Abdomen Flashcards
GI history
- Opening consultation wash hands, PPE, Intro, confirm patient, explain, consent
- PC – Do not interrupt
- HPC – SOCRATES (Site, onset, character radiation, associated symptoms, time course, exacerbating or relieving factors, severity).
- ICE
- Summarise, signpost
- Systemic enquiry: Fevers, weight change, fatigue, anorexia, weight loss, nausea, fever, pruritis confusion, bowel changes…
- Travel history (if suggestive of infective aetiology) – area, diet, insect bites, contaminated water
- PMH: Medical conditions (eg endoscopy, iron def anaemia, constipation, crohns, coeliac, gallstones…), surgery, procedures, allergies and reaction
- Drug History – prescribed or OTC, dose, type, frequency, route, side effects, contraception and pregnancy. Meds with GI S/E = opiates penicillin, ondansetron.
- FH – of GI disease (liver/bowel problems), if close relatives deceased ask age and how.
- SH – Accomm, living, carer, support, smoking, alcohol, recreational drug use, diet, exercise sexual history.
- Closing – summarise, questions/concerns, thank, dispose PPE, wash hands.
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Upper GI symptoms
- Jaundice – hepatitis, liver cirrhosis, biliary obstruction
- Aphthous ulceration – ulcers inside mouth, can be associated with iron, B12+folate def, Crohn’s
- Vomiting – Infections, GORD, pyloric stenosis, vowel obstruction, gastroparesis pharyngeal pouch and oesophageal structure
- Haematemesis – vomiting blood Mallor Weiss tear, oesopehageal variceal rupture) or coffee ground in appearance (eg, gastric or duodenal ulcer)
- GORD – epigastric discomfort burning in nature
- Dysphagia – Difficulty swallowing which may affect solid food, liquids or both depending on its severity
- Odynophagia – pain during swallowing which may be associated with oesophageal obstruction (eg, stricture) or infection.
Lower GI symptoms
- Abdo paain – localised or generalised
- Abdominal distention – ascites, constipation, bowel obstruction, organomegaly and malignancy
- Constipation – dehydration, reduced bowel motility + medications
- diarrhoea – causes include infection (CDiff), IBS, IBD, Meds (laxatives), constipation (overflow) and malignancy
- Steatorrhoea – Presence of excess fat in faeces so appear pale and difficult to flush. Pancreatitis, pancreatic cancer, biliary obstruction, coeliac disease and medications (Orlistat)
- Malaena – dark, tar luje sticky stools containing digested blood secondary to upper GI bleeding (peptic ulcer)
- Haematochezia – Fresh red blood passed per rectum which may be caused by haemorrhoids, anal fissures and lower GI malignancy
Location of pain in relation to pathology
- R Iliac fossa = appendicitis, crohn’s disease, ectopic pregnancy
- L iliac fossa = diverticulitis, ectopic pregnancy
- Epigastric pain = oesophagitis and gastritis
- R Upper quadrant = cholecystitis and hepatitis
- Flank pain = renal colic and pyelonephritis
- Suprapubic pain = UTI
GI risk factors
pre-existing medical conditons (GORD, Crohn’s), FH GI disease, alcohol, smoking, recreational drugs, diet.
What is an acute abdomen?
Sudden onset of severe abdominal pain over short period. Initial assessment should attempt to determine if the patient has an acute surgical problem that required immediate and prompt surgical intervention or urgent medical therapy.
When is Urgent vs less urgent intervention needed for acute abdomen
- Bleeding (AAA, ruptured ectopic pregnancy, gastric ulcer, trauma)
- Perforated viscus -> peritonitis. Rigid abdomen, invol guarding, reduced/absent bowel sounds, tachycardia.
- Ischaemic bowel – severe pain out of proportion to clinical signs is this until proven otherwise. Also raised lactate and physiologically compromised. Diffuse and constant pain
Less Acute:
- Colic: Abdominal pain that crescendos to be very severe then goes away. Biliary/ureteric colic and bowel obstruction
- Peritonism – locatsed inflamm
Invetsiagtions for Acute abdomen
Lab tests:
- Urine dipstick = signs infection or haematuria and prgenancy test
- ARterial blood gas = bleeding or septic patients, lactate for signs tissue hypoperfusion and rapid Hb level
- Routine bloods = FBCS, U&Es, LFTs, CRP, amylase and G&S surgery likely
- Bloo cultures
Imaging:
- Erect CXR (for free abdominal air or lower lobe lung pathology)
- US = kidneys, ureters, bladder, biliary tree, liver
- CT imaging = of abdomen
- If emergency then ECG to exclude cardio pathology as referred pain
Core management of an acute abdomen
- IV access
- Nil by mouth status
- Analgesia
- Antiemetics
- Intiial imaging
- VTE prophylacis
- Urine dip
- Bloods
- If unwell consider urinary catheter and or nasogastric tube if needed and start IV fluids and monitor flud balance.
AReas of the abdomen pain and pathology

Patho of Acute appendicitis
Typically due to direct luminal obstruction, usually secondary to faecolith or lymphoid hyperplasia, impacted stool or rarely an appendiceal or caecal tumor. When obstructed, commensal bacteria in the appendix can multiply resulting in acute inflammation. Reduced venous drainage and localized inflammation can result in increased pressure within the appendix and can result in ischemia.
If untreated, ischameia within appendiceal wall can lead to necrosis and appendix can perforate.
Risk factors of acute appendicitis
FH, Ethnicity (Caucasians more common but if minorities get it then more risk perforation), environmental (summer).
Investigations for appendicitis
Investigations: clinical diagnosis but ultrasound or CT often requested to help.
Risk stratification scores: Men (appendicitis inflammatory response score), women (adult appendicitis score), children (shera score).
Describe and elicit from a given patient the classical presentation of acute appendicitis
- Abdominal pain: Initially peri-umbilical, classically dull and poorly localised (from visceral peritoneum inflammation) but later migrates to right iliac fossa to be localised and sharp (from parietal peritoneum inflammation).
- Vomiting (typically after pain), anorexia, nausea, diarrhoea or constipation
- Rebound tenderness and percussion pain over McBurney’s point (2/3 away between umbilical and ASIS) and guarding (especially if perforated appendix)
- If severe – sepsis, tachycardic, hypotensive
- Appendiceal abscess may also present with RIF mass
- Rovsing’s sign: RIF fossa pain on palpation of LIF.
- Psoas sign: RIF pain with extension of the right hip. Specifically suggests inflamed appendix abutting psoas major muscle in retrocaecal position.
Typical clinical presentation acuet appendicits in children
Mostly present atypical like diarrhoea, urinary symptoms or even left sided pain. Therefore, exam cardiorespiratory and urinary as well as GI. In all boys do genital exam to exclude testicular torsion or epididymitis.
In a child under 6 who has had symptoms for over 48hours is significantly more likely to be suffering from perforated appendix so period of active obs is needed.
Main differential diagnosis of appendicitis
- Gynaecological – pvarian yst rupture, ectopic pregnancy, pelvic inflammatory disease
- Renal – ureteric stones, UTI, pyelonephritis
- GI – IBD, Meckel’s diverticulum, diverticular disease
- Urological – testicular torsion, epididymo-orchitis
right iliac fossa pain differentials
GI causes:
- Appendicitis
- Crohn’s disease
- Mesenteric adenitis – by viral or bacteria infection. May have high temp and other evidence of viral infection. If laparotomy then enlarged mesenteric lymph nodes
- Diverticulitis – Diverticula and inflammation and/or abscesses may occur in ascending colon and perforation
- Meckel’s diverticulitis – Meckels diverticulum is congenital in 2%
- Perforated peptic ulcer – usually upper quadrant pain but may be lower.
- Right inguinal hernia/femoral hernia – may also be tenderness and irreducible swelling over hernial orifice and symptoms of bowel obstruction.
- Malignancy – carcinoma of caecum or AC can present with bowel perforation
Gynaecological causes:
- Pelvic inflammatory disease/salpingitis/ pelvic abscess with typically vaginal discharge
- Ectopic pregnancy in right fallopian tube
- Ovarian torsion – usually when ovary enlarged by cucts. Adnexal tenderness
- Threatened or complete miscarriage – esp if history bleeding
- Mittelschmerz (ovulation pain), Fibroid degeneration, Pelvic tumour
Urological: Ureteric colic (shooting, intermittent pain), UTI, testicular torsion or epididymo-orchitits
Other: Infections (TB, typhoid, Yersinia spp, herpes zoster), AAA, situs inversus
Chronic – IBS, Carcinoma, Crohns, pelvic tumours, endometriosis, right hip pathology, familial Mediterranean fever.
Treatment options for acute appendicits
Current definitive is laparoscopic appendicectomy. Some debate about conservative antibiotic therapy in uncomplicated appendicitis. If cases of appendiceal mass, antibiotic therapy is favoured, with interval appendectomy then 6-8weeks later.
Surgical Intervention: Gold standard for laparoscopic appendectomy as low morbidity and in females better visualisation of uterus and ovaries. Appendix should be routinely sent to histopathology to look for malignancy and entirety of abdomen inspected for other pathology like Meckel’s diverticulum.
Explain possible complications of acute appendicits
Mortality associated with appendicitis in developed health systems is low (0.1-0.24%).
- Perforation – and can cause peritoneal contamination (children may have delayed presentation)
- Surgical site infection – depends on simple or complicated appendicitis
- Appendix mass- where omentum and small bowel adhere to appendix
- Pelvic abscess – presents as fever with palpable RIF mass, can be confirmed CT scan for confirmation, management usually with antibiotics and percutaneous drainage of abscess,
Acute pancreatitis - what is it
- inflammation of the pancreas. Can be distinguished form chronic by it limited damage to the secretory function of the gland with no structural damage developing. Repeated acute episodes can eventually lead to chronic.
Patho of acute pancreatitis
- All causes trigger premature and exaggerated activation of digestive enzymes within pancreas and hence pancreatic inflammatory response which leads to increased vascular permeability and fluid shifts.
- Enzymes are released from the pancreas into systemic ciruclation, causing autodigestion of fats an blood vessels
- Fat necrosis can cause the release of FFA which react with serum calcium to form chalky deposits in fatty tissue resulting in hypocalcaemia
- Severe or end stage pancreatitis will eventually result in partial or complete necrosis of pancreas
DDx of pancreatitis
(Pain that radiates to the back)
- AAA
- Renal calculi
- Chronic pancreatitis
- Aortic dissection
- Peptic ulcer disease
Investigations for pancreatitis
- Lab tests: serum amylase (3x normal), LFTs, serum lipase
- IMaging: abdominal US if cause unknown (can show sentinel loop sign), contrast enhanced CT
Explain the causes of pancreatitis
Majority can occur secondary to gallstone disease or excess alcohol consumtpion but causes are wide ranging ‘GET SMASHED’
- Gallstones
- Ethanol (alcohol)
- Trauma
- Steroids
- Mumps
- Autoimmune disease like SLE
- Scorpion venom
- Hypercalcaemi
- Endoscopic retrograde cholangio-pancreatography (ERCP)
- Drugs like azathioprine, NSAIDs or diuretics


























