61. Abdominal pain Flashcards
Peritonitis.
a) Types
b) Causes
c) Clinical fx
d) Investigations
e) Management
a) - Localised - adjacent to inflamed organ (eg appendicitis)
- Generalised - signifies rupture;
- SBP - in patients with cirrhosis and ascites
- Abscess
b) UGI - PUD, malignancy, iatrogenic
- LGI - appendicitis, malignancy, diverticular, ischaemia, hernia, IBD
- Other: cholecystitis, liver disease, pancreatitis
c) - Obs: fever (abscess - swinging), tachycardic, hypotensive
- Abdo: rigid, tender, rebound tenderness, guarding, knees flexed, shallow breathing, absent bowel sounds
d) - Bedside: urine dip, pregnancy test
- Bloods: FBC (raised WCC), UEs and creatinine, LFTs, amylase, lactate, etc. Blood cultures.
- Imaging - this may include abdominal X-ray, upright CXR, ultrasound, CT scanning, MRI and contrast studies.
- Special tests: Peritoneal fluid analysis for culture and amylase level
e) - A-E approach: oxygen, IV access, nil by mouth, fluids, bloods, escalate (surgical review), analgesia
- IV Abx
+/- surgical drainage
Gallstone disease.
- Differentiating biliary colic from acute cholecystitis and acute cholangitis
- Biliary colic: sudden onset of RUQ pain, radiating to the back; may be colicky or constant; poss nausea/vomiting, APYREXIAL
- Cholecystitis: continuous RUQ/epigastric pain, FEVER, LOCAL PERITONISM, RAISED WCC/CRP, MURPHY SIGN
- Cholangitis: Charcot’s triad of fever, JAUNDICE and RUQ pain, SEPTIC features (tachycardia, hypotension, confusion)
Gallstones.
a) Composition
b) Risk factors
c) Presentation
d) Investigations
e) Management
f) Prevention
a) Cholesterol (80%), bile pigments, bile acids
b) 5Fs (fair, fat, female, fertile, forty), obesity (or sudden weight loss post-bariatric surgery), FHx gallstones, diabetes, loss of bile salts (ileal resection, terminal ileitis),
c) Asymptomatic (most). Of the symptomatic: biliary colic (55%), cholecystitis (30%), cholangitis, obstructive jaundice (choledocholithiasis), gallbladder empyema, pancreatitis, bowel obstruction (gallstone ileus)
d) - Bedside: urinalysis, ECG (exclude differentials)
- Bloods: FBC, CRP, LFTs,
- Imaging: USS (most effective modality for cholesterol stones)
- Special tests: ERCP (may also be therapeutic)
e) - Conservative: watch and wait (esp. if incidental)
- Surgical: lap chole
- Other: mechanical/shock-wave lithotripsy
f) Ursodeoxycholic acid (UDCA) - e.g. in obese patients undergoing bariatric surgery - reduces risk of developing gallstones; however, it has no effect on symptoms once they have formed
Cholecystitis.
a) Clinical fx
b) Tokyo criteria for diagnosis (A, B, C - for C give possible findings)
c) Management
d) If GB inflammation is found without evidence of gallstones - what is the diagnosis? (causes)
e) Complications
a) - Continuous RUQ/epigastric pain, fever, local peritonism (e.g. Murphy’s sign)
b) A (local inflammation) - RUQ pain or Murphy’s sign
B (systemic) - fever, elevated WCC or elevated CRP
C (imaging) - findings characteristic of acute cholecystitis (e.g. pericholecystic fluid, gallstones/debris)
1 from each of A + B or C = suspected
1 from each of A + B + C = definite
c) - Bedside: urine dip, ECG
- Bloods: FBC, CRP, (raised WCC/CRP) LFTs
- Imaging: USS (GB thickening, pericholecystic fluid, gallstones)
- Special tests:
- Analgesia: opioids or NSAIDs
- IV fluids
- Prophylactic IV ABx (e.g. 3rd gen cephalosporin)
- Lap chole within 1 week (open if emergency)
d) Acalculous cholecystitis (5% of cholecystitis): caused by major trauma, malnutrition, surgery or illness
e) - Gallbladder empyema
- Abscess - liver, subphrenic
- Cholangitis
Cholangitis.
a) Clinical fx
b) Tokyo criteria for diagnosis
c) Most common infecting organisms
d) Management
a) Charcot’s triad of fever, jaundice and RUQ pain; may also have septic features (tachycardia, hypotension, confusion)
- note: biliary stasis predisposes to infection
b) A (systemic) - fever/chills or raised WCC/CRP
B (cholestasis) - jaundice or elevated LFTs
C (imaging) - biliary dilatation or evidence of cause
1 from each of A + B or C = suspected
1 from each of A + B + C = definite
c) Gram negatives: e. coli, klebsiella, enterobacter
d) - Bloods
- Imaging: Contrast CT +/- MRCP
- IV ABx: 3rd gen cephalosporin (active against gram negatives) or tazocin if septic.
- Surgical drainage of GB/ removal if required
Pancreatitis: causes - I GET SMASHED
Idiopathic GALLSTONES ETHANOL Trauma Steroids Malignancy/mumps Autoimmune Scorpion stings Hypercalcaemia/ hyperlipidaemia ERCP Drugs - azathioprine, tetracyclines
Acute pancreatitis.
a) Clinical fx
b) Management
c) Causes of a raised amylase
d) Assessment of severity - Glasgow score (PANCREAS)
e) Complications
a) - Severe upper abdominal pain (epigastric/LUQ; radiates to back) of sudden onset with vomiting
- Signs of shock (tachy, hypotensive), peritonism
- Jaundice
b) Bedside:
- Bloods: serum amylase (3x normal) /lipase, FBC, UEs, CRP, calcium, glucose, LFTs (may show gallstone/alcohol cause)
- Imaging: contrast CT (diagnostic)
- A-E assessment
- Pain relief - pethidine/buprenorphine (NOT morphine due to possible spastic effect on sphincter of Oddi)
- IV fluids
- Nil by mouth (+ NG if vomiting)
- If infection - give IV ABx (not given routinely)
- If gallstone cause - ERCP, stenting, drainage, etc.
- Surgery if complications develop
c) - Ectopic pregnancy
- Renal failure
- DKA
- Perforated duodenal ulcer
d) PaO2 <8kPa, Age >55, Neutrophilia, Ca2+ <2 mmol/L, Renal failure (Urea >16 mmol/L), Enzymes (LDH >600iu/L, AST >200iu/L), Albumin <32g/L, Sugar (glucose >10)
e) Necrosis, abscess, infection, fluid collections, ascites
Chronic pancreatitis.
a) Risk factors
b) Clinical fx
c) Investigations (vs. acute)
d) Management
a) Alcohol, smoking, genetics, biliary disease, cystic fibrosis
b) - Abdominal pain (episodes similar to acute pancreatitis), nausea/vomiting, loss of appetite,
- Exocrine dysfunction (malabsorption with weight loss, diarrhoea, steatorrhoea and protein deficiency),
- Endocrine dysfunction (diabetes)
c) - FBC, CRP, amylase (usually normal), glucose, Ca2+, renal function, UEs
- secretin stimulation test/ faecal elastase (exocrine fx)
- HbA1c (endocrine fx)
- Imaging: CT - calcification, atrophy or duct dilatation
d) Conservative: manage risk factors (alcohol, smoking),
- Medical: replace pancreatic enzymes (e.g. Creon), control blood sugars (e.g. insulin), pain relief (analgesic ladder; beware gastroparetic effect of opioids)
- Surgery- fluid drainage, pancreas resection
Pancreatic carcinoma.
a) Risk factors (including specific familial syndromes)
b) Histopathology
c) Clinical fx (consider symptoms, signs and differences based on the anatomical site of the cancer)
d) Management
e) What surgical procedure may be curative?
a) Age, alcohol, smoking, high BMI, poor diet, chronic pancreatitis, FHx, IBD
Familial - BRCA1, BRCA2, familial adenomatous polyposis, Peutz-Jeghers syndrome, familial melanoma syndromes, Lynch syndrome, von Hippel-Lindau syndrome, multiple endocrine neoplasia type 1
b) Exocrine tumours - adenocarcinoma (95%) - mostly ductal; endocrine tumours rarer
c) - Head - painless, progressive obstructive jaundice
- Body/tail - epigastric discomfort, pain radiating to the back, weight loss, nausea, loss of appetite
- Steatorrhoea/malabsorption
- Acute pancreatitis (consider malignancy in elderly patients/ those without risk factors)
- Signs: jaundice, tenderness, Courvoisier’s sign, epigastric mass (late), ascites, Virchow’s node
d) - Bloods: FBC, CRP, amylase, LFTs, CA-19-9 (limited diagnostic value but useful for guiding treatment)
- Imaging: USS first line; contrast CT usually follows
- Surgery: resection is only curative method (< 20% cases suitable)
- Supportive/palliative: chemotherapy, stenting bile ducts, pain management, nutrition,
e) Whipple procedure: proximal pancreatico-duodenectomy - scar (bilateral subcostal - like liver transplant Mercedes-Benz scar without the sternotomy)
Epigastric pain.
a) Most common causes
b) Life-threatening causes
c) Other surgical causes
d) Non-surgical causes
e) Common investigations
a) Related to gastric acid:
- GORD (reflux, burning, cough, risk factors)
- Gastritis (often worse after food)
- PUD (chronic gnawing pain, duodenal better with food, gastric worse with food)
b) - Ruptured aortic aneurysm (collapse, pulsatile mass)
- Obs: ectopic, pre-eclampsia
- Peritonitis (rigid, peritonism, shock, fever)
c) - Inflammation: pancreatitis, cholecystitis/cholangitis, IBD
- Cancer: gastric, pancreatic
- Obstruction (note - bowel obstruction usually umbilical): bowel obstruction (pain, obstipation, vomiting, distension), biliary obstruction (jaundice)
d) DKA, referred pain (e.g. MI, pleuritis, renal colic, UTI), functional (e.g. IBS), shingles, mesenteric adenitis (children), lactose intolerance
e) - Bedside: urine dip, pregnancy test, ECG
- Bloods: FBC (anaemia), CRP, clotting, UEs, LFTs, amylase
- Imaging: erect CXR/AXR (bowel obstruction), USS, CT abdomen, endoscopy (usually OGD), barium studies, CXR, diagnostic laparoscopy, laparotomy
- Special tests: H. Pylori test; hydrogen breath test
Periumbilical pain.
a) Surgical causes (1 to consider in young boys)
b) Medical causes
c) Investigations
a) Bowel obstruction, constipation, appendicitis, ruptured AAA, peritonitis, bowel ischaemia, ectopic pregnancy, pancreas, lymphoma/lymph nodes;
young boys - testicular torsion
b) Gastroenteritis, DKA, UTI, IBD, retention, hypercalcaemia
c) - Bedside: pregnancy, urine dip, ECG, bladder scan
- Bloods: FBC, CRP, group and save/cross-match, UEs, LFTs, calcium, glucose, amylase
- Imaging: CXR (pneumoperitoneum), AXR (bowel obstruction), USS, CT, endoscopy, diagnostic lap
RUQ pain.
a) Causes - more common/less common
b) Investigations
a) - Gallbladder - gallstones, etc.
- Liver - hepatitis, hepatomegaly (stretching of liver capsule), liver mets, Fitz-Hugh-Curtis syndrome, etc.
- Renal - colic, pyelonephritis
- Hepatic flexure involvement - cancer, IBD, ischaemia, constipation, diverticula
- Medical causes: pneumonia/pleurisy, DKA, UTI, MI, sepsis, hypercalcaemia
- MSK pain
b) Bedside: urine dip, pregnancy test, ECG
- Bloods: FBC, CRP, UEs, group and save/cross-match, LFTs, amylase, glucose,
- Imaging: USS, CT, erect CXR
- Special tests: ?ERCP
LUQ pain.
a) Surgical causes
b) Medical causes
c) Investigations
a) - Spleen - infiltration (e.g. leukaemia, infection), rupture, infarction (SCD)
- Stomach - gastroenteritis, PUD, tumour, gastritis
- Pancreas - pancreatitis, tumour
- AA rupture
- Splenic flexure involvement - diverticular dx, IBD, tumour, ischaemia, constipation
- Renal - colic, tumour
b) DKA, MI, pneumonia/pleurisy, porphyria, SCD, shingles, sepsis, hypercalcaemia
c) As for RUQ (possible blood film)
RIF pain.
a) GI causes
b) Obs and gynae causes
c) Other
a) Appendicitis, terminal ileitis (Crohn’s), hernia, Meckel’s diverticulum, diverticular dx (more common in LIF), cancer, perforation, constipation
b) - Gynae: PID, ovarian cyst torsion/rupture, fibroid degeneration, Mittelschmerz, pelvic tumour
- Obs: ectopic, miscarriage, labour, abruption
c) Urological - UTI, retention, renal colic, testicular torsion, epididymo-orchitis, tumour
- MSK - psoas abscess, right hip pathology
- Medical: DKA, hypercalcaemia
d) - Bedside: urine dip, pregnancy, swabs if appropriate, ?bladder scan
- Bloods: FBC, CRP, UEs/creatinine, glucose, LFTs
- Imaging: USS, CT, erect CXR
- Special tests: endoscopy, diagnostic lap
LIF pain.
a) Most common vs. RIF
b) Other causes
c) Investigations
a) Diverticular dx, constipation, cancer, sigmoid volvulus
b) As for RIF:
- GI- IBD, hernia
- Gynae (PID, ovarian, mid-cycle, fibroid, pelvic tumour)
- Obs (ectopic, miscarriage, labour, abruption)
- Urological - retention, UTI, renal colic, testis torsion, tumour
c) As for RIF; more emphasis on sigmoidoscopy/ colonoscopy
