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* year 3 core conditions (detailed) > abdominal > Flashcards

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
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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

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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

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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)
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5
Q

GORD:

- complications? 6

A
  • oesophagitis
  • ulcers
  • oesophageal strictures
  • iron deficiency
  • barrets oesophagus
  • pulm fibrosis (very rare)
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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
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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
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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)
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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)

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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
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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

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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
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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

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14
Q

peptic ulcer disease:

- complications? 3

A
  • bleeding
  • perforation
  • gastric cancer
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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!

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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

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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

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18
Q

what is the name of the risk score used for upper GI bleeds

A

Rockall risk scoring

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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

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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

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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

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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
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23
Q

crohn’s disease:

- extra-GI symptoms/signs? 5

A
  • iritis
  • arthritis
  • erythema nodosum
  • pyoderma gangrenosum
  • clubbing
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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

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25
Q

crohn’s disease:

  • non-pharmalogical treatments? 4
  • pharmalogical treatments? 4
  • surgical treatments? 1
A
  • 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
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26
Q

crohns:

- differentials? 11

A
  • ulcerative colitis
  • infective colitis
  • pseudomembranous colitis*
  • ischaemic colitis
  • microscopic colitis
  • diverticulitis (norm LLQ though)
  • IBS
  • coeliac disease
  • anal fissure
  • cancers
  • endometriosis
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27
Q

UC:

  • risk factors?
  • age + gender affected?
A
  • 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

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28
Q

UC:

  • GI symptoms? 4
  • systemic symptoms? 4
A
  • 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

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29
Q

UC:
- signs? 14

incl extraintestinal signs/associated conditions

A

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
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30
Q

UC:

  • blood tests? 5
  • other investigations? 4
A
  • 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

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31
Q

UC:

  • non-pharma management? 2
  • pharm treatment? 3
  • surgical treatment? 1
A
  • 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

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32
Q

UC:

- differentials? 11

A
  • crohn’s disease
  • infective colitis
  • pseudomembranous colitis*
  • ischaemic colitis
  • microscopic colitis
  • diverticulitis
  • IBS
  • coeliac disease
  • anal fissure
  • cancers
  • endometriosis
33
Q

IBS:

  • prevalence?
  • risk factors? 2
  • triggers? 4
  • age + gender affected?
A

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
Q

IBS:

- most common symptoms? 6

A
  • 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
Q

IBS:

  • less common symptoms? 5
  • signs on examination? 2
A
  • lethargy
  • nausea
  • back ache
  • urinary urgency/frequency +/- incontinence
  • dyspareunia (pain during sex)

examination is normal, bar:

  • general abdo tenderness
  • abdo distension
36
Q

IBS:

  • investigations?
  • differential diagnosis? 7
A

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
Q

IBS:

  • non-pharm treatments? 4
  • pharm treatments? 3
A

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
Q

infective gastroenteritis:

  • prevelence?
  • risk factors? 4
A

about 20% of uk pop every year

  • young
  • old
  • travellers
  • immunocompromised
39
Q

infective gastroenteritis:

  • symptoms? 3
  • investigations? 1
A
  • sudden onset diarrhoea +/- vomiting
  • fever
  • malaise

(- blood/mucus in stools)

diagnosis norm made on history
- culture of stool sample to find causative organism

40
Q

infective gastroenteritis:

  • non-pharm treatments? 1
  • pharm treatments? 2
A
  • 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
Q

infective gastroenteritis:

- differential diagnosis? 8

A
  • 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
Q

acute pancreatitis:

  • incidence?
  • most common causes? 2
  • other causes? 7
A

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
Q

acute pancreatitis:

  • symptoms? 2
  • signs? 5
A
  • 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
Q

what are the two signs of retroperitoneal haemorrhage seen in severe acute pancreatitis?

where are they seen?

A

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
Q

acute pancreatitis:

  • bloods? 5
  • other investigations? 3
A
  • 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
Q

acute pancreatitis:

  • non-pharm management? 3
  • pharm managements? 2
  • surgical management? 1
A
  • 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
Q

acute pancreatitis:

  • differential diagnoses:
  • – liver/gallbladder? 4
  • – other GI? 4
  • – other? 2
A
  • 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
Q

chronic pancreatitis:

  • most common cause? 1
  • 2nd most common cause? 1
  • other causes/risk factors? 7
A

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
Q

chronic pancreatitis:

- symptoms? 7

A
  • 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
Q

chronic pancreatitis:

- signs? 5

A
  • 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
Q

chronic pancreatitis:

  • bloods? 1
  • other investigations? 1
A
  • 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
Q

chronic pancreatitis:

  • non-pharm management? 5
  • pharm treatment? 5
  • surgery? 1
A
  • 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
Q

differential diagnoses for chronic pancreatitis:

  • Liver/gall bladder/pancreas? 4
  • other GI? 4
  • other? 4
A
  • 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
Q

Gallstones:

  • who does it affect? 4
  • other risk factors? 7
A
  • female
  • fat
  • fourty
  • fertile
  • diabetes mellitus
  • crohns disease
  • oral contraceptive
  • HRT
  • pregnancy
  • smoking
  • recent weight loss

nb gallstones are common!

55
Q

gallstones:
- 4 different presentations?

incl signs/symptoms

A

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
Q

gallstones:

  • bloods? 2
  • other investigations? 1
A
  • 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
Q

gallstones:

  • non-pharm treatment? 1
  • pharm treatment? 2
  • surgical treatment? 1
A
  • 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
Q

differential diagnosis for gallstones:

  • liver? 2
  • bile duct? 2
  • pancreas? 2
  • stomach? 3
  • other GI? 2
A
  • liver cancer
  • acute hepatitis
  • chorangiocarcinoma
  • bile duct strictures
  • pancreatitis
  • pancreatic cancer
  • PUD
  • gastritis
  • GORD
  • IBS
  • IBD
59
Q

acute viral hepatitis:

  • risk factors for Hep A? 4
  • risk factors for Hep B? 4
  • risk factors for Hep C? 2
A

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
Q

Acute viral hepatitis:

  • symptoms? 5
  • signs? 3
A
  • 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
Q

acute viral hepatitis:

- blood tests? 2

A
  • LFTs
  • virus serology (depending on virus suspected by Hx)

nb different antibodies show whether past infection, current infection or vaccination

62
Q

acute viral hepatitis:

  • non-pharm management? 3
  • pharm treatment? 2
A
  • 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
Q

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
A

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
Q

acute appendicitis:

  • incidence?
  • age most commonly affected?
  • risk factors? 2
  • pathogenesis?
A

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
Q

acute appendicitis:

  • symptoms? 4
  • what % of people present with ‘classical’ presentation?
A
  • 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
Q

acute appendicitis:

  • most common/reliable clinical signs? 3
  • special clinical tests? 3
  • other accessory signs? 5
A
  • 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
Q

acute appendicitis:

  • blood tests? 2
  • other investigations? 3
A
  • FBC
  • CRP
  • pregnancy test
  • urine dipstick (rule out UTI)
  • USS (or CT if unsure)
68
Q

acute appendicitis:

  • pharm management? 2
  • surgical treatment? 1
A
  • antibiotics (metronidazole + cefuroxime)
  • analgesia
  • urgent appendicectomy (laproscopic or open)
69
Q

differential diagnoses for acute appendicitis:

  • GI? 8
  • urological? 3
  • gynaecological? 6
  • other? 2
A
  • 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
Q

bowel obstruction causes:

  • small bowel? 2
  • large bowel? 4
  • rarer causes of either? 6
A

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
Q

bowel obstruction:
- symptoms? 5

incl variation between large + small bowel obstruction

A
  • 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
Q

bowel obstruction:

- signs? 3

A
  • 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
Q

bowel obstruction:

  • main investigation?
  • when surgical management?
  • when conservative/supportive management?
A

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
Q

femoral hernias:

  • frequency compared to inguinal hernias?
  • gender + age affected?
  • risk factors? 4
  • pathogenesis?
A

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
Q

femoral hernias:

  • clinical presentation?
  • treatment?
A

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
Q

differential diagnoses for femoral hernias:

  • vascular? 2
  • other? 4
A
  • saphena varix (bad varicose vein)
  • femoral aneurysm
  • inguinal hernia
  • an enlarged Cloquet’s node
  • lipoma
  • psoas abscess
77
Q

inguinal hernias?

  • two types?
  • gender + age affected by each type?
  • other risk factors? 4
  • pathogenesis?
A

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
Q

inguinal hernias

  • clinical presentation?
  • non-pharm management? 2
  • when treat surgically? 4
A
  • 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
Q

differential diagnosis of inguinal hernias:

  • unique to men? 2
  • vascular? 2
  • other? 4
A
  • hydrocele
  • spermatocele*
  • saphena varix (bad varicose vein)
  • femoral aneurysm
  • femoral hernia
  • an enlarged Cloquet’s node
  • lipoma
  • psoas abscess

* year 3 core conditions (detailed) (12 decks)

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