Abdominal Emergencies

Question 1

3 types of pain the abdomen can experience

Answer 1

Visceral, somatic and referred

Question 2

What is visceral pain like

Answer 2

Afferent nerve fibres, dull, poorly localised, can be from any area (foregut, midgut, hindgut)

Question 3

What is somatic pain like

Answer 3

Parietal peritoneum, sharp, well localised, made worse by movement, better lying still

Question 4

What causes referred pain

Answer 4

From nerves transmitting visceral and somatic pain

Question 5

Causes of colicky pain

Answer 5

Intestinal obstruction

Question 6

Causes of constant pain

Answer 6

Peritoneal irritation

Question 7

Pain from small gut

Answer 7

More frequent pain, mid abdomen

Question 8

Pain from large gut

Answer 8

Lower abdomen, hindgut structure, frequency of contractions reduced

Question 9

What is peritonitis

Answer 9

It is an examination finding, where there is guarding or percussion tenderness. Can be localised or generalised

Question 10

Causes of primary peritonitis

Answer 10

Spontaneous bacterial peritonitis

Question 11

Causes of secondary peritonitis

Answer 11

Perforation, appendicitis

Question 12

Causes of important abdominal emegencies

Answer 12

Ruptured AAA, cholecystitis, appendicitis, diverticulitis, ischaemic bowel, bowel obstruction, pancreatitis

Question 13

Risk factors for gallstones

Answer 13

Fat, female, fertile, forty, family history - also weight loss, increasing age, metabolic syndrome

Question 14

Consequences of gallstones

Answer 14

Biliary colic, cholangitis, cholecystitis, severe cholecystitis, pancreatitis

Question 15

Causes of bowel obstruction

Answer 15

Adhesions (congenital bands, post-op, inflammatory), hernias, vovulus, intraluminal (tumour or FB), strictures (malignant - colorectal, benign - crohns)

Question 16

What is a simple obstruction

Answer 16

One point of obstruction and no vascular compromise

Question 17

What is a closed loop obstruction

Answer 17

2 points of obstruction such as lower bowel obstruction with competent IC valve, leading to distension and perforation

Question 18

What is a stangulated obstruction

Answer 18

Vascular compromise, ischaemic, perforation, peritonism, fever and raised WCC

Question 19

Complications of perforated diverticulitis

Answer 19

Local/pelvic abscess, purulent peritonitis, faecal peritonitis, purulent and faeculant

Question 20

What makes up an appendix mass

Answer 20

Small bowel, omentum, intraabdominal fat, sometimes colon and fallopian tube

Question 21

Why does an appendix mass form

Answer 21

Body tries to seal off the infection

Question 22

Treatment of appendix mass

Answer 22

Usually treated with antibiotics and avoid surgery as it normally settles.
If >4cm then radiologically drain.

Question 23

What is happening if a patient is moderately well with appendicitis

Answer 23

Local infection and abscess, can become walled off with omentum

Question 24

What is happening if a patient is unwell with appendicitis

Answer 24

Inflammation, ischaemia, perforation, and widespread peritonitis

Question 25

Symptoms of cholangitis

Answer 25

Ascending cholangitis, obstructive jaundice, pain or no symptoms

Question 26

How to rule out AAA

Answer 26

US scan

Question 27

Key finding in ischaemic bowel

Answer 27

High lactate

Question 27

Key finding in ischaemic bowel

Answer 27

High lactate

Question 28

When does amylase peak in pancreatitis

Answer 28

12 hours after

Question 29

Symptoms of upper GI bleed

Answer 29

Haematemesis, melaena, syncope, dizziness, haematochezia, hypotension, tachycardia

Question 30

Most common causes of upper GI bleeds

Answer 30

Peptil ulcer, mallory-weiss tear, erosion, oesophagitis, varices

Question 31

Key history points for upper GI bleed

Answer 31

Liver disease, profuse recent vomiting, peptic ulcer disease, gastritis, H.pylori infection, alcohol, NSAIDs

Question 32

What suggests a variceal bleed

Answer 32

Evidence of decompensated liver disease, jaundice, ascites, encephalopathy

Question 33

What is the Glawgos-Blatchford score used for

Answer 33

Risk assessment tool of choice in ED for management of upper GI bleed

Question 34

What is the Rockall score used for

Answer 34

Risk assessment tool for identifying high risk upper GI bleeds

Question 35

Management of somatostatins in variceal bleeds

Answer 35

Somatostatins (Octreotide) and vasopressins (Terlipressin), broad spectum antibiotics

Question 36

Management of non-variceal bleeding

Answer 36

Endoscopy

Question 37

What is a balloon haemorrhage

Answer 37

Effective method of controlling a variceal haemorrhage until definitive intervention

Question 38

Common causes of lower GI bleeding

Answer 38

Diverticular disease, IBD, neoplasia, benign anorectal disease, angiodysplasia

Question 39

What is included in the BLEemergency department criteria

Answer 39

Ongoing bleeding, hypotension, abnormal clotting, altered mental status, significant co-morbidities

Question 40

What does the BLEED classification stand for

Answer 40

Bleeding Low systolic BP Elevated prothrombin time Erratic mental status Disease - unstable comorbid

Question 41

What is the management of an unstable lower GI bleed

Answer 41

Colonscopy +/- angiography if massive

Question 42

Management of stable patient with lower GI bleed

Answer 42

Colonscopy

Question 43

Other investigations for lower GI bleeding

Answer 43

Proctoscopy, technetium labelled red blood cell staining, upper GI endoscope, CT angiography, recto-sigmoidoscopy

Question 44

When is surgical intervention required for lower GI bleeds

Answer 44

Haemodynamically instability persists despite aggressive resuscitation or bleeding continues/recurs