcium low, phosphate normal or elevated, urea elevated, creatinine elevated
arterial blood gases:
pH varies from 7.00 to 7.30 in diabetic ketoacidosis (DKA); arterial bicarbonate ranges from <10 mmol/L (<10 mEq/L) in severe DKA to >15 mmol/L (>15 mEq/L) in mild DKA
urinalysis:
positive for glucose and ketones; positive for leukocytes and nitrites in the presence of infection
serum ketones:
elevated
FBC:
elevated WBC count
plasma glucose in diabetic ketoacidosis
elevated
urinalysis in diabetic ketoacidosis
positive for glucose and ketones; positive for leukocytes and nitrites in the presence of infection
serum ketones in diabetic ketoacidosis
elevated
opiod withdrawal Hx
history of drug use/misuse; fever, chills, nausea, vomiting; crampy abdominal pain; change of bowel habit; sweating, tremors, confusion, agitation, anxiety, muscular aches, increased salivation, dilated pupils
opiod withdrawal O/E
diffuse abdominal pain and tenderness; abdomen usually not distended; dilated pupils, confusion, sweating, copious salivation
opioid withdrawal labs
urine drug screen:
positive
gas chromatography-mass spectroscopy:
positive
hepatitis Hx
perinatal exposure, family history of hepatitis B virus infection, blood transfusions, high-risk activities (e.g., multiple sexual partners, men who have sex with men, injection drug users, intravenous drug use); right upper quadrant pain; fever, chills, fatigue, myalgia/arthralgia; nausea, vomiting; jaundice
hepatitis O/E
right upper quadrant tenderness; hepatosplenomegaly; jaundice; ascites; maculopapular or urticarial rash
hepatitis labs
FBC:
elevated; non-specific
LFTs:
elevated transaminases (alanine aminotransferase/aspartate aminotransferase), alkaline phosphatase, and bilirubin
serum electrolytes, urea, and creatinine:
usually normal
hepatitis serology and antigens:
positive
hepatitis imaging
ultrasound right upper quadrant:
poorly defined margins and coarse, irregular internal echoes in hepatitis B
prothrombin time:
prolonged
gastroenteritis Hx
nausea, vomiting, diarrhoea, crampy abdominal pain; history of sick contacts with similar symptoms; ingestion of questionable food or water; recent travel to places with insanitary conditions
gastroenteritis O/E
dehydration; tachycardia; soft, non-distended abdomen; diffuse abdominal tenderness
gastroenteritis labs
FBC:
elevated WBC count
serum electrolytes and urea:
variable, may show dehydration
stool for culture, ova and parasites:
may identify infectious agent
gastroenteritis imaging
stool leukocytes:
positive
CT abdomen/pelvis with oral and intravenous contrast:
may show non-specific thickening of affected bowel
infectious colitis Hx
fever, chills, nausea, vomiting, diarrhoea (may be bloody), abdominal pain; abdominal distention, malaise, and anorexia; may have been recent travel, community outbreak or close contact with people with similar symptoms, recent use of antibiotics or hospitalisation; immunocompromise
infectious colitis O/E
pyrexia, abdominal pain and tenderness; variable signs from mild dehydration to hypovolaemic shock/septic shock (hypotension, tachycardia); peritonitis; possible abdominal distention
infectious colitis labs
FBC:
elevated WBC count and/or anaemia
serum electrolytes and urea:
variable, may show dehydration
stool culture:
may identify infectious agent
faecal occult blood:
positive
infectious colitis imaging
abdominal x-ray:
may show distended colon
CT abdomen/pelvis with contrast:
may show thickened and inflamed segments of colon or all of colon affected; may show pneumatosis or localised perforation or perforation with phlegmon/abscess in severe cases
sickle cell crisis Hx
history of sickle cell anaemia; diffuse bodily pain which can include abdominal pain, bone pain, chest pain; may also have fatigue, fever, jaundice, tachycardia, delayed growth and puberty; skin ulcers
sickle cell O/E
diffuse acute abdominal pain and tenderness on palpation; patient is uncomfortable in any position; abdomen is usually not distended; fever
sickle cell labs
FBC with reticulocyte count:
some degree of anaemia occurs in most patients with sickle cell disease; leukocytosis common in acute pain crises
peripheral blood smear:
presence of nucleated red blood cells, sickle-shaped cells, and Howell-Jolly bodies
urea and creatinine:
normal or elevated
LFTs:
variable
bacterial cultures:
pathogen detected
sickle cell crisis imaging
abdominal ultrasound:
may show enlarged spleen or presence of gallstones; hepatomegaly
CT abdomen/pelvis:
may show enlarged spleen or presence of gallstones; hepatic or renal infarction
haemoglobinopathy testing:
sickle cell haemoglobin mutation
CXR:
presence of pulmonary infiltrate(s) may be an indication of acute chest syndrome
endometriosis Hx
dysmenorrhoea; cyclical lower abdominal/pelvic/back pain, often 1-2 weeks before menstruation and during menstruation; pain during bowel movements; dyspareunia; sub-fertility; urinary or bowel obstruction; depression
endometriosis O/E
discomfort and uterosacral ligament nodularity during bimanual/rectovaginal examination; tenderness on palpation in lower abdomen; fixed retroverted uterus in late stages; pelvic mass (ovarian endometriomas)
endometriosis imaging
transvaginal ultrasound:
may show ovarian endometrioma (homogeneous, low-level echoes) or evidence of deep pelvic endometriosis such as uterosacral ligament involvement (hypoechoic linear thickening)
diagnostic laparoscopy:
direct visualisation of endometrial implants and histological confirmation of biopsies
rectal endoscopic ultrasound:
hypoechoic nodule or mass
MRI pelvis:
hypointense, irregular thickening or mass of uterosacral ligament; replacement of fat tissue plane between uterus and rectum/sigmoid with tissue mass
testicular torsion Hx
history of previous on-off testicular pain; sudden-onset testicular pain with nausea and vomiting; scrotal oedema/swelling/erythema; abdominal pain also often present
testicular torsion O/E
severe testicular pain and tenderness on affected side; may be swollen; affected testicle is located higher than the non-affected testicle, often in horizontal position; reduced or absent cremasteric reflex
testicular torsion imaging
surgical exploration of the scrotum:
testicular torsion
grey-scale ultrasound:
presence of fluid and the whirlpool sign (the swirling appearance of the spermatic cord from torsion as the ultrasound probe scans downwards perpendicular to the spermatic cord)
FBC:
normal
power Doppler ultrasound:
absent or decreased blood flow in the affected testicle; decreased flow velocity in the intratesticular arteries, increased resistive indices in the intratesticular arteries
colour Doppler ultrasound:
absent or decreased blood flow in the affected testicle; decreased flow velocity in the intratesticular arteries, increased resistive indices in the intratesticular arteries
spectral Doppler:
non-homogeneous and/or asymmetric vascular perfusion compared with the unaffected testis
scintigraphy:
decreased uptake of radioactive technetium-99m to the affected testicle in patients with testicular torsion
scintigraphy in testicular torsion
decreased uptake of radioactive technetium-99m to the affected testicle in patients with testicular torsion
kidney stones Hx
previous history of kidney stones; may be asymptomatic to severe abdominal flank pain radiating to the groin; other symptoms include nausea, vomiting, diaphoresis, haematuria; urinary frequency/urgency; occupations in hot conditions (e.g., chefs, steel workers); family history of stones
kidney stones O/E
often obese; abdomen soft; when in pain, may be severe, unable to find comfortable position; tender to palpation/percussion of costovertebral angle/flank; if urosepsis also present may be tachycardic, hypotensive, pyrexial
kidney stones labs
urinalysis:
dipstick positive for leukocytes, nitrates, blood; microscopic analysis positive for WBCs, red blood cells, or bacteria; may be normal
FBC:
normal or raised WBC count
serum electrolytes, urea, and creatinine:
normal or deranged
uric acid level:
normal or elevated
kidney stones imaging
non-contrast helical CT abdomen/pelvis (stone protocol):
calcification seen in renal collecting system or ureter
renal ultrasound:
calcification seen within urinary tract
retrograde urethrogram:
calcification seen within urinary tract or a filling defect seen
intravenous pyelogram:
calcification seen within urinary tract or a filling defect seen when dye is passing through the kidney and down the ureter
pyelonephritis Hx
family history of kidney stones; history of urinary tract infection, stress incontinence, or frequent sexual intercourse; fever with chills; dysuria, frequency, urgency; flank pain; nausea, vomiting, diaphoresis, haematuria
pyelonephritis O/E
pyrexia; flushed looking; flank pain and/or costovertebral angle tenderness on palpation/percussion
pyelonephritis labs
urinalysis:
pyuria (>10 WBCs per high-power field [HPF]), red blood cells ≥5/HPF, leukocyte esterase, nitrites, WBC casts, proteinuria up to 20 g/L (2 g/dL)
Gram stain:
typically gram-negative rods; less typically gram-positive cocci
urine culture:
positive
FBC:
leukocytosis
CRP:
elevated
pyelonephritis imaging
CT abdomen/pelvis with intravenous contrast:
altered renal parenchymal perfusion; altered excretion of contrast; perinephric fluid; non-renal disease; may show abscess formation
renal ultrasound:
gross structural abnormalities; hydronephrosis; stones; perirenal fluid collections
99mTc-dimercaptosuccinic acid scintigraphy:
inflammation or scarring of the renal cortex; unequal distribution of renal function between the kidneys
MRI:
structural anomalies of the genitourinary system (prenatal); renal inflammation or masses; abnormal renal vasculature; urinary obstruction
volvulus Hx
steady abdominal pain that may have colicky characteristics varying from vague discomfort to excruciating (severe unremitting pain suggests gangrenous bowel); history of abdominal surgery, abdominal or inguinal hernia; nausea, vomiting, emesis may be absent in patients with sigmoid volvulus (more common in older or debilitated patients); periumbilical or hypogastric pain, diarrhoea or constipation (depending on the degree and location of the obstruction)
volvulus O/E
often diffuse abdominal distension and tenderness; faint or no bowel sounds, rigid abdomen, guarding, rebound tenderness, fever, or haematochezia
volvulus labs
ABG:
may be normal; metabolic acidosis; elevated lactate
CXR:
may see free air under the diaphragm
FBC:
elevated WBC count
serum electrolytes:
may be normal in early obstruction; may confirm hypochloraemia and hypokalaemia; urea and creatinine may be elevated
CRP:
may be elevated
volvulus imaging
plain abdominal x-rays:
partial or complete obstruction; dilated bowel loops; air-fluid levels; abdominal free air with perforation
CT of abdomen:
bowel obstruction with whirl pattern of mesentery
intussusception Hx
more common in children than in adults; classic presentation of severe, colicky pain alternating with lethargy; may also present with vague abdominal complaints; severe, cramp-like abdominal pain; children may be inconsolable; vomiting
intussusception O/E
occult or frank blood mixed with mucus giving currant-jelly appearance, abdominal tenderness, and palpable mass
intussusception labs
FBC:
elevated WBC count
serum electrolytes:
may be normal in early obstruction; may confirm hypochloraemia and hypokalaemia; urea and creatinine may be elevatedMore
CRP:
may be elevated
intussusception imaging
ultrasound:
tubular mass in longitudinal view; target lesion in transverse view
CT of abdomen and pelvis:
target lesion: intraluminal soft-tissue density mass with an eccentrically placed fatty area; reniform mass: high attenuation peripherally and lower attenuation centrally; sausage-shaped mass: alternating areas of low and high attenuation representing closely spaced bowel wall, mesenteric fat, and/or intestinal fluid and gas
perforated duodenal ulcer Hx
acute onset of severe epigastric pain, nausea, vomiting, and loss of appetite; more common in men than women; history of melaena or bright red blood from rectum, episodic epigastric pain relieved by eating; use of non-steroidal anti-inflammatory drugs; may have latent period with symptom improvement that may last several hours, followed by peritonitis with fever, nausea, vomiting, and peritoneal signs; referred pain to shoulders secondary to diaphragmatic irritation
perforated duodenal ulcer O/E
tachycardia, fever, epigastric tenderness, rigid abdomen, guarding, rebound tenderness, and occult or frank blood in stool
perforated duodenal ulcer labs
ABG:
may be normal; metabolic acidosis; elevated lactateMore
blood cultures:
may detect bacteraemia
FBC:
elevated WBC count
serum electrolytes:
may show elevated creatinine and ureaMore
CRP:
usually elevated
serum lipase or amylase:
normal
may be positive for helicobacter pylori
perforated duodenal ulcer imaging
CT of abdomen and pelvis:
pneumoperitoneumMore
plain abdominal x-rays:
abdominal free air on erect abdominal film
CXR:
may see free air under the diaphragm
ruptured ovarian cyst Hx
often days 20 and 26 of a normal menstrual cycle; often follows intercourse, exercise, or pelvic examination; sudden-onset lower abdominal pain, may be lateralised to left or right; light vaginal bleeding; postural dizziness if marked haemorrhage (associated with rupture of corpus luteum cyst, specifically among patients on anticoagulants or with bleeding disorders)
ruptured ovarian cyst O/E
light vaginal bleeding; vital signs usually normal, but may be low-grade fever; may have tachycardia/hypotension if severe bleeding in association with coagulopathy or anticoagulant use; signs of peritonitis if haemoperitoneum present
ruptured ovarian cyst imaging
transvaginal ultrasound:
enlarged ovary or portion of ovarian tissue; may be cystic, solid, or mixed; free pelvic fluid
positive or negative pregnancy test
abdominal aortic dissection Hx
severe, sharp, or tearing pain in thorax or abdomen, pain radiates to neck or back, history of hypertension, increased risk in Marfan’s syndrome and Ehlers-Danlos syndrome or other collagen vascular disorders, painless dissection is rare
abdominal aortic dissection O/E
hypertension in distal dissection; lower extremity pulse deficit, sensory or motor deficits (including numbness, tingling, or transient paraplegia); ischaemia and, if mesenteric arteries involved, bowel ischaemia with rigid abdomen, guarding and rebound tenderness
abdominal aortic dissection labs
serum urea and electrolytes:
elevated urea
Abdominal aortic dissection imaging
plain abdominal x-rays:
aortic wall calcification consistent with abdominal aortic aneurysm; loss of psoas shadow in presence of rupture
CT angiography of chest and abdomen:
two aortic lumina separated by intimal flap or displaying different rates of contrast opacification
magnetic resonance angiography of chest and abdomen:
two aortic lumina separated by intimal flap; branch vessel involvement; aortic regurgitation
CXR:
widened aortic silhouette; widened mediastinum
contrast aortography:
two aortic lumina separated by intimal flap; branch vessel involvement; aortic regurgitation
ischaemic colitis Hx
fever, vomiting, diarrhoea, abdominal pain, and bloody stools; history of vascular disease, recent abdominal aortic aneurysm repair, sepsis, myocardial infarct, or atrial fibrillation
ischaemic colitis O/E
diffuse abdominal pain or localised to area of colon affected with little or no distension
ischaemic colitis labs
FBC:
elevated WBC count
serum lactate:
elevated if tissue hypoxia
ischaemic colitis imaging
CT abdomen/pelvis with oral and intravenous contrast:
may show thickened and inflamed segments of colon; pneumatosis or gas in mesenteric veins suggestive of ischaemia
colonoscopy:
pale or bluish mucosa with haemorrhagic lesions
obstruction series:
pneumatosis or gas in mesenteric or portal vein but not specific to ischaemic colitis
MRI abdomen with contrast:
may show thickened and inflamed segments of colon; pneumatosis or gas in mesenteric veins suggestive of ischaemia
diagnostic laparoscopy:
full thickness ischaemia may be seen; ischaemia restricted to mucosa will not be seen
meckel’s diverticulitis Hx
sudden-onset severe abdominal pain, often starts periumbilical with migration to right lower quadrant; nausea, vomiting, anorexia, fever, diarrhoea
mocker’s diverticulitis O/E
fever, tachycardia, patient may be lying in right lateral decubitus position with hips flexed; no or decreased bowel sounds; pain commonly originates near the umbilicus or the epigastrium; right lower quadrant (McBurney’s point) tenderness with rigid abdomen; guarding and rebound tenderness; psoas sign (right lower quadrant pain with right thigh extension)
meckel’s diverticulitis labs
FBC:
low haemoglobin and haematocrit; leukocytosis with left shift
meckel’s diverticulitis imaging
technetium-99m pertechnetate scan (‘Meckel scan’):
ectopic focus or ‘hot spot’; enhancement of diverticulum
plain abdominal radiography:
dilated bowel loops with air-fluid levels and paucity of distal gas suggests bowel obstruction; free air on upright film suggests a perforation; a density in the right side of the abdomen suggests an intussusception
CT scan of the abdomen and pelvis:
blind-ending fluid-filled and/or gas-filled structure in continuity with distal ileum
ultrasound of the abdomen:
tubular mass in longitudinal views and a doughnut or target appearance in transverse views suggests intussusception
