Abdomen: Masses, Pain & Acute abdomen Flashcards
Masses in the abdomen can be caused by… (6Fs)
> Fat > Faeces > Flatus > Foetus > Fluid > Fatal growth (Fucking big tumour)
History of PC
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
PMHx/ Comorbidities/ Social hx/ FHx
Diabetes
Heart and lung disease
Medication
Allergies
not fit = no operation
Smoking, alcohol
FHx of cancer
PREGNANCY!!!
What is a key question to ask (if female)?
Are the pregnant???
If they don’t know –> pregnancy test
Abdominal examination - Inspection
Contour SHape Pulsations Prominent veins Scars Rashes Colour other lesions? Breathing
Ask to cough and stand up - hernia.
Abdo exam - Palpation
Systematic Tender area last light then deep palpation liver, spleen, kidneys Hernial orifices PR exam
Mass on examination & percussion
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?
Auscultation
Bowel sounds
Bruit
Investigations
> 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
What does air under the diaphragm indicate?
Something has burst/perforated
What is the gold standard investigation for an abdominal mass patient
CT scan
What should go at the top of differential diagnoses?
Life threatening things - what could cause the patient to die right in front of me?
What does sudden onset epigastric pain radiating to the back indicate?
AAA rupture
retroperitoneal
Abdominal aortic aneurysm - Ix and exam
CT scan
Pulsatile epigastric mass, feel for detail pulses
Renal mass
May be ballotable.
Ultrasound scan, CT
has to be large to be able to feel it.
Hx - renal failure. weight loss.
Pancreatic Mass
Hx - weight loss, non tender, alcohol
ERCP, CT , biopsy
LATE PRESENTATION
Colorectal Cancer
VERY COMMON.
Hx - altered bowel habit, PR bleeding, weight loss, anaemia
Small bowel obstruction, localised mass
CT & colonoscopy
Gynaecological
Arise from the pelvis.
May seem large, superior border is palpable. Inferior border is difficult to palpate.
Transvaginal ultrasound
CT SCAN
If you cannot get below a mass in the pelvic area, what may this indicate?
It is gynaecological in nature.
Sister Mary Joseph Node
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.
Should you give pain medication to patients who have just come in with pain?
Yes.
Then you will have a calmer patient to talk to and get a clearer history from
What causes a shift in pain from umbilicus to the right iliac fossa?
Appendicitis
What kind of pain could laughing or coughing cause exacerbate?
Peritonitis
Guarding
Shallow breathing
Pain
Site Time and mode of onset Severity Nature Progression The end Duration Relieving / exacerbating factors Radiation
what did your pain prevent you from doing?
SOCRATES
Site Onset Character Radiation Associations Time Exacerbating/relieving factors Severity
Shifting vs spreading pain
Spreading pain - radiates, spreads from a focal point
Shifting - pain moves from one place to another
History - time
- last Wednesday
- Wed 3rd April 2013
- Wed 3rd April 2013, (5 days ago)
- Wed 3/4/2013 (5 days ago), at 1 am
- Wed 3/4/2013 (5 days ago) at 1 am, woke him up from sleep
Precise
Kids with appendicitis commonly do not want to..?
Walk around
Any pain that “annoys” the diaphragm
Gives shoulder tip pain
c3,4,5 keeps the diaphragm alive
Before an abdo exam of a patient with abdo pain, what should you give?
IV morphine.
Be as gente as possible
Site of maximal tenderness
If a kid presents with abdominal pain, what could you ask them to do?
Push out their tummy and then suck it as far in as they can .
If they can, there is probably not much wrong
Ureteric colic - what should not be used?
Morphine - worsens the condition as it raises ureteric pressure
Examination - applying painful stimuli
DO NOT DO REBOUND TENDERNESS
- Take a deep breath in
- Puff up your tummy
- suck your tummy in
- give me a gentle cough
- give me a big cough
- Percuss - start furthest away from painful site
- Lightly palpate while distracting
Tenderness to percussion
Peritonism
Abdominal guarding
Peritonitis
Diverticulitis - common area of pain?
Left iliac fossa
Very sick
Extreme pain and tenderness
High pulse rate
Low blood pressure
ABCs
Analgesia early
McBurney’s Point (appendicitis)
Locality of greatest sensitiveness to pressure
About 1/3rd of the way between anterior superior iliac spine and umbilicus.
Perforated appendix - what kind of pain?
Generalised pain and guarding with peritoneum
Where does the appendix almost always perforate?
Tip or base
Iliopsoas Test
Indicates that the appendix is retrocoecal in orientation
Appendicitis in pregnancy
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
What is an acute abdomen?
Less than 10 days
Causing severe morbidity or threat to life.
Munchausen Syndrome & Drug Seekers
> Common acute abdomen admission
> Seem genuine
Drug seekers not usually IVDU
> HIGHLY manipulative
> Tend to have clustering of admissions relating to stress
Acute abdomen - symptoms
Abdominal pain//
> visceral
> parietal
> extra-abdominal
Location
Radiation
Associated symptoms//
- nausea/vomiting
- burping
- heartburn/ indigestion
- change in bowel habit
- PR blood/mucous
Acute abdomen - vague pain that suddenly localises
-
Vomiting
> Colour of vomit > Green or foodstuff (bile) > Projectile > Blood > Coffee grounds
Acute abdomen - constipation
> Means different things to people
> Clarify
> Laxative use?
Acute abdomen - signs O/E
> Pain > Localised peritonism > Generalised peritonitis > Guarding > Rebound tenderness > Press in LIF, pain in RIF
- moribund
- Unwell?
- moving or still
- holding abdomen
- scars
Bowel obstruction auscultation
Tinkling sounds
Erythema ab igne
Hot water bottle rash
exposure to heat
Cullen’s sign
Superficial oedema and bruising in the subcutaneous fatty tissue around the umbilicus
Grey turner
Bruising of the flanks
Retroperitoneal haemorrhage
could be pancreatitis
Initial Investigations - Acute Abdomen
> Bloods
AMYLASE
AMYLASE
> ABGs
AXR, erect CXR
Erect CXR is first line and useful if abnormal; pre-op investigation
GOLD STANDARD - CT
Gold standard investigation for acute abdomen?
CT scan
Ultrasound
Very useful in RUQ & RIF pain
Useful in kids
Women with pelvic pain
Acute abdomen - key things to look for
Look for and exclude:
> pancreatitis
symptomatic AAA
Look at plain AXR & CXR
Perforated Duodenal Ulcer - treatment
Resuscitate Abx Theatre (or not) Patch repair Eradicate H pylori PPI
Colonic emergencies
Obstruction Volvulus Acute diverticulitis Toxic colitis Perforations
Colonic emergencies - management
> Volvulus
— decompress using a rigid sigmoidoscope
> Malignant obstruction
— stent or operate
> Diverticulitis
— spectrum from abx to hartmann’s
> Typhilitis
— abx or operate
Classification of diverticulitis
Hinchey Classification
I - para colic abscess
II - pelvic abscess
III - purulent peritonitis
IV - facecal peritonitis
Hartmann’s procedure
Remove sigmoid colon
Leave the rectum
Bring out colostomy
Peritonitis leads to…
death
esp. faecal peritonitis
