3- abdominal pain & acute abdomen Flashcards
what region is pain felt in from
a) foregut
b) midgut
c) hindgut
a) epigastric pain
b) umbilical
c) hypogastric pain
what is pain assessment acronym? (first one you use when taking history?)
SOCRATES
site, onset, character, radiation, associated symptoms, timing, exacerbating/relieving factors, severity
what is pain areas for appendicitis etc?
starts vague when visceral peritoneum but when parietal peritoneum starts to become irritated, more specific area of pain
what are associated symptoms of abdominal pain to ask about?
- ANS activated - nausea, sweating
- cytokine effects - malaise, fever
- oral - appetite, diet, vomit (volume, frequency, colour, blood)
- anus - diarrhoea, PR blood
- urinary - colour, blood, frequency
- vagina - abnormal discharge, periods, pregnant
what is acute abdominal pain usually like?
generally 7 days or less
- usually sharp (parietal peritoneum)
what is chronic abdominal pain usually like?
= weeks, months,years
- social, psychological issues
- often varying intensity
what acronym can you ask about after SOCRATES - for further questions?
RED M&S SOFA
R = radiology history →scans
E = endoscopy history
D = drugs→blood thinners? (bad for surgery)
M = medical history
&
S = surgical history
S = social history (smoking, drinking)
O = last oral intake
F = family history
A = allergies
what can cause pain felt in right hypochondriac region?
- gallstones
- stomach ulcer
- pancreatitis
what can cause pain felt in left hypochondriac region?
- stomach
- ulcer
- duodenal
- biliary colic
-pancreatitis
what can cause pain felt in epigastric region?
- stomach ulcer
- heartburn/indigestion
- pancreatitis, gallstones
- epigastric hernia
what can cause pain felt in right lumbar region?
- kidney stones
- urine infection
- constipation
- lumbar hernia
what can cause pain felt in left lumbar region?
- kidney stones
- diverticular disease
- constipation
- inflammatory bowel disease
what can cause pain felt in umbilical region?
- pancreatitis
- early appendicitis
- stomach ulcer
- inflammatory bowel
- small bowel
- umbilical hernia
what can cause pain felt in right iliac region?
- appendicitis
- constipation
- pelvic pain
- groin pain
- inguinal hernia
what can cause pain felt in left iliac region?
- diverticular disease
- pelvic pain
- groin pain
- inguinal hernia
what can cause pain felt in pubic region?
- urine infection
- appendicitis
- diverticular disease
- inflammatory bowel
- pelvic pain (gynae)
what are initial management priorities of abdominal pain?
- pain relief
- simple quick tests = urinalysis, bloods, x-ray
- consider oxygen
- IV fluids
- consider blood transfusion if bleeding
- consider early IV antibiotics if strong suspicion of sepsis
- consider CT or other scans
what inflammations of things can lead to peritonitis (inflammation of peritoneum)?
- Appendicitis
- Cholecystitis
- Pancreatitis
- Peptic ulcer
- Diverticulitis
- GI tract perforation
- Acute mesenteric ischaemia
what are serious medical things that cause acute abdomen pain (like conditions - not organ stuff in abdomen)?
- Diabetic ketoacidosis
- Pyelonephritis
- Inferior MI
- PE or Lower lobe pneumonia
what obstructions can cause acute abdominal pain?
- Bowel obstructions
- Strangulated hernia
- Renal colic
what are causes of shock causing acute abdomen pain?
- Leaking AAA / dissection
- Ectopic pregnancy
what is felt on physical exam for peritonitis?
guarding & tender (bumps in road sore), look different to obstructive
what are symptoms of obstructive causes for abdominal pain?
distended, vomiting, no wind (blocked pipe)
what is seen on end of bed test for peritonitis?
- Flushed face
- Motionless
- Foetal position
- Shallow rapid respiration
what is seen on end of bed test for obstruction abdominal pain?
- Distended abdomen
- Sick bowls
- Vomiting
what is seen on end of bed test if less concerning abdominal pain?
- Crying / sobbing
- Sunglasses
- Away for a smoke
what are causes of shock?
- inadequate fluid absorption(insufficient intake or vomiting)
- blood loss (AAA, ectopic pregnancy, trauma)
- pump failure (MI)
- loss of systemic vascular resistance (sepsis)
- leaky capillaries from inflammatory response (sepsis, peritonitis, pancreatitis)
what should you look for on inspection of abdomen in clinical exam?
- Surgical scars
- Distended abdomen
- Obvious masses… and is it pulsatile
- External hernia
- Discolored skin changes
- Visible organomegaly (unusual)
- Stigmata of liver failure e.g. ascites, jaundice
what blood tests should be done for abdominal pain?
- full blood count = white cell count + neutrophil
- U&E’s = urea & electrolytes (renal function)
- amylase (marker for pancreatitis)
- LFTs (liver function tests)
- glucose
what radiography scans can be done for abdominal pain?
- x-rays →not massively helpful but quick and sometimes do
- CT scan →good for when people very ill
- abdominal ultrasound →use a lot, good for gallbladder disease good for gallstones and urinary tract stones, good for ectopic pregnancy, used in trauma
- erect chest x-ray →essential for upper abdominal pain, especially if sudden pain (done when sitting upright)
what requires immediate surgical intervention?
ruptured AAA(abdominal aortic aneurysm), ruptured ectopic pregnancy, bleeding spleen, liver, mesentery
what is common presentation for ruptured AAA? how treat?
abdominal aortic aneurysm -present with shock, pulsatile mass in abdomen, elderly male w hypertension +PVD
- treat by fix with graft in open surgery or radiologically
what are causes of urgent surgical intervention?
- Appendicitis
- Perforation (peptic ulcer, diverticular perforation)
- Bowel obstruction with tender abdomen ?ischaemic bowel
- Mesenteric ischaemia
- sigmoid volvulus = twist in bowel
- Sepsis
- Persistent, significant bleeding
what timeframe is
a) immediate surgical intervention
b) urgent surgical intervention
c) non-urgent surgical intervention
a) immediately
b) with 4-6 hours
c) within 48 hours
what is common presentation of acute appendicitis?
- Migratory pain (umbilicus to Right Iliac Fossa)
- Nausea / vomiting
- Loss of appetite
- Mild fever
- Looks flushed
- Guarding RIF – McBurney’s point = 1/3 from ASIS to umbilicus (where base of appendix lies →most tender point)
what is perforation look like on xray?
pneumoperitoneum = free air under diaphragm
what is mesenteric ischaemia?
cause for urgent surgical intervention = blood supply blocked off to gut - difficult to diagnose as vague symptoms and can be tricky on CT scan
can be very devastating
what is common presentation of incarcerated hernia?
cause for urgent surgical intervention
- sudden onset of pain →usually femoral or inguinal
- Forceful brown liquid vomiting
- Clinical exam usually reveals diagnosis (except in obturator hernia)
when can toxic megacolon occur? what urgency of surgery is required?
large colon becomes distended and loses blood uppy →happens in IBD or c.difficile colitis
= required urgent surgical intervention
what are most common causes of non-surgical intervention?
- Cholecystitis
- Simple Small Bowel Obstruction (ie. Without suspicion of dead bowel)
- Diverticulitis
- Simple incarcerated hernia (ie. Not strangulated hernia with bowel inside)
what is acute cholecystitis?
= very common, often some sort of blockage problem (usually gallstone) - inflammation of gallbladder
what is common presentation of acute cholecystitis?
- get epigastric pain and can move to right upper quadrant pain
- vomiting, fever
- murphy’s sign →deep breaths as move to right upper quadrant, can feel very inflamed gallbladder and patient gets pain as it hits our hand
what test for acute cholcystitis?
ultrasound
what is small bowel obstruction?
= cause for non-urgent surgical intervention
= most caused by adhesions or hernias (others: incarcerated hernia, cancer deposits, Crohn’s, gallstone ileus)
what is treatment and scan to confirm diagnosis of small bowel obstruction?
→CT scan to confirm (can do x-ray)
treatment = compress gut, treat with fluids and keep eye on nutrition →if fails the surgery
how can you identify small bowel obstruction on
a) abdominal x-ray
b) CT
a) laddering of small bowel - fluid filled loops
b) dilated then collapsed bowel (transition point)
what is acute pancreatitis? what are 2 most common causes?
common = infection of pancreatitis
= gall stones & alcohol
what is mnemonic for remembering causes of pancreatitis?
I – Idiopathic
G – Gallstones (esp calculi <5 mm) & Genetic mutations
E – Ethanol/ alcohol (especially spirits)
T – Trauma & obstructing Tumors of the pancreas
S – Surgery & Steroids
M – Mumps & other infectious triggers
A – Autoimmune
S – Scorpion stings (Tityus trinitatis)
H – Hypercalcaemia / Hyperlipidaemia
E – ERCP-induced pancreatitis
D – Drug side-effect
&
S – Smoke (duration associated with non-Gallstone AP)
what do you need to diagnose pancreatitis?
to diagnose need 2 out of 3
- epigastric pain
- elevated enzyme (amylase 3x normal)
- imaging confirmation with CT or other
