Abdo conditions Part I Flashcards
AAA definition and epidemiology
What are the 2 types?
Permanent and irreversibly localised dilation of the AA by 50%. So 3cm or more
5% of population over 60
True aneurysm: ; dilation involves all 3 layers
Pseudoaneurysm: collection of blood in the adventitia
Pathophys of AAA
What is the most common site
Results from failure of major structural proteins of aorta – elastin + collagen.
Elimination of elastin from tunica media = aortic wall ↑susceptible to force of blood pressure.
Most commonly found in the infrarenal portion of the AA
Risk factors/ causes of AAA
Atherosclerosis RFs: smoking, age, HTN, hyperlipidaemia
Trauma
Infection e.g. endocarditis, tertiary syphillis
Inflammatory causes: Takayasu’s aortitis , Behcet’s disease
CTDs, marfans and ehlers-Danlos
Older caucasian males
FamHx
Symptoms of an unruptured AAA
Symptoms of a ruptured AAA
Unruptured: most are asymptomatic
Possible pain in back, abdo, loin or gron
Ruptured: Central abdo pain + lower back pain in pt with unknown aneurysm
SUDDEN +SEVERE. Shock/ collapse/ syncopy
Ruptured AAA should be considered in any pt with hypotension +atypical abdominal symptoms
Signs of a AAA OE
Pallor + sweating.
Hypotension (50%).
Mottled skin of the lower body (livedo reticularis)
Grey Turner’s sign (flank brusing)- ONLY IN RETROPERITONEAL HAEMORRHAGE
Pulsatile expansile mass: Felt using bimanual palpation either side of the midline
Decreased ABPI
One or both femoral pulses may be absent
Abdominal bruit
Tachycardia (50%)
Investigations for AAA
ECG (if TAA- rule out MI), CXR + possibly lung function tests.
Blood tests:
FBC (may reveal ↑WCC), clotting screen, renal + liver function.
ESR +/or CRP (if inflammatory cause suspected)
Cross-match if surgery planned.
Imaging:
Ultrasound: can detect aorta expansion from as little as 3mm
CT: Visceral arteries, Mural thrombus and Crescent sign’ (blood within thrombus- may predict imminent rupture), para-aortic inflammation, ct with contrast can show rupture of aneurysm.
MRI angiography may be used: safer as nephrotoxic contrast not used
Regarding AAA what should we encourage men >66/ women >70 to do
Self- refer to NHS AAA screening programme if they have not been screened and have the following RFs (same applies to women aged 70+): COPD CVD PVD FamHx AAA Hyperlipidaemia HTN current or ex smoker.
Conservative, medical and surgical management of unruptured AAA
Conservative: 3-4.4cm = Annual US
4.5-5.5cm = 3 monthly US
>5.5cm =consider surgery + 3 monthly US
DVLA must be notified of aneurysms >6cm. >6.5cm disqualifies person from driving. Reduce CV risks
Medical: Blood pressure control
Consider Statins (Atrovastatin 80mg), Aspirin 75mg + Antiplatelet therapy- AAA pts have ↑ cardiovascular disease risk.
Surgical: indicated for aneurysms >5.5cm can be open repair or EVAR (stent graft put in through femoral arteries)
Management of ruptured AAA
A-E IT! High flow O2.
Two large bore cannulas.
Send blood for FBC, U&E, glucose, clotting screen, LFTs and group & save bloods.
Consider activating major haemorrhage protocol or using O negative blood stored in A&E.
IV analgesia – morphine titrated to response.
IV anti-emetic – cyclizine 50mg.
Give IV fluids if needed but not excessively.
Alert vascular surgeon and anaesthetist at an early stage – aortic cross clamping often required to resuscitate severely hypovolaemic patient
Appendicitis definition
Etymology
Pathophysiology
Acute inflammation of the appendix
Most common surgical emergency, lifetime incidence 6%. Can occur at any age but peaks at 10-20 yo
Appendix normally acts as a reservoir for gut associated lymphoid tissue
Luminal obstruction leads to distention of appendix due to increased mucus production, bacterial overgrowth and suppurative inflammation
This causes impaired lymphatic and venous drainage
Resulting in ischaemia, necrosis and potential perf
Risk factors for appendicitis
Pos FamHx Infection e.g. e.coli and bacteroides Malignancy Children breastfed for <6 months Recent viral illness or lymphadenopathy
Appendicitis symptoms
Periumbilical/ epigastric crampy abdo pain that moves to the RIF in 24-48 hours
Pain worsened by movement or driving over uneven roads
Constipation though diarrhoea may occur
Sudden relief of pain indicates perforation
Murphy’s triad: Nausea and vomiting, low-grade fever and RIF pain
McBurney’s point: Deep tenderness here is a sign of acute appendicitis. The point is 2/3rds the distance between the navel and the R- ASIS
Appendicitis signs
Tachycardia Fever (low grade: Between 37.5 and 38.5^C) Facial Flushing Dry Tongue Halitosis: Chronic bad breath Peritonism
Rebound or percussion tenderness in RIF
Pain on right during PR exam suggests inflamed low-lying pelvis appendix
Anorexia
Bowel sounds may be reduced particularly on the right side compared to left
Define:
Rovsing’s sign
Psoas sign
Obturator sign
Hop test
Rovsing: Positive when pressure over the patient’s left lower quadrant causes pain in the right lower quadrant
Psoas sign: Passive extension of the right thigh with the person in the left lateral position elicits pain in the right lower quadrant
Obturator sign/ cope pain: Passive internal rotation of the flexed right thigh elicits pain in the lower right quadrant. Shows if appendix is close to obturator
Hop test: hopping or jumping causes abdo pain
Appendicitis investigations
Bedside:
Urinalysis: To exclude UTI: pts may have leukocytes
Pregnancy test: to exclude ectopic pregnancy
Cap blood glucose: Nausea, vomiting, anorexia may cause hypoglycaemia
Labs
FBC: Will show neutrophil leucocytosis present
U&Es: Anorexia, nausea, vomiting may cause deranged renal function
CRP: May be elevated with acute inflammation
G&S= appendicitis management typically operative
US: Appendix not always visualised but may show non compressible appendix, wall thickening with associated hyperaemia. Should be used in children, pregnant or breastfeeding women
CT: High diagnostic accuracy and reduces negative appendectomy rate. Not routinely indicated: only if diagnosis is uncertain
