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G.I. > Abdomen: Masses, Pain & Acute abdomen > Flashcards

Abdomen: Masses, Pain & Acute abdomen Flashcards

1
Q

Masses in the abdomen can be caused by… (6Fs)

A 
> Fat
> Faeces
> Flatus
> Foetus
> Fluid
> Fatal growth (Fucking big tumour)
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2
Q

History of PC

A

Does it change when lying down?

Is it tender?

Duration?

Blood loss, gynae symptoms, vomiting, urinary symptoms. bowel habit, weight loss, anorexia.

Where are they in their menstrual cycle?

Any previous operations?

Jaundice

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3
Q

PMHx/ Comorbidities/ Social hx/ FHx

A

Diabetes
Heart and lung disease

Medication
Allergies

not fit = no operation

Smoking, alcohol

FHx of cancer

PREGNANCY!!!

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4
Q

What is a key question to ask (if female)?

A

Are the pregnant???

If they don’t know –> pregnancy test

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5
Q

Abdominal examination - Inspection

A 
Contour
SHape
Pulsations
Prominent veins
Scars
Rashes
Colour
other lesions?
Breathing

Ask to cough and stand up - hernia.

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6
Q

Abdo exam - Palpation

A 
Systematic
Tender area last
light then deep palpation
liver, spleen, kidneys
Hernial orifices 
PR exam
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7
Q

Mass on examination & percussion

A

Is it:

Tender
Fixed --- bad
Hard
Smooth edge/craggy
Moves on respiration
Pulsatile

Percussion//

for organs
fluid or solid?
Ascites - able to shift fluid around?

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8
Q

Auscultation

A

Bowel sounds

Bruit

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9
Q

Investigations

A

> CT**

    • delineates mass and anatomy
    • biopsy

> Erect CXR

    • air under diaphragm
    • lung metastases

> Supine Abdominal Xray

    • dilated small bowel loops
    • dilated large bowel loops
  • calcification of aorta

> Ultrasound (transabdo/transvaginal)
– over major organs

> Sigmoidoscopy/colonoscopy/ upper GI endoscopy
ERCP
Laparoscopy

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10
Q

What does air under the diaphragm indicate?

A

Something has burst/perforated

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11
Q

What is the gold standard investigation for an abdominal mass patient

A

CT scan

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12
Q

What should go at the top of differential diagnoses?

A

Life threatening things - what could cause the patient to die right in front of me?

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13
Q

What does sudden onset epigastric pain radiating to the back indicate?

A

AAA rupture

retroperitoneal

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14
Q

Abdominal aortic aneurysm - Ix and exam

A

CT scan

Pulsatile epigastric mass, feel for detail pulses

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15
Q

Renal mass

A

May be ballotable.

Ultrasound scan, CT

has to be large to be able to feel it.

Hx - renal failure. weight loss.

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16
Q

Pancreatic Mass

A

Hx - weight loss, non tender, alcohol

ERCP, CT , biopsy

LATE PRESENTATION

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17
Q

Colorectal Cancer

A

VERY COMMON.

Hx - altered bowel habit, PR bleeding, weight loss, anaemia

Small bowel obstruction, localised mass

CT & colonoscopy

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18
Q

Gynaecological

A

Arise from the pelvis.

May seem large, superior border is palpable. Inferior border is difficult to palpate.

Transvaginal ultrasound

CT SCAN

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19
Q

If you cannot get below a mass in the pelvic area, what may this indicate?

A

It is gynaecological in nature.

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20
Q

Sister Mary Joseph Node

A

Palpable nodule bulging into the umbilicus as a result of metastasis of a malignant cancer in the pelvis or abdomen.

Indicates wide spread disease

Very poor outcomes.

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21
Q

Should you give pain medication to patients who have just come in with pain?

A

Yes.

Then you will have a calmer patient to talk to and get a clearer history from

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22
Q

What causes a shift in pain from umbilicus to the right iliac fossa?

A

Appendicitis

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23
Q

What kind of pain could laughing or coughing cause exacerbate?

A

Peritonitis

Guarding
Shallow breathing

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24
Q

Pain

A 
Site
Time and mode of onset
Severity
Nature
Progression
The end
Duration
Relieving / exacerbating factors
Radiation

what did your pain prevent you from doing?

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25
Q

SOCRATES

A 
Site
Onset
Character
Radiation
Associations
Time
Exacerbating/relieving factors
Severity
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26
Q

Shifting vs spreading pain

A

Spreading pain - radiates, spreads from a focal point

Shifting - pain moves from one place to another

27
Q

History - time

A
  1. last Wednesday
  2. Wed 3rd April 2013
  3. Wed 3rd April 2013, (5 days ago)
  4. Wed 3/4/2013 (5 days ago), at 1 am
  5. Wed 3/4/2013 (5 days ago) at 1 am, woke him up from sleep

Precise

28
Q

Kids with appendicitis commonly do not want to..?

A

Walk around

29
Q

Any pain that “annoys” the diaphragm

A

Gives shoulder tip pain

c3,4,5 keeps the diaphragm alive

30
Q

Before an abdo exam of a patient with abdo pain, what should you give?

A

IV morphine.

Be as gente as possible

Site of maximal tenderness

31
Q

If a kid presents with abdominal pain, what could you ask them to do?

A

Push out their tummy and then suck it as far in as they can .

If they can, there is probably not much wrong

32
Q

Ureteric colic - what should not be used?

A

Morphine - worsens the condition as it raises ureteric pressure

33
Q

Examination - applying painful stimuli

A

DO NOT DO REBOUND TENDERNESS

  1. Take a deep breath in
  2. Puff up your tummy
  3. suck your tummy in
  4. give me a gentle cough
  5. give me a big cough
  6. Percuss - start furthest away from painful site
  7. Lightly palpate while distracting
34
Q

Tenderness to percussion

A

Peritonism

35
Q

Abdominal guarding

A

Peritonitis

36
Q

Diverticulitis - common area of pain?

A

Left iliac fossa

37
Q

Very sick

A

Extreme pain and tenderness
High pulse rate
Low blood pressure

ABCs
Analgesia early

38
Q

McBurney’s Point (appendicitis)

A

Locality of greatest sensitiveness to pressure

About 1/3rd of the way between anterior superior iliac spine and umbilicus.

39
Q

Perforated appendix - what kind of pain?

A

Generalised pain and guarding with peritoneum

40
Q

Where does the appendix almost always perforate?

A

Tip or base

41
Q

Iliopsoas Test

A

Indicates that the appendix is retrocoecal in orientation

42
Q

Appendicitis in pregnancy

A

The appendix can change position during all stages of pregnancy.

However most of the time it does not and it presents the same as normal appendicitis

43
Q

What is an acute abdomen?

A

Less than 10 days

Causing severe morbidity or threat to life.

44
Q

Munchausen Syndrome & Drug Seekers

A

> Common acute abdomen admission

> Seem genuine
Drug seekers not usually IVDU

> HIGHLY manipulative

> Tend to have clustering of admissions relating to stress

45
Q

Acute abdomen - symptoms

A

Abdominal pain//
> visceral
> parietal
> extra-abdominal

Location
Radiation

Associated symptoms//

  • nausea/vomiting
  • burping
  • heartburn/ indigestion
  • change in bowel habit
  • PR blood/mucous
46
Q

Acute abdomen - vague pain that suddenly localises

A

-

47
Q

Vomiting

A 
> Colour of vomit
> Green or foodstuff (bile)
> Projectile
> Blood
> Coffee grounds
48
Q

Acute abdomen - constipation

A

> Means different things to people

> Clarify

> Laxative use?

49
Q

Acute abdomen - signs O/E

A 
> Pain
> Localised peritonism
> Generalised peritonitis 
> Guarding
> Rebound tenderness
> Press in LIF, pain in RIF
  • moribund
  • Unwell?
  • moving or still
  • holding abdomen
  • scars
50
Q

Bowel obstruction auscultation

A

Tinkling sounds

51
Q

Erythema ab igne

A

Hot water bottle rash

exposure to heat

52
Q

Cullen’s sign

A

Superficial oedema and bruising in the subcutaneous fatty tissue around the umbilicus

53
Q

Grey turner

A

Bruising of the flanks

Retroperitoneal haemorrhage

could be pancreatitis

54
Q

Initial Investigations - Acute Abdomen

A

> Bloods
AMYLASE
AMYLASE

> ABGs
AXR, erect CXR
Erect CXR is first line and useful if abnormal; pre-op investigation

GOLD STANDARD - CT

55
Q

Gold standard investigation for acute abdomen?

A

CT scan

56
Q

Ultrasound

A

Very useful in RUQ & RIF pain

Useful in kids

Women with pelvic pain

57
Q

Acute abdomen - key things to look for

A

Look for and exclude:

> pancreatitis
symptomatic AAA

Look at plain AXR & CXR

58
Q

Perforated Duodenal Ulcer - treatment

A 
Resuscitate
Abx
Theatre (or not)
Patch repair
Eradicate H pylori
PPI
59
Q

Colonic emergencies

A 
Obstruction
Volvulus
Acute diverticulitis
Toxic colitis 
Perforations
60
Q

Colonic emergencies - management

A

> Volvulus
— decompress using a rigid sigmoidoscope

> Malignant obstruction
— stent or operate

> Diverticulitis
— spectrum from abx to hartmann’s

> Typhilitis
— abx or operate

61
Q

Classification of diverticulitis

A

Hinchey Classification

I - para colic abscess
II - pelvic abscess
III - purulent peritonitis
IV - facecal peritonitis

62
Q

Hartmann’s procedure

A

Remove sigmoid colon

Leave the rectum

Bring out colostomy

63
Q

Peritonitis leads to…

A

death

esp. faecal peritonitis

G.I. (20 decks)

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