Abdominal pain Flashcards
An international study involving referral to 26
surgical departments in 17 countries revealed nonspecific
1
2
3
the most common conditions.
abdominal pain (34%), acute appendicitis (28%) and cholecystitis (10%)
T or F
As a general rule, upper abdominal pain is caused
by lesions of the upper GIT and lower abdominal
pain by lesions of the lower GIT
T
Colicky midline umbilical abdominal pain
(severe) → vomiting → distension = ______
small bowel
obstruction (SBO).
Midline lower abdominal pain → distension →
vomiting = _______
large bowel obstruction (LBO).
If cases of acute abdomen have a surgical cause,
the pain nearly always precedes the _____
vomiting
________ must be considered in
an elderly person with arteriosclerotic disease or
in patients with atrial fibrillation presenting with
severe abdominal pain or following myocardial
infarction
Mesenteric artery occlusion
Up to ________of presentations of abdominal pain
are considered to be non-specific, whereby no
specific cause is found
one-third
A study on chronic abdominal pain 4 showed that the commonest reasons (approximate percentages) were
no discoverable causes (50%), minor causes including muscle strains (16%), irritable bowel syndrome (12%), gynaecological causes (8%), peptic ulcers and hiatus hernia (8%).
Red flag pointers for acute abdominal pain
History 1 2 3 4 5 6
- Collapse at toilet
- Lightheadedness
- Ischaemic heart disease
- Progressive-vomiting pain, distension
- Menstrual abnormalities
- Malignancy
Red flag pointers for acute abdominal pain
Signs 1 2 3 4 5 6
- Hypotension
- Atrial fibrillation or tachycardia
- Fever
- Prostration
- Rebound tenderness and guarding
- Decreased urine output
Dangers of misdiagnosis • \_\_\_\_\_\_\_\_ → rapid hypovolaemic shock • \_\_\_\_\_\_\_\_ → rapid hypovolaemic shock • \_\_\_\_\_\_\_\_ → peritonitis/pelvic abscess • \_\_\_\_\_\_\_\_ → peritonitis • \_\_\_\_\_\_\_\_ → gangrene
Ectopic pregnancy Ruptured AAA Gangrenous appendix Perforated ulcer Obstructed bowel
Early appendicitis
presents typically with ___________some 4 to 6
hours later.
central abdominal pain
that shifts to the right iliac fossa (RIF)
Disaccharidase deficiencies, such as _______ are associated with cramping abdominal pain,
which may be severe
lactase
deficiency,
Specific pitfalls in the dx
Failing to examine _______ in a patient
with intestinal obstruction
hernial orifices
Misleading temporary improvement (easing of
pain) in _____ or ______
perforation of gangrenous appendix or
perforated peptic ulcer
Spinal dysfunction of the _____ or _______ can cause referred pain
to the abdomen
lower thoracic spine
and thoracolumbar junction
________ can be most relevant, especially
in recurrent or chronic abdominal pain where no
specific cause can be identified in most cases.
Psychogenic factors
_______ is hospital admission by
deception, often with severe abdominal pain without
convincing clinical signs or abnormal investigation
Munchausen syndrome
special clinical tests for abdominal pain:
_______ (a sign of peritoneal tenderness with acute cholecystitis); iliopsoas and obturator signs
Murphy sign
_______ occur through
defects in transversus abdominal muscle lateral
to the rectus sheath—usually below the level of
the umbilicus
Spigelian hernias
PE:
Palpation: palpate with gentleness—note any
guarding or rebound tenderness: guarding
indicates _______
rebound tenderness indicates _____ (bacterial peritonitis, blood)
peritonitis;
peritoneal irritation
Patient pain indicator:
the ______indicates focal peritoneal irritation;
the_______indicates visceral pain
finger pointing sign
spread palm sign
Atrial fibrillation: consider ____
mesenteric artery
obstruction
- ______ sepsis and volume depletion
- _______: sepsis, pneumonia, acidosis
- Pallor and ‘shock’: _______
Tachycardia:
Tachypnoea
acute blood loss
Auscultation: note bowel activity or a_______ (best before palpation and percussion)
succussion
splash
Causes of a ‘silent abdomen’:
1
2
3
diffuse sepsis, ileus, mechanical obstruction (advanced
Hypertympany indicates _____
mechanical obstruction
_______if
raised to greater than three times normal upper
level acute pancreatitis is most likely
serum amylase and/or lipase (preferable
What can you see in a plain abdominal xray
— \_\_\_\_\_\_\_—70% opaque — \_\_\_\_\_\_\_—only 10–30% opaque — air in biliary tree — calcified aortic aneurysm — marked distension sigmoid →\_\_\_\_\_ — distended bowel with fluid level → \_\_\_\_\_\_\_\_\_\_ — enlarged caecum with large bowel obstruction — blurred right psoas shadow →\_\_\_\_\_\_\_
kidney/ureteric stones
biliary stones
sigmoid volvulus
bowel obstruction
appendicitis
What can you see in a plain abdominal xray
sentinel loop of gas in left upper quadrant
(LUQ) → _________
acute pancreatitis
chest X-ray: air under diaphragm → _______
perforated ulcer
Dxtics
________ good for hepatobiliary system,
kidneys and female pelvis
ultrasound:
T or F
UTZ can be affected by shadows
T
_________—diagnosis of acute
cholecystitis
HIDA or DIDA nuclear scan
__________: gives excellent survey of abdominal
organs including masses and fluid collection
CT scan
________: shows bile duct obstruction and pancreatic
disease
ERCP
______ is a rhythmic pain with regular spasms
of recurring pain building to a climax and fading. It
is virtually pathognomonic of_____
Colicky pain
intestinal obstruction
______ is a true colicky abdominal pain, but
so-called biliary colic and kidney colic are not true
colics at all
Ureteric colic
________ usually arises from disorders of the
embryologic foregut, such as the oesophagus, stomach
and duodenum, hepatobiliary structures, pancreas
and spleen
Epigastric pain
_______ usually arises from disorders of structures of
the embryologic midgut
Periumbilical
pain
structures from the
_______ tend to refer pain to the lower abdomen or
suprapubic region
hindgut
The intra-abdominal sensory receptors can
be considered as innervating______ or ________
peritoneum.
visceral or parietal
Visceral _________ are triggered
by intestinal distension or tension on mesentery
or blood vessels while _______ are triggered by
mechanical, thermal and chemical stimuli
mechanoreceptors
nociceptors
The pain
from viscera is felt as __________localised while
stimulation of parietal peritoneal nociceptors gives a
pain that is experienced directly at the site of insult.
diffuse and poorly
Acute abdominal pain in children
Common causes/probability diagnosis:
1
2
3
- infant colic
- gastroenteritis (all ages)
- mesenteric adenitis
Acute abdominal pain in children
Serious causes, not to be missed:
- ________ (peaks at 6–9 months)
- ________ (mainly 5–15 years)
- bowel obstruction
intussusception
acute appendicitis
Acute abdominal pain in children:
Rarities: 1 2 3 4
- Meckel diverticulitis
- Henoch–Schönlein purpura
- sickle crisis
- lead poisoning
This is the occurrence in a well baby of regular,
unexplained periods of inconsolable crying and
fretfulness, usually in the late afternoon and evening,
especially between 2 weeks and 16 weeks of a
Infant ‘colic’ (period of infant distress)
Infant ‘colic’ (period of infant distress)
Crying worst at around ______ weeks of age
10
Infant ‘colic’ (period of infant distress)
Drugs are not generally recommended, but for very
severe problems some preparations can be very
helpful (e.g. _________
simethicone
__________is the diagnosis that should be
foremost in one’s mind with a child aged between
3 months and 2 years presenting with sudden onset
of severe colicky abdominal pain, coming at intervals
of about 15 minutes and lasting for 2–3 minutes
Intussusception
What is the pathophysiology of Intussusception?
It is due to the telescoping of a segment of bowel into the adjoining distal segment (e.g. ileocaecal segment), resulting in intestinal obstruction.
What is the cause of Intussusception?
It is usually idiopathic but
can have a pathological lead point (4–12 years) (e.g.
polyp, Meckel diverticulum)
Sign of Intussusception?
Sausage-shaped mass in right upper quadrant
(RUQ) anywhere between the line of colon and
umbilicus, especially during attacks (difficult to
feel)
Signs of Intussusception
• _________ (i.e. emptiness in RIF to palpation)
• Alternating high-pitched active bowel sounds
with absent sounds
• Rectal examination: _______
Signe de dance
± blood
Diagnosis of Intussusception
• Ultrasound
•___________ (with caution) also
used for diagnosis and treatment
Oxygen or barium enema
Treatment of Intussusception
• _______ by air or oxygen from the
‘wall’ supply (preferred) or barium enema
• Surgical intervention may be necessary
Hydrostatic reduction
In any child complaining of acute abdominal pain,
enquiry should be made into ______
drug ingestion
A common cause of colicky abdominal pain in children
is _______
cigarette smoking (nicotine)
AA in children
This may occur at any age, being more common
in children of_________ and in
adolescence, and uncommon in children under
3 years of age
school age (10–12 years)
A serious point of confusion can occur between ________, causing diarrhoea and vomiting, and acute
gastroenteritis
pelvic
appendicitis
This presents a difficult problem in differential
diagnosis with acute appendicitis because the history
can be very similar. At times the distinction may
be almost impossible
Mesenteric adenitis
T or F
with mesenteric adenitis localisation of pain and tenderness is definite, rigidity is less of a feature, the temperature is higher, and anorexia, nausea and vomiting are also lesser features
F
pain and tenderness not as definite
Mesenteric adenitis can sometimes present an
anaesthetic risk and patients are usually quite ill in
the immediate _______ period. Treatment is
symptomatic and includes ample fluids and paracetamol.
postoperative
__________—three distinct
episodes of abdominal pain over 3 or more months—
occurs in 10% of school-aged children
Recurrent abdominal pain (RAP)
How many percent of RAP can organic cause be found?
In only 5–10%
of children will an organic cause be found
Possible causes of RAP
• Constipation •\_\_\_\_\_\_\_\_\_ (pain with extreme pallor) •\_\_\_\_\_\_\_\_\_ (symptoms related to milk ingestion) • \_\_\_\_\_\_\_\_\_ (may disturb child about 60 minutes after falling asleep)
Childhood migraine equivalent
Lactose intolerance
Intestinal parasites
Non-organic RAP
Clinical features
- __________ abdominal pain
- pain localised to or just above_______
acute and frequent colicky
umbilicus
Non-organic RAP
- no radiation of pain
- pain lasts less than _____
- nausea frequent and vomiting rare
60 minutes
Non-organic RAP
• \_\_\_\_\_\_(never wakes the child at night) • minimal umbilical tenderness • anxious child • \_\_\_\_\_\_\_\_\_\_ personality • one or both parents intense about child’s health and progress
diurnal
obsessive or perfectionist
Psychogenic factors
Some children will have
obvious psychological problems or even be school
avoidant, a common factor being ______
family disruption
Abdominal pain in the elderly
Problems arise with management because the ________
and there is _________so
that fever and leucocytosis can be absent
pain threshold is raised (colic in particular is less severe)
an attenuated response to infection
An ______ may be asymptomatic until it ruptures
or may present with abdominal discomfort and a
pulsatile mass noted by the patient
AAA
AAA
_______ is advisable in first-degree relatives over 50 years
Ultrasound screening
The
normal diameter of the abdominal aorta, which is
palpated just above the umbilicus, is 10–30 mm,
being 20 mm on average in the adult; an aneurysm is
greater than _____ in diameter.
30 mm
Greater than _____
is significantly enlarged and is chosen as the arbitrary
reference point to operate because of the exponential
rise in risk of rupture with an increasing diameter
50 mm
AAA TX
The patency of a _____after
5 years is approximately 95% (
Dacron graft
AAA
Investigations
• ______ (good for screening) in relatives
>50 years (obesity a problem)
• CT scan (clearer imaging). ________ scan is
investigation of choice.
• MRI scan (best definition)
Ultrasound
Helical/spiral
This is a real surgical emergency in an elderly person
who presents with acute abdominal and perhaps
back pain with associated circulatory collapse
Rupture of aneurysm
intense pain + pale and ‘shocked ±
back pain ______
ruptured AAA
Acute intestinal ischaemia arises from ________occlusion from either an embolus
or a thrombosis in an atherosclerotic artery
superior mesenteric artery
Clinical features of aute mesenteric ischemia
1
2
3
4
• Abdominal pain—gradually becomes intense (see
FIG. 34.7 )
• Profuse vomiting
• Watery diarrhoea—blood in one-third of patients
(later) (refer CHAPTER 44)
• Patient becomes confused
Signs of aute mesenteric ischemia 1 2 3 4
• Localised tenderness, rigidity and rebound over
infarcted bowel (later finding)
• Absent bowel sounds (later)
• Shock develops later
• Tachycardia (may be atrial fibrillation and other
signs of atheroma
Dx of aute mesenteric ischemia.
X-ray (plain) shows _____ due to
mucosal oedema on gas-filled bowel.
_______ gives the best definition while
______ is performed if embolus is
suspected.
However, it is commonly only diagnosed at______
‘thumb printing’
CT scanning
mesenteric arteriography
laparotomy
Management of aute mesenteric ischemia.
Early surgery may prevent gut necrosis but massive
______may be required as a lifesaving
procedure.
resection of necrosed gut
In pts with mesenteric ischemia:
• _______ can occur but
usually in patients with circulatory failure.
• _________ occlusion is less severe
and survival more likely
Mesenteric venous thrombosis
Inferior mesenteric artery
_______ usually causes severe lower
abdominal pain, which may not be apparent in a
senile or demented person.
Acute retention of urine
Causes of Acute retention of urine
- 2
3
enlarged prostate or prostatitis
bladder neck obstruction by faecal loading
or other pelvic masses
or anticholinergic drugs
Mx of Acute retention of urine
• Perform a _______and empty rectum
of any impacted faecal material.
• _________to relieve
obstruction and drain (give antibiotic cover).
• Have the catheter in situ and seek a urological
opinion. Send specimen for MCU.
rectal examination
Catheterise with size 14 Foley catheter
_____ is encountered typically in the aged,
bedridden, debilitated patient. It may closely resemble
malignant obstruction in its clinical presentation.
Spurious diarrhoea can occur, which is known as
_____
Faecal impaction
‘faecal incontinence’
localised RIF pain + a/n/v + guarding
acute appendicitis
AA signs
pain on resisted flexion of right leg,
on hip extension or on elevating right leg (due
to irritation of psoas especially with retrocaecal
appendix)
± Psoas sign:
AA signs
_________pain on flexing patient’s right
thigh at the hip with the knee bent and then
internally rotating the hip (due to irritation of
internal obturator muscle)
± Obturator sign:
AA signs
_______ tenderness in RIF while palpating
in LIF
Rovsing sign:
Variations and cautions in AA
• _________ → localised mass and
tenderness
• _________: pain and rigidity less and
may be no rebound tenderness; loin tenderness;
positive psoas test
• _________: no abdominal rigidity; urinary
frequency; diarrhoea and tenesmus; very tender
PR; obturator tests usually positive
Abscess formation
Retrocaecal appendix
Pelvic appendix
Variations and cautions in AA
• ________: pain often minimal and
eventually manifests as peritonitis; can simulate
intestinal obstruction
• Pregnancy (occurs mainly during second
trimester): pain is higher and more lateral; harder
to diagnose; peritonitis more common
• Perforation more likely in the ____, ________, ______
Elderly patients
very young, the
aged and the diabetic
AA
plain X-ray findings
may show local distension, blurred
psoas shadow and fluid level in caecum
Management of AA
Immediate referral for surgical removal. If perforated,
cover with ____ or _______
cefotaxime and metronidazole
SBO
The more _____ the obstruction,
the more severe the pain.
proximal
colicky central pain + vomiting +
distension
SBO
Signs of SBO
• Patient weak and \_\_\_\_\_ • Visible peristalsis,\_\_\_\_\_\_ • Abdomen soft (except with \_\_\_\_\_) • Tender when distended • Increased sharp, tinkling bowel sounds • Dehydration rapidly follows, especially in children and elderly
sitting forward in distress
loud borborygmi
strangulation
LBO
The cause is commonly________r (75% of
cases), especially on the left side, but it can occur in
______ or _______ of the sigmoid colon (10%
of cases) and caecum
colon cancer
diverticulitis or in volvulus
LBO
_____is more common in older men and has a sudden and severe onset. The pain is less severe than in SBO
Sigmoid volvulus
ddx of LBO
pseudo-obstruction of the colon or ______
(Ogilvie syndrome
Clinical features of LBO
- __________ pain (even with cancer)
- Each spasm lasts less than 1 minute
- Usually hypogastric midline pain (see FIG. 34.11 )
- Vomiting may be absent (or late)
- Constipation, no flatus
Sudden-onset colick
colicky pain + distension ± vomiting
LBO
X-ray of LBO:
distension of large bowel with separation
of haustral markings, especially caecal distension
— sigmoid volvulus shows a ______
— ________ confirms diagnosis
distended loop
gastrografin enema
T or F
perforated duodenal ulcer is more common than a gastric ulcer
T
3 stages of perforated peptic ulcer
1
2
3
1 prostration 2 reaction (after 2–6 hours)—symptoms improve 3 peritonitis (after 6–12 hours
sudden severe pain + anxious, still,
‘grey’, sweaty + deceptive improvement
perforated peptic ulcer
presents as
severe true colicky pain due to stone movement and
ureteric spasm
ureteric colic
________is not a true colic but a constant
pain due to blood clots or a stone lodged at the pelvic–
ureteric junction
Kidney renal colic
Features of ureteral colic
- _____—stone in kidney
- ______—ureteric stone
- ______—stone in bladder
loin pain
kidney/ureteric colic
strangury
Clinical features of ureteral colic
• Maximum incidence ______ years (M > F)
• Intense _____: in waves, each lasting
30 seconds with 1–2 minutes respite
• Begins in_______ (see FIG. 34.13 )
- Usually lasts <8 hours
- ± Vomiting
30–50
colicky pain
loin and radiates around the flank to
the groin, thigh, testicle or labia
Dxtics of ureteral colic
______microscopy; blood testing strip (negative
does not exclude calculus)
• Plain X-ray: most stones—kidney, ureter, bladder
(75%)—are ______ (calcium oxalate and
phosphate)
________ confirms opacity, level of obstruction,
kidney function and any anatomical
abnormalities
Urine:
radio-opaque
• IVP:
Dxtics of ureteral colic
• Ultrasound: may locate calculus but will exclude
obstruction
• ________ is the ‘gold standard’
(sensitivity 97%, specificity 96%) (will show
easily missed radiolucent 11 uric acid stones
Non-contrast spiral CT
In ureteral colic:
Further pain can be alleviated by __________ but should be limited to two a
day.
indomethacin
suppositories
The calculus is likely to pass spontaneously if
______ (90%) <4 mm pass spontaneously
<5 mm
If calculus ______ intervention will usually be required
by extracorporeal shock wave lithotripsy or
surgery
> 5 mm
A repeat IVP may be necessary if there is evidence
of obstruction for more than _____
3 weeks
Facts about urinary tract calculi
• The prevalence is _______ population per
year
• The lifelong incidence is _____
• The recurrence is up to ______ (most within
2 years)
• The typical age range is 20 to 50 years (peaks at
28 years)
1 to 3 per 1000
10%
75%
Some patients who present with typical colic may be
feigning their pain mainly because they are opioid
dependent and seeking drugs by deception. What is this called?
Phony colic
the stereotyped patient is female, 40,
fat, fair and fertile it can occur from adolescence to
old age and in both sexes
Biliary pain
Features of Biliary pain
- acute onset severe pain
- _______or at night (often wakes 2–3 am)
- constant pain (not colicky)
- lasts 20 minutes to 2–6 hours
- maximal______
post-prandial
RUQ or epigastrium
Biliary pain:
• may radiate to ____
• painful episode builds to a crescendo for about
20 minutes; may recede or last for hours
• some relief by assuming_________
• ± nausea and vomiting with considerable retching
• often a history of biliary pain (may be mild) or
jaundice
tip of right shoulder or scapula
flexed posture
Signs of Biliary colic
• Patient anxious and restless, usually in a flexed position or rolling in agony • Localised tenderness\_\_\_\_\_\_\_over fundus of gall bladder (on transpyloric plane) • Slight rigidity
(Murphy sign)
Diagnosis of biliary obstruction
• Abdominal ultrasound/DIDA • Helical CT • \_\_\_\_\_\_\_\_\_ if previous cholecystectomy • LFTs may show elevated \_\_\_\_ and \_\_\_\_\_
Intravenous cholangiography
bilirubin and alkaline
phosphatase
Tx of biliary obstruction
• Gallstone dissolution or _______ (in those
unable to have surgery)
• ____________ (main procedure)
lithotripsy
Cholecystectomy
Types of gallstones:
Two main types—cholesterol and pigment
bilirubin
70% of people with gall bladder stones are
asymptomatic, but risk of developing symptoms
is about _____ over 20 years
15%
______ is associated with gallstones in over 90%
of cases and there is usually a past history of biliary
pain. It
Cholecystitis
The causative
organisms of acute cholecystitis are usually aerobic bowel flora (e.g. _____ and _____
E. coli,
Klebsiella species and Enterococcus faecalis).
With acute pancreatitis there may be a past history
of ________ or a past history of ______
(35%) or gallstone disease (40–50%).
previous attacks
alcoholism
severe pain + nausea and vomiting
+ relative lack of abdominal signs
acute
pancreatitis
acute pancreatitis dx
WCC—\_\_\_\_\_\_ • Serum \_\_\_\_\_\_\_\_\_ (preferred as more sensitive and specific) or serum amylase • CRP—elevated • Serum glucose ↑, calcium ↓
leucocytosis
In comparison to acute pancreatitis, the pain of
chronic pancreatitis is _______
milder but more persistent.
____ and _______may result from
pancreatitis and weight loss and steatorrhoea become
prominent features
Malabsorption and diabetes
Pain associated with _________ is
indistinguishable from that of chronic pancreatitis
but generally tends to be more severe and more
prominent in the back
pancreatic cancer
Chronic Panc
Give pancreatic enzyme supplements (e.g.
pancrelipase) for________
steatorrhoea
The patient with __________ is usually over
40 years of age, with long-standing, grumbling, leftsided
abdominal pain and constipation, but can have
irregular bowel habit
acute diverticulitis
Typical clinical features of acute diverticulitis are:
- acute onset of pain in the_________
- pain increased with walking and ______
- usually associated with constipation
left iliac fossa
change of
position
Can be generalised due to intra-abdominal sepsis
following perforation of a viscus e.g. peptic ulcer,
appendix, diverticulum
Peritonitis
abx for peritonitis
Usual antibiotic
treatment is IV cephalosporins or amoxy/ampicillin +
gentamicin + metronidazole. 1
Spontaneous bacterial
peritonitis can occur in any patient with _______
ascites.
What to do in abdominal stitch
• stop and rest, then walk—don’t run
• apply deep massage to the area with the palps
(fleshy tips) of the middle three fingers
• perform slow or deep breathing
___________—this may allow the identification
of chronic adhesive obstruction, small bowel
tumours or inflammation, or intra-abdominal
malignancy
laparoscopy
T or F
It is possible to have recurrent episodes of subacute
inflammation of the appendi
t
