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
Types of Hernias
Inguinal Femoral Incisional Hiatus Spigelian (quite rare, occurs on the linea semilunaris of the abdomen)
Hernia Symptoms and RF
- Lump in groin
- Vomiting
- Groin Pain
- Scrotal Swelling
RF:
- Age
- Obesity
- Constipation
- Chronic cough
- Heavy lifting (gym
Define Reducible, Incarcerated, Obstructed and Strangulated Hernias
Reducible–when the contents of the hernia can be manipulated back into its original position through the defect from which it emerges
Incarcerated hernia (irreducible)–the hernia is compressed by the defect causing it to be irreducible (i.e. unable to be pushed back into its original position)
Obstructed hernia–(contains bowel) contents of hernia compressed to the extent that the bowel lumen is no longer patent –> bowel obstruction
Strangulated hernia–the compression around the hernia prevents blood flow into the hernial contents causing ischaemia to the tissues and pain
Femoral vs Inguinal Hernias
Femoral More common in females* More commonly strangulated Surgery recommended Older Often contain omentum
Inguinal More common in males and females Less commonly strangulated Can be treated without surgery Younger Contains mainly bowel
Examination for hernia
Swells/appears on coughing; may reduce on supination
May be reducible on pressure
Strangulated* signs – tender, red, colicky abdominal pain, distension, vomiting
Direct vs Indirect Hernia
How to differentiate
Directly through the weak abdominal wall
Indirectly down the inguinal canal
- Reduce the hernia
- Place a finger over the deep inguinal ring (just above the midpoint of the inguinal ligament)
- Ask the patient to cough and if the hernia re-appears, it cannot be an indirect hernia (must be direct)
Anatomical position of Femoral and Inguinal Hernias
Femoral
Lateral & inferior to pubic tubercle
Inguinal
Superior & medial to public tubercle
Hernia Invx and Mx
Largely just a clinical diagnosis
- USS (1st line)
Femoral
- Surgical repair (higher strangulation risk)
Inguinal
- Reassurance (if left, strangulation is a potential complication)
- Elective surgery
A 26-year-old bodybuilder attends the local day-surgical clinic upon referral from his GP due to a groin lump. The general surgical registrar suspects a hernia and so performs a simple test to ascertain the type of hernia to determine the most appropriate management. The doctor reduces the hernia and then places their finger over the deep inguinal ring. The patient is asked to cough and the hernia does not reappear. What is the most likely type of hernia?
Femoral hernia Direct inguinal hernia Indirect inguinal hernia Spigelian hernia Hiatus hernia
Indirect inguinal hernia
Pancreatitis Definition and Aetiology
Inflammation of the pancreas; this can be either in an acute or chronic setting and may involve the surrounding organs
Activation of the pancreatic enzymes resulting in tissue damage and inflammation
Pancreatitis RF
GET SMASHED
Gall stones, Ethanol, Trauma, Scorpion Venom (Trinidad scorpion), Mumps/Malignancy, Autoimmune, Steroids, Hyperlipidaemia/Hypercalcaemia/Hyperparathyroidism, ERCP, Drugs (e.g. Thiazides)
Acute - Gallstones or ETOH
Chronic - ETOH 70%, Idiopathic 20%
Pancreatitis Symptoms
Epigastric pain
Radiates to back
Relieved on sitting forward
Worst on movement
Chronic: Recurrent pain, weight loss, bloating, steatorrhoea
Pancreatitis Examination
- Epigastric tenderness
- Fever
- Shock, tachycardia, tachypnoea
- Reduced bowel sounds
Cullen’s + Grey Turners
Due to intra-abdominal bleeding from pancreatic inflammation
Fox’s sign” - bruising over inguinal ligament
Pancreatitis
Bloods:
- Amylase* (3x normal in acute, normal in chronic)
- Others (e.g. FBC, x-match, etc.) USS – gallstones?
Faeces:
- Faecal elastase = high in CHRONIC
Imaging:
- Acute: Erect CXR & AXR – ?pleural effusion; CT – exclude other causes
- Chronic: AXR - pancreatic calcification; ERCP/MRCP – early (duct dilation), late (duct strictures)
*amylase is raised in ANY case of acute abdomen (e.g. also in perforation due to obstruction).
Pancreatitis Prognostic Indicator
PaO2 <7.9kPa Age >55yo Neutrophils >15x109/L Calcium <2mmol/L Renal function: Urea >16mmol/L Enzymes: LDH >600U/L or AST >200U/L Albumin <32g/L Sugar >10mmol
Pancreatitis Mx
Medical
- Fluid Balance
- Catheter & NG tube if vomiting
- Analgesia, glucose control (chronic pancreatitis leads to diabetes)
Surgical
- ERCP (e.g. remove gallstone)
- Further surgery if complications are serious (most management for pancreatitis is passive or medical though)
Pancreatitis - prognosis and complications
Prognosis
- 20% run severe course with 70% mortality
- 80% run milder with 5% mortality
- Chronic reduces LE by 10-20 years
Local – pseudocysts, duodenal obstruction, pancreatic ascites
Systemic – diabetes, steatorrhea, reduced quality of life
Which of the following may be raised in chronic pancreatitis? Amylase Calcium Faecal elastase Albumin Haematocrit
Faecal elastase
Which of the following is not a cause of acute pancreatitis?
Mumps Hypocalcaemia Thiazide drugs Trinidad scorpion bite Steroids
Hypocalcaemia
It’s HyperCa
Intestinal Obstruction Definition and RF
A broad condition resulting from the blockage of the flow of the intestines
RF:
Hernia
Surgery (look for scars)
Small Bowel
- Adhesions from prior operations (most common cause in western world)
- Malignancy
Large Bowel
- Colorectal malignancies
- Sigmoid/caecal volvulus
- Paralytic Ileus/Postoperative ileus
Intestinal Obstruction Signs and Symptoms
Diffuse pain
Constipation
Abdominal Distention
Vomiting (higher obstruction)
Intestinal Obstruction
Examination
General Inspection
- Abdominal distension
- Pyrexia, sweating (potential perforation or infarction)
Auscultation
- High-pitched, tinkling bowel sounds
- Absent bowel sounds
Intestinal Obstruction Investigations
Bloods – normal panel (e.g. FBC, x-match, U&Es, etc.)
Plain AXR and CT – ?volvulus, ?malignancy
Normal bowel size follows 3/6/9 rule
3cm = small bowel
6cm = large bowel
9cm = caecum
Eponymous sign for bowel perforation
Rigler’s sign: Represents air seen on both sides of the intestine wall
Intestinal Obstruction Mx and Prognosis
Medical
- “Drip & suck” (Drip + NG tube)
- Conservative if volvulus decompresses
Surgical
- Laparotomy (esp. if peritonitic)
Prognosis
Small bowel: mortality at 25% with delayed surgery >36 hours; drops to 8% at <36 hours
An overweight 65-year-old woman visits her general practitioner with discomfort in her right groin. On examination, the suggestion of a reducible groin lump is noted. She is routinely referred to the surgical outpatient clinic with a possible diagnosis of inguinal hernia. However, two weeks later and before her surgical appointment, she again visits her general practitioner, this time with vomiting, diarrhoea, and colicky abdominal pain. What is the next most appropriate management step?
Administer antibiotics Give IV fluids Insert an NG tube Give IV fluids and insert an NG tube Administer an enema
Give IV fluids and insert an NG tube
Intestinal Ischaemia
Definition, Causes and RF
Impaired blood transfusion to the intestine, resulting in ischaemia of the bowel wall. Also known as acute mesenteric ischaemia
Causes:
- Arterial thrombosis (athero) or embolim
- Venous thrombosis (in hypercoagulable states)
- Non-occlusive disease (e.g. hypotension, HF)
RF
- Old age
- Cardiovascular disease
- AF
- Hypotensive state (Car accidents)
Intestinal Ischaemia Symptoms and signs (Acute)
Acute: Sudden onset diffuse pain
Shock Signs
Normal Exam
Intestinal Ischaemia Invx
AXR – perforation (Rigler’s sign), megacolon
Angiography – show blockages
ECG – look for MI or AF
Intestinal Ischaemia Symptoms and signs (Chronic)
Chronic b/c combination of a low-flow state, such as heart failure, and atherosclerotic disease
Symptoms:
- Intermittent gut claudication (Poorly localised, Post-prandial abdomen pain)
- PR Bleeding
- Weight loss
Signs: Normal Abdo exam, blood on DRE
A 70-year-old gentleman presents to the A&E department with sudden-onset severe diffuse abdominal pain. Observations are taken in the ambulance which show an irregularly irregular pulse rate of 130 and a blood pressure of 76/60mmHg. An abdominal X-ray is performed as soon as possible which shows the Rigler sign and the physician diagnoses an acute form of mesenteric ischaemia with perforation. What is the most likely cause for the acute onset of the mesenteric ischaemia?
Atherosclerotic disease Embolism Thrombosis Polycythaemia vera Idiopathic
Embolism
A 70 year old man presents with worsening pain in the left lower abdomen, associated with an absence of bowel movements and passage of flatus for 6 days. He started vomiting just prior to admission. His surgical and medical histories are unremarkable. On examination, there is abdominal distention, lower left quadrant and periumbilical tenderness, no guarding, hyper resonant to percussion. PR rectum empty and no blood.
What is the investigation of choice and what would be the differentials?
Irritable bowel syndrome Large bowel obstruction Small bowel obstruction Colonic Dysmotility Constipation Related Pseudo-Obstruction
AXR: The X-Ray shows multiple air-fluid levels and dilated loops of large bowel. There is a markedly distended loop of sigmoid colon assuming an inverted U-shape
A 75 year old man presents with mild cramping pain in the left lower abdomen for 1 day. During the same time, he twice passed stools well mixed with fresh blood. Medical history reveals history of hypertension and chronic kidney disease. He smoked heavily when younger but has stopped 5 years ago. FBC shows high leucocyte count. on examination: no distension, guarding or palpable masses, no noted organomegaly all hernia orifices normal - some tenderness noted over left lower quadrant. Colonoscopy shows mucosal inflammation and ulceration at watershed area.
What is the investigation of choice and what would be the differentials?
Diverticulitis
Malignancy
Ulcerative colitis
Ischaemic colitis
Colonoscopy: large, necrotic-appearing mass occupying most of the descending colon
Biopsy: necrotic colonic mucosa - no features suggestive of malignancy
