Abdominal Pain Flashcards
What are the symptoms of incaecerated/ strangulated hernia?
history of hernia, intermittent, cramp-like abdominal pain; painful bulge; nausea, vomiting, decreased or absent bowel function; absence of flatus; distended abdomen
What are the signs of strangulated hernia?
high-pitched (hyperactive) bowel sounds with rushes; distended abdomen, tenderness to abdominal palpation; tender bulge in abdominal wall or inguinal/femoral region; involuntary guarding; or indirect hernia (more common on right than left)
What first line investigations would you consider in strangulated hernia?
plain abdominal x-rays: may see dilated loops of bowel
chest x-ray: may see free air under the diaphragm
FBC: may not see any abnormalities with early obstruction; elevated WBC count as bowel infarction develops
serum electrolytes: may not see any abnormalities with early obstruction; may confirm hypochloraemia and hypokalaemia
What other investigations would you consider in strangulated hernia?
CT of abdomen and pelvis: may see dilated loops of proximal bowel with collapsed loops posterior to site of obstruction
What are the symptoms of cholecystitis?
history of cholelithiasis and biliary colic; intense right upper quadrant pain, lasting more than 30 minutes, exacerbated by eating (especially fatty foods); right shoulder pain (referred pain from the gallbladder may be felt in the right shoulder or interscapular region); fever, nausea, and/or vomiting; more common in women than men
What are the signs of cholecystitis?
fever, tachycardia, right upper quadrant tenderness, Murphy’s sign (right upper quadrant tenderness with arrest of inhalation during palpation), palpable gallbladder (30% to 40% of patients), local guarding, and jaundice (mild jaundice present in about 10% of patients)
What first line investigations would you consider in cholecystitis
FBC: elevated WBC count
liver function panel: may see elevated alkaline phosphatase, bilirubin, and aminotransferase
right upper quadrant ultrasound: gallstones; thickened gallbladder wall (>4 mm); pericholecystic fluid; may also see ultrasonographic Murphy’s sign
What other investigations would you consider in cholecystitis?
cholescintigraphy: no contrast filling in gallbladder; may see patent cystic duct
What are the risk factors of cholecystitis?
obesity, age over 50, pregnancy, use of oestrogen, history of liver disease, cirrhosis, and pancreatitis
What are the symptoms of gastric ulcer?
background of recurrent upper abdominal pain (dyspepsia); with nausea, vomiting, loss of appetite, and pain made worse by food; weight loss; use of non-steroidal anti-inflammatory drugs; sudden-onset severe upper abdominal pain with fever, nausea, vomiting, and peritoneal signs; referred pain to shoulders secondary to diaphragmatic irritation
What are the signs of gastric ulcer?
often points to site of pain (‘pointing sign’); develops into spreading upper abdominal pain; fever, peritoneal signs with guarding and rebound
What first line investigation would you consider in gastric cancer?
FBC: microcytic anaemia; elevated WBC count
Serum antibodies to Helicobacter pylori: may be positive
plain abdominal x-rays: may see abdominal free air on erect abdominal film if perforation present
What other investigations would you consider in gastric cancer?
upper gastrointestinal series with water-soluble contrast: extravasation of contrast from stomach
oesophagogastroduodenoscopy with biopsy: may show Helicobacter pylori on culture and/or malignancy on histology
fasting serum gastrin level: hypergastrinaemia in Zollinger-Ellison syndrome
What are the symptoms of appendicitis?
sudden-onset, constant, severe abdominal pain often periumbilical with migration to right lower quadrant, usually worse on movement; nausea, vomiting, anorexia, fever, diarrhoea, more common in children and young adults; pain may improve after appendix rupture
What are the signs of appendicitis?
fever, tachycardia, patient may be lying in right lateral decubitus position with hips flexed; no or decreased bowel sounds; pain commonly originates near the umbilicus or the epigastrium; right lower quadrant (McBurney’s point) tenderness with rigid abdomen; guarding and rebound tenderness; psoas sign (right lower quadrant pain with right thigh extension)
What first line investigations would you consider in appendicitis?
FBC: elevated WBC count
human chorionic gonadotrophin (hCG) (if female): variable
CT scan of abdomen and pelvis with intravenous, oral, and rectal contrast: thickened appendix to 5-7 mm; periappendiceal inflammation; appendicolith; periappendiceal abscess; fluid collections; oedema; phlegmon
What other investigations would you consider in appendicitis?
right lower quadrant ultrasound: non-compressible appendix of ≥7 mm in anteroposterior diameter appendicolith; interruption of the continuity of the echogenic submucosa; periappendiceal fluid or mass
What are the symptoms of ectopic pregnancy
vaginal bleeding with severe, usually unilateral pelvic pain; amenorrhoea or painless vaginal bleeding; history of recent early pregnancy or missed last menstrual period; risk factors include history of ectopic pregnancy, tubal surgery, pelvic inflammatory disease, infertility treatment and pregnancy with an intrauterine device in situ
What are the signs of ectopic pregnancy?
may have palpable adnexal mass with or without tenderness; rigid abdomen, guarding, and rebound tenderness with ruptured ectopic leading to haemoperitoneum, tachycardia and hypotension; vaginal bleeding on speculum examination
What first line investigations would you consider in ectopic pregnancy?
hCG: positive
FBC: possible anaemia
pelvic ultrasound: blood or pseudogestational sac in uterus,may see ectopic pregnancy, or complex mass in adnexa
What other investigation would you consider in ectopic pregnancy?
diagnostic laparoscopy: ectopic pregnancy or complex mass seen
What are the symptoms of acute pancreatitis?
acute-onset, constant, severe mid-abdominal/epigastric pain that often radiates to the back; nausea, vomiting; anorexia; history of biliary colic, alcohol misuse, use of specific medicines (e.g., sulphonamides, tetracycline, oestrogens, corticosteroids), trauma, or surgery
What are the signs of acute pancreatitis?
varying degrees of abdominal tenderness, usually worse in the epigastric region; guarding, abdominal distension, and reduced or absent bowel sounds; ecchymoses in the skin of one or both flanks (Turner’s sign) and/or the periumbilical area (Cullen’s sign)
What first line investigations would you consider in acute pancreatitis?
serum amylase: elevated (3 times the upper limit of normal)
serum lipase: elevated (3 times the upper limit of normal)
FBC: elevated WBC count
LFTs: elevated aspartate transaminase (AST) (>37 IU/L); elevated alanine transaminase (ALT) (>40 IU/L); elevated alkaline phosphatase (>126 IU/L); elevated bilirubin (>1.0 mg/dL)
chemistry panel: elevated glucose >6.4 mmol/L (115 mg/dL)
serum triglycerides: often elevated >5.6 mmol/L (500 mg/dL)
What other investigations would you consider in acute pancreatitis?
abdominal ultrasound: may see ascites, gallstones, dilated common bile duct, and enlarged pancreas
CT scan of abdomen with oral and intravenous contrast: may see enlarged pancreas, peripancreatic inflammation, and ascites
abdominal MRI: may see enlarged pancreas, peripancreatic inflammation, and ascites
What are the symptoms of acute diverticulitis?
persistent left lower quadrant pain; fever, anorexia, nausea, vomiting, and abdominal distension (with ileus), patient may have a known history of diverticulosis
What are the signs of acute diverticulitis?
fever; left lower quadrant tenderness; frank blood in stool; diffuse tenderness with peritoneal signs (guarding, rebound tenderness, rigid abdomen) with perforation or ruptured abscess
What first line investigations would you consider in acute diverticulitis?
FBC: elevated WBC count
CT abdomen/pelvis with intravenous, oral, and rectal contrast: may see diverticula, inflammation of pericolonic fat, thickening of the bowel wall, free abdominal air, and an abscess
abdominal ultrasound: may see fluid collections around the colon or a thickened hypoechoic bowel wall
What other investigations would you consider in acute diverticulitis?
water-soluble contrast enema: may see diverticula along with extravasation of contrast material into an abscess cavity or into the peritoneum
endoscopy: may see inflamed diverticulum, abscess and perforation
laparoscopy: allows direct visualisation of bowel if diagnosis is unclear
What are the symptoms of ulcerative colitis?
bloody mucous diarrhoea and/or frank blood; fever, abdominal pain, weight loss, and growth retardation; back and joint pain and stiffness
What are the signs of ulcerative colitis?
abdominal tenderness; fevers; skin rash; episcleritis; pallor; guaiac-positive stools or frank blood on rectal exam
What first line investigations would you consider in ulcerative colitis?
FBC: variable degree of anaemia, leukocytosis, or thrombocytosis
comprehensive metabolic panel (including LFTs): hypokalaemic metabolic acidosis; elevated sodium and urea; elevated alkaline phosphatase, bilirubin, AST, and ALT; hypoalbuminaemia
stool studies: negative culture and Clostridium difficile toxins A and B; WBCs present; elevated faecal calprotectin
plain abdominal radiograph: dilated loops with air-fluid level secondary to ileus; free air is consistent with perforation; in toxic megacolon, the transverse colon is dilated to ≥6 cm in diameter
CT abdomen/pelvis with oral and intravenous contrast: may show thickening, inflammation, abscess, fistulisation, obstruction of the bowel; biliary dilation suggests primary sclerosing cholangitis
colonoscopy/sigmoidoscopy: rectal involvement, continuous uniform involvement, loss of vascular marking, diffuse erythema, mucosal granularity, fistulas (rarely seen), normal terminal ileum (or mild ‘backwash’ ileitis in pancolitis)
biopsies: continuous distal disease, mucin depletion, basal plasmacytosis, diffuse mucosal atrophy, absence of granulomata, and anal sparing; only mucosal/submucosal involvement
What other investigations would you consider in ulcerative colitis?
double-contrast barium enema: results range from a fine granular appearance of the bowel wall to diffuse ulceration, thumbprinting (due to mucosal oedema), and narrowing and shortening of the bowel, depending on the severity of the disease
serological markers: perinuclear antineutrophil cytoplasmic antibody (pANCA) and anti-Saccharomyces cerevisiae antibody (ASCA): about 70% of patients with ulcerative colitis have positive pANCA; about 70% of patients with Crohn’s disease have positive ASCA
radionuclide studies: positive areas of inflammation
What are the differentials for right upper hypochrondrium pain?
Costochondritis Biliary Colic (Gallstones) Hepatitis Renal Colic Pneumonia
What are the differentials for left upper hypochondrium pain?
Pneumonia Costochondritis Spleen infection Splenomegaly Renal Colic Constipation Spleen rupture
What are the differentials for epigastric pain?
GORD MI Gastritis Oesophagitis Peptic Ulcer Pancreatitis Biliary Tract Disease
