61. Abdominal pain Flashcards

Question

pathophysiology bilairy colic

Answer 1

Gallbladder neck is impacted by a gallstone. No inflammatory response, yet the contraction of the gallbladder against the occluded neck will result in pain worse after eating as Fatty acids stimulate the duodenum endocrine cells to release cholocystokinin (CCK) which in turn stimulates the contraction of the gallbladder

Answer 2

Investigations: - USS (90-95% sensitive) - LFTs and inflammatory marker normal - Lipase normal - Gold standard investigation for gallstones: magnetic resonance cholangiopancreatography (MRCP)- can show potential defects in biliary tree Management: Analgesia: for severe pain : diclofenac 75mg IM. A second dose can be given after 30 minutes if necessary.if CI IM opioid For mild to moderate pain : paracetamol or NSAID ef diclofenac which can be given orally or rectally if nausea is a problem - Lifestyle factors (reduce fatty foods especially before surgery, don’t need to as much after surgery) - Referral for elective laparoscopic cholecystectomy

Answer 3

magnetic resonance cholangiopancreatography (MRCP)- can show potential defects in biliary tree

Answer 4

acute cholecystitis

Answer 5

fever tenderness murphys sign positive no jaundice

Answer 6

Investigations: Carried out in hospital - abdominal USS - Bloods (raised WCC, raised CRP, serum amylase) Management: Admit to hospital Analgesia Monitoring IV fluids Antibiotics Surgical assessment for cholecystectomy (to be done within 1 week of presentation, ideally within 48 hours)

Answer 7

A stone located in Hartmanns pouch (an out-pouching of the gallbladder wall at the junction with the cystic duct) or in the cystic duct itself can cause compression on the adjacent common hepatic duct. This results in an obstructive jaundice, even without stones being present within the lumen of the common hepatic or common bile ducts. Investigation: MRCP Management: Laparoscopic cholecystectomy

Answer 8

PC: recurrent or untreated acute cholecystitis —> persistent inflammation of gallbladder wall Management: Elective cholecystectomy

Answer 9

Gallbladder fills with pus and patient may become septic PC: similar to acute cholecystitis

Answer 10

Infection of biliary tract caused by biliary outflow obstruction and biliary infection. Stasis of fluid allows bacterial colonisation. Main organisms are: e.coli, klebsiella and enterococcus

Answer 11

charcots triad - indicates ascending cholangitis

Answer 12

PC: fever, jaundice, RUQ pain (charcots triad) HoPC: may have pyrexia, rigours, jaundice, RUQ tenderness, confusion, hypotension, tachycardia Red flags: Environment: MHx: gallstones, recent ERCP procedure, previous cholangitis DHx: oral contraceptive pill and fibrates FHx: SHx: diet rich in fatty foods

Answer 13

Initial management: IV access Fluid resuscitation Antibiotics broad spectrum eg co-amoxiclav +metronidazole Investigation/management: blood cultures USS first line - bile duct dialtation ERCP with or without sphincterotomy and stunting Long term may require cholecystectomy of gallstones were the cause

Answer 14

fever tenderness jaundice confusion hypotension tachycardia

Answer 15

inflammation of the pancreas. Autodigestion of pancreatic tissue by the pancreatic enzymes, leading to necrosis, caused most commonly by gallstones or alcohol Each cause will trigger a premature and exaggerated activation of the digestive enzymes within the pancreas. The resulting pancreatic inflammatory response causes an increase in vascular permeability and subsequent fluid shifts (often termed “third spacing”). Enzymes are released from the pancreas into the systemic circulation, causing autodigestion of fats (resulting in a ‘fat necrosis’) and blood vessels (sometimes leading to haemorrhage in the retroperitoneal space). Fat necrosis can cause the release of free fatty acids, reacting with serum calcium to form chalky deposits in fatty tissue, resulting in hypocalcaemia.

Answer 16

GET SMASHED Gall stones Ethanol Trauma Steroids Mumps Autoimmune Scorpion stings Hypertriglyceridemia, hypercalcaemia and hyperparathyroidism ERCP – endoscopic retrograde cholangiopancreatography Drugs – such as sodium valproate, azathioprine and sulphonamides

Answer 17

pancreatitis

Answer 18

PC: sudden onset severe constant epigastrium pain radiating to the back/flanks with profuse vomiting HoPC: worsen with movement and improve by leaning forwards/in foetal position. If caused by gallstones, pain may be described as sudden and knife-like, and may be worse after food. If alcohol-related, pain may be of less abrupt onset and poorly localized. Red flags: Environment: alcohol intake MHx: DHx: sodium valproate, azathioprine and sulphonamides

Answer 19

- pain better on leaning forwards - fever (inflammation or sepsis) - signs of shock - Cullen’s sign (bruising around the umbilicus) and Grey Turner’s sign (bruising in the flanks) , representing retroperitoneal haemorrhage.

Answer 20

Plan: Investigation: Admit to hospital Fluid resus, access, abx, o2, parenteral feeding Bloods: lipase, amylase (3x upper limit), liver and renal function, and inflammatory marker levels. Imaging: contrast CT is best for pancreatitis. Investigating cause: USS for gallstones Management: ERCP if gallstones is the cause Cholecystectomy

Answer 21

Lipase is lit !! raised serum lipase is more accurate for acute pancreatitis, as it remains elevated longer than amylase Serum amylase or serum lipase – diagnostic of acute pancreatitis if 3x the upper limit of normal* Amylase can also be marginally raised in pathologies such as bowel perforation, ectopic pregnancy, or diabetic ketoacidosis

Answer 22

assess for any concurrent cholestatic element to the clinical picture. Patients with acute pancreatitis noted that an alanine transaminase (ALT) level >150U/L has a positive predictive value of 85% for gallstones as the underlying cause

Answer 23

alcoholic hepatitis non alcoholic fatty liver disease viral hepatitis autoimmune hepatitis drug induced hepatitis

Answer 24

abdominal pain, fatigue, pruritus, muscle and joint aches, N+V, jaundice, fever (viral hepatitis)

Answer 25

LFTS: “hepatitic picture” - high transaminases (AST/ALT) with proportionally less of a rise in ALP. Transaminases are liver enzymes released into the blood as a result on inflammation of the liver cells Bilirubin can also rise as a result of inflammation of the liver cells—> jaundice Elevation in unconjugated bilirubin indicates pre-hepatic or hepatic jaundice eg hepatitis. Whereas conjugated indicates he pato cellular or cholestasis.

Answer 26

A - ass E - eating

Answer 27

A - ass (F-O) B - blood-borne (PP) C - cerious and circulation (PP) D - depends on B (PP) E - eating (F-O)

Answer 28

A - self-resolves usually within 1-2 months, worse outcome rare B- 90% of people self-resolve, 10% chronic, antiviral medication can slow progression C- 25% self resolve, Direct acting antiviral medication for 8-12 weeks (curative in 90% of patients) D- Increases complications and severity of Hep B E- Usually self-resolve within 1 month, can become chronic if immunocompromised

Answer 29

Cirrhosis : fibroscan Hepatocellular carcinoma : USS

Answer 30

Surface antigen (HBsAg) – active infection Core antibodies (HBcAb) – implies past (or current) infection

Answer 31

hepatitis B

Answer 32

PC Type 1: adults, typically women in late 40s and 50s, around or after menopause. fatigue and features of liver disease

Answer 33

Anti-nuclear antibodies (ANA) Anti-smooth muscle antibodies (anti-actin) Anti-soluble liver antigen (anti-SLA/LP)

Answer 34

children in their teenage or early twenties present with acute hepatitis with high transaminases and jaundice

Answer 35

Anti-liver kidney microsomes-1 (anti-LKM1) Anti-liver cytosol antigen type 1 (anti-LC1)

Answer 36

Invetsigations Bloods: Raised transaminases (ALT and AST), IgG levels and it is associated with many autoantibodies such as ANA,LKM1 Big: Diagnosis confirmed using liver biopsy Management 1. High dose steroids (prednisolone) 1b. Taper steroids and introduce immunosuppressants such as azathioprine 2. Liver transplant in end stage disease, however can recur in transplanted livers

Answer 37

complications are rare and there is no increased risk of hepatocellular cancer

Answer 38

people travelling to or going to reside in areas of high or intermediate prevalence, if aged > 1 year old people with chronic liver disease patients with haemophilia men who have sex with men injecting drug users individuals at occupational risk: laboratory worker; staff of large residential institutions; sewage workers; people who work with primates

Answer 39

hep B surface antigen = active infection /chronic infection

Answer 40

hep B surface antibody = immunised = infection cleared after exposure = current infection

Answer 41

core antibodies = past infection cleared after exposure = chronic infection

Answer 42

marker of viral replication and implies high infectivity

Answer 43

evidence of immune response

Answer 44

this is a direct count of the viral load

Answer 45

1. Pegylated Interferon alpha (weekly injectable for 48 weeks) which aims to stimulate the immune system to fight the virus, 2. oral anti-viral agent which suppresses viral replication (Tenofovir or Entecavir once a day, long term)

Answer 46

- Avoid having unprotected sex, unless the partner has been vaccinated and is immune - Avoid sharing needles in inject drugs - Avoid sharing toothbrushes or razors with people in the house - Avoid drinking alcohol

Answer 47

Type: DNA virus Transmission: Blood or bodily fluids (sexual intercourse, sharing needles, tattoos, toothbrushes, surgical procedures, vertical transmission) Vaccine available: yes Acute infection self resolves in 90% of patients, 10% become chronic as it integrates DNA into own DNA so carrier continues to produce viral proteins Not curable but can use pegylated interferon alpha or oral anti-virals such as tenofovir or entecavir to keep virus at bay if it is affecting the liver

Answer 48

Type: RNA virus Transmission: faecal-oral route, contaminated water or food Vaccination available: yes PC: N+V, anorexia, jaundice Can cause cholestasis —> dark urine and pale stools and moderate hepatomegaly Management resolves without treatment in around 1-3 months.

Answer 49

Hepatitis C antibody test: will be positive if the patient has ever been exposed to the hepatitis C virus, but DOESN’T mean they are actively infected HCV RNA is done in patients with a positive HCV antibody to confirm current infection, by means of a PCR.

Answer 50

1/4 self resolve, rest chronic hep C

Answer 51

cure All patients with current HCV infection (HCV RNA detected) should be offered a course of potentially curative treatment. Cure is defined as an undetectable HCV RNA in blood 12 weeks after the end of treatment (sustained virological response – “SVR12”).

Answer 52

1. NS3/4A protease inhibitors (end in –previr) e.g. grazoprevir 2. NS5A inhibitors (end in –asvir) e.g. elbasvir 3. NS5B inhibitors (end in –buvir) e.g. sofosbuvir

Answer 53

flu-like symptoms, depression, fatigue, leukopenia, thrombocytopenia

Answer 54

rheumatological problems: arthralgia, arthritis eye problems: Sjogren's syndrome cirrhosis (5-20% of those with chronic disease) hepatocellular cancer cryoglobulinaemia: typically type II (mixed monoclonal and polyclonal) porphyria cutanea tarda (PCT): it is increasingly recognised that PCT may develop in patients with hepatitis C, especially if there are other factors such as alcohol abuse membranoproliferative glomerulonephritis

Answer 55

Type: RNA virus Transmission: blood and bodily fluids, At risk groups include intravenous drug users and patients who received a blood transfusion prior to 1991 (e.g. haemophiliacs). Vaccine available: no test: hep C antibody test- if positive test for RNA to confirm current infection treatment: antiviral medication for 8-12 weeks (curative in 90% of patients) grazoprevir, elbasvir, sofobuvir

Answer 56

Type: RNA virus Occurs only in people with hepatitis B infection (attaches to HBsAg) Increases complications and severity of Hep B Notifiable disease test: PCR of hep D RNA no treatment, inteferon sometimes used but poor evidence

Answer 57

Co-infection: Hepatitis B and Hepatitis D infection at the same time. Superinfection: A hepatitis B surface antigen positive patient subsequently develops a hepatitis D infection. Superinfection is associated with high risk of fulminant hepatitis, chronic hepatitis status and cirrhosis.

Answer 58

Type: RNA virus Transmission: faecal oral Vaccination: no causes a similar disease to hepatitis A, but carries a significant mortality (about 20%) during pregnancy Management Usually self-resolve within 1 month Rarely → chronic hepatitis esp if immunocompromised

Answer 59

Fulminant hepatitis (FH) or acute liver failure (ALF) is defined by an INR > 1.5 and the presence of hepatic encephalopathy but the absence of chronic, underlying (or prior) disease.

Answer 60

epigastric pain, later more generlaised syncope

Answer 61

An upright ('erect') chest x-ray is usually required when a patient presents with acute upper abdominal pain This is a useful test, as approximately 75% of patients with a perforated peptic ulcer will have free air under the diaphragm

Answer 62

PC: pruritus, fatigue, GI disturbance and abdo pain, jaundice, cardiovascular disease, xanthelasma, pale stools, signs of cirrhosis and failure (ascites, splenomegaly, spider naevi) HoPC: Red flags: Environment: MHx: other autoimmune conditions (thyroid, coeliac), rheumatoid conditions (systemic scleorisis, sjorgrens, rheumatoid arthritis) DHx: FHx: SHx: middle aged women (think b for boobs) ICE:

Answer 63

immune system attacks the small bile ducts within the liver → cholestasis → back pressure causes fibrosis, cirrhosis and liver failure. Bile acids, bilirubin and cholesterol build up in the bloodstream and cause symptoms.

Answer 64

LFTs: alkaline phosphatase is the first liver enzyme to be raised (as with most obstructive pathology), other liver enzymes and bilirubin are raised later in disease Autoantibodies: anti-mitochondrial antibodies (AMA) is most specific to PBC, anti-nuclear antibodies are present in 35% of patients Scan: required before diagnosis to exclude an extrahepatic biliary obstruction (typically a right upper quadrant ultrasound or magnetic resonance cholangiopancreatography (MRCP) ESR raised IgM raised Liver biopsy is used for diagnosing and staging disease Primary biliary cholangitis - the M rule IgM anti-Mitochondrial antibodies, M2 subtype Middle aged females MRCP

Answer 65

Ursodeoxycholic acid reduces the intestinal absorption of cholesterol (slows disease progression and improves symptoms) Colestyramine is a bile acid sequestrate in that it binds to bile acids to prevent absorption in the gut and can help with pruritus due to raised bile acids Liver transplant in end stage liver disease (bilirubin >100) Immunosuppression (e.g. with steroids) is considered in some patients

Answer 66

cirrhosis → portal hypertension → ascites, variceal haemorrhage osteomalacia and osteoporosis (decreased bone formation due to impaired calcium and vitamin d absorption resulting from cholestasis) significantly increased risk of hepatocellular carcinoma (20-fold increased risk) Distal renal tubular acidosis Hypothyroidism

Answer 67

PC: jaundice, chronic RUQ pain, pruritis, fatigue, hepatomegaly HoPC: Red flags: Environment: MHx: ulcerative colitis DHx: FHx: FH of UC or PSC SHx: male aged 30-40 ICE:

Answer 68

intrahepatic or extrahepatic ducts become structured and fibrotic → obstruction to the flow of bile out of the liver and into the intestines. Chronic bile obstruction leads to liver inflammation (hepatitis), fibrosis and cirrhosis

Answer 69

MRCP (magnetic resonance cholangiopancreatography) - MRI scan of the liver, bile ducts and pancreas. In primary sclerosis cholangitis it may show bile duct lesions or strictures.

Answer 70

p-ANCA Autoantibodies: No antibodies are highly sensitive or specific to PSC. They aren’t very helpful in diagnosis but they can indicate where there is an autoimmune element to the disease that may respond to immunosuppression. Antineutrophil cytoplasmic antibody (p-ANCA) in up to 94% Antinuclear antibodies (ANA) in up to 77% Anticardiolipin antibodies (aCL) in up to 63%

Answer 71

anti-mitochondrial antibodies (AMA) is most specific to PBC, anti-nuclear antibodies are present in 35% of patients

Answer 72

ulcerative colitis Acute bacterial cholangitis Cholangiocarcinoma develops in 10-20% of cases Colorectal cancer Cirrhosis and liver failure Biliary strictures Fat soluble vitamin deficiencies

Answer 73

Liver transplant can be curative but is associated with its own problems (around 80% survival at 5 years). ERCP can be used to dilate and stent any strictures Colestyramine is a bile acid sequestrate in that it binds to bile acids to prevent absorption in the gut and can help with pruritus due to raised bile acids Monitoring for complications (such as cholangiocarcinoma, cirrhosis and oesophageal varices)

Answer 74

2ww urgent direct access upper GI endoscopy if: - dysphagia - aged 55 and over with weight loss and any of the following: - upper abdominal pain - reflux - dyspepsia. Consider non‑urgent direct access upper GI endoscopy if: - haematemesis Consider non‑urgent direct access upper gastrointestinal endoscopy to assess for stomach cancer in people aged 55 or over with: - treatment‑resistant dyspepsia - upper abdominal pain with low haemoglobin levels - raised platelet count with any of the following: nausea vomiting weight loss reflux dyspepsia upper abdominal pain - nausea or vomiting with any of the following: weight loss reflux dyspepsia upper abdominal pain.

Answer 75

Tenderness (Murphy) suggests cholangitis Fever - suggests ascending cholangitis or cholecystitis (could have empyema etc) Deranged LFTs - bile duct stone - ascending cholangitis Pancreatitis - bile duct stone - ascending cholangitis

Answer 76

Renal colic (kidney stones) Ruptured abdominal aortic aneurysm Pyelonephritis

Answer 77

Peritonitis refers to inflammation of the peritoneum, the lining of the abdomen. - local peritonitis is caused by underlying organ inflammation, for example, appendicitis or cholecystitis. - Generalised peritonitis may be caused by perforation of an abdominal organ (e.g., perforated duodenal ulcer or ruptured appendix) releasing the contents into the peritoneal cavity and causing generalised inflammation of the peritoneum.

Answer 78

sudden onset acute abdo pain exacerbated by movement eg coughing. Often pain may be generalised and then become localised, shock, fever, sinus tachycardia, nausea and vomiting, abdo swelling, o/e: - gurading - rigidity - rebound tenderness - pain on coughing - percusiion tenderness - absence of bowel sounds suggests paralytic ileus

Answer 79

Guarding refers to voluntary contraction of the abdominal wall musculature, usually the result of fear, anxiety, or the laying on of cold hands. Rigidity refers to involuntary contraction of the abdominal musculature in response to peritoneal inflammation, a reflex that the patient cannot control.

Answer 80

Infected: - Perforation of part of the GI tract, or, in women, of the reproductive system - distruption of peritoneum by surgery or trauma : bacteria frome xternal environemnt - spontaenous bacterial peritonitis - systemic infections sucha s TB Non-infected: - leakage of sterile body fluids such as blood/bile - they will usually become infected once in the peritoneal cavity, causing full blown peritonitis within 24-48 hours. - autoimmune disease sucha s lupus

Answer 81

- perforation of GI tract --> Gram negative bacteria and anaerobic bacteria eg E. coli. - Disruption of the peritoneum – e.g. by surgery or trauma --> external environemnt --> staph aureus

Answer 82

sepsis loss of fluid and electrolyte disturbance abscess Difficulty breathing – due to pressure of fluid on diaphragm.

Answer 83

if the patient’s condition does not improve and there is continuing fever and high white cell count.

Answer 84

inform a senior Erect CXR to check for air under the diaphragm Serum amylase to rule out pancreatitis. Ultrasound / CT to confirm diagnosis IV fluids and electrolytes IV abx Surgery - laparotomy

Answer 85

ascites abdominal pain fever

Answer 86

paracentesis: neutrophil count > 250 cells/ul

Answer 87

intravenous cefotaxime is usually given

Answer 88

Alcoholic liver disease

Answer 89

patients who have had an episode of SBP patients with fluid protein <15 g/l (low protein = low wcc etc to fight off infection) and either Child-Pugh score of at least 9 or hepatorenal syndrome NICE recommend: 'Offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less until the ascites has resolved'

Answer 90

Adhesions (e.g. following previous surgery) are the most common cause of small bowel obstruction, followed by hernias.

Answer 91

tumour - this accounts for 60% of cases of large bowel obstruction volvulus diverticular disease

Answer 92

abdominal xray

Answer 93

common in both: - 'constipation' with complete obstruction and lack of flatulence - diffuse, central abdominal pain - tinkling bowel sounds more so early on more in small bowel - nausea and vomiting typically bilious vomiting - ask abt previous surgeries (adhesions) more in large bowel: - distension - signs of perforation - ask abt symptoms of undelrying cause eg colon cancer, diverticualr

Answer 94

initial steps: NBM IV fluids nasogastric tube with free drainage "drip and suck" small bowel obstruction: some patients settle with conservative management but otherwise will require surgery large bowel obstruction: EMERGENCY SURGERY IF SIGNS OF PERFORATION may have a period (72hr) of conservative management but around 75% will eventually require surgery. IV abx if perforation or sugrery planned

Answer 95

IIschaemic colitis describes an acute but transient compromise in the blood flow to the large bowel. This may lead to inflammation, ulceration and haemorrhage.

Answer 96

'watershed' areas such as the splenic flexure

Answer 97

acute/subacute onset - abdo pain, - rectal bleeding: Haematochezia usually occurs within 24 hours after the onset of abdominal pain. - diarrhoea, urgency, tenesmus, or less commonly constipation. Fever and tachycardia might be present in severe cases, indicating systemic involvement or progressing towards gangrenous colitis. fluid/electrolyte loss → dehydration, shock, metabolic acidosis

Answer 98

acute mesenteric ischaemia - superior mesenteric artery colonic ischaemia - superior and inferior mesenteric arteries (switch is 2/3 along TC) here is watershed area splenic flexure (Griffiths point) and rectosigmoid junction (Sudek's point) supplied by MARGINAL ARTERY (where 70% of colonic ischaemia occurs) The SMA supplies the bowel from the lower part of the duodenum to two-third of the transverse colon. The IMA supplies a large intestine from the distal one-third of the transverse colon to the rectum.

Answer 99

The abdominal pain is typically severe, of sudden onset and out-of-keeping with physical exam findings (not as tender as youd expect at first) Bleeding occurs late Classically patients have a history of atrial fibrillation.

Answer 100

ct with contrast

Answer 101

atrial fibrillation

Answer 102

urgent surgery - bowel resection IV abx more so if colonic

Answer 103

Mild crampy pain, tenderness Prominent bloody diarrhoea

Answer 104

may be thought of as 'intestinal angina'. It is most commonly seen in elderly patients with a history of smoking, hypertension, and hyperlipidemia. The symptoms of CMI include abdominal pain, weight loss, nausea, vomiting, and diarrhoea. The diagnosis of CMI is made through imaging studies such as CT angiography or magnetic resonance angiography. Treatment options for CMI include medical management, endovascular interventions, and surgical revascularization.

Answer 105

chronic mesenteric ischameia

Answer 106

Ectopic pregnancy is when a pregnancy is implanted outside the uterus. The most common site is a fallopian tube. An ectopic pregnancy can also implant in the entrance to the fallopian tube (cornual region), ovary, cervix or abdomen.

Answer 107

Previous ectopic pregnancy Previous pelvic inflammatory disease Previous surgery to the fallopian tubes Intrauterine devices (coils) Older age Smoking

Answer 108

Constant lower abdominal pain in the right or left iliac fossa Vaginal bleeding Lower abdominal or pelvic tenderness Cervical motion tenderness (pain when moving the cervix during a bimanual examination) Missed period It is also worth asking about: Dizziness or syncope (blood loss) Shoulder tip pain (peritonitis)

Answer 109

transvaginal USS positive pregnancy test

Answer 110

A gestational sac containing a yolk sac or fetal pole may be seen in a fallopian tube. Sometimes a non-specific mass may be seen in the tube. When a mass containing an empty gestational sac is seen, this may be referred to as the “blob sign”, “bagel sign” or “tubal ring sign” (all referring to the same appearance).

Answer 111

Most common site: ampulla More dangerous : isthmus

Answer 112

The adnexa is the region adjoining the uterus that contains the ovary and fallopian tube, as well as associated vessels, ligaments, and connective tissue.

Answer 113

A pregnancy of unknown location (PUL) is when the woman has a positive pregnancy test and there is no evidence of pregnancy on the ultrasound scan.

Answer 114

monitor hCG and chanegs in symptoms - In an intrauterine pregnancy, the hCG will roughly double every 48 hours. A rise of more than 63% after 48 hours is likely to indicate an intrauterine pregnancy. A repeat ultrasound scan is required after 1 – 2 weeks to confirm an intrauterine pregnancy. A pregnancy should be visible on an ultrasound scan once the hCG level is above 1500 IU / l. - A rise of less than 63% after 48 hours may indicate an ectopic pregnancy. When this happens the patient needs close monitoring and review. - A fall of more than 50% is likely to indicate a miscarriage. A urine pregnancy test should be performed after 2 weeks to confirm the miscarriage is complete.

Answer 115

Expectant management (awaiting natural termination) Medical management (methotrexate) Surgical management (salpingectomy or salpingotomy)

Answer 116

Patient: Follow up needs to be possible to ensure successful termination Symptoms: No significant pain Bloods: HCG level < 1500 IU / l USS: The ectopic needs to be unruptured Adnexal mass < 35mm No visible heartbeat

Answer 117

The ectopic needs to be unruptured Adnexal mass < 35mm No visible heartbeat No significant pain + HCG level must be < 5000 IU/l + Confirmed absence of intrauterine pregnancy on ultrasound

Answer 118

methotrexate

Answer 119

Anyone that does not meet the criteria for expectant or medical management requires surgical management. Most patients with an ectopic pregnancy will require surgical management. This include those with: Pain Adnexal mass > 35mm Visible heartbeat HCG levels > 5000 IU / l

Answer 120

Laparoscopic salpingectomy is the first-line treatment for ectopic pregnancy. This involves a general anaesthetic and key-hole surgery with removal of the affected fallopian tube, along with the ectopic pregnancy inside the tube. Salpingotomy should be considered for women with risk factors for infertility such as contralateral tube damage around 1 in 5 women who undergo a salpingotomy require further treatment (methotrexate and/or a salpingectomy)

Answer 121

Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of ectopic pregnancy.