Abdominal pain Flashcards
what increases intra-abdominal pressure?
-straining
-holding breath (using
loo/lifting heavy objects)
-coughing
what causes weakness of abdominal muscles?
age
obesity
iatrogenic (surgery)
describe how a hernia occurs?
Occurs when organ or fatty tissue squeezes through weak spot in surrounding muscle of connective tissue called fascia
The abdominal wall, a sheet of tough muscle and tendon that runs down from the ribs to the legs at the groins, acts asthe body’s corset. Its function, amongst other things, is to hold in the abdominal contents, principally the intestines.
If a weakness should open up in that wall, then the corseteffect is lost and what pushes against it from the inside (the intestines) simply pushes through the opening. The ensuing bulge, which is often quite visible against the skin, is the hernia.
what are the most common types of hernias?
Inguinal Femoral Umbilical Midline Recurrent Incisional Strangulated Hiatus
are hernias painful?
Most hernias do not hurt. Paradoxically, the larger ones often hurt less, the reason being that a large ‘window’ in the abdominal wall that allows the intestine to slide in and out easily is not usually the cause of pain. Pain tends to occur when something is getting ‘squeezed’. That is often (although not exclusively) associated with smaller hernias.
do most hernia’s occur in men or women?
95% men
if in women more likely femoral than inguinal
describe inguinal hernias?
inguinal-75% of abdominal wall hernias. Fatty tissue, bowel section pushes into groin. Most common type of hernia and most common in men. Superb-medial to pubic tubercle, 2 types-direct (superficial) and indirect (deep). Direct inguinal hernias are due to defect in posterior abdominal wall which is more common and pressure on the deep inguinal ring won’t affect it. Indirect hernias have no defect in the wall and the contents enter via the deep ring, less resistance for structures to pass through anatomical inguinal ring compared to muscle defects, so these are more likely to emerge within the tested. Not able to reappear if deep inguinal ring were occluded
describe femoral hernias?
fatty tissue/bowel section pushes into groin. This is uncommon but is more common in females. Inferno-lateral to the pubic tubercle (and medial to femoral pulse
what type of hernias are associated with ageing and repeated abdominal strain?
inguinal and femoral
how would a hiatus hernia present?
stomach pushing up into chest by getting through diaphragm which can cause dyspepsia, unknown aetiology
how would a diaphragmatic hernia present?
organs in abdomen move into chest through diaphragm being incomplete of weak
how would a surgical/incisional hernias present?
tissue pokes through surgical wound that hasn’t fully healed
what actions make hernias appear and what reduces it?
coughing and straining makes hernias appear
lying down reduces it
where does the spermatic cord and abdominal contents enter and exit the inguinal canal?
Entry of abdominal contents into inguinal canal = deep ring = superior to the midway point of the inguinal ligament
Exit of abdominal contents = superficial ring = superior to pubic tubercle
where is the inguinal ligament?
runs between the ASIS and the ‘midpoint between the ASIS-Pubic tubercle’
These two structures are effectively sitting next to each other, with the canal being most medial.
what are the 2 types of inguinal hernia?
direct
indirect
what is a direct inguinal hernia?
pierces through posterior wall of abdomen
what is an indirect inguinal hernia
Indirect doesn’t pierce through the posterior wall, it follows the path of least resistance (and is therefore more common)
which type of hernia are more common; inguinal or femoral?
inguinal
which type of hernia occurs more laterally; inguinal or femoral?
femoral
how can you clinically tell the difference between a direct and indirect hernia?
Clinically telling the difference… stick your finger over the deep inguinal ring which should be above the mid-point of the inguinal ligament. If you’re on the deep ring and there’s change, you’re controlling an indirect hernia. If there isn’t any change, it’s because the herniation originated via muscle weakness in the posterior abdominal wall. N.B. This test isn’t that reliable and doesn’t carry significance with respect to management.
what is the femoral canal?
: NAVY VAN – pneumonic used to remember how the femoral nerve, artery and vein run anatomically (the Y represents the creases in the groin)
Femoral artery & vein enclosed within a sheath which the femoral canal is medial to. It contains the lymph node of Cloquet & a little bit of fatty tissue.
why is there a high risk of strangulation with a femoral hernia?
If abdominal contents leak into the femoral canal, there is a high risk of strangulation & obstruction, purely because the canal sits on the lateral side of the lacunar ligament which has a sharp edge.
what is a strangulated hernia?
Strangulated: a hernia that has strangulated will present as an irreducible and tender tense lump with pain out of proportion to clinical signs which may be accompanied with features of obstruction
describe epigastric hernia?
Upper midline through fibres of linea allba
Usually secondary to raised chronic intra-abdominal pressure such as obesity, pregnancy or ascites
Prevalence - upto 10% in mainly middle aged men
Typically asymptomatic may present as midline mass that disappears when lying on back
Differential-divarication of recti
describe paraumbilical hernias?
Herniation through the linea alba around the umbilical region but not through umbilicus itself.
Secondary to raised chronic intra-abdominal pressure and present as lump around umbilical region.
Common.
Risk factors – obesity and pregnancy
Contain pre-peritoneal fat
Don’t commonly strangulate
describe spligelian hernia?
Rare and occurs at semilunar line around level of arcuate line
Small tender mass at lower lateral edge of rectus abdominus.
High risk of strangulation so should be repaired
describe obturator hernias?
Hernia of pelvic floor through obturator foramen into obturator canal. More common in women due to wider pelvis and typically older patients. Mass in upper medial thigh and features of small bowel obstruction. In Half of patients compression of obturator nerve will cause Howship-Romberg sign
describe littre’s hernia?
Rare abdominal hernia where there is herniation of a Meckel’s diverticulum, most commonly in the inguinal canal and may become strangulated
describe lumbar hernia?
Rare posterior hernias that typically occur spontaneously or iatrogenically following surgery. Preset as posterior mass often with back pain
describe richter’s hernia?
Can occur at any site. It is a partial herniation of the bowel where the anti-mesenteric border becomes strangulated so only part of the bowel lumen is within hernial sac. Tender irreducible mass at the herniating orifice with varying levels of obstruction. Often surgical emergencies.
describe femoral hernia?
Uncommon. High rate of strangulation because of narrow neck. Occur when abdominal viscera or omentum pass through the femoral ring and into femoral canal. More common in women due to wider pelvis. Small lump in groin but usually asymptomatic and around 30% present as emergency. Due to the tightness of the femoral ring the hernia is unlikely to be reducible
describe inguinal hernia?
Abdominal cavity contents enter into inguinal canal. Most common type of hernia. Can be direct of indirect. Lump in groin. If it becomes incarcerated it will become painful, tender and erythematous. Features of bowel obstruction. Features of strangulation if blood supply is compromised. Test for cough impulse, location, reducibility and if it enters the scrotum
what are the common complications of hernias?
obstruction
strangulation
what is obstruction of a hernia?
bowel can get stuck in inguinal cord
what is strangulated hernia?
cut off blood supply to a section of organ or tissue trapped in hernia
what are common complications of hernias in the groin?
Iatrogenic undescended testis (trapped testicle)
Injury to vas deferens (sterility if bilateral)
Testicular atrophy
describe the epidemiology of colon cancer?
Third most common cancer in men and second in women. Incidence is higher in men
More common with age and peaks in the over 80s. Since the 1970s incidence has increased
30% present with advanced disease (mets/locally invasive so resection can’t happen)
what are the characteristics of colon cancer?
Mainly sigmoid colon and at rectosigmoid junction
Usually small, annular and ulcerated
what investigations should be done in a patient with unsuspected colon cancer?
Bloods – FBC, WCC, CEA, CRP + ESR
Foecal occult (as part of screening programme/ in suspected bowel cancer)
Colonoscopy (with biopsy) – has been viewed as the reference standard for years; patients shouldn’t have major co-morbidities
Barium enema/ flexible sigmoidoscopy – offered to patients with major co-morbidities
CT colonography – doesn’t require sedation and is still somewhat sensitive but if a lesion is found, they’ll need colonoscopy anyway
PET CT? – looking for metastasis
what are the clinical features of colon cancer?
Significant, unintentional weight loss Anorexia Malaise Blood in/ with stools Mucous in stools (from tumour secretion) Intestinal obstruction (can be acute, chronic or acute on chronic) Bowel perforation Evidence of mets: Jaundice/ abdominal distension from ascites/ hepatomegaly
describe the features of right sided (ascending) colon cancer?
More likely to grow beyond the mucosa
No bowel obstruction -> grows large, late diagnosis
Can ulcerate and bleed -> anaemia symptoms
Unexplained weakness
describe the features of left sided (descending) colon cancer?
More likely to be ring-shaped infiltrating masses -> napkin-ring constriction
Napkin-ring constriction -> colicky pain
Constriction -> blood streaked stools = haematochezia
Change in bowel habit (can be diarrhoea, constipation or the two alternating)
what are the localised causes of peritonitis?
- trauma
- transmural bowel inflammation
- transmural inflammation of other viscera within the abdominal cavity (salpingitis, cholecystitis)
- transmural ischaemia through bowel obstruction or strangulating hernia
what conditions cause transmural bowel inflammation?
appendicitis
diverticulitis
Crohn’s
what are the causes of generalised peritonitis?
- Caused by anything that causes localised peritonitis, it’s just left for longer
- Perforation of any organ which could cause peritoneal irritation e.g. stomach, colon, gallbladder, pancreas
- Iatrogenic/ chemical peritonitis: when a foreign substance (e.g. talcum powder from operating gloves) is introduced into the peritoneum.
- Spreading intraperitoneal infection e.g. faecal contamination following bowel perf, rupturing of abscess, infection of ascitic fluid, anastomotic leak, trauma, surgery
what are the clinical signs of localised peritonitis?
- Primary intra-abdominal process, e.g. appendicitis
- Localised abdominal pain
- Localised tenderness
- Guarding – contraction of abdominal muscles over the area of tenderness when palpated
- Rebound tenderness – lift the hand following palpation and movement of peritoneum causes pain. Percussion/ asking the patient to cough are good ways to elicit this (because it’s anything disturbing the peritoneum)
- Rectal tenderness (anterior)
- Features of mild systemic toxicity – malaise, low-grade fever, tachycardia (to increase cardiac output in high demand situation, i.e. infection), leucocytosis
what are the clinical signs of generalised peritonitis?
-Severity of symptoms depends on cause of peritonitis:
Intraperitoneal infection starts okay then gets worse as it spreads, chemical peritonitis is worst at the beginning and gets better once it’s spread over different organs.
-Rigidity of abdominal wall
-Diffuse tenderness
-Bowel sounds may be absent due to peristaltic peritonitis
-Radiographically: air under the diaphragm with perforated viscus, signs of intestinal ileus.
-Postural hypertension where there is massive exudation of inflammatory fluid -> hypovolemia & cold patient
-Patient is systemically very ill – high grade fever, tachycardia (to compensate for hypotension), prostration
what are important diagnostic factors to be considered in bowel obstruction?
Failure to pass flatus or stool
Constipation
Abdominal distention
Abdominal pain (crampy and intermittent, can be severe and tends to precede vomiting)
Vomiting
Abdominal tenderness
Peritonitis (due to ischaemic/necrosis and/or perforation
what are the risk factors for large bowel obstruction?
Previous abdominal surgery
Older age
Female
what should be considered during history in a patient with bowel obstruction?
Crohn’s disease
PICA-foreign body ingestion increases risk of impaction, preventing passing of abdominal contents
Malrotation-increases risk of volvulus which always causes obstruction
Appendicitis-abscess formation could cause obstruction
what are the benign causes of bowel obstruction?
- intra-abdominal adhesions (65-75%)
- hernias
- crohn’s
- colonic volvulus
- strictures
- ingestion of a foreign body
- diverticular disease
what are the malignant causes of bowel obstruction?
colorectal cancer
what are the causes of pain in the right iliac fossa?
- appendicitis
- cholecystitis
- Crohn’s
- ischaemic bowel disease
- perforated duodenal ulcer
- large bowel obstruction
- ureteric stone
- pelvic inflammatory disease
- ectopic pregnancy
- mesenteric adenitis (in children)
what are the characteristic signs and symptoms of appendicitis?
Can begin centrally and then shift to the right iliac fossa. After a few days it may be described as a continuous band of pain across the flank region (pointing to peritonitis)
Nausea & vomiting
what are the characteristic signs and symptoms of cholecystitis?
Pain is usually in the upper right quadrant and radiates to the right shoulder (unless gallbladder is low hanging - RIF)
what are the characteristic signs and symptoms of Crohn’s disease?
Diarrhoea with blood, fatigue, weight loss, pain acute and localised, closely mimics appendicitis (though this pain will come and go and therefore be familiar to the patient)
what are the characteristic signs and symptoms of ischaemic bowel disease?
Pain should be acute in onset and localised to whatever part of the bowel had its blood supply cut off
what are the characteristic signs and symptoms of perforated duodenal ulcer?
Men > Women, peak = 40-60-year olds
Indigestion/ epigastric pain
what are the characteristic signs and symptoms of large bowel obstruction?
Constipation before vomiting, dehydration, hepatomegaly… pain is not that common a symptom
what are the characteristic signs and symptoms of ureteric stone?
Colicky, ‘loin-groin’ pain
what are the characteristic signs and symptoms of pelvic inflammatory disease?
Almost always caused by sexually transmitted organisms
Variable presentation, may also be an acronym for ‘poorly investigated disease’
Lower abdominal pain is usually bilateral
what are the characteristic signs and symptoms of ectopic pregnancy?
Amenorrhoea followed by bleeding & pain (vague lower abdo discomfort to generalised pain in 90% of cases)
what are the characteristic signs and symptoms of mesenteric adenitis?
Typically presents in <30s
Abdo pain can be generalised or localised
Possible pyrexia, diarrhoea with or without vomiting
Recent upper respiratory tract infection
what are the common causes of a ruptured viscous?
adhesions incarcerated/strangulated hernia appendicitis impacted faeces crohn's malignancy volvulus intestinal atresia
what are the rarer causes of ruptured viscous?
- intra abdominal abscess from perforated appendicitis/diverticulitis
- gallstone ileus
- gastric ulcers
- acute pancreatitis
- intestinal bexoars
describe how adhesions can lead to ruptured viscous?
rubbing against bowel increasing friction and the likelihood of damage to the walls, cramp like abdominal pain, distended abdomen and presence of abdominal scars
how does malignancy lead to ruptured viscous?
invading the different layers of the bowel wall, it will eventually perforate it if it grows big enough. Blood in stools & change in bowel habit would be the two earliest symptoms and anaemia among the latest.
how does volvulus lead to ruptured viscous?
cut off blood supply to the bowel and it will start to necroes, strangulation also makes perforation more likely.
when would intestinal atresia present?
onset would be in neonates if due to malformation of bowel.
what are intestinal bezoars?
indigestible material that accumulated in the GI tract… they usually form in the stomach.
what is a gallstone ileus?
passage of gallstone through sphincter of Oddi followed by its impaction within the intestinal lumen. Accounts for 1% of all small bowel obstructions.
