2.5// Abdominal Pain Flashcards
What does the term acute abdomen refer to?
the rapid onset of severe symptoms of abdominal pathology
What amy an acute abdomen indicate?
a potentially life-threatening condition that requires urgent surgical intervention
What should immediate assessment focus on?
- what quadrant (it can be any quadrant of the abdomen)?
- intermittent, sharp, dull, achy or piercing pain?
*radiating from a focal site?
*accompanied by nausea and vomiting?
What reduces unnecessary admission for abdomen issues?
experienced surgeon
How may a patient with acute surgical pathology deteriorate?
rapidly
What do patients with severe, unremitting symptoms warrant?
thorough investigation and close monitoring
acute abdomen can occur without pain in who?
older people
children
immunocompromised
last trimester of pregnancy
How does abdominal pain in older people, the immunocompromised, and pregnant women often present, and what does this lead to?
atypically
leading to delayed diagnosis of life-threatening abdominal pathology
An acute abdomen is diagnosed by a combination of what? (4)
history
physical examination
imaging
laboratory results
What are the commonest causes of acute abdomen?
nonspecific abdominal pain
renal colic
biliary colic
cholecystitis
appendicitis
diverticulitis
What are diverticula?
small bulges or pockets that can develop in the lining of the intestine as you get older
How do people usually know they have diverticula and why?
usually they get no symptoms and only know they have them when they have a scan
What is having diverticula without symptoms called?
diverticulosis
When diverticula do cause symptoms, what is often that symptom?
pain in the lower tummy
What is it called when diverticula do cause pain?
diverticular disease
What can lead to diverticula causing severe symptoms?
them being inflamed or infected
What is it called when diverticula are inflamed or infected?
diverticulitis
What are the different parts of the colon? (6)
appendix
caecum
ascending colon
trasverse colon
descending colon
sigmoid colon
How should you asses a patient?
systematic approach (evaluating airway, breathing, circulation, disability, exposure)
How do you correct hypovolaemia?
fluids and/or blood products
How do you treat ruptured abdominal aortic aneurysm (AAA) or aortic dissection?
especially careful fluid management
When should an urgent urological consultation be obtained?
if testicular torsion is suspected
What should you include with your full blood count in all patients?
electrolytes, creatinine, urea
What should you give to patients suspected to have an ongoing haemorrhage?
antifibrinolytic such as tranexamic acid
When are prophylactic antibiotics recommended?
for patients with a perforated viscus, diverticulitis, appendicitis, mesenteric ischaemia, ruptured AAA
What should you consider in patients with epigastric pain, particularly accompanied by sweating?
myocardial infarction
What are the key components of the history?
- a detailed evaluation of the pain
- type and time of last meal or other oral intake
- past medical and surgical history, medication use, and family history.
- a detailed evaluation of the pain (site, onset, character, radiation, referral, associated symptoms and signs, time course, exacerbating and relieving factors, and severity)
- type and time of last meal or other oral intake (information required if surgery is indicated)
- past medical and surgical history, medication use, and family history.
In what order should the physical examination be done?
Measure vital signs: blood pressure, temperature, and pulse rate.
- Inspection-Make a general assessment of how ill the patient appears.
- Auscultation-chest and abdomen
- Percussion
- Palpation
- Other important examinations: rectal, pelvic, scrotal/testicular
Why do you do auscultation before palpation?
to put the patient at ease and increase cooperation
also palpation may stimulate bowel activity and thus falsely increase bowel sounds if performed before auscultation
What are the anatomical parts of the male pelvic area?
bladder
prostate
penis
urethra
scrotum
tunica vaginalis
testis
epididymis
vas deferens
anus
seminal vesicles
rectum
What are common differentials for abdominal pain?
- Adhesions
- Incarcerated/strangulated hernia
- Cholecytitis
- Perforate gastric ulcer
- Appendicitis
- Ectopic pregnacy
- Pelvic inflammatory disease
- acute pancreatitis
- acute diverticulitis-RF up until here
- Ulcerative colitis
- Chohn´s disease
- cholelithiasis
- gastrointestinal malignancy-RF
- Mallory-Weiss tear
- Diabetic ketoacidosis-RF
- Opioid withdrawal
- hepatitis
- gastroenteritis
- infectious colitis
- sickle cell crisis
- endometriosis
- testicular torsion
- kidney stones
- pyelonephritis
What is pyelonephritis?
a type of urinary tract infection where one or both kidneys become infected
What is a mallory-weiss tear?
a tear of the tissue of your lower esophagus
What are abdominal adhesions?
bands of scar tissue that form between abdominal organs- mainly the small intestine
What are imaging tests that can be done?
Plain abdominal x-ray:
Erect chest x-ray if perforation is suspected:
Computed tomography (CT) of abdomen:
ultrasound
Magnetic resonance imaging (MRI):
Fluoroscopy:
endoscopy
What are the indications for the erect chest radiograph (CXR)?
to exclude free gas under the diaphragm as a result of a perforated viscus
and to attempt to exclude an intrathoracic condition asa cause for the abdominal symptoms
What is a perforated viscus also known as?
intestinal or bowel perforation
What is a perforated viscus/ intestinal or bowel perforation?
a full thickness disruption of the intestinal wall, with subsequent leakage of enteric contents into the peritoneal cavity
What is fluoroscopy?
a type of medical imaging that shows a continuous x-ray image on a monitor
What is cholecystitis?
inflammation of gallbladder
What is the WBC count in cholecystitis?
raised
What else may be elevated in cholecystitis?
elevated alkaline phosphatase, bilirubin, aminotransferase
What can be caused by cholecystitis and why?
Jaundice in acute cholecystitis due to reduced excretion which may be caused by pressure on the ducts by the distended gallbladder
What may the presence of abdominal scars give clues to?
previous and current pathology and the likelihood of adhesions
When can rebound tenderness be present?
appendicitis, diverticulitis and any condition where there is irritation of the parietal peritoneum
What can be palpated with ectopic pregnancy?
there is often a palpable adnexal mass with or without tenderness, and vaginal bleeding on speculum examination
What is adnexal mass?
a lump in tissue near the uterus, usually in the ovary or fallopian tube
What lab tests should be done?
Full blood count
Serum electrolytes
Urinalysis
Pregnancy test
Coagulation studies:
Comprehensive metabolic panel
Serum amylase and lipase levels
Serum lactic acid levels
What is biliary colic?
it is defined as pain in the abdomen, due to obstruction usually by stones in the cystic duct of the biliary tree
What is the pain caused by in biliary colic?
due to contraction
What is causing it to contract in biliary colic?
CCK (cholecystokinin)
What are the parts of the abdomen involved in biliary colic?
gallbladder
cystic duct
hepatic duct
liver
common bile duct
pancreatic duct
duodenum
What is cholecystitis?
it is a redness and swelling (inflammation) of the gallbladder
When does cholecystitis occur?
when bile gets trapped in the gallbladder
What usually causes cholecystitis?
gallstones blocking tubes that lead out of gallbladder
What is the difference between biliary colic and cholecystitis?
inflammation
What is cholangitis?
inflammation of the bile duct system
What are causes of acute cholangitis?
bacterial infection
gallstones
blockages
tumour
What is RUQ pain?
Acute right upper quadrant pain
What is LUQ pain?
acute left upper quadrant pain
Is there RUQ pain, fever or jaundice with biliary colic?
there is RUQ pain
there is no fever or jaundice
Is there RUQ pain, fever or jaundice with cholecystitis?
there is RUQ pain and fever
no jaundice
*jaundice is present in 10% of cholecystitis cases
Is there RUQ pain, fever or jaundice with cholangitis?
there is RUQ pain, fever and jaundice
How does a patient with biliary colic present?
steady severe pain in the RUQ
symptoms last between 15mins and 5h
How does a patient with cholecystitis present?
biliary pain lasting more than 5 hours accompanied by features of inflammation e.g., fever, marked RUQ tenderness, leukocytosis
How does a patient with cholangitis present?
sudden onset epigastric or LUQ pain whicvh may radiate to the back, nausea and vomiting common causes are gallstones and excessive alcohol consumption
Would you expect inflammation in biliary colic?
No
Why is there jaundice with cholangitis?
bilirubin would not secreted from the liver, so you would have jaundice
elevation of LFT (aka elevated liver enzymes)
Where is Murphy’s sign seen?
acute cholecystitis
What is Murphy’s sign?
pain on inspiration when you palpate on the RUQ, absent in LUQ
Label.
What would you see in an ultrasound in cholecystitis?
gallstones
hyperechoic gallstone with posterior shadowing
What are the two types of gallstones?
pigment gallstones
cholesterol gallstones (80%)
What are risk factors for cholesterol gallstone disease?
obesity
aging
oestrogen treatment
pregnancy
diabetes
What are risk factors for pigment gallstones?
haemolytic anaemia
black pigment gallstones form whenever an increased load of bilirubin reaches the liver
What is the general pathogenesis of gallstones?
there is supersaturation
gallstones made of water, bilirubin and salts
Imbalances in the constituents of bile and biliary sludge secondary to gallbladder hypokinesis can lead to the precipitation of insoluble stones. When these gallstones cause physical blockages in the biliary tree and beyond, pain, inflammation, and infection can result in damage to the gallbladder and a host of other organs.
What are some complication caused by gallstones?
gallstone pancreatitis
acute cholecystitis
causing biliary obstruction
gallstone ileus
biliary fistula
bouveret syndrome
mirizzi’s syndrome
What is Mirizzi’s syndrome?
Mirizzi’s syndromeis a rare complication in which a gallstone becomes impacted in thecystic ductor neck of thegallbladdercausing compression of the common hepatic duct, resulting in obstruction and jaundice.
defined as common hepatic duct obstruction caused by extrinsic compression from an impacted stone
What is bouveret syndrome?
Bouveret syndromerefers to agastric outlet obstruction secondary to impaction of a gallstone in the pylorus or proximalduodenum. Thus, it can be considered a very proximal form ofgallstone ileus.
What do impacted gallstones in the cystic duct cause?
acute cholecystitis
What is gallstone ileus?
it is an uncommon cause of a mechanical small bowel obstruction
*small bowel ileus is different to bowel ileus
When does gallstone ileus occur?
when stone obstructs ileocecal valve after migrating through the fistula
What is a fistula?
A fistula is an abnormal connection between two body parts, such as an organ or blood vessel and another structure
What are types of biliary fistula? (5)
Cholescystoduodenal
Cholecystocolic
cholecystogastric
cholecystocholedochal
choledochoduodenal
What are some finding in gallstone ileus?
Areas of perforation in ischemic fundus
radiograph shows gas in billiary tree
Radiograph shows obstruction of small intestine
Gallbladder perforations area serious complication of acute cholecystitisand represent an advanced stage of the disease.
What is the treatment for symptomatic gallstones?
a laparoscopic cholecystectomy
What do you need to gain consent for a laparoscopic cholecystectomy?
knowledge of procedure
explain diagnosis
treatment options
purpose of procedure
risks-what will you do to mitigate the risks?
explain advantages and disadvantages of antimicrobial chemoprophylaxis
patient has capacity unless proven otherwise
complications-may need to be open up
consent-clinicians providing the treatment.
What are the two types of complications?
general vs specific
early vs late
What are examples of general complications?
(in any procedure)
bleeding
around infection
blood clots
What are specific complications?
(in a specific surgery)
bile duct injury
damage to other structures
What are early post-operative complications?
risk of infection, wound cleaning, patient factors, anaesthetic factors
What are some complications after undergoing cholecystectomy?
the development of diarrhea or bloating due to alteration of biliary flow
there is also the possibility of having a cystic duct remnant that could potentially lead to stone formation and cause mirizzi syndrome
