21. Diverticular Disease and acute abdomen Flashcards
What is diveritcular disease
outpouchings of the colonic mucosa and submucosa through inherent weakness in the outer muscle layers
what is the most common site for diverticular disease and why
sigmoid colon
- probably due to pressure effects associated with chronic constipation and/or accumulation of faecal matter
what are the recognised risk factors for diverticula disease of the colon
o Hereditary factors
o Increasing age
o Chronic constipation (and a low fibre diet)
o High intake of meat and red meat
name the frequent complications of colonic diverticulitis
o Infection resulting in diverticulitis. Clinical presentation will be very similar to acute appendicitis with pain frequently located in the left side of the abdomen or the hypogastrium
o Bleeding: occult or overt
o Perforation (very serious and due to possible leakage of faeces giving rise to faecal peritonitis)
o Abscess formation: diverticular abscess similar to appendicular abscess
Define acute abdomen
condition of severe abdominal pain, usually requiring emergency surgery, caused by acute disease of or injury to the internal organs
if the site of abdominal pain is generalised what could this suggest
o Perforated viscous
o Acute pancreatitis
o Medical cause ie diabetic ketoacidosis
Acute abdomen:
if the site of pain is RUQ what are the common causes
Gallbladder disease (cholecystitis, cholangitis etc)
Duodenal ulcer
Acute pancreatitis
Medical disorder (pneumonia referred pain)
pyelonephritis
hepatitis
Acute abdomen:
if the site of pain is LUQ what are the common causes
Acute pancreatitis
Spontaneous splenic rupture
Medical disorder (pneumonia)
Pyelonehpritis
Acute abdomen
if the site of pain is RIF what are the common causes
Acute appendicitis Perforated duodenal ulcer Chrons Diverticulitis Constipation Renal colic Obs and Gynae (ectopic pregnancy, ruptured ovarian cyst, salpingitis) inguinal hernia testicular torsion
Acute abdomen:
if the site of the pain is LIF what are the common causes
Diverticulitis Constipation Obs and Gynae (ectopic pregnancy, ruptured ovarian cyst, salpingitis) IBD UTI
acute abdomen:
if the site of the pain is epigastric what are the common causes
Peptic or duodenal ulcer
Acute pancreatitis
cholecystitis
MI
Acute abdomen:
If the site of the pain is central what are the common causes
Early appendicitis (pain often starts in centre of abdomen before moving to RIF) Small bowel obstruction Acute pancreatitis Mesenteric thrombosis AAA
acute abdomen:
if the site of the pain is suprapubic region what are the common causes
Acute urinary retention
UTI
Ectopic pregnancy
what are the classical signs of acute abdomen
- Low grade fever
- Tenderness
- Rigidity and guarding
- Rebound tenderness
- Bowel sounds: absent in peritonitis, increased inn small bowel obstruction
- Abdominal distention: can be due to bowel obstruction and abdomen filling with gas or can be due to fluid (ascites). Can also be a foetus in women
what are the main investigations for acute abdomen
o Full blood count o Biochemical profile – U&Es; Liver function tests o CRP o Serum Amylase o Serum glucose o Blood gas including lactate measurement o Pregnancy Test in women (always!) o Urine dipstick (haematuria in UTI) o Erect Chest x-ray o Supine abdominal film
If there is a peforation of a viscus what does a CT show
free gas in the abdomen (under the diaphragm)
Give 3 presentations of an acute abdomen that require urgent intervention
bleeding
perforated viscus
ischaemic bowel
give some causes of bleeding in an acute abdomen
ruptured AAA
ruptured ectopic pregnancy
gastric ulcer
trauma
give some causes of a perforated viscus
peptic ulcerations, small or large bowel obstruction, diverticular disease and IBD
how does the movement of a patient different between having peritonitis and having renal colic
- peritonitis: These patients often lay completely still (not to move their abdomen) and look unwell
- compared to renal colic, whereby the patient is constantly moving and cannot get comfy
on examination of a perforated viscus they will show what kind of signs (to do with peritonitis)
o Tachycardia and potential hypotension
o Completely rigid abdomen with percussion tenderness
o Involuntary guarding
o Reduced or absent bowel sounds, suggesting the presence of a paralytic ileus
An patient who has severe pain out of proportion to the clinical signs has what diagnosis til proven otherwise
ischaemic bowel
in patients with ischemic bowel what would their blood results show
acidaemic with a raised lactate
what is the definitive diagnosis of ischemic bowel
CT scan with IV contrast, with early surgical involvement
Give some presentations of acute abdomen which are less acute
Colic
Peritonism
what are the common types of colic
in bilary colic, ureteric colic and bowel obstruction
what is peritoneum and give a classic example
refers to the localised inflammation of the peritoneum, usually due to inflammation of a viscus that then irritates the visceral (and subsequently, parietal) peritoneum
- classic example is acute appendicitis, when the pain migrating from umbilical region to the RIF
when looking at Abdo x ray what systematic approach can you use
stand back at look at obvious abnormalities
then be systematic : Rectum, bowel, KUB, organs and finally bones
Abdo X ray: gas appears black on X ray and so wher is gas usually found
o Stomach- almost always
o SB- 2 or 3 loops
o Sigmoid and rectum- almost always
What are the differentiating features of a large bowel on an AXR
o Peripheral
o Hasutral markings don’t extend wall to wall
what are the differentiating features of a small bowel on an AXR
o Central
o Valvulae extend across the lumen
in someone with colitis what would you see on an AXR
thickening of the colon
thick white line running alongside the lumen which is oedema of the colonic wall
in toxic megacolon you see a very dilated large bowel
in proximal constiaption what do you tend to see
pixelated appearance in the ascending colon
tell me what small bowel obstruction looks like
o There is valvulae along the whole small bowel and no visible large bowel
o Large bowel obstruction can also give dilated small bowel appearance if there is an incompetent IC valve
what is the classical sign if someone has sigmoid volvulus
clinically the abdomen will be distended and can see the coffee bean signs
Profound metabolic acidosis can be a sign of bowel infarction caused by an embolism (eg in a patient with AF) in the mesenteric artery
no answer
in women of childbearing age what can you not afford to miss
ectopic pregnancy
