Abdominal pain Flashcards
How does the patient describe her symptoms?
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
Does the patient have any health problems?
Borderline diabetes
Should loose weight and eat better
What is found in the lifestyle history?
Works in a bank
Glass of wine most nights
3-4 bottles a week
What is the doctors plan of action?
Examine
Run bloods
Painkiller
Explain what’s going on
What does acute abdomen refer to?
Rapid onset of severe symptoms that may indicate potentially life-threatening intra-abdominal pathology
In who can pain free acute abdomen occur in?
older people
children
immunocompromised
last trimester of pregnancy
What are some feature of acute abdominal pain?
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.
What should immediate assessment focus on?
Distinguishing patients with true acute abdomen that requires urgent surgical intervention from patients who can initially be managed conservatively
How is acute abdomen diagnosed?
History Physical examination Radiography Laboratory results OR Diagnostic laparoscopy
In what can a laparoscopy be used therapeutically?
appendicitis, cholecystitis, lysis of adhesions, hernia repair, and many gynaecological causes of an acute abdomen.
What can help stratify the risk of appendicitis in patients presenting with acute abdominal pain?
The Appendicitis Inflammatory Response (AIR) score
The Pediatric Appendicitis Risk Calculator (pARC)
What is discourage in undiagnosed patients with acute abdomen?
Use of narcotic analgesia
because of concerns that symptoms would be masked, the examination hindered, and, therefore, the correct diagnosis missed
Why can diagnosis be delayed in older people?
More co-morbidities
Dementia (issues communicating issues)
PNS dysfunction can alter perception of pain and temperature
Why can diagnosis be delayed in pregnant women?
Enlargement of uterus displaces and compresses abdo organs
Physiological leukocytosis
Hesitancy to conduct radiographs
What are common differentials for acute abdomen?
Adhesions
Incarcerated/strangulated hernia
Cholecystitis
Gastric ulcer
What are uncommon differentials for acute abdomen?
Volvulus
Intussusception
Duodenal ulcer
Ruptured ovarian cyst
What are the abdo causes of acute abdo (from common to less)?
Intestinal obstruction Peritonitis secondary to infection Haemorrhage Ischaemia Contamination by gastrointestinal contents
What can cause abdominal haemorrhage?
ectopic pregnancy, ruptured aortic aneurysm
What can cause abdominal ischaemia?
ovarian torsion, mesenteric ischaemia
What processes can lead to contamination by GI contents?
perforated duodenal or gastric ulcer
What causes obstructions?
Adhesions Hernia incarcerations Volvulus Gallstones Intussusception IBD Neoplasm Congenital abnormalities
What can cause inflammation?
cholecystitis appendicitis acute pancreatitis acute diverticulitis Meckel diverticulitis UC Crohn's
What should happen in females of child bearing age with acute abdomen?
should always have a pregnancy test to rule out ectopic pregnancy
What are gynae causes of acute abdomen?
ruptured ovarian cyst, ovarian torsion, pelvic inflammatory disease, and endometriosis
What does Budd-Chiari syndrome involve?
Hepatic venous outflow obstruction and the abdominal pain may present with hepatomegaly and ascites
What can cause an abdominal wall haematoma?
Spontaneous Trauma Exercise Coughing Procedure
What are some abdominal infective diseases?
hepatic abscess or hepatitis
gastroenteritis, infectious colitis, typhlitis
What is Fitz-Hugh Curtis syndrome?
a complication of pelvic inflammatory disease, comprises right upper quadrant abdominal pain associated with perihepatitis
What are the metabolic causes of acute abdomen?
Uraemia, diabetic ketoacidosis, Addisonian crisis, and hypercalcaemia
Inherited -
acute intermittent porphyria and hereditary Mediterranean fever.
What are the toxic causes of acute abdomen?
Heavy metal poisoning
Narcotic withdrawal
What are the urological causes of acute abdomen?
Testicular torsion
Kidney stones
Pyelonephritis
What should be done while awaiting the results of lab tests?
Surgical consult
IV access
Vitals monitored and corrected
When should surgery be conducted with limited pre-op eval?
In patients exhibiting evidence of hypovolaemic shock with a known or suspected haemoperitoneum
What must be done if there is a potential haemorrhage?
Two large-bore IV lines
Typing and cross-matching
Fluid resus (2L isotonic)
Antifibrinolyitc? Tranexamic acid?
What is BP goal for AAA or aortic dissection?
Systolic 80-90
What can excess fluid replacement cause?
cause dilutional and hypothermic coagulopathy
lowers blood viscosity
increased perfusion pressure from the expanded volume can lead to secondary clot disruption
What should be done if a perforation, diverticulitis or appendicitis is suspected?
Broad-spec AB
As can lead to sepsis
Urinalysis and culture samples ideally done before
In who should you consider mesenteric ischaemia?
Pain disproportionate to the signs Older Smoking PVD AF
What is required for mesenteric ischaemia treatment?
Oxygen
Fluid
Empirical AB
Surgical and radiological consult
What are the key components in the history?
Time and onset
Previous instances of similar pain
What indicated acute appendicitis?
Sudden-onset umbilical pain radiating to right iliac fossa
What is suggestive of a gastric ulcer?
Long-term epigastric pain
sudden worsening may indicate perforation of the ulcer
What may indicate oesophageal perforation?
Sudden epigastric pain following vomiting
Epigastric pain?
Gastric ulcer Pancreatitis Perforated oesophagus Mallory-Weiss tear MI
LUQ pain?
Splenic infarct Ruptured splenic artery aneurysm Pyelonephritis Kidney stones Perforation Malignancy (colon)
RUQ pain?
Cholelithiasis Cholecystisis Hepatitis Hepatic abscess Fitz-Hugh Curtis syndrome Perforation Malignancy Kidney stones Pyelonephritis Acute api in pregnancy
LLQ pain?
Sigmoid volvulus Diverticulitis Crohn's UC Kidney stones GI malignancy Psoas abscess Strangulated hernia Gynae concerns
RLQ pain?
Api Kidney stones GI malignancy Psoas abscess Strangulated hernia Gynae concerns
Persistent lateralised pain?
Ascending or descending colon
Kidney
Gallbladder
Ovary
Pain with radiation to the back?
pancreatitis, abdominal aortic dissection, or ruptured abdominal aortic aneurys
Right scapula pain?
Gallbladder disease, liver disease, or irritation of right hemidiaphragm
Left scapula pain?
Cardiac disease, gastric disease, pancreatic disease, splenic disease, or irritation of left hemidiaphragm
Testicular pain?
kidney stones or ureteral disease.
Associated systemic symptoms?
cholecystitis, a ruptured duodenal ulcer, gastric ulcer, appendicitis, acute mesenteric ischaemia, PID, acute diverticulitis, hepatic abscess, hepatitis, abdominal wall haematoma, or spider bites
Obstructive bowel process?
No recent bowel movement
What must you ask the patient?
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
What is important with the examination?
Vitals PIPPA Rigid abdomen Distended Guarding Rebound tenderness Murphy's sign
What is Murphy’s sign?
Right upper quadrant tenderness with arrest of inhalation during palpation
What is a rectal examination conducted for?
presence of occult or frank blood, pain, or mass
What lab tests should be done?
FBC
Electrolytes
Urinalysis
Pregnancy test
What other lab tests can be done?
Metabolic panel
Coagulation studies
Serum amylase
Lactic acid levels
What imaging can be done?
AXT Erect CXR CT USS MRI
In who would a laparoscopy be considered?
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.
What are the three diagnosis related to gallstones?
Biliary colic
Cholecystitis
Ascending cholangitis
What are the features of biliary colic?
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
What are the features of cholecystisis?
Pain Murphy's sign - when diaphragm flattens gallbladder hits hand and pain worsens Fever Gallstone blocks the cystic duct Elevated WBCs and CRP
What are the features of ascending cholangitis?
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
What are the majority of gallstones?
Asymptomatic
Incidental findings
What is the diagnosis of our patient and why?
Acute cholecystitis
Normal LFTs
What is the investigation of choice for gallstones?
Abdo USS
How are gallstones formed?
High level of cholesterol in the bile
High bilirubin
Both cause crystallisation of bile
What are the risk factors for gallstone disease?
High fat diet Female Fat Fair Fourties Fertile OCP Crohn's or IBS Recent weight loss
What comprises bile?
98% water Bile salts Bilirubin Electrolytes Cholesterol
What affects the composition of gallstones?
Age
Diet
Ethnicity
What are the types of gallstones?
Cholesterol stones
Pigment stones
Mixed
What are the features of pigment stones?
Bilirubin breakdown products (from breakdown of RBCs) Small Dark Numerous From excess bile pigment production
Give an example of a condition that would cause pigment stones?
Haemolytic condition
What are the other complications of gallstones?
Acute pancreatitis
Gallstone Ileus
Gallbladder cancer
What are the characteristics of pancreatitis?
High amylase and lipase
What is gallstones ileus?
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
What is the treatment for symptomatic cholecystisis?
Laparoscopic cholecystectomy
What is needed to obtain consent?
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
What is essential re the person giving consent?
Consent must be voluntary
Patient must have capacity
What are the risks and complications of a laparoscopic cholecystectomy?
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
What are some general surgical risks?
Infection
General anaesthetic (allergy?)
Chronic pain
How can we categorise complications?
General vs. Specific
Early vs. Late
What are the early risks?
Wounds - keep dry and clean
What are some late risks?
Hernias
Scar not healing properly
What is the biliary system?
series of ducts within the liver, gallbladder, and pancreas that empty into the small intestine
What is the role fo the gallbladder?
component of the extrahepatic biliary system where bile is stored and concentrated
How is the gallbladder attached to the rest of the extrahepatic biliary system?
Via the cystic duct
What do hepatic lobules contain?
Central vein Portal triads (bile duct, portal vein, hepatic artery)
What connects the peripheral vasculature to the central vein?
Epithelial lined sinusoids run between the hepatocytes and connect the peripheral vasculature to the central vein
What is the function of the canals of hering?
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
What are the layers of the gallbladder wall?
Innermost mucosal layer (columnar epithelium with microvilli)
Lamina propia
Outer serosal layer
From what does the gallbladder develop?
Foregut
What happens at the 4th week of embryogenesis?
structure called the hepatic diverticulum appears. The hepatic diverticulum goes on to become the liver, extrahepatic biliary system, and a portion of the pancreas.
What happens at week 6 of embryogenesis?
The common bile duct and part of the pancreas rotate around the duodenum
Which cells are stimulated by fatty acids?
I-cells
Release CCK
CCK stimulates the smooth muscle of the gallbladder
CCK also signals the sphincter of Oddi to relax
Where are bile acids synthesised?
Liver from cholesterol pre-cursors
What is the RDS of bile acid production catalysed by?
cholesterol 7α—hydroxylase
What happens in the RDS?
The bile acids are conjugated to the amino acids glycine and taurine and become soluble bile salts.
Describe enterohepatic circulation
The bile salts are reabsorbed in the distal ileum of the small intestine and recycled back to the liver
Why does bile not being able to enter the duodenum cause jaundice?
the buildup of bilirubin
What is the most specific test to diagnose cholecystisis?
Hepatobiliary Iminodiacetic acid (HIDA) scan
What can cause acalculous cholecystitis?
Infection
Low perfusion
Biliary stasis
What drugs can increase risk of gallstone formation?
HRT
Somatostatin analogues
Fibrates
What are the main features of brown pigment stones?
Biliary tract infections
More frequent in Asia
What are the main features of black pigment stones?
Mainly consist of calcium bilirubinate
Found in haemolytic anaemia or ineffective haematopoesis in patients with CF
What are the three mechanisms of cholesterol stone formation?
Cholesterol supersaturation of bile
Gallbladder hypomotility
Kinetic, pro-nucleating protein factors
What is cholesterol supersaturation?
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.
What are the main features of gallbladder hypomotility?
altered interdigestive gallbladder emptying
seen in several risk groups for cholesterol gallstones, e.g. patients with diabetes mellitus, and rapid weight loss
