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Year 4 - ACC Core Condition > Abdominal condition 1 > Flashcards

Abdominal condition 1 Flashcards

1
Q

pathophysiology of Abdominal Aortic Aneurism

A

irreversible dilation of the vessel by at least 50% of normally expected diameter (2cm)

caused by degrading of the elastic layer of the artery

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2
Q

what is the normal diameter of the abdominal aorta

A

2 cm ( but inc with age)

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3
Q

presentation of unruptured AAA

A

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

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4
Q

presentation of ruptured AAA

A

hypoTN

atypical abdominal symptoms

sudden onset and severe pain in the back

syncope

shock

collapse

PEA cardiac arrest

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5
Q

where is the most common place in the abdominal aorta for the aneurysm to occur

A

infra-renal portion of the abdominal aorta

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6
Q

examination finding of AAA

A

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

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7
Q

investigation fot AAA

A

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

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8
Q

Management of ruptured AAA

A

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

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9
Q

Aetiology of appendicitis

A

infection and obstruction caused by lymphoid tissue hyperplasia, faecolith or filarial worms leading to oedema, ischaemic necrosis and perforation

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10
Q

presentation of appendicitis

A

abdo pain - starts generalised, then becomes to localised to the RIF

lack of appetite and sometimes vomiting and diarrhoea

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11
Q

findings on examination for appendictis

A

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)

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12
Q

investigation for appendicitis

A

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

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13
Q

management of appendicitis

A

appendectomy - eith open or laproscopic

ABX - metronidazol and cefuroxime

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14
Q

differentials of appendicitis

A 
ectopic pregnancy 
UTI 
PID 
diverticulitis 
mesentric adenitis 
cystitis
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15
Q

what is another name for biliary tract infection

A

cholecystitis

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16
Q

RF of cholecystitis & gall stones

A

5 fs

Fat 
Forty 
Female 
Fiar 
Fertile
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17
Q

what are 2 main types of gallstone

A

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)

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18
Q

what is the biggest cause of acute cholecystitis

A

gallstone

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19
Q

presentation of acute cholecystitis?

A

often asymptomatic

continuous epigastric/RUQ pain –> can radiate to R shoulder

vomiting, fever, local peritonism

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20
Q

clinical signs of acute cholecystitis

A

exam often normal

Murphy’s sign - pain on inhalation due to peritonisum

fever Gallbladder mass

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21
Q

investigation for cholecystitis

A

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

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22
Q

management of acute cholecystitis

A

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

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23
Q

what are the different types of bowel obstruction

A

mechanical and functional

small and large bowel

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24
Q

what does biliary colic mean

A

Biliary colic = RUQ pain, radiate to the back +/- jaundice

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25
Q

what can cause mechanical bowel obstruction

A 
adhesion
constipation
tumours 
hernias 
sigmoid/caecal volvulus 
diverticular stricture 
rare 
foreign body 
gallstone illeus 
CD strictures 
intussusception 
TB
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26
Q

which section of the bowel is bowel volvus most commonly seen?

A

sigmoid

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27
Q

what can cause functional bowel obstruction

A

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

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28
Q

clinical features of bowel obstruction

A

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

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29
Q

investigation for bowel obstruction

A

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

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30
Q

management for bowel obstruction

A
  • 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
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31
Q

what is drip and suck

A

it is nasogastric depression of the gastric content as part of the management of the small bowel obstruction

32
Q

causes of diverticulitis

A

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

33
Q

which part of the GIT is diverticulitis found

A

sigmoid colon

34
Q

definition of the diverticulitis

A

inflammation to the diverticulum - can be acquired or congenital

35
Q

what can diverticulitis lead to?

A

peri-colic abscess

frank peritonitis

36
Q

presentation of diverticulitis

A

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

37
Q

investigation for diverticulitis

A

bloods - FBC, U&Es, CPR and WCC

erect CXR (perforation, free gas and fluid collections), AXR and USS

38
Q

management for diverticulitis

A

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

39
Q

definition of ectopic pregnancy

A

fertilised ovum implants outside the uterine cavity

40
Q

where is the most likely place for an ectopic pregnancy to occur

A

in the fallopian tube - ampulla/narrow inextensible isthmus

41
Q

which type of ectopic pregnancy is most likely to rupture

A

in the inextensible isthmus

42
Q

RF for ectopic pregnancy

A

anything that slows the ovum to pass - PID or previous surgery

prosgesterone only pill

smoking

IVF

IUD

43
Q

what is the biggest RF for ectopic pregnancy

A

previous ligation of the tube –> 9x more likely to have ectopic pregnancy

44
Q

presentation of ectopic pregnancy

A

sudden, severe, lower abdo pain

shoulder tip pain (irritation to the diaphragm)

vaginal bleeding

bloating

collapse/fainting

D+V

amenorrhoea 6-8 wks

peritonism

45
Q

investigation for an ectopic pregnancy

A

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

46
Q

management of ectopic pregnancy

A

if stable - expectant and medical management according to criteria (hCG<5000 Iu/L)

if unstable - surgical management

47
Q

what are the selection criteria for expectant and medical management of ectopic pregnancy

A

asymptomatic or mild symptoms

hCG< 5000 ru

ectopic pregnancy < 3cm on scan with no foetal activity

no haemoperitoneum on TVS

48
Q

what is expectant as an management for ectopic pregnancy

A

watch and wait medically - check up every week

49
Q

what is the medical management of ectopic pregnancy

A

methotrexate as a single dose (teratogenic)

suggest future use of reliable contraceptive

50
Q

definition of miscarriage

A

foetal death < 24 wks

51
Q

causes of miscarriage

A

• 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

52
Q

presentation of miscarriage

A

vaginal bleeding

pain (lower chance of baby surviving)

vaginal discaharge –> conception materials

53
Q

investigations for miscarriage

A 
•	hx and examination 
•	blood group and rhesus factors 
•	pregnancy test 
•	TV USS 
serum HCG – inc if viable, dec if complete miscarriage
54
Q

management of miscarriage

A

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

55
Q

what is ovarian cyst

A

A fluid-filled sac present in the ovarian tissue

56
Q

how common is ovarian cysts

A

extremely common particularly in women of reproductive age

57
Q

what size of ovarian cysts would you expected to not cause any problem

A

< 5cm

58
Q

what are the different types of ovarian cysts

A

physiological

infectious

benign neoplastic

malignant neoplastic

metastatic

59
Q

which cancer most commonly cause metastatic ovarian cyst

A

ovarian, endometrial, colonic and gastric cancer

60
Q

symptoms of ovarian cysts

A

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

61
Q

examination finding of ovarian cysts

A

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

62
Q

investigation of ovarian cysts

A

FBC
tumour markers - Ca-125, AFP, Ca-19.9, LDh, hCG and CEA
transvaginal USS
MRI abdo

63
Q

management of acute presentation of ovarian cysts

A

if unstable –> laparotomy

64
Q

management of ovarian cysts in pre menopausal women

A

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

65
Q

management of ovarian cysts in post menopausal women

A

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

66
Q

what is pelvic inflammatory disease

A

infection spread from the cervix ascendingly to the ovary, uterus, fallopian tubes etc

can also descend from other organs eg appendix but not common

67
Q

most common cause of PID

A 
STI
uterine instrumentation (hysterectomy, insertion of IUD, TOP - terminal of pregnancy)
68
Q

which STI most likely to cause PID

A

Chlamydia

Gonorrhoea

69
Q

symptoms of PID

A

lower abdo pain (can be both bilateral and unilateral)

can be constant/intermittent

deep dyspareunia

vaginal discharge

intermenstrual/poscoital bleeding

dysmenorrhoea

fever

70
Q

examination finding of PID

A

vaginal discharge maybe present

cervical motion tenderness

uterine tendernes

adnexal tenderness

71
Q

investigation for PID

A

vulvovaginal/endocervical swabs - for chlamydia and gonorrhoea + MC&S

FBC ( WCC elevated)

CRP

TVS ( if tubo-ovarian abscess)

72
Q

management of PID

A

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

73
Q

what are the aetiologies of abdominal aortic aneurysms?

A

sometimes idiopathic

aethersclerosis

trauma

infection - mycotic aneurysm (endocarditis), tertiary syphilis

connective tissue disorder - Marfan’s & Ehlers-Danlos

inflammatory - Takayasu’s aortitis

74
Q

presentation of acute cholangitis

A

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

75
Q

management of acute cholangitis

A

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

76
Q

management of unstable/ruptured ectopic pregnancy

A

surgical
- lap salpingostomy/salpingectomy
if hCG does not return to undetectable post-surgery –> single dose methotraxate

Year 4 - ACC Core Condition (3 decks)

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