Abdomen: Common Presentations, Acute Conditions Flashcards
What are the key UGI symptoms you want to ask about
-what could they be indicative of?
Jaundice - hepatitis, cirrhosis, biliary obstruction (GS, pancreatic cancer?)
Mouth ulcers - B12, Fe, folate def, Crohns?
Vomiting - infection, GORD, bowel obstruction (bilious), cancer?
Hematemesis - bright red (Mallory Weiss tear, esophageal variceal rupture) coffee grounds (gastric/duodenal ulcer?)
GERD - worsened by lying flat, better with antacids
Dysphagia - esophageal cancer
Odynophagia - esophageal obstruction?
What are the key LGI symptoms you want to ask about
-what could they be indicative of
Abdo pain (local/general) -ECTOPICS, AAA!
Abdo distension - ascities, constipation, obstruction, cancer?
Constipation - dehydration, decreased motility, medications?
Diarrhoea - infection (CDiff), IBD, IBD, cancer
Steatorrhoea - pancreatitis, pancreatic cancer, biliary obstruction, celiac, orlistat?
Melena - UGI blood (peptic ulcer?)
Hematochezia - hemorrhoids, anal fissure, lower malignancy
What systemic symptoms would you like to ask about
Anorexia Weight loss - malabsorption/malignancy Nausea Fatigue Fever - infection? => appendicitis, diverticulitis, meningitis, pancreatitis Itch - cholestasis? Confusion - hepatic enceph?
Possible causes for abdo pain in specific regions
RIF - appendicitis, Crohns, ectopic?
LIF - diverticulitis, ectopic?
Epigastric - esophagitis, gastritis?
RUQ - cholecystitis, hepatitis?
Flank - renal colic, pyelonephritis
Suprapubic - UTI
GI risk factors?
- past medical history
- FHx
- Social
Preexisting GI disease - GORD, Crohns
Past abdominal surgery - adhesions
FHx - FAP? GI cancers
Social - alcohol, smoking, recreational drugs, diet?
Travel history?
-when would you do this?
If likely to be infective?
Where did they go, what did they do Diet? Insect bites? Contaminated water? Any vaccinations before travel? - malaria prophylaxis
Past medical history
Past procedures, surgeries - bowel resection, endoscopy, colonoscopy?
Laxatives, loperamide?
Antacids
PPIs, H2 rec ant?
Immunosuppresants?
Any SE of meds?
- aspirin, NSAIDS - GI bleeds
- opiates - constipation, nausea
- penicilin - hepatitis
- ondasetron - constipation
FHx of GI disease
GI cancers - FAP, Lynch, KRAS, BRCA?
IBD
Age of diagnosis and passing if relevant
SHx
Pack years - GI cancer, Crohns
Alcohol - GI malignancy, alcoholic hepatitis, pancreatitis
IVDU - Hep B, C
Diet - low fibre, fluid => constipation
-foods that trigger pain (fat and biliary colic, gluten => celiac)
Key questions to ask for C/D/V
Frequency, volume, consistency
Colour and contents
- blood in vomit => fresh or old?
- blood in stool => fresh or old?
- mucus in stool => could be colon issue
- billous vomit => BO?
Anorexia, weight loss => malignancy?
-colorectal, stomach, esophageal?
Anemia
-Fe, B12, folate diet? => absorption issue/GI bleeding?
GI systems review
GI systems review
-work down body
Difficulty or pain swallowing Reflux Indigestion N+V Abdominal pain Changes in bowel habits => constipation, diarrhoea Blood in stool, vomit
Key questions to ask for dysphagia
Difficulty swallowing solids, liquids or both
- Solids only => mechanical obstruction (cancer?)
- Solids and liquids => neuromuscular issue (scleroderma, achalasia?)
Constant/intermittent/progressive
-further help differentiate between physical obstruction or neuromuscular issues
Pain on swallowing => weight loss?
Neurological systems review - stroke, PD, MG, ALS, dementia, bulbar localisation
Work down body
-decision making, memory, seizures and falls, behaviour, sight, hearing, balance and dizziness, taste, weakness, tingling, bowels and bladder
GI review
Key questions to ask for indigestion/heartburn
Explode as pain
GI review
Screen for MI
Red flags for cancer - anemia, weight loss, anorexia, recent onset progression, melena, dysphagia
Systems review that may aid in diagnosis
General
-fever, sweats
Urology
-FUNDWISE B
Gynae
- pregnant?
- intermenstrual, post coital, post menopausal bleeds
- discharge
- painful periods, dyspareunia, pelvic pain
Possible non abdo differentials for abdo pain
MI
- cardiac risk factors
- ACS-like
Pnemonia
-resp risk factors
DKA
-ketotic breath, blurry vision, N+V, reduced consciousness
Appendicitis vs diverticulitis
- risk factors
- core features
- investigations
- management
Appendicitis risk factors
-young
Core features Intermittent E => constant severe RIF pain Anorexia, nausea, C+D Fever Rovsings, Psoas
Peritonitis and rupture - widespread guarding => CXR pneumoperitoneum
Investigations - clinical diagnosis
- high WCC, CRP
- abdo US to rule out other pelvic causes
Management
Supportive - analgesia, fluids, ABx
Definitive - appendectomy
Diverticulitis risk factors
-older, low fibre
Core features
LIF pain, C+D
Fever
Investigations - abdo CT
-high WCC, CRP
Management
ABx, analgesia, low fibre
Prevention - high fibre, hydration, physical activity
Pancreatitis
- risk factors
- core features
- investigations
- management
Risk factors
- gallstones
- alcohol
Core features Constant E abdo pain, N+V+D Fever Onset within 24-48hrs Cullens, Turners
Investigations - high amylase, lipase
-LFT, US - GS
Management
Supportive - fluids, analgesia, NBM until nausea+pain improve
Definitive
-GS - cholecystectomy
-alcohol - reduce intake
Complications
-drainage of abscesses, debridement of necrotic tissue + IV ABx
Cholelithiasis, cholecystitis, choledocholithiasis, cholangitis
- risk factors
- core features
- investigations
- management
Gallstone risk factors
-fat, 40, female, fertile
Cholelithiasis - intermittent RH pain with fatty foods
Cholecystitis - constant RH pain, fever
Choledocholithiasis - obstructive jaundice
Cholangitis - fever, obstructive jaundice, RUQ pain, confusion, shocked
Investigations
- abdo US - GS
- stool, urine sample - obstructive jaundice
- LFT - cholestatic, hepatic if bile backing up into liver
- High WCC if inflammed
Management
Supportive - fluids, analgesia, ABx
No inflammation - elective cholecystectomy
Inflammed - cholecystectomy
CBD involvement - ERCP GS removal + cholecystectomy
Peptic ulcers
- risk factors
- core features
- investigations
- management
Risk factors
- NSAID use
- smoking, alcohol, stress
- FHx
Core features
Indigestion, N+V
Worse with spicy
Better with milk, alkalis
Investigations
HPylori test - urea breath/stool test
ODG + biopsy - confirm ulcer
Management
Address cause
-HPylori eradication - amox+claryth+metro, recheck in 4-6wks
-stop NSAIDs if possible, reduce alcohol, stress, smoking
Supportive - PPIs, can add alginates/antacids
Bowel obstruction
- risk factors
- core features
- investigations
- management
Risk factors
- past abdo surgery
- hernias
- malignancy, Crohns, diverticulosis
Core features
Abdo pain, distension, no flatus/feces, N+V
Tinkling bowel sound
Investigations - AXR, CT (dilated bowel loops)
-ABG lactate - any ischemia
Management
Conservative - drip and suck (IV fluids, NG suction, urinary output monitoring
Surgical - laparotomy if cause unlikely to resolve
Renal/ureteric colic
- risk factors
- core features
- investigations
- management
Risk factors
- dehydration
- FHx
Core features
Loin to groin intermittent pain
Haematuria, dysuria, urinary frequency
Investigations - Xray, CT KUB to confirm stone
Management Supportive - simple analgesia, fluids Definitive -watchful waiting if likely to pass -surgery - shockwave/ureteroscopy
UTI
- risk factors
- core features
- investigations
- management
Risk factors
- past UTI
- sexually active
- low estrogen
- DM, obesity, IC
- stones, surgery, catheters, pregnant
Core features
FUND
Investigations - clinical diagnosis
-urinedip - leukocytes, RBC, nitrites
Management
Definitive if symptomatic - nitrofurantoin/trimethoprim
-treat if pregnant or catheterised
Supportive - remove catheters, fluids, perineal hygiene
Endometriosis
- risk factors
- core features
- investigations
- management
Risk factors
-FHx
Core features
Pain on urination, defecation, sex, menstruation
Heavy periods
Difficulty getting pregnant
Investigations
-pelvic US, laparoscopy
Management
Supportive - analgesia, contraception
Surgery - removal of endometriosis tissue, hysterectomy
GI investigations you may consider
-which ones must you never forget!
Bedside Abdo exam Groin, hernia exam DRE NEVER FORGET PREGNANCY TEST! Urinedip, MSC, stool sample
Bloods FBC - inflammation, anemia, CRP, ESR LFT - cholestatic or hepatic issue U&E - kidney function BM - diabetes Amylase, lipase - pancreas function INR, G&S - if surgery needed Blood culture - infection
Imaging CXR - pneumoperitoneum AXR - Abdo US Pelvic US CT
CDiff infection
- risk factors
- core features
- investigations
- management
Risk factors
- older age, IC, exposure
- recent surgery
- ABx treatment - clindamycin, coamox, cephalosporins, ciproflox
Core features
Abdo pain, diarrhoea
Investigations - CDiff toxins in stool
- high WCC
- U&E - severity of fluid loss
Management
Supportive - fluids, stop ABx, analgesia
-stay at home until diarhhoea free for 48hrs
Definitive - vancomycin 10 days
Complications
- toxic megacolon - constipation, distenstion
- perforation, peritonitis
Pyelonephritis
- risk factors
- core features
- investigations
- management
Risk factors
- sexually active
- stones, stents, catheters, pregnant
- IC, DM, obese
Core features
Fever/rigors + flank pain + N+V
UTI presentation
Watch out for sepsis
Investigations - urinedip and MSU
Management => A&E
Broad spec ABx => narrow when MSU results out
Coeliac disease
- risk factors
- core features
- investigations
- management
Risk factors
-FHx (T1DM, coeliac, AI thyroid)
Core features
GI - mouth ulcers, abdo pain, diarrhoea, steatorrhea
Skin - dermatitis herpetiformis
Systemic - Weight loss, fatigue
Investigations
Initial - IgA transglutaminase, total IgA
Definitive - intestinal biopsy for villous atrophy, crypt hyperplasia,
Management
Definitive - gluten free diet (avoid wheat, barley, rye)
Supportive - annual review (height, weight, diet, nutritional deficiency check)
Resources - Coeliac UK
Crohns vs ulcerative colitis
- risk factors
- core features
- investigations
- management
Risk factors for IBD
- FHx
- smoking (protective in UC, damaging in C)
- appendectomy protective in both
Core features of Crohns
GI - mouth ulcers, abdo pain, diarhoea
Systemic - weight loss, fatigue, joint swelling, eye pain
Core features of UC
GI - abdo pain, bloody diarrhoea, urgency
Systemic - weight loss, fatigue, joint swelling, eye pain
Investigations
Rule out or in
-FBC - anemia from malabsorption/blood loss
-CRP, ESR - active inflammation
-U&E, LFT - dehydration, electrolyte disturbances, disease activity
-ferritin, B12, folate, VitD - nutritional deficiencies from malabsorption
-coeliac IgA tga - rule out celiac
-stool microscopy, culture - rule out CDiff, GI infection
-fecal calprotectin - GI inflammatory marker
Definitive - colonoscopy + biopsy
Management
Acute - CS
Maintenance
-Crohns - thiopurine
-UC - 5ASA/thiopurine
-can escalate to biologics (infliximab - TNFa)
Support - NHS website, Crohns and Colitis
Ruptured AAA
- presentation
- specific investigations
- specific management
Severe generalised pain
- back pain
- low GCS, collapse
- widespread guarding tenderness
Urgent abdo US, CT angio
Immediate management
-2 wide bore IV cannulas - fluid resus, permission hypotension
-ACTIVATE MASSIVE HEMORRHAGE PROTOCOL
Definitive management
-urgent surgical repair (open/endovascular if stable)
Peritonitis, perforation
- possible causes
- presentation
- specific investigations
- specific management
Causes - perforated from
- peptic ulcer
- appendicitis, diverticulitis
- toxic megacolon from CDiff, IBDs
- ectopics
Severe generalised abdo pain
-widespread guarding, tenderness
Investigations
- erect CXR - pneumoperitoneum
- CT abdo, pelvis - locate perforation
Immediate management
-2 wide bore IV cannulas - fluid resus
Definitive management
-urgent surgical repair
General hospital management
- immediate
- surgery
IV fluids
Analgesia (WHO ladder)
Antiemetics
VTE prophylaxis - antiembolism socks, dalterparin unless surgery in U2hrs
Surgery needed
- NBM
- INR, G&S
- stop AC/AP
Upper GI bleed management
- possible causes
- investigations
- initial management
- specific treatment of acute bleeds
- prevention of future bleeds
Variceal - from liver disease
Non variceal - peptic ulcers, cancer, MW tear, esophagitis
Examination for common causes
Variceal - signs of liver disease
Non variceal - signs of cancer
Bloods
- FBC - acute/chronic blood loss
- CRP - inflammation
- LFT, coagulation screen - liver disease
- U&E - dehydration
- INR, G&S/M
Initial management - A-E
- 2 wide bore cannulas, urinary catheter - IV fluid resus to maintain BP, monitor UO
- if needed, trigger massive hemorrhage protocol - transfuse blood, FFP, platelets
Clotting abnormality management Stop AC/AP Warfarin - give PTC, VitK DOAC - give idarucizumab for dabigatran, andexanet alfa for -bans Plt U50 - platelet transfusion High INR - VitK or FFP Fibrinogen U1 - cryoprecip
Specific treatment of acute variceal bleeds
-terlipressin, IV ABx, endo band ligation
Specific treatment of acute non variceal bleeds
-IV PPI, endo laser/clips
Varices
-propanolol, banding, TIPPS
Non variceal - treat underlying cause
Peptic ulcer - PPI + HPylori investigations/avoid precipitants
