4. GI Luminal Disease Flashcards
RUQ pain - dDx?
Biliary colic, cholecystitis, cholangitis, Hep,Liver abscess, pancreatitis
Epigastrium pain - dDx?
Gastritis, GORD, PUD, Gastric peforation, pancreatitis, oesophagitis
LUQ pain - dDx?
Splenic rupture/infarct/abscess, pancreatitis
Right or left flank pain -dDx?
Renal colic, pyelonephritis, colitis
Periumbilical pain - dDx
SBO, Ruptured AAA, Gastroenteritis, Mesenteric ischaemia
RIF pain - dDx?
Appendicitis, ovarian torsion, tubo-ovarian abscess, ectopic pregancy, colitis, ovarian cyst
Suprapubic pain - dDx?
Cystitis, pelvic inflammatory disease, STI, pregnancy
LIF pain - dDx?
Colitis, diverticulitis eg. sigmoid colon, ovarian torsion, TOA, ovarian cyst, ectopic pregnancy
Visceral abdominal pain suggestive of?
Poorly localised, autonomic pain
Which structures are colicky pain more likely to be experienced in?
Luminal structures- pain gets more sever if bowel contracts against obstruction
How is the pain of peritonitis described
Sharp, well localiseed ( dermatomal innervation), but if perforated may be generalised, pain may get very severe
How does pain from cholecystitis radiate
RUQ to right shoulder
How does pain from pancreatitis radiate and what other Sx and FHx might there be
To back, vomitting and possible hc of gallstones or alcohol access
What disease can commonly cause peritonism
Appendictis
What does guarding indicate, and what other sign may be observed
Peritonitis, guarding
Common obs and blood in cholecystitis?
Pain and unwell, high CRP
Common obs and blood in cholangitis
Very unwell, deranges LFT- billi and ALP raised
Is pancreatitis more likely to be epigastric or RUQ pain
epigastric pain
Can appendicitis cause RUQ pain
yes if retrocaecal
Value of CRP in RUQ pain
Check for infxn (w/ WBC)
What is lactate a marker of
Bowel ischaemia- or just not very well
What are glucose and amylase markers of
Hepatitis
What is the role of urinalysis in abd pain
Signs of infxn or kidney stones (haematuria)
What can CXR show in abd pain
Air under diaphragm- perforation
Differnce in sensitivity of USS and MRCP for gallstones and bile duct stones
USS better for gallstones, MRCP for BDS
Appendicitis signs and Ix
Sudden, severe RIF pain, or pain from central (vague pain) to IF (Localised) , worse on coughing
Rebound tenderness
May have guarding and rigidity
Generally malaise and unwell
May have N+V+D
Mild fever,High CRP, WBC, normal Hb
If systemically unwell, may have high fever, severe abd pain and more generalised abdominal pain
ERCP findings for biliary colic and cholecystitis
Gallstones and thickened gallbladder wall resp.
Tx for acute cholecystitis
IV abx and cholecystectomy for acute cholecystitis
Biliary colic treatment
Cholecystitis, but in OPD
Likely cause of small amount of free air under diaphragm
Duodenal Ulcer
What to rule out in 22 yo lady with lower abd pain, what Ix for this
ectopic pregnancy, ovarian diseases, appendicitis, pelvic USS
Possible GI causes of lower abd pain
Appendicitis, diverticulitis
70 year old male with generalised abd pain, abd distention and vomitting
Grad onset, vomitting dark green liquid
Waves for the last 48 hrs
2 similar ep over past 12 mo (colicky pain), resolved spontaneously
Possible cause? Ox and Ix?
SBO. Tympanic to percussion,
Tinkling bowel sounds on ascul, mildy tender, RIF scar, tachycardia. Do CXR, may do CTAP - eg. can show SBO with transtition point in RIF, Dilatation of bowel -
Adhesion may be caused by scar tissue
Possible causes of SBO include
SBO
Hernias, adhesion (previous operations- should check for scars), CD ( CBO rare, suacute with colickly pain more common)
LBO
Colon cancer and volvulus ( eg. that of sigmoid colon)
Na and K levels in vomitting
Low
Early Mx for SBO
Analgesia, IV fluids + bowel rest, nil by mouth large bore NGT to decompress bowel
Conservative Mx in adhesions or partial obstruction in CD
Exploratory laoratomy to address pri cause eg. resect stricture or CRC
Operation vs observation for SBO
If ischaemic due to close loop obstruction, may need to cut scar tissue and resect bowel
If relatively well then NGT and fluids for 2? Days, pt may get better w/o op.
When should CXR be done most commonly for abd pain
obstruction (dilated loops) or perforation (free air)
When should amylase be tested
suspected pancreatitis
What is passing flatus a common sx of
BO
Likely disease if particular foods trigger it
Gallstone disease
What disease is more likely to improve with passing of motion or flatus
IBS
Unwell, gen. abd pain, peritonism, tachycardia, hypotension, fever, guarding, generalised perionism - what may this be
May be perforated viscus?
Signs of BO
Abd distension, not moving bowels or passing flatus , vomitting
Where is pain likely to be in rupture AAA and other Sx
shoulder tip referred pain, palpable AA, pain that goes to the back, hyperT
Sx in abdominal ischaemia, and is pain acut or chronic
Generalised peritonism and abd pain
High lactate, passage of red or darker blood in stool
Acute pain!
Age of pts who get mesenteric ischaemia
Age > 50 years
More severe Sx of acute mesenteric ischaemia
bowel necrosis and perforation, and, in advanced cases, fever, tachycardia, and hypotension will be present
Ix of acute mesenteric ischaemia
- CT of abdomen:
- vessel thrombosis; thickened bowel wall; abnormal bowel wall enhancement; pneumatosis; portal or mesenteric venous gas
- Plain abdominal x-rays:
- may see dilated loops of bowel; air-fluid level; bowel wall thickening; formless loops of large or small bowel; pneumatosis; vascular gas‘
- CXR:
- Free air under diaphragm
Sx of IBS
Bloating , const. or diarrheoa, esp if gets better on BO
How might Crohn’s disease cause recurrent abdominal pain?
Prev resections- adhesions, or stricturing which may cause obstruction- more subacute/chronic than obstructing bowel cancer
Difference in patient positioning in peritonism vs colic
Staying still ( as movement aggravates pain) vs writhing around
What is pallor a sign of in acute abdomen
Shock - Sepsis, GI bleeding, perforation
What is jaundice in acute abdomen sign of
Gallbladder or liver problems
What are the causes of localised peritonism vs generalised peritonism
Appendicitis vs advance perforation
Describe bowel sounds in peritonism
absent
Describe bowel sounds in BO
Tinkling/high pitch
What are deranged cholestatic liver FTs a sign of
Cholangitis, gallstones, cholecystitis
What can urinalysis tell you in acute abdomen
Ketones + glucose suggest DKA, WCC may suggest pyelonephritis
What does fluid level on AXR show
Obstruction
What can be seen on AXR apart from dilated loops of bowel and fluid level
Toxic megacolon
what can ultrasound abdomen show you
Gallstones, cholecystitis
When would CTAP be done
Infective peforation or abdominal complications susp.
What does sudden onset pain suggest
Perforation ( duodenal ulcer, IBD), rupture of aneurysm or ovarian cyst, torsion of ovarian cyst, acute pancreatitis
what does back pain suggest
Acute pancreatits, rupture of aortic aneurysm ( back to front, sever pain), renal tract disease eg. kidney stones or pyelonephritis
What does more gradual onset of abd pain suggest
Inflammatory conditions like appendicitis, IBD, diverticulitus
abd pain with rectal bleeding/ melena
PMHx of AF and COPD, sats 91, BP 90/60, Pulse 160 AF, Temp 36, abdomen rigid and silent to auscultation. Elevated CRP, lactate and WCC
Intestinal ischaemia
Causes of intestinal ischaemia
Acute - vascular occlusion due to embolism or rupture of pre-existing arterial thrombosis, in low output states like shock in pts with pre-existing vasc disease
Chronic- insidious development of ischaemic Sx like abdominal pain that is worse after eating
Risk factors for Intestinal ischaemia
Elderly pts with vasc disease, co-existing cardiac arrhythmias and co-morbitites like diabetes
Secondary to conditions resulting in low output like shock of any cause
Diff in presentation of colonic and SB ischaemia
Colonic- acute abdomen, significant LGIB ( fresh rectal), large areas of ulceration, Splenic flexure and left proximal colon often affected , usually resolves spontaneously
SB - may have sig. weight loss if chronic due to nutritional failure, may have acute abdomen, perotinsim, diarrheoa/ melena, fresh rectal bleeding, very unwell
Mx of bowel ischaemia
Aspirin and statins for acute intestinal ischaemia
MRI and angiogram considered to see if there is a critical vasc lesion that can be treated by stenting
Exploratory laparotomy with potential resection of affected bowel can be considered in severe intestinal iachaemia with acute abd
dDx for appendicitis
Ileo-caecal CD with abscess formation - often have RIF pain
Acute salpingitis in women - vaginal discharge and adnexal tenderness of vaginal examination
Non-specific mesenteric lymphadenitis in younger indiv
Acute Terminal ileitis sec to infxn
How to confirm Dx of appendicitis
CTAP or ultrasound
Mx of appendicitis
Laparoscopic or open removal
Treatment with abx and drainage if appendix mass or abscess is present due to rupture
possible MHx in BO
CD- prone to stricturing or narrowinng of bowel
Gut or abd op - adhesions ( most common cause)
Opiates- slow transit constipation leading to obstruction
Risk factors for LBO include
Colorectal adenomas, IBD, diverticular disease are all risk factors , so is radiotherapy
Px of BO, Ox and Bloods
Central colicky abdominal pain, abdominal distention and vomiting, reduced/no bowel movement
May have constipation
Possible pyrexia or nausea
Increased bowel sounds, Tinkling bowel sounds in complete obstruction
Elevated WCC and CRP
Initial Ix for SBO
AXR
also do DRE - may reveal lower colonic path like rectal cancer in LBO
CT or MRIAP may provide more accurate data on level of obst,
CT should be first line? ABG and FBC should also be done
How is pain of abdominal colic described
Diffuse, vague visceral pain according to divisions of foregut, midgut and hindgut
SBO vs LBO vs complete BO
Profuse vomiting vs less vomiting, no bowel movement ( and may have tenesmus) vs no passage of wind and sig. distention- and peritonitism will develop over time
What does peritonism suggest in BO
Strangulation or perforation of intestine
Mx of BO, including complete SBO
Bowel rest, nil by mouth
Large bore NGT to decompress
Complete- supportive care first line, dluid resusc, decompress and analgesia
What is parlytic ileus
Cond where intestinal motility stops, can occur postoperatively or in electrolyte imbalances, features can mimic mechanical obst.
How to diff parlaytic ileus from BO
Absent bowel sounds `
What causes peritonitis
- gastroduodenal ulcers (UGI)
- CD, appendicitis (SB)
- Divericular disease ( Colon)
- Following instrumentaiton eg. colonscopy
- Breakdown of intestinal surgical anastomosis post-operatively
- Pancreatic fluid in severe pancreatitis
- Bile from free bile from gallbladder or bileducts
- SBP, common in advance ALD pts
Features of peritonitis
pain more localised, assoc with guarding
Pain worse with coughing and deep breathing, rebound and percussion tenderness, rigity
Effect of peritonitis on gut motility, what is seen on XR
Toxix, may have silent abdomen with no bowel sounds, dilatation of intestines on X-ray
Complication of peritonitis
If uncontrolled can lead to SIRS and septic shock
Mx of peritonitis
If sec to intestinal perforation, need surgical intervention to resect tissue or repair perforation and wash out peritoneal cavity
IV abx
What do Ix for adhesions show
- dilated loops of proximal bowel with collapsed loops posterior to site of obstruction
- May have high-pitched bowel sounds or absent bowl sounds, tenderness, involuntary guarding, distended abdomen?
- Elevated CRP may be observed
- Chest x ray may show free air under diaphragm
- CXR shows dilated bowel (maybe)
Sx of diverticulitis
- LLQ pain
- Fever, anorexia, nausea, vomitting
- Abdominal distension with ileus
- Fever, LLQ tenderness, peritoneal signs ( guarding, rebound tenderness, rigid abdomen) with perforation or ruptured abscess
- Elevated WBC,CTAP - diverticulitis may be observed, bowel wall thickening , free abdominal air
When should surgery be done for BO
- Surgery is indicated in patients with adhesional obstruction if there are signs ofperitonitis, hernia strangulation, or bowel ischaemia.
- Computed tomographic evidence of a non-adhesional cause (tumour, hernia, volvulus, or gallstone) a is an indication for surgery
