12. Acute Abdomen

Question 1

What is the acute abdomen?

Answer 1

Severe abdominal pain
Duration 5 days or less
Very wide range of differnetials (may include basal pneumonias and MI’s)

Question 2

What is important to keep in mind before delivering an abdominal x-ray

Answer 2

patient must be erect/semi erect for ten minutes to get rid of intra-peritoneal gas

Question 3

When is a supine abdo x-ray useful?

Answer 3

Sigmoid volvulus, possible toxic megacolon, confirming obstructoin, looking for kidney stones but avoiding CT dose

Question 4

What other abdominal investigation is useful?

Answer 4

Ultrasound of abdo and pelvis. Good for

Acute cholycystitis, ovarian athology, acute appendicitis (rule out everything except appendicitis), renal swellings.

Question 5

What are emergency conditions for patients with abdominal pain?

Answer 5

Intra-abdominal heamorrhage
Viscus organ perforation
Mesenteric ischaemia
Bowel obstruction

Question 6

Describe the course of a perforation

Answer 6

Typically caused by a perforated ulcer or colonic diverticulitis.
Leads to perotinitis inflammation in the peritoneum
Requires prompt surgical management and a washout to prevent bowel contents from causing abdominal sepsis

Question 7

What are the symptoms of peritonitis?

Answer 7

Rock solid abdomen (involuntary guarding)
Patient lying completely still
Increased lactate and inflammatory markers

Question 8

What is the first line investigation for a perforated bowel?

Answer 8

Erect chest x-ray, sensitive to free gas. must be upright for at least 10 minutes.

Question 9

What is a bowel obstruction?

Answer 9

Physical obstruction of the bowel causing widening of proximal bowel and collapse of distal bowel.

Question 10

What are the symptoms of a bowel obstruction?

Answer 10

Choliky abdominal pain
Nausea and vomiting
Absolute constipation (no constipation or faeces)
Absent bowel sounds
Deranged obs, increased blood lactate and inflammation

Question 11

What is the best test for a bowel obstruction?

Answer 11

CT is test of choice to see obstruction

Abdo x-ray may look normal. Only test of choice when individual has had a previous sigmoid volvulous

Question 12

What is a sigmoid volvulus?

Answer 12

Twisting of sigmoid colon causing obstruction. More common after surgery causing adhesions in the bowel.

Question 13

What are the causes of a small bowel obstruction?

Answer 13

Adhesions, hernias - most common

May also be strictures, tumours, intusussception, volvulus, foreign bodies

Question 14

How do you diagnose an abdominal adhesions from a CT

Answer 14

It is a diagnosis of exclusion as they cant be seen on CT

Question 15

What is meant by the coffee bean sign?

Answer 15

In reference to a sigmoid volvulus, dialted, necrotic sigmoid colon has the appearance of a coffee bean on an abdominal x-ray.

Question 16

What are the symptoms of a ruptured AAA?

Answer 16

Generalised abdominal back pain/loin pain
Collapse
Hypotensive
Pulsatile abdominal mass
Lower limb ischemia

Question 17

What is mesenteric ischemia?

Answer 17

Injury to the small intestine typically due to vascular disease leading to ischemic changes.

Question 18

What are the signs of mesenteric ischemia?

Answer 18

Generalised abdo pain out of proportion to the examiantion
Unremarkable abdominal exam
High lactate

Question 19

What abdominal issues may be present if there is pain in the right upper quadrant?

Answer 19

Cholecystitis
Pyelonephritis
Ureteric colic
Hepatitis
Pneumonia

Question 20

What abdominal issues may be present if there is pain in the left upper quadrant?

Answer 20

Gastric Ulcer
Pyelonephritis
Ureteric colic
Pneumonia

Question 21

What abdominal issues may be present if there is pain in the right lower quadrant?

Answer 21

Appendicitis
Ureteric Colic
Inguinal hernia
IBD
UTI
Gynaecological
Testicular torsion

Question 22

What abdominal issues may be present if there is pain in the left lower quadrant?

Answer 22

Diverticulitis
Ureteric colic
Inguinal hernia
IBD
UTI
Gynae problems
Testicular torsion

Question 23

Describe the presentation of cholecystitis?

Answer 23

Sudden RUQ pain radiating to the back
Murphy’s sign (palpate and breathe in, gall bladder hits hand. Big ouchy). Increased inflammatory markers

Charcot’s triad- fevre, RUQ pain, Jaundice
Shock and altered mental state- obstructive picture

Question 24

What is the diagnostic criteria of pancreatitis?

Answer 24

acute onset of severe epigastric pain
Elevated amylase/lipase
Imaging features consistent on CT, MRI, US

Question 25

What are the complications of pancreatitis?

Answer 25

Pancreatic fluid collection
Necrosis
Pseudocystspancreatic abscess
Vascular issues

Question 26

Describe the symptoms of appendicitis

Answer 26

Initially poorly localised perilumbrical that migrates to the RLQ
Nausea,vomiting, anorexia,
tachycardia, pyrexia, RLQ, tenderness, guarding
Raised inflammatory markers

Question 27

What is the management for appendicitis?

Answer 27

Vital in females of reproductive age to do pregnancy test
Rule of ectopic pregnancy
USS for exclusion
CT if diagnosis unclear/perforation suspected