13. Acute Abdomen Flashcards
What are the 9 abdominal regions?
What are some immediate life-threating causes of acute abdominal pain (need action in the hour)?
What are some rapid life-threating causes of acute abdominal pain (need action in 1h-1d)?
And 1-2d?
[Pic]
NB: pubic region = hypogastric region; R and L groin = R and L iliac region; R and L flanks = R and L lumbar regions. Can also be divided into quadrants
AAA, haemorrhage, MI (referred pain), ruptured ectopic pregnancy
Mesenteric/bowel ischaemia (e.g. from BV clot), peritonitis, volvulus/intussusception, complicated hernia (e.g. strangulated), DKA
Pancreatitis, appendicitis, cholecystitis, bowel obstruction, rupture/torsion of ovarian cyst, intra-abdominal abscess
Mild morbidity - diverticulitis, PUD, biliary/renal colic, endometriosis, IBD, UTI
No morbidity - gastroenteritis, constipation, IBS
List the organs related to the following regions:
a) R hypochondrium
b) L hypochondrium
c) R lumbar/flank
d) L lumbar/flank
e) R iliac fossa/groin
f) L iliac fossa/groin
g) Epigastric region
h) Umbilical region
i) Suprapubic/hypogastric region
a) R lobe of liver, gall bladder
b) spleen, fundus of stomach
c) R kidney and ascending colon
d) L kidney and descending colon
e) Caecum, appendix, R ovary, R fallopian tube
f) Sigmoid colon, L ovary, L fallopian tube
g) L lobe of liver, stomach
h) Coils of small intestine
i) Urinary bladder, rectum/anus
What are the possible causes for sudden or gradual acute abdomen?
List some possible associated symptoms & what you would want to know about each one.
Sudden: perforation, haemorrhage, infarct
Gradual: peritoneal irritation, hollow organ distension
Vomiting: nausea? Frequency, quantity, contents: digested food, bile, blood (upepr GI bleed due to PU/oesophageal varices?), faeculent (obstruction), association with pain (before or after)
Bowel symptoms: diarrhea/constipation vs. change in bowel habits, change in colour
Jaundice: onset, duration, obstructive, pale stools, dark urine, pruritis
Constitutional symptoms: wt loss (cancer?), appetite loss, malaise, lethargy
Urinary symptoms: frequency, urgency, incontinence, nocturia, dysuria, post micturation dribbling, incomplete voiding. ALWAYS DO DIP
Gynae symptoms: menorrhagia, abdo/pelvic pain, vaginal discharge, delayed/absent period, dyspareunia
What features would you want to know if a pt reports blood on defecation?
What drugs would you ask about in their DHx, SHx and FHx?
Type: bright/dark red (bright = ischaemic bowel polyp? haemorrhoids?), clots, melaena. Faecal occult blood
Relationship to defecation: on paper (haemorrhoids?)/in pan/mixed with stool/on stool surface
Quantity: drops, tea spoon, cup
DHx: Steroids, NSAIDs (PU bleeding?), abx, allergies
SHx: alcohol consumption, smoker, drugs, home care, last meal
FHx: bowel cancer, IBD
Briefly summise the abdo exam.
What condition is the image showing, and what are some possible causes?
General exam: hands, eyes, mouth LN
Inspection: scars, masses/asymmetry, pulsations, cough, distension (5 F’s - flatulence, faeces, fat, foetus, fluid, flatus)
Superficial palpation: guarding, pain
Deep palpation: liver, spleen, kidneys, bladder, uterus, masses, aneurysms, hernias
Percussion: masses, liver edge, spleen, bladder. Ascites: fluid thrill, shifting dullness [Pic]
Auscultation: bowel sounds. Abnormal = obstructed, tinkling. Bruits
Clubbing.
Cardiac: infective endocarditis, sickle cell
Resp: CF, bronchial carcinoma, bronchiectasis, empyema
GI: IBD, GI lymphoma, celiac/hepatic disease
Other: thyroid acropatchy (Graves’), pregnancy, malignancy
What can you see in the 5 images?
Top L clockwise:
Arrow = air under diaphragm, air-fluid level = perforated bowel? EMERGENCY!
Jaundice
Virchow’s node - LN in L supraclavicular fossa, supplied from lymph vessels in abdo cavity
Fresh PR bleed
Small bowel obstruction - can see plicae circularis. Tx: decompress via NGT (aspiration - drip & suck + fluids). NB one end of small bowel to other >4cm = dilated; large bowl >6cm.
What are the 4 special tests that can be done during an abdominal exam?
What other exams would you do?
- *1. Rovsing’s sign:** pain > in RIF than LIF when LIF pressed
- *2. Psoas sign:** pain on extending hip if retrocaecal appendix due to irritation of peritoneum posterior to iliopsoas group of hip flexors in abdomen
- *3. Murphy’s point:** lay 2 fingers over the RUQ. Ask pt to breathe in. This causes pain and arrest of inspiration as an inflamed GB impinges on your fingers. Test only +ve if same test in LUQ does not cause pain
- *4. McBurney’s point:** 2/3 of the way along from the umbilicus to the R ASIS (as appendix inflammation progresses the somatic, lateraliesd pain settles here)
Genital, hernia, cardiovascular and chest
Case 1
19yo female, 4/7 hx of central, now RIF pain, nauseated, anorexic, feverish, no dysuria, LMP 9/7 ago, no PV discharge, no other PMH.
A: talking
B: RR 22, sats 98 on RA, chest clear
C: HR 120, CRT <2s, BP 110/75
D: GCS 15, BG 6, Temp 38.2
E: no rashes, warm to touch, abdo soft, tender with involuntart guarding and rebound tenderness in RIF
What are you going to do?
Results: normal XRs. WCC 16, CRP 150.
VBG: lactate 3 (indicator of sepsis), pH 7.32.
Urine: leuc -ve, nit -ve, bCHG -ve, ket +ve
What do you deduce from these?
Which of the following choices of surgical insertion is most commonly used for appendicitis? [Pic]
Access x 2 (2 large bore cannulas for taking blood and giving fluids and abx)
Fluids
Abx
O2
Blood tests (FBC - Hb, WCC, U + Crt, Na, K (if v. dehydrated U and Crt will be high), CRP (infection)
Urine output
Raised WCC and CRP. Raised lactate, acidotic (need to give fluids to decrease)
- *McBurney incision:** line between umbilicus and R ASIS, 1/3 ASIS to unbilicus = McBurney’s point. [Pic]
- NB: Kocher for cholecystectomy, Midline for all emg. laparotomy, McBurney+Battle+Lanz = appendicostomy, Rutherford for sigmoid colectomy. Pfannenstiel - C-section*
What are some differentials for the patient with abdominal pain (apart from appendicitis)?
How would you manage the patient with appendicitis?
Ectopic pregnancy, ruptured ovarian follicle/ovarian torsion, PID - tuboovarian abscess, gastroenteritis + mesenteric adenitis (adenoids in abdo), viral mesenteric lymphadenitis, Meckel’s diverticulum, Crohn’s, yersina/TB
Abx, laparoscopic appendicectomy (keyhole), or open (stopped now due to larger cut), can convert laparoscopic -> open if can’t find appendix
