Abdominal pain Flashcards
Appendicitis ?
Inflammation of the appendix
FEATURES
- Abdominal pain originating in lower central region of stomach btw iliac fossa (Hypogastric / pubic region) -------------------> the spreads to Right iliac fossa (RLQ).
0 PAIN IS
OFTEN
CONSTANT
AND
ACCOMPAINED
BY
INTERMITTENT
CRAMPS AND
GET WORSE
WITH
MOVEMENT
OR
COUGHING.
(in pregnant women - RLQ tenderness may only appear after 1ST trimester due growing baby.
notes *
Remember that the location of the pain can vary depending on the position of the appendix:[21]
o Retrocaecal appendix - flank or back pain
o Retroileal appendix - testicular pain due to irritation of the spermatic artery or ureter.
o Pelvic appendix - suprapubic pain
o Paracolic long appendix with tip inflammation in the right upper quadrant may cause pain in this region.
- Anorexia
(almost always present - if patients is always hungry & wants to eat) - nausea & vomiting - especially in pregnant patients
NOTE - Localised peritonitis with guardinh in the region is indicative of a ruptured appendix - emergency
Guarding - muscle contract to protect from pain- if there in stiffness / feel hard - indicative of serious pathology.
- Signs of Peritonitis - abdominal distension , percussion dullness , rebound tenderness, absent bowel sounds , guarding.
i
- if the whole abdomen is tense & rigid - sign of generalised peritonitis (inflammation of peritoneum) - sign of perforated appendix.
perforated appendix ———————-> can lead to peri appendicular abscess (collection of pus near appendix) - felt as a palpable mass.
- low grade fever
- reduced bowel signs - sign of perforation
UNCOMMON
0 Psoas sign - flexed right hip - sign of retrocaecal appendicitis.
0 Constipation or diahrroae
Investigations for appendicitis ?
CRP - raised
FBC - mild leukocytosis
Imaging if needed ;
Ultrasound in pregnancy , if inconclusive MRI.
- for others radiologist consulted to determine best imaging to use.
CT abdominal contrast enhanced use if :
- suspected malignancy
- suspected appendicular abscess
- Ultrasound inconclusive
- Findings - abnormal appendix - diameter above 6mm)
CONSIDER - to exclude differentials
- Urinalysis - exclude UTI
- Pregnancy test - exclude pregnancy / ectopic.
- Group & save - for surgery candidates
Treatment of Appendicitis ?
UNCOMPLICATED APPENDICITIS - fit for surgery
1ST LINE Supportive measures (analgesia e.g. para or morphine , fluids , obstetric support (for pregnancy) + Appendicectomy
SURGERY NOT POSSIBLE/ UNWANTED - (not used in pregnancy - have surgery - it has said to be safe)
1ST LINE
0 Supportive measure + antibiotics
COMPLICATED APPENDICITIS
Supportive treatment + emergency Appendicectomy + post operative antibiotics
0 ABCDE signs
- signs of sepsis ?
- fluids
- take BP , HR etc measurements (Vital sign monitoring)
0 Analagesia
if they have abscess or phlegmon :
Laproscopic appendicectomy is done
if this not possible :
IV antibiotics + percutaneous image guided drainage
- if patient has been having conservative management e.g no surgery consider surgery if symptoms persist longer than 6 weeks
What is Diverticular disease & it is derivatives ?
Diverticular - sac like protrusions through muscular wall of colon.
In Diverticular disease - the Diverticular cause symptoms
SYMPTOMS
- Abdominal pain (Intermittent - usually in LLQ - opposite to appendicitis )
- Bloating
- Periods of constipation which can alternate with episodes of diarrhoea.
0 Diverticulitis - is when the diverticula become infected and inflamed
TYPES - Uncomplicated diverticulitis - localised infection not extending to peritoneum.
Complicated - associated with perforation , peritonitis , rectal bleeding , abscess , fistula , obstruction.
SYMPTOMS
- Severe Lower quadrant abdominal pain
- Fever
- General malaise
- Change in bowel habit
- Occasional rectal bleeding
(Leukocytosis - especially suspect if history of Diverticulosis)
SIGNS
- Guarding and /or tenderness in LLQ
- pelvic tenderness on digital rectal examination.
Diverticulosis - is Diverticula without symptoms- sometimes it ma present as large painless rectal bleed.
RISK FACTORS OF ALL
0 low dietary fibre 0 Age - 50 years and above WEAKER o NSAIDS are associated with perforation of colonic diverticula - and bleeding. o Obesity (BMI above 30)
Investigation for Diverticulitis ?
FBC with diffential - Polymorphonuclear leukocytosis (type of WBC - Neutrophil , eosinophil , basophil)
0 CRP - elevated - if greater than 170mg/L - greater probability of needing surgery.
CONSIDER
0 CT scan of abdomen - imaging of choice to confirm acute diverticulitis.
(Other imaging e.g MRI , Ultrasound - only done if CT cannot be done)
- X rays abdo - can also be done if acute diverulitis is expected.
0 Blood culture - if signs of systemic sepsis.
0 CXR - if suspected perforation - assess Pneumoperitoneum.
Treatment of Diverticulosis ?
No symptoms :
1st line
Dietary changes - increased fibre (including fruit & veg)
& lIfestyle changes - conselled to stop smoking or lose weight if needed.
Treatment of Diverticular disease ?
Symptomatic ;
e.g LLQ pain , bloating , constipation
1st line :
0 Diet modification (fibre & hydration) + Fibre supplementation.
ADJUCNT - oral antibiotic -
0 Amoxicillin / Clavulanate
0 Ciprofloxacin
0 Metronidazole
if evidence of infection or bacterial overgrowth.
(Broad spectrum - covering gram + & -) - risk of inducing Pseudomembranous colitis (inflammation of the colon due to overgrowth of C.difficle - common cause of diarrhoea after antibiotic use.
( C.difficle - lives in the intestine normally - antibiotics use can cause overgrowth)
Treatment of Uncomplicated Symptomatic Diverticulitis ?
1st line 0 Analgesia o Para - 1st o Tramadol - 2nd - opioid o Morphine sulphate - Tertiary
ADJUCNT - oral antibiotics
(in those with abdo pain , fever , leukocytosis - can be treated at home if CT scan rules out complications)
ADJUCNT - Low residue die - fibre resistriction (low in diet)——————-> reduces frequency & volume of stools ——–> reduces pain.
2ND LINE
IV antibiotics - if no improvement in symptoms after 72hrs of oral - have to be admitted to hospital.
+ Analgesia , low residue diet.
Treatment of complicated Symptomatic Diverticulitis ?
ACUTE RECTAL BLEEDING
1st line Endoscopic/angiographic - haemostasis - Colonoscopy done to localise bleeding - then method used to stop bleeding ?
PLUS - supportive therapy + antibiotics + Analgesia + low residue diet.
2ND LINE - BLEEDING NOT CONTROLLED
Surgery + supportive therapy + antibiotics + analgesia + low fibre diet
unresponsive to intravenous antibiotics or with abscess >3 cm diameter, perforation, fistulae, or obstruction
- radiological drainage / surgery + IV antibiotics + analgesia + low residue diet.
RECURRENT DIVERTICULITIS - elective colectomy.
What is Nephrolithiasis ?
Kidney stones
(more common in men - but difference is narrowing.)
PRESENT WITH :
Severe , acute flank pain that can radiate to the ipsilateral groin (if men - TESTICULAR PAIN (does always radiate - some are also asymptomatic)
-
due to Acute renal colic (type of abdominal pain - commonly caused by obstruction of ureters by dislodged kidney stones)
(either flank as kidneys on both left & right ) - flank is just above the iliac fossa region)
- Costovertebral tenderness (angle on the back btw 12th rib and veterbral column) - indicates kidney pathology.
OTHER SYMPTOMS
- urinary frequency /urgency - if in ureter irritates lining causing this.
Haematuria
-
RISK FACTORS
0 Dehydration 0 Diet - high salt intake 0 Crystaluria - cloudy urine due to crystals - oversaturated with these. 0 Obesity 0 Personal history of kidneys stones.
- if urinary obstruction associated with fever urgent decompression is needed.
if also have fever , tachycardia , hypotension - indicates sepsis.
Investigations of renal colic ?
Non contrast helical CT scan - URGENT - WITHIN 24 HRS OF PRESENTATION -not pregnant
- Findings :
0 Calcification in renal system / ureter
0 Hydronephrosis - kidneys stretch , dilated because of build up of urine.
0 Perinephric stranding - ( appearance of oedema within perirenal space on CT , MRI) ——————–. Sign of underlying inflammation / infection - non -specific (can also be linked to pyelonephritis , urolithiasis (basically nephrolithasis ), trauma , renal lymphoma
- sometimes a little is seen when patient ages - kidney sweat. )
PREGNANT/ CHILD
- Renal Ultrasound - URGENT;
- calcification within urinary tract
- Dilation
- if inconclusive in children Non contrast CT - low dose can be done.
OTHER TEST
0 Urine analysis
may see:
- Haematuria (micro - most likely)
- WBC - raised suggest infection (pyelonephritis / urinary tract infection)
- RBC
- Bacteria
- Nitrates
0 Serum electrolytes , urea & creatine
Can suggest underlying pathology :
Hypercalcemia - Hyperparathyroidism
Hyperuricaemia - suggest gout.
Pregnancy test
Treatment of renal colic ?
ACUTE RENAL COLIC - NO OBSTUCTION
1ST LINE
0 Hydration & analgesia
NSAIDS (any route (parental is the most effective) ——————-> IV Paracetamol (if NSAIDS contraindicated / not working) —————————-> Opiod ( if they have opiod - indiced nausea give antimetic )
Antispasmodics are not to be used : 0 ALVERINE CITRATE 0 ATROPINE SULFATE 0 DICYCLOVERINE HYDROCHLORIDE 0 HYOSCINE BUTYLBROMIDE 0 MEBEVERINE HYDROCHLORIDE 0 PEPPERMINT OIL 0 PROPANTHELINE BROMIDE
CONFIRMED RENAL / URETERIC STONE - non pregnant & evidence of obstruction + infection
IST LINE
0 Urgent decompression (drainage of built up fluid) + antibiotic therapy
( if no infection - no antibiotics)
IF NO EVIDENCE OF OBSTRUCTION :
1ST LINE
Hydration + anlagesia
Consider :
0 antibiotic therapy - if sign of infection
0 Watchful waiting - for renal stones - if less than 5mm & asymptomatic.
. (if above 5 - 10 mm and patient agrees to watch - inform of risk )
* For uretic stone - no watchful waiting - due to risk of instruction and kidney damage - MEDICAL EXPULSIVE THERAPY - e.g alpha blocker :
- Tamsulosin - not given if have planned cataracts surgery (risk of intraoperative floppy iris ) syndorme
- Alfuzosin
- Doxazosin
- Terazosin
-Indoramin
0 Consider surgery
- larger than 10mm or remain after conservative management.
PREGNANT - specialist referral - urologist / gynaecologist
ONGOING
- following acute episode
Hydration + diet modification (add lemon juice - calcium binding prevention , salt restriction)
Consider
- Alkalisation e.g. oral potassium citrate , sodium bicarbonate - dissolve stones.
For ongoing - acute - follow up after acute renal colic - medical prevention therapy - further knowlegde.
f the patient has a specific metabolic abnormality, individualised preventative therapies may be required in addition to dietary modification.[31][75][76] These patients will need to be managed in a specialist metabolic clinic setting where they can be offered tailored advice and interventions. These abnormalities and recommended interventions include:
Uric acid stones: urinary alkalinisation with potassium citrate or sodium bicarbonate[31]
Hypercalciuria and recurrent stones that are more than 50% calcium oxalate: thiazide diuretic with or without potassium citrate (after the patient has restricted their sodium intake to no more than 6 g per day)[15]
Hypocitraturia and recurrent stones that are more than 50% calcium oxalate: urinary alkalinisation (e.g., potassium citrate); sodium bicarbonate or sodium citrate can be considered if the patient is at risk for hyperkalaemia[15][76]
Hyperoxaluria: oxalate chelator (e.g., calcium, magnesium, or colestyramine), potassium citrate, pyridoxine; a rare condition
Cystinuria: high fluid intake alongside urinary alkalinisation with potassium citrate, thiol binding agent (e.g., tiopronin which is tolerated better than d-penicillamine); a genetic abnormality requiring life-long management.
Most of these strategies are applied to children with nephrolithiasis, although there are a limited number of well-designed trials in this age group
Signs of gastroenteritis ?
0 Sudden-onset diarrhoea (change of stool consistency to loose or watery stools, usually at least three times in 24 hours); blood or mucus in the stool; faecal urgency.
0 Nausea or sudden onset of vomiting.
0 Fever or general malaise.
0 Abdominal pain or cramps.
0 Associated headache, myalgia, bloating, flatulence, weight loss, and
0 malabsorption, depending on the underlying cause of infection.
SIGNS OF DEHYDRATION - ADULTS ?
0 Mild
- Lassitude.
- Anorexia and nausea.
- Light-headedness.
Signs include: - Possible postural hypotension.
0 Moderate Symptoms include: Apathy/tiredness. Dizziness. Nausea. Headache. Muscle cramps. Signs include: Pinched face. Dry tongue or sunken eyes. Reduced skin elasticity. Postural hypotension. Tachycardia. Oliguria.
0 Severe Symptoms include: Profound apathy and weakness. Confusion, leading to coma. Signs include: Marked peripheral vasoconstriction. Hypotension. Tachycardia. Uraemia, oliguria, or anuria. Shock.
