Abdominal condition 1 Flashcards
pathophysiology of Abdominal Aortic Aneurism
irreversible dilation of the vessel by at least 50% of normally expected diameter (2cm)
caused by degrading of the elastic layer of the artery
what is the normal diameter of the abdominal aorta
2 cm ( but inc with age)
presentation of unruptured AAA
mostly have no symptoms, incidental findings in AXR or CTKUB.
can also present with pain in the back+/-abdo+/-loin
pulsatile expansive swelling/limb ischaemia
presentation of ruptured AAA
hypoTN
atypical abdominal symptoms
sudden onset and severe pain in the back
syncope
shock
collapse
PEA cardiac arrest
where is the most common place in the abdominal aorta for the aneurysm to occur
infra-renal portion of the abdominal aorta
examination finding of AAA
triad of abdo/back pain + pulsating abdo mass + hypotension
bimanual palpitation of the supra umbilical region
pulsatile and expansile pulse
abdo bruit
Cullen’s and grey turners’ Sign if ruptured
investigation fot AAA
abdo USS - to confirm the diagnosis of AAA
bloods –> FBC, U&Es, clottings, crossmatch, group & save, clotting, CRP
ECG
USS, CT, MR angiography if non-urgent
Management of ruptured AAA
Acute ruptured AAA
• acute resus A-E, target systolic BP 50-70, NBM for urgent surgical repair (endovascular aneurysm repair EVAR preferred) + ABx for surgery
Symptomatic but not ruptured AAA
• if symptomatic regardless of diameter urgent surgical repair (EVAC preferred) + low-dose aspirin & control HTN (both to lower cardiovascular risk) + Abx for surgery
Incidental finding – small asymptomatic AAA (4 – 5.5cm)
• surveillance + aggressive cardiovascular risk management (low dose aspirin + control HTN + statin + beta-blocker if MI risk high)
Incidental finding – large asymptomatic AAA (>5.5cm in men, > 5cm in women)
• elective surgical repair (EVAR/open) + low-dose aspirin + control HTN +/- beta blocker + abx for surgery
Aetiology of appendicitis
infection and obstruction caused by lymphoid tissue hyperplasia, faecolith or filarial worms leading to oedema, ischaemic necrosis and perforation
presentation of appendicitis
abdo pain - starts generalised, then becomes to localised to the RIF
lack of appetite and sometimes vomiting and diarrhoea
findings on examination for appendictis
abdo pain and guarding in the RIF
could be a tender mass due to an appendix abscess
Rovsing’s sign - inc pain in the RIF when LIF is pressed
Psoas sign - pain on extending the hip if retrocaecal appendix
Cope sign - pain on flexion and internal rotation of the righ hip if appendix is close to the obturator internus
general signs - tachycardia, fever, furred tonged, lying still, coughing hurts, shallow breathe (due to pain)
investigation for appendicitis
usually clinical diagnosis but can also do USS/CT (CT more accurate)
bloods - neutrophil leucocytes, elevated CRP/ESR
US - may show inflamed appendix (not always visible)
CT - highly accurate but not always worth the radiation dose
management of appendicitis
appendectomy - eith open or laproscopic
ABX - metronidazol and cefuroxime
differentials of appendicitis
ectopic pregnancy UTI PID diverticulitis mesentric adenitis cystitis
what is another name for biliary tract infection
cholecystitis
RF of cholecystitis & gall stones
5 fs
Fat Forty Female Fiar Fertile
what are 2 main types of gallstone
cholesterol gallstones = 80% of all gallstones ( from in the bile due to either lack of bile salt or hypercholesterolaemia)
pigment stones - consist of bilirubin polymers, seen in pt with chronic haemolysis (sickle cell)
what is the biggest cause of acute cholecystitis
gallstone
presentation of acute cholecystitis?
often asymptomatic
continuous epigastric/RUQ pain –> can radiate to R shoulder
vomiting, fever, local peritonism
clinical signs of acute cholecystitis
exam often normal
Murphy’s sign - pain on inhalation due to peritonisum
fever Gallbladder mass
investigation for cholecystitis
clinical diagnosis
USS for confirmation of diagnosis –> thicken wall, shrunken GB, fluid.
amylase
Inc in ALP and bilirubin, WBC (possible)
CXR and ECG to rule out atypical MI
management of acute cholecystitis
initial treatment supportive NBM, IV fluids, analgesia (opiate), IV Abx (ceftriaxone + metronidazole + Tazocin/meropenem/imipenem
Definitive treatment
- Cholecystectomy delayed for a few days to allow symptoms to settle
if worsening pain, fever, empyema or gangrene of GB urgent USS abdo/CT to identify pathogens then urgent lab cholecystectomy
what are the different types of bowel obstruction
mechanical and functional
small and large bowel
what does biliary colic mean
Biliary colic = RUQ pain, radiate to the back +/- jaundice
what can cause mechanical bowel obstruction
adhesion constipation tumours hernias sigmoid/caecal volvulus diverticular stricture
rare foreign body gallstone illeus CD strictures intussusception TB
which section of the bowel is bowel volvus most commonly seen?
sigmoid
what can cause functional bowel obstruction
due to paralysis of the muscle controlling the GIT
post-op ileus (most commonly occur post- abdo surgery)
electrolyte disturbance - hypokalemia, hyponatraemia, ureamia
drugs - tricyclics
clinical features of bowel obstruction
colicky abdo pain
vomiting (faceical = sigmoid obstruction, bilious = small intestine)
distension
absolute constipation
absence (late) or tinkling bowel sound
general signs - fever, shock, hernia, dehydration
investigation for bowel obstruction
bloods FBC, U&Es, GC+S, clotting, VBG assess for pH and electrolyte from vomiting and bowel strangulation
AXR + erect CXR
CT (with/without contrast) – to confirm the diagnosis, cause, and guides surgical intervention
Abdo USS – critically ill patients, suspected SBO and contraindicated for contrast CT
management for bowel obstruction
- NBM
- drip and suck IV fluids + NG (Ryles) tube to drain stomach content
- IV analgesia and antiemetics
- surgery if haemodynamically unstable, features of sepsis, signs of ischemia and necrosis, partial obstruction > 3 days
- incomplete SBO can be treated initially conservatively & correction of electrolyte imbalance
- LBO/strangulation requires surgery, emergency if strangulation, stenting can be use
- sigmoid volvulus ‘un-kinked’ with flexible sigmoidoscopy
what is drip and suck
it is nasogastric depression of the gastric content as part of the management of the small bowel obstruction
causes of diverticulitis
lack of dietary fibre is thought to be a cause of inc intra-luminal pressure, causing the mucosa to herniate through the muscle of the gut
the hardened faeces cause stagnation of faces in the neck of the diverticulum allowing bacteria to grow and cause infection
which part of the GIT is diverticulitis found
sigmoid colon
definition of the diverticulitis
inflammation to the diverticulum - can be acquired or congenital
what can diverticulitis lead to?
peri-colic abscess
frank peritonitis
presentation of diverticulitis
abdo pain - lower left-sided colic (sigmoid), constant, dull
fever, tachycardia, tenderness, rigidity
change in bowel habits
pain often relied on defecation
nausea and flatulence
mass in LLQ, bowel sound reduced
abrupt painless bleeding -> if diverticulum bleeding
investigation for diverticulitis
bloods - FBC, U&Es, CPR and WCC
erect CXR (perforation, free gas and fluid collections), AXR and USS
management for diverticulitis
diverticulosis
no treatment, but high fibre diet
diverticulitis
24 hours admission if CRP elevated + ABx ciprofloxacin + Metronidazole
if severe disease
o bowel rest
o IV fluids
o IV Abx ciprofloxacin + metronidazole
o surgical resection if severely sepsis and obstruction
definition of ectopic pregnancy
fertilised ovum implants outside the uterine cavity
where is the most likely place for an ectopic pregnancy to occur
in the fallopian tube - ampulla/narrow inextensible isthmus
which type of ectopic pregnancy is most likely to rupture
in the inextensible isthmus
RF for ectopic pregnancy
anything that slows the ovum to pass - PID or previous surgery
prosgesterone only pill
smoking
IVF
IUD
what is the biggest RF for ectopic pregnancy
previous ligation of the tube –> 9x more likely to have ectopic pregnancy
presentation of ectopic pregnancy
sudden, severe, lower abdo pain
shoulder tip pain (irritation to the diaphragm)
vaginal bleeding
bloating
collapse/fainting
D+V
amenorrhoea 6-8 wks
peritonism
investigation for an ectopic pregnancy
vaginal and speculum exam
serum hCG
TVUSS - gold standard, might be able to see Bagel sign
bloods - FBC, G&S ( if surgery needed)
Serum progesterone and hCG (lower than expected due to failed pregnancy) to help identify failing pregnancy
management of ectopic pregnancy
if stable - expectant and medical management according to criteria (hCG<5000 Iu/L)
if unstable - surgical management
what are the selection criteria for expectant and medical management of ectopic pregnancy
asymptomatic or mild symptoms
hCG< 5000 ru
ectopic pregnancy < 3cm on scan with no foetal activity
no haemoperitoneum on TVS
what is expectant as an management for ectopic pregnancy
watch and wait medically - check up every week
what is the medical management of ectopic pregnancy
methotrexate as a single dose (teratogenic)
suggest future use of reliable contraceptive
definition of miscarriage
foetal death < 24 wks
causes of miscarriage
• foetal abnor
• sporadic chromosomal abnor (most common)
• structural malformation major neural tueb defects eg 1/3 of Downs miscarry
• uterine malformation eg bicornuate uterus
• acute pyrexial illness
• chronic maternal disease eg chronic renal failure
• maternal age
thrombophilia
presentation of miscarriage
vaginal bleeding
pain (lower chance of baby surviving)
vaginal discaharge –> conception materials
investigations for miscarriage
• hx and examination • blood group and rhesus factors • pregnancy test • TV USS serum HCG – inc if viable, dec if complete miscarriage
management of miscarriage
if heavy bleeding –> use ergometrine 500 mcg IM (used to cause uterine to contract so hard to stop bleeding)
expectant management
medical management - misoprostol ( prostaglandin to cause the cervix to ripen (thinning) and cause the uterine to contract
surgical management - EVAC
what is ovarian cyst
A fluid-filled sac present in the ovarian tissue
how common is ovarian cysts
extremely common particularly in women of reproductive age
what size of ovarian cysts would you expected to not cause any problem
< 5cm
what are the different types of ovarian cysts
physiological
infectious
benign neoplastic
malignant neoplastic
metastatic
which cancer most commonly cause metastatic ovarian cyst
ovarian, endometrial, colonic and gastric cancer
symptoms of ovarian cysts
often asymptomatic and incidental findings
chronic pain (dull ache) dysparaurea cyclical pain (with different periods)
can present as acute pain - due to bleeding within the cyst –> ovarian torsion
irregular vaginal bleeding
hormonal effects
abdo swelling/mass - ascites suggest malignancy
examination finding of ovarian cysts
can be normal is cyst small or women obese
if acute presentation - signs of shock
abdo exam - mass from pelvis, tenderness, peritonism or ascites
vaginal exam - vaginal discharge or bleeding
cervical excitation
adnexal mass /tenderness
investigation of ovarian cysts
FBC
tumour markers - Ca-125, AFP, Ca-19.9, LDh, hCG and CEA
transvaginal USS
MRI abdo
management of acute presentation of ovarian cysts
if unstable –> laparotomy
management of ovarian cysts in pre menopausal women
preserve fertility and exclude malignancy
conservative if stable & < 5cm
TVS repeats in 6 wks if no sign of malignancy and symptoms resolve then no surigcal intervention
but if still symopatic –> laparoscopic ovarian cystectomy
management of ovarian cysts in post menopausal women
calculate risk of malignancy
low risk cyst <5cm –> TVS every 4 months and Ca-125
moderate risk cysts –> bilateral oophorectomy
high risk –> referral to cancer centre for staging and laparotomy
what is pelvic inflammatory disease
infection spread from the cervix ascendingly to the ovary, uterus, fallopian tubes etc
can also descend from other organs eg appendix but not common
most common cause of PID
STI uterine instrumentation (hysterectomy, insertion of IUD, TOP - terminal of pregnancy)
which STI most likely to cause PID
Chlamydia
Gonorrhoea
symptoms of PID
lower abdo pain (can be both bilateral and unilateral)
can be constant/intermittent
deep dyspareunia
vaginal discharge
intermenstrual/poscoital bleeding
dysmenorrhoea
fever
examination finding of PID
vaginal discharge maybe present
cervical motion tenderness
uterine tendernes
adnexal tenderness
investigation for PID
vulvovaginal/endocervical swabs - for chlamydia and gonorrhoea + MC&S
FBC ( WCC elevated)
CRP
TVS ( if tubo-ovarian abscess)
management of PID
treat at home with a review after 72 hour if stable if not hospital admission
ceftriaxone or azithromycin for start + doxycycline for 2 weeks + metronidazole fo 2 wks
what are the aetiologies of abdominal aortic aneurysms?
sometimes idiopathic
aethersclerosis
trauma
infection - mycotic aneurysm (endocarditis), tertiary syphilis
connective tissue disorder - Marfan’s & Ehlers-Danlos
inflammatory - Takayasu’s aortitis
presentation of acute cholangitis
Charcot’s triad - fever, RUQ pain, jaundice
if not pick up in time, it can progress to Raynoid’s Pentard - Charcot’s triad + hypotension and confusion
management of acute cholangitis
initial
IV ABx + urgent bile duct drainage (done via endoscopic retrograde approach)
if severe ill stent to reduce time for removing the stone
definitive
lap cholecystectomy to remove the stone
management of unstable/ruptured ectopic pregnancy
surgical
- lap salpingostomy/salpingectomy
if hCG does not return to undetectable post-surgery –> single dose methotraxate
