abdominal Flashcards
1
Q
GORD:
- how common?
- risk factors? 5
- triggers? 6
- causes? 3
A
10-20% in the west
- caucasian
- obese
- pregnant
- smoking
- some drugs (eg Ca channel blockers)
- alcohol
- coffee
- fizzy drinks
- chocolate
- fatty foods
- spicy foods
- hiatus hernia
- loss of sphincter tone
- abdominal pressure
2
Q
GORD:
- symptoms? 6
- extra-oesophageal symptoms? 3
A
- heart burn (dyspepsia) esp after meals, relieved by antacids
- belching/burping
- food/acid regurg
- increased salivation (water brash)
- painful swallowing odynophagia
- fullness feeling
- nocturnal asthma
- chronic cough
- laryngitis/sinusitis
nb heartburn as a symptom has a very high positive predictive value
3
Q
GORD:
- investigations? 3
- non-pharm treatments? 7
A
- try giving pharm treatments and see if symptoms subside
- endoscopy (if symptoms >4wks on treatment or cancer red flags)
- if endoscopy negative, 24hr oesophageal ph monitoring
- reduce triggers
- loose weight
- stop smoking
- take off drugs that relax muscles (Ca channel blockers, nitrites, anti-cholinergics)
- take off drugs that irritate stomach (NSAIDs, bisphosphonates)
- raise head off bed (not extra pillows)
- small meals, don’t eat 3 hours before bed
nb only do barium swallow if suspect hiatus hernia
4
Q
GORD:
- pharm treatments? 3
- surgical treatments? 1
A
- antacids
- alginates (gaviscon)
- PPIs (better than H2-blockers)
nb antacids and alginates only relieve symptoms, don’t stop progression
- surgery to increase resting tone of sphincter (eg nissan fundoplication)
5
Q
GORD:
- complications? 6
A
- oesophagitis
- ulcers
- oesophageal strictures
- iron deficiency
- barrets oesophagus
- pulm fibrosis (very rare)
6
Q
GORD:
- differentials? 5
A
- oesophagitis from corrosives/candida/etc
- hiatus hernia
- gastritis (eg nsaids, h pylori)
- gastric or duodenal ulcer
- cardiac (or pulm) disease
7
Q
peptic ulcers
- two types? (which most common)
- how common?
- most common causes? 2
- other risk factors? 3
A
- duodenal (90%) and gastric (10%)
- 10% lifetime risk
- H pylori (85%)
- drug-induced (NSAIDs, SSRIs, steroids)
- smoking
- increased age
- poor gastric emptying/increased acid secretion
8
Q
describe the pathophysiology for two commonest causes of peptic ulcer disease
A
H PYLORI
- causes inflammation of mucosal lining
- depleting the layer of alkaline mucus + altering gastric acidity
- h pylori impairs the function of cells which produce somatostatin (norm limits acid secretion of parietal cells)
NSAIDS
- inhibit prostaglandin synthesis
- reducing the production of protective alkaline mucus
- thereby increasing risk of ulceration (particularly in stomach)
9
Q
peptic ulcer disease
- symptoms? 3
- signs? 1
- difference in symptoms between duodenal and gastric ulcer?
A
- upper abdo pain (burning sensation, heaviness or ache)
- (bloating)
- (burping)
- tender epigastrum
duodenal ulcer = pain before meals or at night (relieved by eating!) (50% asymptomatic)
gastric ulcer = pain after/during meals (also more likely to be asymptomatic)
10
Q
peptic ulcer disease:
- investigations? 2
- non-pharm treatments? 5
A
- C13 breath test (most accurate, non-invasive h pylori test)
- if over 55 or ALARMS signs: endoscopy
nb there are other, less used, tests
- stop NSAIDs
- reduce stress
- reduce alcohol consumption
- stop smoking
- eat less trigger food
11
Q
peptic ulcer disease:
- pharm treatments? 2
A
if h.pylori:
- triple therapy (2 Abx + PPI)
if drug-induced:
- stop drugs
- PPI (or H2-antagonist)
nb two Abx are norm clarithromycin plus amoxicillin or metronidazole
12
Q
red flags for peptic ulcer disease? 7 (6 are in an acronym)
A
- over 55years
ALARMS
- A = anaemia
- L = loss of weight
- A = anorexia
- R = recent onset/progressive symptoms
- M = melaena/haematemesis
- S = swallowing difficulty
13
Q
peptic ulcer disease:
- differentials? 7
A
- functional (non-ulcer) dyspepsia
- gastritis or duodenitis
- GORD/oesophagitis
- hiatus hernia
- gastric malignancy
- pancreatic cancer
- gallstones
(- duodenal crohns)
(- TB)
(- lymphoma)
also think of possible resp or cardiac conditions
14
Q
peptic ulcer disease:
- complications? 3
A
- bleeding
- perforation
- gastric cancer
15
Q
Acute upper GI bleed:
- causes? 4
- risk factors? 4
A
- peptic ulcer (50%)
- oesophageal varices
- mallory-weiss tears
- gastric cancer
nb peptic erosions (ie before an ulcer) can also cause bleeding but rarely
- liver disease/alcoholism
- h pylori
- NSAIDs
- repeated vommitting (mallory weiss)
nb anti-coagulants don’t (on their own) cause bleeding but they will exacerbate any bleeding that does occur
nb there are other very rare causes!
16
Q
acute upper GI bleed
- symptoms?
- signs?
A
- haematemesis
- melaena
- cold (+ clammy) peripheries
- decreased GCS
- poor urine output
- tachycardic
- low BP (faint pulse)
- rapid breathing
ie signs of shock
17
Q
acute upper GI bleed:
- investigations? 4
A
- bloods (FBC, LFTs, U+E, clotting screen, group + save)
- risk scoring
- urinary catheter to monitor output
- endoscopy asap
nb give IV fluids while this is all going on
18
Q
what is the name of the risk score used for upper GI bleeds
A
Rockall risk scoring
19
Q
acute upper GI bleed:
- treatment? 5
A
- give IV fluids (give RBCs if v poorly)
- stop NSAIDs
- stop/reverse warfarin (or other anti-coags)
- give PPIs
(- Abx) - endoscopy or surgery depending on cause/severity
nb preferably stop drugs before endoscopy
20
Q
crohn’s disease:
- risk factors? 5
- age + gender affected?
A
- smoking
- family history/genetics
- appendectomy
- NSAIDs
- oral contraceptives
- onset is norm between 20-40years
- men = women
nb stress + depression may precipitate relapses
21
Q
crohn’s disease:
- GI symptoms? 5
A
- diarrhoea
- pain on defecation
- abdo pain
- malaise
- weight loss
- anorexia
nb symptoms depend on which part of GI tract affected
nb ileocaecal is most common site - 40% of patients
22
Q
crohn’s disease:
- GI signs? 4
A
- mouth ulcers
- anal or peri-anal skin tag/fistula/abscess
- abdominal tenderness
- palpable mass in RLQ
23
Q
crohn’s disease:
- extra-GI symptoms/signs? 5
A
- iritis
- arthritis
- erythema nodosum
- pyoderma gangrenosum
- clubbing
24
Q
crohn’s disease:
- blood tests? 5
- other investiugations? 3
A
- FBC (for anaemia)
- U+E
- LFTs
- CRP
- ESR
- stool microscopy + culture (rule out infective causes)
- faecal calcprotectin
- endoscopy w biopsy is gold standard
nb on endoscopy see cobblestone appearance with skip lesions + transmural inflammation
25
crohn's disease:
- non-pharmalogical treatments? 4
- pharmalogical treatments? 4
- surgical treatments? 1
- quit smoking
- optimise nutrition
- colorectal cancer screening
- screen for osteoporosis (due to steroid use)
for acute attacks:
- analgesics (paracetamol preferred)
- steroids (prednisolone or hydrocortisone)
- immunosuppressants (azothioprine, mercaptopurine, methotrexate)
- cytokine-modulating drugs (infliximab, adalimumab)
- majority will have at least one surgery usually when drugs fail
- never curative
- beware of short bowel syndrome
26
crohns:
| - differentials? 11
- ulcerative colitis
- infective colitis
- pseudomembranous colitis*
- ischaemic colitis
- microscopic colitis
- diverticulitis (norm LLQ though)
- IBS
- coeliac disease
- anal fissure
- cancers
- endometriosis
27
UC:
- risk factors?
- age + gender affected?
- NOT smoking
- genetics/FH (though stronger in crohn's)
- oral contraceptives
nb stress + depression may precipitate relapses
peak incidence 15-25years
nb smaller peak between 55 + 65
28
UC:
- GI symptoms? 4
- systemic symptoms? 4
- episodic diarrhoea (+/- blood + mucus)
nb more blood than in crohn's
- crampy abdo pain/discomfort (esp in LLQ)
- increased bowel frequency (+pre defecation pain)
- tenesmus (persistent, painful urge to pass stool even with empty rectum)
- fever
- malaise
- anorexia
- weight loss
nb is relapsing + remitting
29
UC:
- signs? 14
incl extraintestinal signs/associated conditions
often there are none
- fever
- tachycardia
- tender, distended abdomen
- clubbing
- erythema nodosum
- pyoderma gangrenosum
- conjunctivitis
- episcleritis
- iritis
- large joint arthritis
- sacroilitis
- ankylosing spondylitis
- primary sclerosing cholangitis (-> cholangiocarcxinoma)
- nutritional deficiencies
30
UC:
- blood tests? 5
- other investigations? 4
- FBC
- U+Es
- LFTs
- ESR
- CRP
- stool microscopy (exclude infective colitis)
- faecal calprotectin
- abdo x-ray
- endoscopy w biopsy is gold standard
nb also more likely to get toxic megacolon
31
UC:
- non-pharma management? 2
- pharm treatment? 3
- surgical treatment? 1
- continue smoking
- optimise nutrition (esp iron, at risk of anaemia)
- analgesia
- aminosalicylates (eg mesalazine, zine/zide suffix) = mainstay!
- steroids (often use supposotries)
(immunomodulation if resistant to above)
nb need hosp admission if severe attack
20% need surgery at some point:
- colectomy w anastamosis or variant, dpending on extent of disease
32
UC:
| - differentials? 11
- crohn's disease
- infective colitis
- pseudomembranous colitis*
- ischaemic colitis
- microscopic colitis
- diverticulitis
- IBS
- coeliac disease
- anal fissure
- cancers
- endometriosis
33
IBS:
- prevalence?
- risk factors? 2
- triggers? 4
- age + gender affected?
10-20% of pop
- FH
- mental health conditions
- stress/anxiety
- mensturation
- gastroenteritis
- certain foods/drinks
- onset norm in 20s
- 2x more women
nb there is no demonstrable abnormalities in GI tract
34
IBS:
| - most common symptoms? 6
- crampy abdo pain (relieved by defecation/passing wind)
- diarrhoea +/or constipation
- feeling of incomplete evacuation
- passing mucus
- abdo bloating + distention
- excessive wind
nb symptoms often worse after food
nb symptoms are chronic (>6 months)
35
IBS:
- less common symptoms? 5
- signs on examination? 2
- lethargy
- nausea
- back ache
- urinary urgency/frequency +/- incontinence
- dyspareunia (pain during sex)
examination is normal, bar:
- general abdo tenderness
- abdo distension
36
IBS:
- investigations?
- differential diagnosis? 7
investigations are focused on excluding other conditions:
- crohn's disease (blood tests + endoscopy)
- UC
- food intolerances (eg lactose, good history)
- coeliac disease (serology)
- colorectal cancer (risk factors, onset)
- ovarian cancer (risk factors, onset)
- endometriosis (symptoms)
37
IBS:
- non-pharm treatments? 4
- pharm treatments? 3
depends on prevailing symptoms (eg avoid sorbitol sweeteners if diarrhoea, cut dietary fibre if constipation)
- alter diet
- avoid triggers
- CBT (second line)
- probiotics
- analgesics (norm avoid NSAIDs)
- smooth muscle relaxants (eg mebeverine)
- low dose amitryptyline or citalopram (second line)
focus of treatment is symptom control
38
infective gastroenteritis:
- prevelence?
- risk factors? 4
about 20% of uk pop every year
- young
- old
- travellers
- immunocompromised
39
infective gastroenteritis:
- symptoms? 3
- investigations? 1
- sudden onset diarrhoea +/- vomiting
- fever
- malaise
(- blood/mucus in stools)
diagnosis norm made on history
- culture of stool sample to find causative organism
40
infective gastroenteritis:
- non-pharm treatments? 1
- pharm treatments? 2
- adequate hydration (incl salts)
if not bloody:
- anti-motility agents
if bloody or v unwell:
- emperic Abx until causative organism identified
nb Abx not normally given as condition is norm self-limiting
nb Abx are actively avoided in patients w suspected enterohaemorrhagic E. coli infection as may increase risk of haemolytic uraemic syndrome
41
infective gastroenteritis:
| - differential diagnosis? 8
- UTI
- pneumonia
- otitis media
- other systemic infection
in these conditions, vomiting is norm more prominent than diarrhoea
- drug reactions
- other GI conditions
- endocrinopathy
- secretory tumours
nb there are lots of things which could present with D+V - all about history + associated symptoms
42
acute pancreatitis:
- incidence?
- most common causes? 2
- other causes? 7
0.013-0.045% annually
"GET SMASHED"
- Gall stones (38%)
- Ethanol (35%)
- Trauma (1.5%)
- Steroids
- Mumps
- Autoimmune
- Scorpion/Snake venom
- Hyperlipidaemia/Hypercalcaemia/Hypothermia
- ERCP + Emboli
- Drugs
nb other causes:
- pregnancy
- malignancy
- idiopathic
nb drugs that can cause acute pancreatitis:
- -- steroids
- -- sulphonamides
- -- azothioprine
- -- NSAIDs
- -- diuretics
- -- oestrogens
43
acute pancreatitis:
- symptoms? 2
- signs? 5
- sudden onset severe epigastric/central abdo pain
- --- radiating to BACK, sitting forward may relieve
- nausea + vomiting
- local/general abdo tenderness (can incl guarding + rebound tenderness)
- abdominal distension
- tachycardia
- fever
- hypotension
- jaundice
- retro-peritoneal haemorrhage
nb signs can be absent in mild disease
44
what are the two signs of retroperitoneal haemorrhage seen in severe acute pancreatitis?
where are they seen?
cullen's sign
- periumbilical bruising
- "edward CULLEN was a vampire (blood) who had a baby (umbilicus)"
grey turner's sign
- bruising on flanks
- "you have to TURN someone to see this sign properly"
45
acute pancreatitis:
- bloods? 5
- other investigations? 3
- lipase (more specific to pancreas)
- amylase
- CRP
- ABG (to monitor oxygenation + acid base status)
- LFTs
- abdo X-ray (see loss of psoas shadow if ^retroperitoneal fluid)
- CT (or MRI) (to assess severity + complications)
- US (if gallstones + ^AST)
nb should assess severity using a criteria (eg modified glasgow criteria)
46
acute pancreatitis:
- non-pharm management? 3
- pharm managements? 2
- surgical management? 1
- resuscitation with IV fluids (monitor w urine w a catheter)
- give oxygen (if low PaO2)
- nutritional support (consider nil by mouth)
- analgesia (opiods)
- antibiotics (if evidence of necrosis or cholangitis)
- ERCP (if caused by gallstones)
(- cholecystectomy)
47
acute pancreatitis:
- differential diagnoses:
- -- liver/gallbladder? 4
- -- other GI? 4
- -- other? 2
- biliary colic
- acute cholecystitis
- cholangitis
- viral hepatitis
- perforated peptic ulcer
- bowel obstruction
- ischaemic bowel
- gastroenteritis
- ruptured AAA
- MI
nb can mimic most acute abdo problems so high index of suspicion need (history + risk factors important)
nb always rule out pregnancy (incl ectopic)
48
chronic pancreatitis:
- most common cause? 1
- 2nd most common cause? 1
- other causes/risk factors? 7
alcohol misuse (75%)
idiopathic (20%)
- smoking
- autoimmune condition (sjogrens syndrome, IBD, primary biliary cholangitis)
- genetic (familial or CF)
- hyperparathyroidism
- drug-induced
- haemachromatosis
- obstructive (gallstones, strictures)
nb often acute pancreatitis can transform into chronic
49
chronic pancreatitis:
| - symptoms? 7
- epigastric pain (often radiating to back)
- -- can be intermittent, constant or w superimposed acute flares
- -- sitting upright + leaning forward may relieve pain
- nausea + vomiting
- steatorrhoea
- excessive flatulence
- bloating
- weight loss/malnutrition
- symptoms of diabetes mellitus (late stage)
50
chronic pancreatitis:
| - signs? 5
- epigastric tenderness
- signs of chronic alcohol missuse (palmar erythema, spider naevi, ascites etc)
- jaundice (dt blockage of CBD or concurrant liver disease)
- abdominal distension (dt pseudocyst)
- firm skin nodules (dt disseminated fat necrosis)
nb if ruptured duct or pseudocyst then can get signs of fluid leakage - eg SOB
51
chronic pancreatitis:
- bloods? 1
- other investigations? 1
- LFTs (raised if concurrent liver disease or if CBD is blocked)
nb don't do amylase or lipase as these are unreliable for chronic pancreatitis
- ultrasound +/- CT (look for pancreatic cvlacifications
(nb may also see this on AXR)
52
chronic pancreatitis:
- non-pharm management? 5
- pharm treatment? 5
- surgery? 1
- stop smoking
- stop drinking alcohol
- low fat diet
- screen for diabetes mellitus
- screen for osteoporosis
- analgesia
- pancreatic enzyme supplementation
- corticosteroids (if autoimmune)
- treatment of hypercalcaemia (if cause)
- treatment of DM (if have)
if severe weight loss, unremitting pain: consider pancreatectomy or pancreaticojejunostomy as last resort
53
differential diagnoses for chronic pancreatitis:
- Liver/gall bladder/pancreas? 4
- other GI? 4
- other? 4
- acute cholecystitis
- biliary colic
- acute pancreatitis
- pancreatic cancer
- peptic ulcer
- gastroparesis
- intestinal obstruction, ischaemia or infarction=
- IBS (or IBD?)
- post-herpetic neuralgia
- thoracic radiculopathy
- AAA
- MI
54
Gallstones:
- who does it affect? 4
- other risk factors? 7
- female
- fat
- fourty
- fertile
- diabetes mellitus
- crohns disease
- oral contraceptive
- HRT
- pregnancy
- smoking
- recent weight loss
nb gallstones are common!
55
gallstones:
- 4 different presentations?
incl signs/symptoms
biliary colic (most common):
- pain in RUQ (often severe)
- pain lasts >30 mins (<8 hrs)
- pain may radiate to back
- may have nausea + vomitting
- no fever or abdo tenderness
acute cholecystitis (2nd most common):
- same as biliary collic
- PLUS fever + tenderness in RUQ (+ve murphy's sign)
cholangitis (rare):
- same as cholecystitis
- PLUS jaundice
(- rigors)
gallstone pancreatitis (rare):
- severe pain, radiating to back
- nausea/vomitting common
56
gallstones:
- bloods? 2
- other investigations? 1
- FBC (looking for ^WCC in cholecystitis)
- LFTs (obstructive jaundice)
- ultrasound is first line + most accurate imaging
nb even if imaging + bloods are normal, gallstones are not rulled out
nb can use MRCP or ERCP as follow up
nb xray very rarely helpful!
57
gallstones:
- non-pharm treatment? 1
- pharm treatment? 2
- surgical treatment? 1
- avoid fatty foods/drinks that trigger symptoms
- analgesia
- Abx (if clinical signs of infection)
- cholecystectomy
nb if gallstones are in gallbladder and asymptomatic then leave alone
- only if symptomatic or visualised in bile duct then treat with surgery
58
differential diagnosis for gallstones:
- liver? 2
- bile duct? 2
- pancreas? 2
- stomach? 3
- other GI? 2
- liver cancer
- acute hepatitis
- chorangiocarcinoma
- bile duct strictures
- pancreatitis
- pancreatic cancer
- PUD
- gastritis
- GORD
- IBS
- IBD
59
acute viral hepatitis:
- risk factors for Hep A? 4
- risk factors for Hep B? 4
- risk factors for Hep C? 2
Hep A:
- travel to developing countries
- people w clotting factor deficiencies/get infected blood products
- being a child
- occupational hazards (lab or sewage workers, people who work w primates)
Hep B:
- sub-saharan, east asian or pacific island background (most transmission is vertical)
- IVDU
- infected blood products
- risky sexual behaviour
Hep C:
- IVDU (90% of cases)
- blood transfusions/products/donated organs
(- nb risk is low for sexual transmission)
60
Acute viral hepatitis:
- symptoms? 5
- signs? 3
- fever
- malaise/fatigue
- nausea
- arthralgia
- urticaria (commoner in hep B)
- jaundice (rare in kids)
- hepatosplenomegaly
- lymphadenopathy
nb initial infection with hep C often goes unnoticed as symptoms are very mild and vague
61
acute viral hepatitis:
| - blood tests? 2
- LFTs
- virus serology (depending on virus suspected by Hx)
nb different antibodies show whether past infection, current infection or vaccination
62
acute viral hepatitis:
- non-pharm management? 3
- pharm treatment? 2
- avoid alcohol
- immunise sexual contacts (hep B/C only)
- notify public health?
- antivirals
- interferon
nb hep A is almost always self-limiting so just avoid alcohol + wait for it to pass
nb hep C is leading indication for liver transplant in UK
63
differential diagnoses for acute viral hepatitis:
- other viral causes? 3
- bacterial causes? 2
- other infectious causes? 2
- external ingestion of poison causes? 2
- causes due to intrinsic problems? 3
nb obvs if you suspect hep B you should also not rule out hep E etc
- epstein-barr virus
- cytomegalovirus
- acute HIV infection
- leptospirosis*
- syphillis
- malaria
- yellow fever
- alcoholic liver disease
- drug-induced liver disease (eg paracetamol OD)
- autoimmune hepatitis
- metabolic/gentic disease (eg Wilson's)
- granulomatous diseases
64
acute appendicitis:
- incidence?
- age most commonly affected?
- risk factors? 2
- pathogenesis?
lifetime incidence = 6%
- 10-20years
- frequent antibiotic use
- smoking
obstruction of 'entrance' to appendix (norm by a facolith) -> increased intreluminal pressure, bacterial overgrowth -> appendicitis (which can then perforate if bad)
65
acute appendicitis:
- symptoms? 4
- what % of people present with 'classical' presentation?
- abdo pain (most common)
- -- starts periumbilical -> right iliac fossa
- -- pain worsened by movement (coughing, driving over speed bumps) - ask patient to cough + they won't
- anorexia (almost always)
- nausea (rarely vomitting)
- constipation (rarely diarrhoea)
only 50% of people present as above
66
acute appendicitis:
- most common/reliable clinical signs? 3
- special clinical tests? 3
- other accessory signs? 5
- tenderness on percussion of RIF (McBurney's point)
- guarding at RIF
- rebound tenderness
- Rovsing's sign (palpatition of LIF increases pain in RIF)
- Psoas sign (pain in RIF on extension of right thigh)
- Cope/obturator sign (internal rotation of flexed hip ilicits pain in RIF)
- facial flushing
- dry tongue
- halitosis
- low grade fever
- tachycardia
67
acute appendicitis:
- blood tests? 2
- other investigations? 3
- FBC
- CRP
- pregnancy test
- urine dipstick (rule out UTI)
- USS (or CT if unsure)
68
acute appendicitis:
- pharm management? 2
- surgical treatment? 1
- antibiotics (metronidazole + cefuroxime)
- analgesia
- urgent appendicectomy (laproscopic or open)
69
differential diagnoses for acute appendicitis:
- GI? 8
- urological? 3
- gynaecological? 6
- other? 2
- perforated ulcer
- acute cholecystitis
- pancreatitis
- gastroenteritis
- diverticulitis
- intestinal obstruction
- meckel's diverticulum
- crohns disease
- cystitis
- pyelonephritis
- right uteric colic
- ectopic pregnancy
- torted ovary
- ovarian cyst
- endometriosis
- dysmenorrhoea
- PID/salpingitis
- mesenteric adenitis
- diabetic ketoacidosis
70
bowel obstruction causes:
- small bowel? 2
- large bowel? 4
- rarer causes of either? 6
small bowel:
- adhesions
- hernias
large bowel:
- colon Ca
- constipation
- diverticular strictures
- volvulus (bowel twists on its mesentery)
rare:
- crohn's strictures
- gallstone ileus
- intussusception
- TB
- foreign body
- paralytic ileus
nb most things cause mechanical obstruction, except paralytic ileus which is a functional obstruction due to paralysis of gut movement
nb paralytic ileus causes:
- post-abdo surgery
- peritonitis
- spinal injury
- drugs (eg opiates + tricyclic antidepressants)
71
bowel obstruction:
- symptoms? 5
incl variation between large + small bowel obstruction
- colicky abdo pain
- nausea
- vomitting (occurs earlier in small bowel)
- constipation (occurs earlier in large bowel obstruction)
- anorexia
nb pain often not present in functional obstruction (paralytic ileus)
72
bowel obstruction:
| - signs? 3
- abdo distension
- tenderness to palpation
- tinkling bowel sounds (or absent if paralytic ileus)
nb distension is less if small bowel
nb amount of pain depends on if bowel is strangulated etc
73
bowel obstruction:
- main investigation?
- when surgical management?
- when conservative/supportive management?
abdominal x-ray
- small bowel get valvulae conniventes (lines which cross whole gut)
- large bowel get haustra indentations (don't cross whole circumference of gut)
surgical:
- strangulation
- large bowel obstruction
conservative
- small bowel obstruction
- paralytic ileus
nb conservative management often means nbm and 'drip and suck'
74
femoral hernias:
- frequency compared to inguinal hernias?
- gender + age affected?
- risk factors? 4
- pathogenesis?
for every 20 inguinal hernias you see 1 femoral hernia
- however they have a much higher risk of strangulation
- females (wider pelvis)
- middle age/elderly
- straining on toilet (eg if constipated)
- carrying/pushing heavy loads
- obesity
- persistent heavy coughs
defect in the surrounding muscle -> fat or bowel poking into femoral canal
75
femoral hernias:
- clinical presentation?
- treatment?
painful lump in the inner upper part of the thigh or groin
- lump can sometimes be pushed back in or disappears when you lie down
surgical treatment
(as highly likely to strangulate)
76
differential diagnoses for femoral hernias:
- vascular? 2
- other? 4
- saphena varix (bad varicose vein)
- femoral aneurysm
- inguinal hernia
- an enlarged Cloquet's node
- lipoma
- psoas abscess
77
inguinal hernias?
- two types?
- gender + age affected by each type?
- other risk factors? 4
- pathogenesis?
direct:
- "punches DIRECTLY through superficial/medial ring"
- older men
indirect:
- "goes INdirectly to groin via both rings"
- male neonates + children
- straining on toilet
- carrying/pushing heavy loads
- persistent heavy loads
- obesity
defect in muscle or patent inguinal canal
78
inguinal hernias
- clinical presentation?
- non-pharm management? 2
- when treat surgically? 4
- lump in groin or testes (often reducable, appears w cough)
- may be painful or cause altered bowel habits
- pain when coughing or stooping
- loose weight (if obese)
- stop smoking
- if irreducible
- if bowel obstructed
- if strangulated
- if perforated
79
differential diagnosis of inguinal hernias:
- unique to men? 2
- vascular? 2
- other? 4
- hydrocele
- spermatocele*
- saphena varix (bad varicose vein)
- femoral aneurysm
- femoral hernia
- an enlarged Cloquet's node
- lipoma
- psoas abscess
