abdominal Flashcards
GORD:
- how common?
- risk factors? 5
- triggers? 6
- causes? 3
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
GORD:
- symptoms? 6
- extra-oesophageal symptoms? 3
- 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
GORD:
- investigations? 3
- non-pharm treatments? 7
- 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
GORD:
- pharm treatments? 3
- surgical treatments? 1
- 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)
GORD:
- complications? 6
- oesophagitis
- ulcers
- oesophageal strictures
- iron deficiency
- barrets oesophagus
- pulm fibrosis (very rare)
GORD:
- differentials? 5
- oesophagitis from corrosives/candida/etc
- hiatus hernia
- gastritis (eg nsaids, h pylori)
- gastric or duodenal ulcer
- cardiac (or pulm) disease
peptic ulcers
- two types? (which most common)
- how common?
- most common causes? 2
- other risk factors? 3
- 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
describe the pathophysiology for two commonest causes of peptic ulcer disease
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)
peptic ulcer disease
- symptoms? 3
- signs? 1
- difference in symptoms between duodenal and gastric ulcer?
- 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)
peptic ulcer disease:
- investigations? 2
- non-pharm treatments? 5
- 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
peptic ulcer disease:
- pharm treatments? 2
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
red flags for peptic ulcer disease? 7 (6 are in an acronym)
- over 55years
ALARMS
- A = anaemia
- L = loss of weight
- A = anorexia
- R = recent onset/progressive symptoms
- M = melaena/haematemesis
- S = swallowing difficulty
peptic ulcer disease:
- differentials? 7
- 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
peptic ulcer disease:
- complications? 3
- bleeding
- perforation
- gastric cancer
Acute upper GI bleed:
- causes? 4
- risk factors? 4
- 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!
acute upper GI bleed
- symptoms?
- signs?
- haematemesis
- melaena
- cold (+ clammy) peripheries
- decreased GCS
- poor urine output
- tachycardic
- low BP (faint pulse)
- rapid breathing
ie signs of shock
acute upper GI bleed:
- investigations? 4
- 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
what is the name of the risk score used for upper GI bleeds
Rockall risk scoring
acute upper GI bleed:
- treatment? 5
- 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
crohn’s disease:
- risk factors? 5
- age + gender affected?
- smoking
- family history/genetics
- appendectomy
- NSAIDs
- oral contraceptives
- onset is norm between 20-40years
- men = women
nb stress + depression may precipitate relapses
crohn’s disease:
- GI symptoms? 5
- 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
crohn’s disease:
- GI signs? 4
- mouth ulcers
- anal or peri-anal skin tag/fistula/abscess
- abdominal tenderness
- palpable mass in RLQ
crohn’s disease:
- extra-GI symptoms/signs? 5
- iritis
- arthritis
- erythema nodosum
- pyoderma gangrenosum
- clubbing
crohn’s disease:
- blood tests? 5
- other investiugations? 3
- 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
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
crohns:
- differentials? 11
- ulcerative colitis
- infective colitis
- pseudomembranous colitis*
- ischaemic colitis
- microscopic colitis
- diverticulitis (norm LLQ though)
- IBS
- coeliac disease
- anal fissure
- cancers
- endometriosis
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
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
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
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
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
UC:
- differentials? 11
- crohn’s disease
- infective colitis
- pseudomembranous colitis*
- ischaemic colitis
- microscopic colitis
- diverticulitis
- IBS
- coeliac disease
- anal fissure
- cancers
- endometriosis
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
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)
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
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)
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
infective gastroenteritis:
- prevelence?
- risk factors? 4
about 20% of uk pop every year
- young
- old
- travellers
- immunocompromised
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
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
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
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
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
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”
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)
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)
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)
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
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)
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
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)
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
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
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!
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
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!
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
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
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)
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
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
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
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
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)
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
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
acute appendicitis:
- blood tests? 2
- other investigations? 3
- FBC
- CRP
- pregnancy test
- urine dipstick (rule out UTI)
- USS (or CT if unsure)
acute appendicitis:
- pharm management? 2
- surgical treatment? 1
- antibiotics (metronidazole + cefuroxime)
- analgesia
- urgent appendicectomy (laproscopic or open)
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
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)
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)
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
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’
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
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)
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
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
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
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
