21. Diverticular Disease and acute abdomen

Question 1

What is diveritcular disease

Answer 1

outpouchings of the colonic mucosa and submucosa through inherent weakness in the outer muscle layers

Question 2

what is the most common site for diverticular disease and why

Answer 2

sigmoid colon

- probably due to pressure effects associated with chronic constipation and/or accumulation of faecal matter

Question 3

what are the recognised risk factors for diverticula disease of the colon

Answer 3

o Hereditary factors
o Increasing age
o Chronic constipation (and a low fibre diet)
o High intake of meat and red meat

Question 4

name the frequent complications of colonic diverticulitis

Answer 4

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

Question 5

Define acute abdomen

Answer 5

condition of severe abdominal pain, usually requiring emergency surgery, caused by acute disease of or injury to the internal organs

Question 6

if the site of abdominal pain is generalised what could this suggest

Answer 6

o Perforated viscous
o Acute pancreatitis
o Medical cause ie diabetic ketoacidosis

Question 7

Acute abdomen:

if the site of pain is RUQ what are the common causes

Answer 7

Gallbladder disease (cholecystitis, cholangitis etc)
Duodenal ulcer
Acute pancreatitis
Medical disorder (pneumonia referred pain)
pyelonephritis
hepatitis

Question 8

Acute abdomen:

if the site of pain is LUQ what are the common causes

Answer 8

Acute pancreatitis
Spontaneous splenic rupture
Medical disorder (pneumonia)
Pyelonehpritis

Question 9

Acute abdomen

if the site of pain is RIF what are the common causes

Answer 9

Acute appendicitis 
Perforated duodenal ulcer 
Chrons 
Diverticulitis 
Constipation 
Renal colic 
Obs and Gynae (ectopic pregnancy, ruptured ovarian cyst, salpingitis) 
inguinal hernia 
testicular torsion

Question 10

Acute abdomen:

if the site of the pain is LIF what are the common causes

Answer 10

Diverticulitis 
Constipation 
Obs and Gynae (ectopic pregnancy, ruptured ovarian cyst, salpingitis) 
IBD
UTI

Question 11

acute abdomen:

if the site of the pain is epigastric what are the common causes

Answer 11

Peptic or duodenal ulcer
Acute pancreatitis
cholecystitis
MI

Question 12

Acute abdomen:

If the site of the pain is central what are the common causes

Answer 12

Early appendicitis (pain often starts in centre of abdomen before moving to RIF)
Small bowel obstruction 
Acute pancreatitis 
Mesenteric thrombosis 
AAA

Question 13

acute abdomen:

if the site of the pain is suprapubic region what are the common causes

Answer 13

Acute urinary retention
UTI
Ectopic pregnancy

Question 14

what are the classical signs of acute abdomen

Answer 14

• 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

Question 15

what are the main investigations for acute abdomen

Answer 15

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

Question 16

If there is a peforation of a viscus what does a CT show

Answer 16

free gas in the abdomen (under the diaphragm)

Question 17

Give 3 presentations of an acute abdomen that require urgent intervention

Answer 17

bleeding
perforated viscus
ischaemic bowel

Question 18

give some causes of bleeding in an acute abdomen

Answer 18

ruptured AAA
ruptured ectopic pregnancy
gastric ulcer
trauma

Question 19

give some causes of a perforated viscus

Answer 19

peptic ulcerations, small or large bowel obstruction, diverticular disease and IBD

Question 20

how does the movement of a patient different between having peritonitis and having renal colic

Answer 20

• 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

Question 21

on examination of a perforated viscus they will show what kind of signs (to do with peritonitis)

Answer 21

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

Question 22

An patient who has severe pain out of proportion to the clinical signs has what diagnosis til proven otherwise

Answer 22

ischaemic bowel

Question 23

in patients with ischemic bowel what would their blood results show

Answer 23

acidaemic with a raised lactate

Question 24

what is the definitive diagnosis of ischemic bowel

Answer 24

CT scan with IV contrast, with early surgical involvement

Question 25

Give some presentations of acute abdomen which are less acute

Answer 25

Colic

Peritonism

Question 26

what are the common types of colic

Answer 26

in bilary colic, ureteric colic and bowel obstruction

Question 27

what is peritoneum and give a classic example

Answer 27

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

Question 28

when looking at Abdo x ray what systematic approach can you use

Answer 28

stand back at look at obvious abnormalities

then be systematic : Rectum, bowel, KUB, organs and finally bones

Question 29

Abdo X ray: gas appears black on X ray and so wher is gas usually found

Answer 29

o Stomach- almost always
o SB- 2 or 3 loops
o Sigmoid and rectum- almost always

Question 30

What are the differentiating features of a large bowel on an AXR

Answer 30

o Peripheral

o Hasutral markings don’t extend wall to wall

Question 31

what are the differentiating features of a small bowel on an AXR

Answer 31

o Central

o Valvulae extend across the lumen

Question 32

in someone with colitis what would you see on an AXR

Answer 32

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

Question 33

in proximal constiaption what do you tend to see

Answer 33

pixelated appearance in the ascending colon

Question 34

tell me what small bowel obstruction looks like

Answer 34

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

Question 35

what is the classical sign if someone has sigmoid volvulus

Answer 35

clinically the abdomen will be distended and can see the coffee bean signs

Question 36

Profound metabolic acidosis can be a sign of bowel infarction caused by an embolism (eg in a patient with AF) in the mesenteric artery

Answer 36

no answer

Question 37

in women of childbearing age what can you not afford to miss

Answer 37

ectopic pregnancy