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General surgery > Abdominal > Flashcards

Abdominal Flashcards

1
Q

What is the initial approach to acute abdomen?

A

Assess for life-threatening causes

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2
Q

What are some RED FLAGS for abdominal pain?

A 
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
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3
Q

What are some laboratory studies that should be considered when investigating abdominal pain, and why?

A

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

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4
Q

What is the appropriate imaging to select if you are suspecting acute appendicitis?

A

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
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5
Q

What is the appropriate imaging to select if you are suspecting acute diverticulitis?

A

CT abdo pelvis w IV contrast

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6
Q

What is the appropriate imaging to select if you are suspecting acute pancreatitis?

A

U/S abdo

CT abdo w IV contrast (if U/S unequivocal OR pt. critically ill at presentation)

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7
Q

What is the appropriate imaging to select if you are suspecting nephrolithiasis?

A

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)

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8
Q

What is the appropriate imaging to select if you are suspecting AAA in haemodynamically stable patient?

A

U/S abdo

CT/MRI angiography

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9
Q

What is the appropriate imaging to select if you are suspecting AAA in haemodynamically unstable patient?

A

NO IMAGING

Patient should go straight to the operating theatre

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10
Q

What is the appropriate imaging/Ix to select if you are suspecting ACS?

A

ECG

TTE

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11
Q

What is the appropriate imaging to select if you are suspecting haemorrhagic shock?

A

FAST scan (US of abdo looking for fluid/blood)

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12
Q

What is the appropriate imaging to select if you are suspecting a bowel perforation?

A 
CT abdo pelvis w IV contrast
Xray abdo (upright and supine) + CXR (upright)
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13
Q

What is the appropriate imaging to select if you are suspecting a small bowel obstruction?

A 
CT abdo pelvis w IV contrast
Xray abdo (upright and supine) + CXR (upright)
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14
Q

What is the appropriate imaging to select if you are suspecting acute diverticulitis?

A

CT abdo pelvis w IV contrast

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15
Q

What is the appropriate imaging to select if you are suspecting acute mesenteric ischaemia?

A

CT angiography of abdo

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16
Q

What is the classic presentation of acute mesenteric ischaemia and what other signs/sx might be present?

A

Classic: pain out of proportion abdo examination
Other: Blood diarrhoea, abdo distension and peritonitis
** when mesenteric ischaemia has progressed to bowel infarction (< 6 hrs) **

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17
Q

What are the life-threatening dx that must be excluded when a patient presents with acute abdomen?

A 
Ruptured AAA
Aortic dissection
Ruptured ectopic pregnancy
Mechanical bowel obstruction
Acute mesenteric ischaemia
Acute pancreatitis
Acute cholangitis
AMI
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18
Q

What investigations should be done if suspecting peptic ulcer dse?

A

FBE - anaemia if bleeding ulcer
Upper GI endoscopy - mucosal erosions/ulcers
Urea breath test - for H. pylori infection

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19
Q

What test is performed to identify H. pylori infection?

A

Urea breath test

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20
Q

What features might you expect to find on hx/examination in diverticulitis?

A

Fever
LLQ pain
Constipation
Tender mass in LLQ

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21
Q

What features might you expect to find on hx/examination in PUD?

A

Epigastric pain
Pain worse/better with eating: gastric ulcer/duodenal ulcer respectively
Hx of NSAID use
Signs of GI bleed

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22
Q

What might you expect to find on hx/ex in a mechanical bowel obstruction?

A 
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)
23
Q

What might you see on abdo xray in the case of a GI perforation?

A

Pneumoperitoneum

24
Q

What features on hx/ex might you expect in the case of a GI perforation?

A 
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
25
Q

What features on hx/ex might you expect in the case of acute appendicitis?

A 
Migrating abdo pain
  1. epigastric +/ periunbilical - diffuse
  2. RLQ - localised
Fever
Nausea
Anorexia
Guarding, tenderness and rebound tenderness in RLQ
Rovsing's sign
26
Q

What features on hx/ex might you expect in the case of acute pancreatitis?

A 
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
27
Q

What is an important early Ix in suspected pancreatitis, and what might it show?

A

Lipase level - typically >x3 normal

Amylase - less specific

28
Q

What Ix might you consider in suspected acute pancreatitis?

A
  1. Lipase
  2. Abdo U/S - pancreatic oedema, peripancreatic fluid, gallstones
  3. CT abdo w IV contrast - as for U/S, but also peripancreatic fat stranding
    * * not routine - consider if dx is uncertain **
  4. Calcium: hypocalcaemia = poor prognostic indicator
29
Q

What features on hx/ex might you expect in the case of symptomatic cholelithiasis?

A

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

30
Q

What features on hx/ex might you expect in the case of choledocholithiasis?

A 
RUQ pain (lasts > 6 hrs)
Ft. of obstructive jaundice (pee, poo, pruritis, jaundice)
N&V
Normal abdo. examination
31
Q

What features on hx/ex might you expect in the case of acute cholecystitis?

A 
Severe RUQ pain (> 6 hrs)
Fever, chills
N&V
R. shoulder pain, referred
Murphy's +ve
32
Q

What features on hx/ex might you expect in the case of acute cholangitis?

A

Charcot triad: RUQ pain, fever, jaundice

Reynold’s pentad: Charcot triad, hypotension, altered mental status

33
Q

What conditions are complications of gall stone disease (cholelithiasis)?

A

Choledocholithiasis (GS in CBD)
Biliary pancreatitis
Cholecystitis (GB inflammation)
Cholangitis (ascending bacterial infection of biliary tract, due to bile stasis)

34
Q

When suspecting biliary +/ pancreatic causes of abdominal pain, what are some important Ix to consider?

A

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?

35
Q

When faced with acute abdomen, what are some of the systems that must be considered?

A

Cardiovascular
Gastrointestinal
Biliary/pancreatic
Genitourinary

36
Q

When faced with acute abdomen, what are some ddx, according to system involved?

A

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
37
Q

What are some of the feature you might expect to find on hx/ex in a case of acute pyelonephritis?

A 
High fever
Chills
Flank pain
Costovertebral angle tenderness
LUTs: dysuria, frequency, urgency
38
Q

What Ix would you consider in a case of suspected pyelonephritis?

A 
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

39
Q

What are some of the feature you might expect to find on hx/ex in a case of nephrolithiasis?

A 
Colicky flank pain (= renal colic)
Pain severe 
Pain unilateral
Haematuria
N&V
LUTs: dysuria, frequency, urgency
40
Q

What Ix would you consider in a suspected case of nephrolithiasis?

A

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)

41
Q

What Ix would you consider in a suspected case of ruptured ectopic pregnancy?

A 
bHCG
Transabdominal/transvaginal pelvic US
 - free fluid in PoD/Morison pouch
 - empty uturine cavity
 - thickened endometrial lining
 - adnexal mass
 - tubal ring sign
42
Q

What Ix would you consider in a suspected case of ovarian torsion?

A

Pelvic (transabdominal/transvaginal) US (w doppler)

  • enlarged, oedematous ovaries
  • reduced blood flow

** If US findings are not confirmatory **
CT pelvis w IV contrast

43
Q

What Ix would you consider in a suspected case of testicular torsion?

A

CLINICAL dx –> straight to theatre

May consider doppler US
- reduced blood flow/perfusion to affected testicle

44
Q

For what kind of bacteria would you consider using metronidazole?

A

Protozoa

Anaerobic bacteria

45
Q

For what kind of bacteria would you consider using ciprofloxacin?

A

Broad spectrum Abx

  • effective against both G+ and Gi bacteria
  • commonly used to tx GI and GU infections
46
Q

For what kind of bacteria would you consider using ceftriaxone?

A

Some G+

Severe G- (Neisseria meningitidis) that are resistant to beta-lactam Abx

47
Q

For what kind of bacteria would you consider using meropenem?

A

Last resort Abx for severe G+ and G- infections, due to severe SE

48
Q

Can metronidazole be used in pregnancy?

A

C/I in 1st trimester of pregnancy

49
Q

What can be a late complication of acute necrotizing pancreatitis?

A

Pancreatic abscess

50
Q

What is the best prognostic indicator for acute pancreatitis?

A

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

51
Q

What is the criteria used to predict the severity and prognosis of patients with acute pancreatitis?

A

Ranson criteria

  • glucose
  • age
  • LDH
  • AST
  • WCC
  • HCT
  • BUN
  • Calcium
  • pO2
  • Base excess
  • Fluid sequestration
52
Q

What is the most useful initial test in patients with suspected acute pancreatitis?

A

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
53
Q

What is the management of acute pancreatitis?

A

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

General surgery (1 decks)

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