10. Acute Abdomen Flashcards
Appendicitis Definition and Aetiology
Inflammation of the appendix
Gut organisms invade appendix wall after lumen obstruction. This leads to oedema, ischaemic necrosis and perforation.
Appendicitis Symptoms
Acute onset
Umbilical pain that moves to the RIF
Young (5-40yo)
Appendicitis Examination
General inspection:
- General pain
- Staying still (peritonitis)
Palpation:
- Peri-umbilical pain (early)
- Right iliac fossa pain (late)
Eponymous Signs
- Rovsing’s Sign
- Psoas Sign
- Cope’s Sign
- Rebound Tenderness
Describe 4 Eponymous Signs of Appendicitis
Rovsing’s Sign - Pain is greater in RIF than LIF when LIF is pressed
Cope’s Sign - Pain on passive flexion and internal rotation of the hip
Psoas Sign - Pain on extending hip (only with retrocaecal appendix)
Rebound Tenderness - If infection involves peritoneum
Appendicitis Investigations
Alvarado score = a scoring system for diagnosing appendicitis
Bloods – leukocytosis, CRP elevated
USS
CT – very high sensitivity but takes time
Appendicitis Management
If suspected, attempt a prompt appendicectomy
Antibiotics given can include Metronidazole and Cefuroxime
Appendicitis Complications
Perforation
- More common with feacolith involvement (e.g. in children)
Appendix Mass
- The inflamed appendix becomes covered in omentum and forms a mass
(If suspected, wait a few weeks until the inflammation dies down before doing surgery)
Appendix Abscess
A nervous 16-year-old college student attends the local A&E department with her boyfriend, complaining of an episode of sudden onset right-sided pain in her abdomen. Physical examination of the patient is unremarkable except from a small scar located near the inguinal ligament. What is the most appropriate first line investigation in this case?
USS of the abdomen 𝞫-hCG test Full blood count CT scan of the abdomen No investigations, immediate surgery
𝞫-hCG test
The scar is McBurney’s (Gridiron) incision
A 26-year-old professional rugby player presents to the A&E department with abdominal pain in the umbilical area. On initial inspection, the gentleman is feverish with a temperature of 38C and a BP of 115/90. The admitting doctor suspects a diagnosis of appendicitis from the history and performs an abdominal physical examination and passively extends the gentleman’s right hip which elicits pain. Which eponymous sign of appendicitis is being demonstrated here and what does it represent?
Cope’s sign, and a retrocaecal appendix
Psoas sign, and a retrocaecal appendix
Psoas sign, and an appendix located next to obturator externus
Rovsing’s sign, and a retrocaecal appendix
Rovsing’s sign, and an appendix located next to obturator externus
Psoas sign, and a retrocaecal appendix
Diverticular Disease Definition
Diverticulosis = presence of diverticulae outpouchings of the colonic mucosa and submucosa throughout the large bowel
Diverticular disease = diverticulosis associated with complications
Diverticulitis = acute inflammation and infection of diverticulae
Diverticular Disease Classification
Hinchey Classification
Ia: phlegmon
Ib and II: localised abscesses
III: perforation with purulent peritonitis
IV: faecal peritonitis
Diverticular Disease Aetiology
A low fibre diet can lead to loss of stool bulk, –> high pressures are required to expel the stool –> herniations through the muscularis at weak points
Most common in sigmoid colon; can be obstructed with stool, leading to bacterial overgrowth, injury and diverticulitis
Rare<40yo
Common>40yo (60%)
Diverticular Disease Symptoms
Asymptomatic life
- Bloody Stool
- Fever
- LIF Pain
- Urinary Symptoms if diverticular fistulation into the bladder (pneumaturia, faecaluria and recurrent UTIs)
Diverticular Disease
Examination
General Inspection (Acute)
- General pain
- Staying still (peritonitis)
Palpation
- Left iliac fossa pain
Diverticular Disease Investigations
- Bloods – FBC, clotting
- Barium enema (CHRONIC) * NOT in acute –> increase likelihood of perforation
- Flexible sigmoidoscopy ± colonoscopy
- CT (ACUTE) and erect AXR (?perf)
If surgery is indicated, do a cross-match on blood groups in preparation
Diverticular Disease Mx
Acute (Symptomatic)
- IV hydration
- Bowel rest
Chronic (Asymptomatic)
- Soluble, high-fibre diet
- Anti-inflammatories (e.g. Mesalazine)
(may be required with recurrent attacks or complications)
- Hartmann’s
- Primary Anastomosis
When is surgery required for Diverticular Disease?
Recurrent attacks or complications
Primary anastomosis:
- Removal of affected bowel followed by the joining together of the two remaining ends.
- To protect the anastomosis and allow it to heal, adefunctioning(loop) ileostomymay be used to divert bowel contents away from the primary anastomosis
Hartmann’s:
- Removal of diseased bowel and an end-colostomy (stoma) formation with a anorectal stump. Used when Primary Anastomosis (immediate joining) is not possible (inflammation)
- Followed by a primary anastomosis afterwards
Complications of Diverticular Disease
- 10-25% will have >1 episode of Diverticulitis
- Faecal peritonitis
- Peri-colic abscess
- Colonic obstruction
- Perforation
- Fistulas
A feverish 56-year-old woman attends her GP complaining of a sudden appearance of bloody stools. She adds that she has experienced a few episodes of bloody stools before but did not seek medical attention and apart from a fever, she has had no other constitutional symptoms. The GP notes that the patient’s diet is particularly low in fibre and on physical examination, tenderness is found on pressure to the LIF. A DRE shows fresh blood upon removal of a gloved finger. What is the most likely diagnosis?
Angiodysplasia Diverticulosis Diverticulitis Mallory-Weiss tear Gastroenteritis
Diverticulitis
Remember, ‘constitutional symptoms’ are the FLAWSV signs/symptoms!
F Fever L Lethargy A Appetite changes W Weight loss S Night Sweats V Vomiting & nausea
A feverish 65-year-old is brought to the local A&E department by her daughter. She complains about nausea, LIF pain and vomiting. The attending doctor takes a full history and performs an abdominal examination and subsequently makes a diagnosis of acute diverticulitis with some associated signs of peritonism. A erect AXR is taken which shows some air under the diaphragm. What is the most appropriate surgical procedure?
Hartmann’s procedure Primary anastomosis Colectomy and end-ileostomy formation Delorme’s procedure Whipple’s procedure
Hartmann’s procedure - This is an ACUTE presentation so the bowel must be given rest before it is anastomosed
Hernia Definition
A condition in which part of an organ is displaced and protrudes through the wall of the cavity containing it (often involving the intestine at a weak point in the abdominal wall
