Abdominal Flashcards
What is the initial approach to acute abdomen?
Assess for life-threatening causes
What are some RED FLAGS for abdominal pain?
Sudden onset of severe pain Pain that interrupts sleep Bilious vomiting Haematemesis, haematochezia Hypotension, tachycardia Pt. lying very still Pain writhing in pain Jaundice Guarding +/ rigidity Rebound tenderness Absent/tinkling bowel sounds Gross abdominal distension Pain out of proportion with abdo. findings High-risk pt. characteristics - age >50 - prev. abdo. surgery - hx of CAD +/ AF
What are some laboratory studies that should be considered when investigating abdominal pain, and why?
Blood gas analysis
- recurrent vomiting can cause hypochloraemic hypokalaemic metabolic alkalosis
- ischaemic bowel can cause metabolic acidosis (lactic acidosis)
Lactate
- elevated lactic indicates tissue hypoxia
- eg. hypotension/shock in pancreatitis
- eg. bowel infarction due to bowel obstruction/mesenteric ischaemia
Troponin
- consider checking in pt. with CAD RFs/hx
Serum glucose
FBE
- leucocytosis –> infection/inflammatory process (ie. acute appendicitis)
- Anaemia –> acute/acute on chronic blood loss
- Low HCT –> acute blood loss
- High HCT –> dehydration
Coags
- elevated INR –> onset of sepsis
- coagulopathy needs correcting prior to surgery
UEC
- evaluate renal function and electrolyte imbalances
LFTs
- cholestatic picture typical in choledocholithiasis, cholangitis, and gall stone pancreatitis
> cholestatic picture: ALP prominently ^, mild AST ^, ALT, conjugated hyperbilirubinaemia (dark wee, pale stools)
> hepatocellular picture: ALT and AST prominently ^, moderate ALP ^
Lipase/amylase
- 3x increase in lipase = diagnostic for acute pancreatitis
Blood type and screen
ESR/CRP
- consider if concern re inflammatory process (eg. peritonitis, IBD)
Urinalysis
- haematuria / nitrates / urinary crystals –> UTI / nephrolithiasis
- haematuria can be present in ruptured AAA
- mild pyuria may be present acute appendicitis
bHCG urine test
- all woman of reproductive age: consider ectopic pregnancy
Cultures (urine, blood)
- urine: if urinalysis indicates UTI
- blood: if suspected sepsis
What is the appropriate imaging to select if you are suspecting acute appendicitis?
Usually diagnosed clinically (ie. no imaging required)
Consider imaging in pt. with atypical presentations
U/S is less sensitive but is often performed in RLQ pain in order to reduce radiation exposure
- Most sensitive imaging, if necessary: CT abdo pelvis w IV contrast
What is the appropriate imaging to select if you are suspecting acute diverticulitis?
CT abdo pelvis w IV contrast
What is the appropriate imaging to select if you are suspecting acute pancreatitis?
U/S abdo
CT abdo w IV contrast (if U/S unequivocal OR pt. critically ill at presentation)
What is the appropriate imaging to select if you are suspecting nephrolithiasis?
U/S abdo and pelvis (preferred if presentation is typical: renal colic)
CT abdo pelvis w/o IV contrast (pref. if presentation is atypical/pt. >75yo)
What is the appropriate imaging to select if you are suspecting AAA in haemodynamically stable patient?
U/S abdo
CT/MRI angiography
What is the appropriate imaging to select if you are suspecting AAA in haemodynamically unstable patient?
NO IMAGING
Patient should go straight to the operating theatre
What is the appropriate imaging/Ix to select if you are suspecting ACS?
ECG
TTE
What is the appropriate imaging to select if you are suspecting haemorrhagic shock?
FAST scan (US of abdo looking for fluid/blood)
What is the appropriate imaging to select if you are suspecting a bowel perforation?
CT abdo pelvis w IV contrast Xray abdo (upright and supine) + CXR (upright)
What is the appropriate imaging to select if you are suspecting a small bowel obstruction?
CT abdo pelvis w IV contrast Xray abdo (upright and supine) + CXR (upright)
What is the appropriate imaging to select if you are suspecting acute diverticulitis?
CT abdo pelvis w IV contrast
What is the appropriate imaging to select if you are suspecting acute mesenteric ischaemia?
CT angiography of abdo
What is the classic presentation of acute mesenteric ischaemia and what other signs/sx might be present?
Classic: pain out of proportion abdo examination
Other: Blood diarrhoea, abdo distension and peritonitis
** when mesenteric ischaemia has progressed to bowel infarction (< 6 hrs) **
What are the life-threatening dx that must be excluded when a patient presents with acute abdomen?
Ruptured AAA Aortic dissection Ruptured ectopic pregnancy Mechanical bowel obstruction Acute mesenteric ischaemia Acute pancreatitis Acute cholangitis AMI
What investigations should be done if suspecting peptic ulcer dse?
FBE - anaemia if bleeding ulcer
Upper GI endoscopy - mucosal erosions/ulcers
Urea breath test - for H. pylori infection
What test is performed to identify H. pylori infection?
Urea breath test
What features might you expect to find on hx/examination in diverticulitis?
Fever
LLQ pain
Constipation
Tender mass in LLQ
What features might you expect to find on hx/examination in PUD?
Epigastric pain
Pain worse/better with eating: gastric ulcer/duodenal ulcer respectively
Hx of NSAID use
Signs of GI bleed
What might you expect to find on hx/ex in a mechanical bowel obstruction?
Colicky pain (pain may become constant if affected bowel loops become ischaemic) Obstipation/bloating Progressive N&V (late) Diffuse abdo. distension Tympanic abdo Collapsed rectum on DRE Tinkling bowel sounds Hx of abdo surgery (adhesions -> SBO)
What might you see on abdo xray in the case of a GI perforation?
Pneumoperitoneum
What features on hx/ex might you expect in the case of a GI perforation?
Diffuse abdo pain of sudden onset N&V Constipation/obstipation (due to ileus) Diffuse abdo guarding, rigidity, rebound tenderness Absent bowel sounds Loss of liver dullness on RUQ percussion
What features on hx/ex might you expect in the case of acute appendicitis?
Migrating abdo pain 1. epigastric +/ periunbilical - diffuse 2. RLQ - localised Fever Nausea Anorexia Guarding, tenderness and rebound tenderness in RLQ Rovsing's sign
What features on hx/ex might you expect in the case of acute pancreatitis?
Severe epigastric pain - constat Pain radiating to the back (circumferential pain) Pain relieved by leaning forward N&V Epigastric tenderness, rigidity, guarding Hypoactive bowel sounds (due to ileus) Possibly fever Hx of alcohol use/gall stones
What is an important early Ix in suspected pancreatitis, and what might it show?
Lipase level - typically >x3 normal
Amylase - less specific
What Ix might you consider in suspected acute pancreatitis?
- Lipase
- Abdo U/S - pancreatic oedema, peripancreatic fluid, gallstones
- CT abdo w IV contrast - as for U/S, but also peripancreatic fat stranding
* * not routine - consider if dx is uncertain ** - Calcium: hypocalcaemia = poor prognostic indicator
What features on hx/ex might you expect in the case of symptomatic cholelithiasis?
Biliary colic: RUQ pain, w radiation to R. shoulder (typically lasts < 6 hrs)
Pain onset postprandially (triggered by fatty meal)
Dyspepsia
Flatulence
Possibly fever
N&V
Normal abdo examination
What features on hx/ex might you expect in the case of choledocholithiasis?
RUQ pain (lasts > 6 hrs) Ft. of obstructive jaundice (pee, poo, pruritis, jaundice) N&V Normal abdo. examination
What features on hx/ex might you expect in the case of acute cholecystitis?
Severe RUQ pain (> 6 hrs) Fever, chills N&V R. shoulder pain, referred Murphy's +ve
What features on hx/ex might you expect in the case of acute cholangitis?
Charcot triad: RUQ pain, fever, jaundice
Reynold’s pentad: Charcot triad, hypotension, altered mental status
What conditions are complications of gall stone disease (cholelithiasis)?
Choledocholithiasis (GS in CBD)
Biliary pancreatitis
Cholecystitis (GB inflammation)
Cholangitis (ascending bacterial infection of biliary tract, due to bile stasis)
When suspecting biliary +/ pancreatic causes of abdominal pain, what are some important Ix to consider?
Lipase
?Pancreatitis?
Abdo U/S
?Pancreatitis / Cholelithiasis / Choledocholithiasis / Acute cholecystitis / Acute cholangitis?
LFTs
?Choledocholithiasis / Acute cholangitis ?
MRCP / ERCP
?Choledocholithiasis / Acute cholangitis?
WCC
?Acute cholecystitis / Acute cholangitis?
CRP
?Acute cholangitis?
Blood cultures
?Acute cholangitis?
When faced with acute abdomen, what are some of the systems that must be considered?
Cardiovascular
Gastrointestinal
Biliary/pancreatic
Genitourinary
When faced with acute abdomen, what are some ddx, according to system involved?
Cardiovascular
- ACS
- Mesenteric ischaemia
- Rupture/impending rupture of AAA
- Aortic dissection
Gastrointestinal
- Bowel obstruction
- Peptic ulcer
- Bowel perforation
- Acute appendicitis
- Diverticulitis
Biliary/pancreatic
- Acute pancreatitis
- Cholelithiasis
- Choledocholithiasis
- Cholecystitis
- Cholangitis
Genitourinary
- Nephrolithiasis
- Pylonephritis
- Ovarian torsion
- Ectopic pregnancy (ruptured)
- Testicular torsion
What are some of the feature you might expect to find on hx/ex in a case of acute pyelonephritis?
High fever Chills Flank pain Costovertebral angle tenderness LUTs: dysuria, frequency, urgency
What Ix would you consider in a case of suspected pyelonephritis?
FBE: ^ WCC CRP: ^ ESR: ^ Urinalysis: WBC, haematuria, bacteruria, nitrites Urine culture
** Imaging not routinely recommended in uncomplicated pyelonephritis **
Consider if necessary:
- Renal US
- CT pelvis w & w/o IV contrast - indicated if suspicion of obstruction at presentation (ie. sx: renal colic) OR no improvement after 72 hrs of empiric ABx tx
What are some of the feature you might expect to find on hx/ex in a case of nephrolithiasis?
Colicky flank pain (= renal colic) Pain severe Pain unilateral Haematuria N&V LUTs: dysuria, frequency, urgency
What Ix would you consider in a suspected case of nephrolithiasis?
Urine dipstick and urinalysis: gross/microscopic haematuria
Urine microscopy: urinary crystals
CT abdo pelvis: non-enhanced (non-contrast) CT = gold standard
U/S: method of choice when trying to avoid radiation exposure (pregnant, children, frequent stones)
What Ix would you consider in a suspected case of ruptured ectopic pregnancy?
bHCG Transabdominal/transvaginal pelvic US - free fluid in PoD/Morison pouch - empty uturine cavity - thickened endometrial lining - adnexal mass - tubal ring sign
What Ix would you consider in a suspected case of ovarian torsion?
Pelvic (transabdominal/transvaginal) US (w doppler)
- enlarged, oedematous ovaries
- reduced blood flow
** If US findings are not confirmatory **
CT pelvis w IV contrast
What Ix would you consider in a suspected case of testicular torsion?
CLINICAL dx –> straight to theatre
May consider doppler US
- reduced blood flow/perfusion to affected testicle
For what kind of bacteria would you consider using metronidazole?
Protozoa
Anaerobic bacteria
For what kind of bacteria would you consider using ciprofloxacin?
Broad spectrum Abx
- effective against both G+ and Gi bacteria
- commonly used to tx GI and GU infections
For what kind of bacteria would you consider using ceftriaxone?
Some G+
Severe G- (Neisseria meningitidis) that are resistant to beta-lactam Abx
For what kind of bacteria would you consider using meropenem?
Last resort Abx for severe G+ and G- infections, due to severe SE
Can metronidazole be used in pregnancy?
C/I in 1st trimester of pregnancy
What can be a late complication of acute necrotizing pancreatitis?
Pancreatic abscess
What is the best prognostic indicator for acute pancreatitis?
Haematocrit
Acute pancreatitis –> 3rd space losses –> ^^ haematocrit
=> the decrease in HCT following IVT administration provides and indications of the severity of the the 3rd space losses, and thus, an indication of the severity of the pancreatitis overall
What is the criteria used to predict the severity and prognosis of patients with acute pancreatitis?
Ranson criteria
- glucose
- age
- LDH
- AST
- WCC
- HCT
- BUN
- Calcium
- pO2
- Base excess
- Fluid sequestration
What is the most useful initial test in patients with suspected acute pancreatitis?
Ultrasound
- main purpose: detect gall stones and/or dilatation of the biliary tract (indicating biliary origin)
- what you might see: indistinct pancreatic margins (oedematous swelling), peripancreatic fluid, evidence of necrosis, abscesses, pancreatic pseudocysts
What is the management of acute pancreatitis?
General
- Admission
- Assessment of dse severity (consider ICU)
- Fluid resuscitation: aggressive ehydration with crystalloids
- Analgesia: IV opioids (ie. fentanyl)
- Bowel rest and IV fluids until pain subsides
- NG tube indicated only if patients vomiting +/ significant abdo distension
- Nutrition: enteral feeding when pain subsides (low-fat)
- Antibiotics: only in patients with evidence of infected necrosis
Procedures/surgery (if biliary pancreatitis)
> Urgent ERCP and sphincterotomy (< 24hrs)
- pt. w evidence of choledocholithiasis +/ cholangitis
> Cholecystectomy (preferably during same admission, or within 6 wks)
- all pt. with biliary pancreatitis
