Abdo pain Flashcards
Features of GORD
burning central chest pain relieved by antacids and worse on lying down or after a meal.
Dry cough
Increased salivation
GORD Rx
Antacids, PPI, H2 antagonist
Criteria for endoscopy in GORD
Dysphagia
> /=55 and alarm sx (dysphagia, wt loss, haematemesis)
> /=55 and resistant to Rx.
Pancreatitis features
Epigastric pain radiating to back, relieved by sitting forwards
Vomiting
Jaundice
Shock
Ileus
Rigid abdomen ± local or generalised tenderness
Tachycardic
Fever
Cullen’s sign (peri umbilical bruising) or grey turner’s (flank bruising, develops after a few days)
Pancreatitis causes
Gallstones (35%)
Ethanol (35%)
Trauma (1.5%)
Steroids
Mumps
Autoimmune
Scorpion
Hyperlipidaemia/hypothermia/hypercalcaemia
ERCP (5%), emboli
Drugs
Pregnancy
Idiopathic
Cancer (neoplasia)
When will amylase be raised in pancreatitis? What is defined as raised?
First 24-48hrs
> 1000u/ml or 3x normal
What else can amylase be raised in?
Renal failure
Cholecystitis
Mesenteric infarct
GI perforation
What is a more specific marker than amylase for pancreatitis?
Lipase is more sensitive and specific
How can CRP predict severe pancreatitis?
> 150 36hrs post admission
Investigations for pancreatitis
LFTs, FBC, U&Es, Amylase, glucose, ca2+, coagulation screen
CRP
ABG
AXR
Erect CXR
CT
US if gallstones and raised AST
ERCP if LFTs worsen
What might an AXR show in pancreatitis?
Decreased psoas shadow (fluid)
Sentinel loop of proximal jejunum due to ileus
Why do you get an erect CXR in pancreatitis?
Excludes e.g. perf
Why do you CT in pancreatitis?
Severity and complications e.g. necrotising pancreatitis and oedema
What score can you use for pancreatitis severity?
Modified Glasgow Score (3 or more on admission and on subsequent tests within 48hrs = ICU/HDU)
Management pancreatitis?
O2 if necessary
Insert NG tube (or can have oral feeding if no nausea/vom/abdo pain)
IV fluids
Catheter to monitor fluid status
Analgesia ± anti-emitic
ERCP and remove gallstones if necessary
?ABx if associated infection
May need ICU management if other organs affected
How do you monitor pancreatitis?
Repeat CT
Features of peptic ulcer
Epigastric pain related to hunger/food/time of day
Fullness after meals
Heartburn
Tender epigastrium
(±dizziness, fainting if bleeding)
Red flags with peptic ulcer
ALARMS
Anaemia
wt Loss
Anorexia
Recent onset or progressive sx
Melaena/haematemesis
Swallowing difficulty
What are the two scoring systems used for GI bleeds?
Glasgow Blatchford score and Rockall score
What is the Blatchford score for in GI bleed
To calculate how severe the bleed is and so how quickly they’ll need endoscopy
What is the Rockall score for in GI bleed?
Future risk of re-bleed/mortality (it has a pre and post endoscopy section)
Other causes of GI bleeding?
Mallory-weiss tear
Oesoph varices
Gastritis
Oesophagitis
Duodenitis
Malignancy
What is it important to establish in acute GI bleed?
Are they shocked?
What should your ABCDE management be in GI bleed
Oxygen as they are acutely unwell
2lg bore cannulas in MCF- take bloods (FBC, U&Es, LFT, VBG, clotting, crossmatch 4-6u)
Fluid bolus if shocked, or O neg if necessary if fluid isn’t getting it under control. If the fluid works a bit then you have time to get a full cross match.
ECG
ABG
What useful things do you get on a VBG?
pH and lactate (sepsis)
Hb (quicker than FBC)
glucose (good in DKA)
Potassium (hyperkalaemia)
What is the significance of rebleeding GI bleed?
40% mortality
Food ____ gastric ulcer, ____ duodenal ulcer
Worsens gastric
Relieves duodenal
When would you transfuse in GI bleed?
Hb <70
What are the five gall bladder stone issues?
- cholelithiasis
- biliary colic
- cholecystitis
- choledocholithiasis
- cholangitis
What is cholelithiasis?
Harmless stones in GB
what is biliary colic?
after a fatty meal, pain <6h and apyrexial
What is cholecystitis?
Inflammed GB- biliary colic that won’t go away- RUQ pain >6h + pyrexia
What is choledocholithiasis?
gallstones in CBD. LFT derangement, pain, apyrexial
What can choledocholithiasis lead to?
Pancreatitis or cholangitis
What is cholangitis?
infected or inflamed biliary tree secondary to impacted stone or stricture.
Charcot’s triad - RUQ, fever, jaundice
May become Reynold’s Pentad (+ hypoperfusion and decreased consciousness) = shock
Management biliary colic
Analgesia
Rehydrate
Elective lap-chole. (potential complication of waiting could be pancreatitis)
Presentation of acute cholecystitis
Epigastric/RUQ pain radiating to right shoulder
Vomiting
Fever
May have RUQ mass
Murphy’s sign (inhale when palpate the GB having breathed out)
Investigations for acute cholecystitis?
FBC, U+E, glucose, amylase, LFT
CXR
ECG (pain could be atypical MI presentation)
USS (shows thickened GB containing stones, fluid, dilated CBD)
Management acute cholecystitis or cholangitis
Analgesia
NBM
IV fluids
Antibiotics (e.g. coamox)
Refer to surgeons for lap-chole
Aneurysm is dilatation of ?%
> 50% original
What is a pseudoaneurysm
Blood in adventitia, communication with lumen. Often following trauma
What tissue disorders can cause AAA
Marfans, Ehlers danlos
Is there screening for AAA?
Yes men age 65 USS
Risk of rupture <5.5cm
<1%/yr
Risk of rupture >6cm?
25%/yr
When is rupture more likely
Smoker
Woman
FHx
HTN
When do you get elective surgery for AAA?
> 5.5cm
Expanding >1cm/year
Symptoms
Investigations to do with AAA
ECG
FBC, cross match 10-40u
2LB cannulae
Management AAA
Straight to theatre. Inform vascular surgeons, anaesthetist and theatre
Give blood if shocked but keep systolic BP <100
What is Rovsing’s sign
Appendicitis- pain in RIF when LIF is palpated
What is psoas sign?
Pain on extending hip in retrocaecal appendix
What is cope sign?
Pain on flexion and internal rotation of hip of appendix near obturator internus
What would be raised in blood tests appendicitis
Neutrophils and CRP
If unsure of appendicitis diagnosis what imaging has high diagnostic accuracy?
CT
What is a closed loop bowel obstruction?
2 points e.g. sigmoid volvulus, risk perf
Peritonism, sharp, constant localised pain with fever and raised WCC suggests what type of bowel obs?
Strangulated
Most common cause of small bowel obstruction?
Adhesions 75%
Bowel obs investigations
FBC, U+E, amylase
AXR
erect CXR
Could do CT for cause
Can you colonoscopy in bowel obs?
NO might perf
Management bowel obs
Drip and suck
Analgesia
Definitive depends but could be conservative, surgery, endoscopic decompression (closed lool) or stent (malignancy)
Where are 95% diverticuli?
Sigmoid colon
Should you colonoscopy in diverticulitis?
No may perf
Investigations diverticulitis
CT diagnose
AXR perf
FBC (WCC raised) CRP
Rx diverticulitis
If mild then home- could do no solids ± Abx
Could admit for:
Analgesia
NBM
Fluids
IV Abx
How is the pain in renal colic?
Severe unilat abdo pain in loin radiating to testicle/labia/tip of penis. Constant underlying pain with excruciating spasms.
±N+V, haematuria
Investigations in renal colic
Urine dip and MSU (haematuria usually. See if concurrent infection)
U+E, Creatanine, glucose, calcium, phosphate, urate
KUB x-ray or CT
Management renal colic
IV/IM analgesic (probably opioid) and antiemitic (e.g. IM metoclopramide)
Admit if shock/persisting pain/pregnant/risk AKI (CKD)/dehydration due to vomiting/unresponsive to Rx/fever
If no admission then ongoing analgesia and antiemitics, normal fluid intake, sieve urine so can send stone to lab, safety net to seek medical attention if fever, rigors, pain increasing. Refer to urology within 7 days onset.
1st line- let it pass itself (sieve urine)
2nd- calcium channel blocker (nifedipine)
3rd- alpha blocker (e.g. tamsulosin)
4th- lithotripsy/surgery
What is the usual pathogen of UTI
Anaerobes
Gram -ve bacteria
Often E coli
Staph saprophyticus 5-10%
Investigations UTI
Dip
MSU in pregnant, male, child, unresponsive to Rx
Bloods if systemically unwell- U+E, FBC, CRP, blood culture
Consider USS
Management UTI
Non pregnant women with 3+ signs cystitis and no vaginal discharge- trimethoprim or nitro for 3 days
Pregnant- seek expert help, antibiotics and confirm eradication
Men- trimethoprim or nitro for 7days
Catheterised- change the catheter and refer to local guidelines
All catheterised urine samples are bacteriuric true or false?
True
When do you MSU a catheterised ?UTI
If symptomatic
