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Abdominal pain Flashcards

1
Q

How does the patient describe her symptoms?

A 
Bad abdominal pain 
Started last night
Slowly getting worse
Slept terribly
Sharp 
Middle and top of tummy
Laughing makes it worse
Sudden onset
Nothing like this before
Stomach pain on and off for a year but not as bad as this
Gets worse when she eats well 
Nausea - vomited once
Tenderness in the right upper quadrant
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2
Q

Does the patient have any health problems?

A

Borderline diabetes

Should loose weight and eat better

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3
Q

What is found in the lifestyle history?

A

Works in a bank
Glass of wine most nights
3-4 bottles a week

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4
Q

What is the doctors plan of action?

A

Examine
Run bloods
Painkiller
Explain what’s going on

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5
Q

What does acute abdomen refer to?

A

Rapid onset of severe symptoms that may indicate potentially life-threatening intra-abdominal pathology

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6
Q

In who can pain free acute abdomen occur in?

A

older people
children
immunocompromised
last trimester of pregnancy

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7
Q

What are some feature of acute abdominal pain?

A

Be located in any quadrant of the abdomen
Be intermittent, sharp or dull, achy, or piercing
Radiate from a focal site
Be accompanied by nausea and vomiting.

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8
Q

What should immediate assessment focus on?

A

Distinguishing patients with true acute abdomen that requires urgent surgical intervention from patients who can initially be managed conservatively

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9
Q

How is acute abdomen diagnosed?

A 
History
Physical examination
Radiography 
Laboratory results
OR
Diagnostic laparoscopy
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10
Q

In what can a laparoscopy be used therapeutically?

A

appendicitis, cholecystitis, lysis of adhesions, hernia repair, and many gynaecological causes of an acute abdomen.

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11
Q

What can help stratify the risk of appendicitis in patients presenting with acute abdominal pain?

A

The Appendicitis Inflammatory Response (AIR) score

The Pediatric Appendicitis Risk Calculator (pARC)

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12
Q

What is discourage in undiagnosed patients with acute abdomen?

A

Use of narcotic analgesia
because of concerns that symptoms would be masked, the examination hindered, and, therefore, the correct diagnosis missed

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13
Q

Why can diagnosis be delayed in older people?

A

More co-morbidities
Dementia (issues communicating issues)
PNS dysfunction can alter perception of pain and temperature

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14
Q

Why can diagnosis be delayed in pregnant women?

A

Enlargement of uterus displaces and compresses abdo organs

Physiological leukocytosis

Hesitancy to conduct radiographs

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15
Q

What are common differentials for acute abdomen?

A

Adhesions
Incarcerated/strangulated hernia
Cholecystitis
Gastric ulcer

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16
Q

What are uncommon differentials for acute abdomen?

A

Volvulus
Intussusception
Duodenal ulcer
Ruptured ovarian cyst

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17
Q

What are the abdo causes of acute abdo (from common to less)?

A 
Intestinal obstruction
Peritonitis secondary to infection
Haemorrhage
Ischaemia
Contamination by gastrointestinal contents
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18
Q

What can cause abdominal haemorrhage?

A

ectopic pregnancy, ruptured aortic aneurysm

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19
Q

What can cause abdominal ischaemia?

A

ovarian torsion, mesenteric ischaemia

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20
Q

What processes can lead to contamination by GI contents?

A

perforated duodenal or gastric ulcer

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21
Q

What causes obstructions?

A 
Adhesions
Hernia incarcerations
Volvulus
Gallstones
Intussusception 
IBD
Neoplasm
Congenital abnormalities
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22
Q

What can cause inflammation?

A 
cholecystitis
appendicitis
acute pancreatitis
acute diverticulitis  
Meckel diverticulitis
UC
Crohn's
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23
Q

What should happen in females of child bearing age with acute abdomen?

A

should always have a pregnancy test to rule out ectopic pregnancy

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24
Q

What are gynae causes of acute abdomen?

A

ruptured ovarian cyst, ovarian torsion, pelvic inflammatory disease, and endometriosis

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25
Q

What does Budd-Chiari syndrome involve?

A

Hepatic venous outflow obstruction and the abdominal pain may present with hepatomegaly and ascites

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26
Q

What can cause an abdominal wall haematoma?

A 
Spontaneous
Trauma
Exercise 
Coughing
Procedure
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27
Q

What are some abdominal infective diseases?

A

hepatic abscess or hepatitis

gastroenteritis, infectious colitis, typhlitis

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28
Q

What is Fitz-Hugh Curtis syndrome?

A

a complication of pelvic inflammatory disease, comprises right upper quadrant abdominal pain associated with perihepatitis

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29
Q

What are the metabolic causes of acute abdomen?

A

Uraemia, diabetic ketoacidosis, Addisonian crisis, and hypercalcaemia

Inherited -
acute intermittent porphyria and hereditary Mediterranean fever.

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30
Q

What are the toxic causes of acute abdomen?

A

Heavy metal poisoning

Narcotic withdrawal

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31
Q

What are the urological causes of acute abdomen?

A

Testicular torsion
Kidney stones
Pyelonephritis

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32
Q

What should be done while awaiting the results of lab tests?

A

Surgical consult
IV access
Vitals monitored and corrected

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33
Q

When should surgery be conducted with limited pre-op eval?

A

In patients exhibiting evidence of hypovolaemic shock with a known or suspected haemoperitoneum

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34
Q

What must be done if there is a potential haemorrhage?

A

Two large-bore IV lines
Typing and cross-matching
Fluid resus (2L isotonic)
Antifibrinolyitc? Tranexamic acid?

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35
Q

What is BP goal for AAA or aortic dissection?

A

Systolic 80-90

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36
Q

What can excess fluid replacement cause?

A

cause dilutional and hypothermic coagulopathy
lowers blood viscosity
increased perfusion pressure from the expanded volume can lead to secondary clot disruption

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37
Q

What should be done if a perforation, diverticulitis or appendicitis is suspected?

A

Broad-spec AB
As can lead to sepsis
Urinalysis and culture samples ideally done before

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38
Q

In who should you consider mesenteric ischaemia?

A 
Pain disproportionate to the signs
Older 
Smoking
PVD
AF
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39
Q

What is required for mesenteric ischaemia treatment?

A

Oxygen
Fluid
Empirical AB
Surgical and radiological consult

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40
Q

What are the key components in the history?

A

Time and onset

Previous instances of similar pain

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41
Q

What indicated acute appendicitis?

A

Sudden-onset umbilical pain radiating to right iliac fossa

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42
Q

What is suggestive of a gastric ulcer?

A

Long-term epigastric pain

sudden worsening may indicate perforation of the ulcer

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43
Q

What may indicate oesophageal perforation?

A

Sudden epigastric pain following vomiting

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44
Q

Epigastric pain?

A 
Gastric ulcer
Pancreatitis
Perforated oesophagus
Mallory-Weiss tear
MI
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45
Q

LUQ pain?

A 
Splenic infarct
Ruptured splenic artery aneurysm
Pyelonephritis 
Kidney stones
Perforation 
Malignancy (colon)
46
Q

RUQ pain?

A 
Cholelithiasis 
Cholecystisis
Hepatitis
Hepatic abscess 
Fitz-Hugh Curtis syndrome
Perforation 
Malignancy
Kidney stones
Pyelonephritis 
Acute api in pregnancy
47
Q

LLQ pain?

A 
Sigmoid volvulus
Diverticulitis
Crohn's
UC
Kidney stones
GI malignancy
Psoas abscess 
Strangulated hernia
Gynae concerns
48
Q

RLQ pain?

A 
Api 
Kidney stones
GI malignancy
Psoas abscess
Strangulated hernia
Gynae concerns
49
Q

Persistent lateralised pain?

A

Ascending or descending colon
Kidney
Gallbladder
Ovary

50
Q

Pain with radiation to the back?

A

pancreatitis, abdominal aortic dissection, or ruptured abdominal aortic aneurys

51
Q

Right scapula pain?

A

Gallbladder disease, liver disease, or irritation of right hemidiaphragm

52
Q

Left scapula pain?

A

Cardiac disease, gastric disease, pancreatic disease, splenic disease, or irritation of left hemidiaphragm

53
Q

Testicular pain?

A

kidney stones or ureteral disease.

54
Q

Associated systemic symptoms?

A

cholecystitis, a ruptured duodenal ulcer, gastric ulcer, appendicitis, acute mesenteric ischaemia, PID, acute diverticulitis, hepatic abscess, hepatitis, abdominal wall haematoma, or spider bites

55
Q

Obstructive bowel process?

A

No recent bowel movement

56
Q

What must you ask the patient?

A 
Associated symptoms
Time of last bowel movement
Nature of last bowel movement
Type and time of last meal
Anorexia?
PMH 
Last menstrual period/contraception 
FH
Travel
57
Q

What is important with the examination?

A 
Vitals
PIPPA
Rigid abdomen 
Distended
Guarding 
Rebound tenderness
Murphy's sign
58
Q

What is Murphy’s sign?

A

Right upper quadrant tenderness with arrest of inhalation during palpation

59
Q

What is a rectal examination conducted for?

A

presence of occult or frank blood, pain, or mass

60
Q

What lab tests should be done?

A

FBC
Electrolytes
Urinalysis
Pregnancy test

61
Q

What other lab tests can be done?

A

Metabolic panel
Coagulation studies
Serum amylase
Lactic acid levels

62
Q

What imaging can be done?

A 
AXT
Erect CXR
CT
USS
MRI
63
Q

In who would a laparoscopy be considered?

A

Clinically stable
No indication for therapeutic surgical intervention
No apparent cause for their abdominal pain after non-invasive procedures
No relative or absolute contraindication to surgery.

64
Q

What are the three diagnosis related to gallstones?

A

Biliary colic
Cholecystitis
Ascending cholangitis

65
Q

What are the features of biliary colic?

A

Constant pain
Gallbladder neck is blocked by the stone
Muscle spasms against the stone cause dull RUQ pain
Nausea or vomiting
Triggered by fatty foods that trigger CCK release and gallbladder contraction
Symptoms for less than 6 hours

66
Q

What are the features of cholecystisis?

A 
Pain 
Murphy's sign - when diaphragm flattens gallbladder hits hand and pain worsens 
Fever
Gallstone blocks the cystic duct 
Elevated WBCs and CRP
67
Q

What are the features of ascending cholangitis?

A

Fever
Jaundice
Gallstone comes out of gallbladder and moves up blocking the hepatic duct
Elevated WBCs and CRP
Abnormal LFTs - raised bilirubin and alkaline phosphatase

68
Q

What are the majority of gallstones?

A

Asymptomatic

Incidental findings

69
Q

What is the diagnosis of our patient and why?

A

Acute cholecystitis

Normal LFTs

70
Q

What is the investigation of choice for gallstones?

A

Abdo USS

71
Q

How are gallstones formed?

A

High level of cholesterol in the bile
High bilirubin
Both cause crystallisation of bile

72
Q

What are the risk factors for gallstone disease?

A 
High fat diet
Female
Fat
Fair
Fourties 
Fertile 
OCP
Crohn's or IBS
Recent weight loss
73
Q

What comprises bile?

A 
98% water 
Bile salts 
Bilirubin
Electrolytes 
Cholesterol
74
Q

What affects the composition of gallstones?

A

Age
Diet
Ethnicity

75
Q

What are the types of gallstones?

A

Cholesterol stones
Pigment stones
Mixed

76
Q

What are the features of pigment stones?

A 
Bilirubin breakdown products (from breakdown of RBCs)
Small
Dark
Numerous 
From excess bile pigment production
77
Q

Give an example of a condition that would cause pigment stones?

A

Haemolytic condition

78
Q

What are the other complications of gallstones?

A

Acute pancreatitis
Gallstone Ileus
Gallbladder cancer

79
Q

What are the characteristics of pancreatitis?

A

High amylase and lipase

80
Q

What is gallstones ileus?

A

Small bowel obstruction secondary to gallstones
Large gallstone enters duodenum and causes blockage
Occurs of extended period of time
Hole forms between gallbladder and duodenum

81
Q

What is the treatment for symptomatic cholecystisis?

A

Laparoscopic cholecystectomy

82
Q

What is needed to obtain consent?

A 
Provide all relevant info - tailor conversation to needs of patients 
Diagnosis 
Prognosis
Risks
Lifestyle 
Explain treatment and benefit
How successful it is likely to be
Who's involved and potential follow ups
Allow patient time to reflect
Give copy of form
83
Q

What is essential re the person giving consent?

A

Consent must be voluntary

Patient must have capacity

84
Q

What are the risks and complications of a laparoscopic cholecystectomy?

A 
Bile leakage 
Injury to bile duct 
Injury to surrounding structures (liver, intestine, bowel and blood vessels)
Leaking of urine
Risk of converting to open surgery
85
Q

What are some general surgical risks?

A

Infection
General anaesthetic (allergy?)
Chronic pain

86
Q

How can we categorise complications?

A

General vs. Specific

Early vs. Late

87
Q

What are the early risks?

A

Wounds - keep dry and clean

88
Q

What are some late risks?

A

Hernias

Scar not healing properly

89
Q

What is the biliary system?

A

series of ducts within the liver, gallbladder, and pancreas that empty into the small intestine

90
Q

What is the role fo the gallbladder?

A

component of the extrahepatic biliary system where bile is stored and concentrated

91
Q

How is the gallbladder attached to the rest of the extrahepatic biliary system?

A

Via the cystic duct

92
Q

What do hepatic lobules contain?

A 
Central vein
Portal triads (bile duct, portal vein, hepatic artery)
93
Q

What connects the peripheral vasculature to the central vein?

A

Epithelial lined sinusoids run between the hepatocytes and connect the peripheral vasculature to the central vein

94
Q

What is the function of the canals of hering?

A

The bile produced by the hepatocytes is drained in the opposite direction of blood flow to the periphery of the lobule by small channels known as the Canals of Hering

95
Q

What are the layers of the gallbladder wall?

A

Innermost mucosal layer (columnar epithelium with microvilli)
Lamina propia
Outer serosal layer

96
Q

From what does the gallbladder develop?

A

Foregut

97
Q

What happens at the 4th week of embryogenesis?

A

structure called the hepatic diverticulum appears. The hepatic diverticulum goes on to become the liver, extrahepatic biliary system, and a portion of the pancreas.

98
Q

What happens at week 6 of embryogenesis?

A

The common bile duct and part of the pancreas rotate around the duodenum

99
Q

Which cells are stimulated by fatty acids?

A

I-cells
Release CCK
CCK stimulates the smooth muscle of the gallbladder
CCK also signals the sphincter of Oddi to relax

100
Q

Where are bile acids synthesised?

A

Liver from cholesterol pre-cursors

101
Q

What is the RDS of bile acid production catalysed by?

A

cholesterol 7α—hydroxylase

102
Q

What happens in the RDS?

A

The bile acids are conjugated to the amino acids glycine and taurine and become soluble bile salts.

103
Q

Describe enterohepatic circulation

A

The bile salts are reabsorbed in the distal ileum of the small intestine and recycled back to the liver

104
Q

Why does bile not being able to enter the duodenum cause jaundice?

A

the buildup of bilirubin

105
Q

What is the most specific test to diagnose cholecystisis?

A

Hepatobiliary Iminodiacetic acid (HIDA) scan

106
Q

What can cause acalculous cholecystitis?

A

Infection
Low perfusion
Biliary stasis

107
Q

What drugs can increase risk of gallstone formation?

A

HRT
Somatostatin analogues
Fibrates

108
Q

What are the main features of brown pigment stones?

A

Biliary tract infections

More frequent in Asia

109
Q

What are the main features of black pigment stones?

A

Mainly consist of calcium bilirubinate

Found in haemolytic anaemia or ineffective haematopoesis in patients with CF

110
Q

What are the three mechanisms of cholesterol stone formation?

A

Cholesterol supersaturation of bile
Gallbladder hypomotility
Kinetic, pro-nucleating protein factors

111
Q

What is cholesterol supersaturation?

A

Precipitation of cholesterol occurs when cholesterol solubility exceeds the (cholesterol saturation index >1)

Cholesterol crystals occur at low phospholipid : cholesterol ratios

Multilammellar vesicles then fuse and may aggregate as solid crystals.

112
Q

What are the main features of gallbladder hypomotility?

A

altered interdigestive gallbladder emptying

seen in several risk groups for cholesterol gallstones, e.g. patients with diabetes mellitus, and rapid weight loss

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