Abdominal pain Flashcards by MA CARMELA CONCEPCION SALES

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%)

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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

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Colicky midline umbilical abdominal pain

(severe) → vomiting → distension = ______

small bowel

obstruction (SBO).

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Midline lower abdominal pain → distension →

vomiting = _______

large bowel obstruction (LBO).

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If cases of acute abdomen have a surgical cause,

the pain nearly always precedes the _____

vomiting

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________ 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

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Up to ________of presentations of abdominal pain
are considered to be non-specific, whereby no
specific cause is found

one-third

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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%).

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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

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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

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Dangers of misdiagnosis
• \_\_\_\_\_\_\_\_ → rapid hypovolaemic shock
• \_\_\_\_\_\_\_\_ → rapid hypovolaemic shock
• \_\_\_\_\_\_\_\_ → peritonitis/pelvic abscess
• \_\_\_\_\_\_\_\_ → peritonitis
• \_\_\_\_\_\_\_\_ → gangrene

Ectopic pregnancy
Ruptured AAA
Gangrenous appendix
Perforated ulcer
Obstructed bowel

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Early appendicitis
presents typically with ___________some 4 to 6
hours later.

central abdominal pain

that shifts to the right iliac fossa (RIF)

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Disaccharidase deficiencies, such as _______ are associated with cramping abdominal pain,
which may be severe

lactase

deficiency,

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Specific pitfalls in the dx

Failing to examine _______ in a patient
with intestinal obstruction

hernial orifices

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Misleading temporary improvement (easing of

pain) in _____ or ______

perforation of gangrenous appendix or

perforated peptic ulcer

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Spinal dysfunction of the _____ or _______ can cause referred pain
to the abdomen

lower thoracic spine

and thoracolumbar junction

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________ can be most relevant, especially
in recurrent or chronic abdominal pain where no
specific cause can be identified in most cases.

Psychogenic factors

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_______ is hospital admission by
deception, often with severe abdominal pain without
convincing clinical signs or abnormal investigation

Munchausen syndrome

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special clinical tests for abdominal pain:

_______ (a sign of peritoneal tenderness with acute cholecystitis); iliopsoas and obturator signs

Murphy sign

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_______ occur through
defects in transversus abdominal muscle lateral
to the rectus sheath—usually below the level of
the umbilicus

Spigelian hernias

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PE:

Palpation: palpate with gentleness—note any
guarding or rebound tenderness: guarding
indicates _______

rebound tenderness indicates _____ (bacterial peritonitis, blood)

peritonitis;

peritoneal irritation

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Patient pain indicator:

the ______indicates focal peritoneal irritation;

the_______indicates visceral pain

finger pointing sign

spread palm sign

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Atrial fibrillation: consider ____

mesenteric artery

obstruction

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______ sepsis and volume depletion
_______: sepsis, pneumonia, acidosis
Pallor and ‘shock’: _______

Tachycardia:
Tachypnoea
acute blood loss

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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

_________—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

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 1. 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

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