Abdo pain Flashcards
What are the aetiology and RFs for an AAA?
AETIOLOGY
-Atheroma
-Trauma
-Infection (syphilis)
-Connective tissue disorders eg Marfan’s, EDS
-Inflammatory eg Takayasu’s aortitis
RISK FACTORS
-Males
->50 y/o
-HTN
-Hypercholesterolaemia
-Smoking
-Connective tissue disorders
What are the signs and symptoms of a ruptured AAA?
S = central abdo / back pain
O = sudden
C = excruciating, throbbing
R = radiates to iliac fossae / groin
A = syncope
SIGNS
-Expansile/pulsatile abdo mass
-Shock, hypotension
-Tachycardia, pale, sweaty
-Absent femoral pulses
-Anaemia
What investigations would you order for a AAA?
-Abdo exam
-AXR (calcium deposits seen where AAA is), USS or CT
-FBC, U+E, glucose, coagulation, LFTs, emergency group + crossmatch
How would you manage a ruptured AAA?
B = 15L NRBM
C = 2x large bore cannulas, fluid resus but keep BP <100 to avoid rupturing a maintained leak
C/D/E = IV analgesia, antiemetics, prophylactic abx
-Escalate to vascular surgeon and anaesthetist
How would you manage a stable AAA?
-Modify RFs - smoking cessation, HTN / hypercholesterolaemia control
-Surgery (only recommended if >5.5cm)
What causes appendicitis and how does it present?
-Gut microbes invade appendix wall after lumen obstruction –> oedema, ischaemia, perforation
SYMPTOMS
-Acute peri-umbilical pain localising to RIF
-N+V, anorexia, constipation, increased urinary frequency
SIGNS
-Tachycardia, shallow breathing, mild pyrexia
-Tenderness at McBurney’s point (1/3 distance from ASIS to umbilicus) + guarding (localised peritonitis)
-ROSVING’S SIGN = pain in RIF when pressing on LIF
-PSOAS SIGN = pain on extending hip (retrocaecal appendicitis)
-COPE SIGN = pain on flexion and internal rotation of R hip
What differential diagnoses are there for appendicitis?
-Acute terminal ileitis (seen in Crohn’s)
-Ectopic pregnancy, ruptured ovarian cyst
-Inflamed Meckel’s diverticulum
-UTI / pyelonephritis
What investigations would you carry out for someone with ?appendicitis?
-Urinalysis (exclude renal colic, UTI)
-Pregnancy test
-Bloods (WCC, ESR, CRP, G+S)
-USS (inflamed appendix, rule out pelvic pathology) / CT
How would you manage a patient with appendicitis?
-Fluid resus if necessary
-IV analgesia + anti-emetics
-Appendectomy
-Abx (metronidazole 500mg/8hr
-Cefuroxime (1.5g/8hr)
What are the signs and symptoms of acute cholecystitis?
SYMPTOMS
-Continuous RUQ or epigastric pain - may refer to R shoulder
-Vomiting / fever
SIGNS
-Local peritonism
-GB mass
-Obstructive jaundice in some cases
-Murphy’s sign = pain and arrest of inspiration when patient breathes with 2 fingers on RUQ
-What investigations would you order for a patient with acute cholecystitis?
-WCC
-USS
-LFTs (sometimes mildly deranged)
How would you manage a patient with acute cholecystitis?
-NBM + analgesia, fluids, abx (cefuroxime 1.5g/8h)
-Laparoscopic cholecystectomy (open surgery if perforation)
What causes biliary colic and how does it present?
-Gallstones become symptomatic if there is cystic duct obstruction or if they have been passed into the common bile duct
SIGNS+SYMPTOMS
-RUQ and back pain
-Jaundice sometimes present
-Colicky abdo pain, worse after fatty foods
What investigations would you order for someone with ?biliary colic?
-Urinalysis
-USS
-CXR
-ECG
What is Charcot’s triad and what disease does it help the diagnosis of?
-Diagnoses cholangitis (bile duct infection)
-RUQ pain
-Jaundice
-Rigors/fever
How do you treat cholangitis?
-Cefuroxime + metronidazole
-Correct any coagulopathy and fluid depletion
-ERCP
What are the different causes of dynamic and adynamic bowel obstruction?
-Dynamic = mechanical obstruction eg malignancy
-Adynamic =
–Paralytic ileus (electrolyte imbalance, spinal injury)
–Pseudo obstruction
What are the different types and causes of SBO?
EXTRINSIC
-Adhesions (likely in post-op patients)
-Hernia
-Neoplasm
-Volvulus (risk of ischaemia and perforation)
-Inflammatory mass
INTRAMURAL
-Crohn’s
-Intussusception (part of bowel slides into adjacent part of bowel)
-Radiotherapy side effect
-TB
-Bowel malignancy
INTRALUMINAL
-Gallstones (after perforation of GB wall, passes into lumen via cholecystodudenal fistula)
-Foreign body
-Faecolith
What are the different types and causes of LBO?
EXTRINSIC
-Volvulus
-Hernia
INTRAMURAL
-Carcinoma
-Diverticular / anastomotic / ischaemic strictures
INTRALUMINAL
-Foreign body
-Faecolith
What are the different symptoms in SBO and LBO?
-Faecal vomiting - SBO = early, LBO = late
-Colicky abdo pain - SBO = severe, LBO = mild
-Constipation - SBO = late, LBO = early
-Distension - SBO = central, LBO = late
What signs does bowel obstruction have?
-Abdo distension
-Guarding, rebound tenderness
-Hyperresonant abdomen on percussion
-Increased bowel sounds (may be absent if paralytic ileus)
What features would a bowel obstruction have on AXR?
-Haustra
–Distinct transverse bands in large bowel
–Do not cross full diameter of bowel
-Valvulae Conniventes
–Transverse bands in small bowel
–Cross full diameter
–Appear more spaced out if dilated
-369 rule
–>3cm is abnormal in dilated SB
–>6cm is abnormal in dilated LB
–>9cm is abnormal in dilated caecum
How would you manage a patient with bowel obstruction?
-IV fluids, abx, BGT
-Catheter
-Barium swallow to determine level of obstruction
-?surgery depending on cause
Where are ectopic pregnancies normally situated?
-Gestational sac is implanted outside of the uterus - 97% in Fallopian tube (1% intra-abdominal)
