Abdominal Pain Flashcards
What is a abdominal aortic aneurysm/
Localised permanent dilatation of the aorta >3cm
What are the risk factors for AAA?
> 50 years - age-related changes in elastin, collagen and smooth muscle
Risk factors for developing atheroma in aorta:
- Hypertension
- Smoking
- Male
- Hyperlipidaemia
- Obesity
Genetic:
- Marfan’s
- Elher’s Danlos syndrome
- Collagen disorders
How are most AAA found?
Most are asymptomatic and found on routine abdominal examination, AXR or USS
What sign can be found on examination of AAA?
Pulsatile and expansile mass
How does a ruptured AAA present?
Sudden onset of severe pain in back/abdomen/loin/groin
Collapse
What signs would be found on examination of ruptured AAA?
Tachycardia Hypotension Cullen's sign Grey-Turner's sign Absent femoral pulses
What investigation must be done in ?AAA?
Urgent abdominal USS
Bloods - FBC, clotting, crossmatch, LFTs, U&Es
What size AAA requires/does not require treatment?
<5.5cm - watch a wait, regular USS monitoring
>5.5cm - surgery (endovascular stent repair or insertion of graft)
What is the acute management of a ruptured AAA?
ABCDE
- High flow oxygen 15L/min via a non-rebreathe mask
- 2 wide bore cannulas in the antecubital fossae
- Bloods - emergency crossmatching, FBC, U&Es, glucose, coagulation, LFTs
- Give fluids in major hypovolaemia but avoid excess
- IV morphine
- IV antiemetics - 50mg cyclizine
- IV antibiotics (prophylactic) - 1.5g cefuroxime + 500mg metronidazole
- Call vascular surgeon and anaesthetist for aortic cross clamping and insertion of Dacron graft
What is the commonest surgical emergency?
Appendicitis
What causes appendicitis?
Lumen of appendix becomes obstructed with:
- Faecolith
- Lymphoid hyperplasia
- Filarial worms
Then gut organisms invade the appendix wall
How does appendicitis present?
Acute abdominal pain that starts in epigastric/umbilical area then localises to the right iliac fossa
Nausea, vomiting, diarrhoea
Anorexia
Fever
What signs can be found in appendicitis?
- Tachycardia, tachypnoea, pyrexia
- Tenderness at McBurney’s point (2/3rds umbilicus to ASIS)
- Guarding due to peritonitis
- Rovsing’s sign - pain in RIF on pressing over LIF
- Psoas sign - pain on extending thigh
- Cope sign - pain on flexion and internal rotation of R thigh
What are some complications of appendicitis?
Electrolyte imbalance from vomiting
Perforation
Ileus
What are some differentials for appendicitis?
Acute terminal ileitis from Crohn’s
Ectopic pregnnacy
Ruptured ovarian cyst
Inflamed Meckel’s diverticulum
How is appendicitis diagnosed?
Clinical diagnosis
Bloods - raised WCC, CRP, ESR
Urinalysis to rule out UTI
Pregnancy test to rule out ectopic
How is appendicitis treated?
Nil by mouth IV fluids IV analgesia + anti-emetics IV Abx (cefuroxime 1.5g/8hr plus metronidazole 500mg/8hr) Laparoscopic appendectomy
What does bile consist of?
Cholesterol
Bile pigments
Phospholipids
What causes acute cholecystitis?
Stone or sludge impaction in the neck of the gallbladder
How does acute cholecystitis present?
- RUQ/epigastric pain
- Refers to right shoulder
- Local peritonism, vomiting, fever (these differentiate it from biliary colic)
What sign is classic in acute cholecystitis?
Murphy’s sign
- Lay 2 fingers over RUQ, ask patient to breathe in, causes patient to catch their breath due to impingement of gallbladder on fingers
- Only positive if same test over LUQ does not cause pain
What causes biliary colic?
Gallstones passing into the common bile duct or obstructing the cystic duct (without infection)
How does biliary colic present?
- RUQ pain
- Jaundice (only if obstructing CBD)
What investigation can diagnose gallstones?
USS
- thickened gallbladder wall
- shrunken gallbladder
- dilated CBD
- stones
What is the treatment for acute cholecystitis?
Lap chole
IV Abx - cefuroxime 1.5g/8hr
What is a bile duct infection called?
Cholangitis
How does cholangitis present?
Charcot’s Triad
1) RUQ pain
2) Jaundice
3) Rigors/fever
What are the LFTs like in obstructive jaundice?
ALP +++
ALT +/normal
Bilirubin +++
What can be used for prophylaxis of gallstones in high risk patients?
Ursodeoxycholic acid
What is the treatment for cholangitis?
Cefuroxime 1.5g/8h IV + metronidazole 500mg/8h IV
What can cause small bowel obstruction?
Adhesions
Hernias
Crohn’s
How does small bowel obstruction present?
- Early vomiting
- Severe colicky abdominal pain
- Late constipation
- Central distention
What can cause large bowel obstruction?
Volvulus
Carcinoma
Constipation
Diverticular strictures
How does large bowel obstruction present?
- Later vomiting
- More constant pain
- Earlier constipation
- Possible absolute constipation = no faeces or flatus
- Distention around flanks
What are the 2 classifications of bowel obstruction?
Mechanical
- Bowel above the level of obstruction is dilated
- Tinkling bowel sounds
- Peritonism is main feature in strangulation
Functional
- Ileus
- Less pain
- Bowel sounds absent
What would an abdominal X-ray of bowel obstruction look like?
Dilated bowel
- Loss of loops (valvulae conniventes) in small bowel
- Loss of haustra in colon
Coffee bean sign = volvulus
Rigler’s sign = pneumoperitoneum due to perforated bowel (both sides of bowel wall can be seen)
What are the normal sizes of bowel on AXR?
<3cm - small bowel
<6cm - large bowel
<9cm - caecum
How can you determine the level of obstruction in bowel obstruction?
Barium swallow
Barium enema
What is the management for acute bowel obstruction?
Drip & Suck
- NG tube and NBM
- IV fluids
Opioid analgesia Antiemetic - cyclizine 50mg Avoid prokinetic durgs e.g. metoclopramide/domperidone ABG if suspected shock Surgical resection if indicated
What parts of the colon are most commonly affected by diverticulitis?
Descending
Sigmoid
What is the main risk factor for diverticulosis?
Lack of dietary fibre
How does diverticulitis present?
Localised lower quadrant abdominal, relieved by defecation Fever Nausea Bloating, flatulence Painless PR bleeding
What bloods should be done in ?diverticulitis?
FBC - raised WCC
CRP - raised
ESR - raised
What imaging should be done in ?diverticulitis?
CXR - pneumoperitoneum
AXR - perforation, free fluid, collections
CT contrast - more accurate in complicated disease
What must not be done in acute attack of diverticulitis?
Colonoscopy
How do you treat a mild attack of diverticulitis?
Bowel rest - fluids only
Antibiotics - cefuroxime and metronidazole
What are some signs of abscess formation in diverticulitis?
Swinging fever
Leucocytosis
Localising signs
What are signs of perforation in diverticulitis?
Ileus
Peritonitis
Shock
Where do ectopic pregnancies mostly occur?
96% fallopian tube
2% interstitial part of uterus
1.5% intra-abdominally
How does an ectopic pregnancy usually present?
Sudden, severe lower abdominal pain
Collapse/syncope
Vaginal bleeding
What must you assume in all women with abdo pain?
They are pregnant until proven otherwise
What investigations should be done in ?ectopic pregnancy?
Pregnancy test
Bloods - serum b-HCG levels, FBC and cross match for rhesus status
What should not be done in ectopic pregnancy?
Bimanual examination
What is the treatment for ectopic pregnancy?
Fluid resuscitate
Methotrexate then refer to gynae
Significant haemorrhage requires urgent surgery
What is the definition of miscarriage?
Foetus dies before 24 weeks gestation
What are the risk factors for miscarriage?
Chromosomal anomalies in more than 50% First pregnancy Maternal disease Age > 30 years Uterine abnormalities Drugs - especially isotretinoin Cervical incompetence Trauma
How do miscarriages present?
Pelvic pain due to early uterine contractions - pain is associated with lower chance of foetal survival
Vaginal bleeding
Hypotension/shock
What is a threatened miscarriage?
Closed os
Vaginal bleeding
50% will miscarry
Presents with light, crampy pain
What signs might be found on examination of miscarriage?
Abdominal tenderness
Cervical dilatation
Products in the os
What investigations should be done in ?miscarriage?
Ultrasound scan to exclude ectopic pregnancy
Pregnancy test - remains positive for several days after foetal death
Rhesus status
Baseline b-HCG
Crossmatch
What should be done if cervical shock present?
Remove products from cervical os using sponge forceps
What should be done if severe bleeding continues in miscarriage?
Administer IM oxytocin/ergometrine 500mcg
What kind of cysts are most ovarian cysts?
Corpus luteum cysts
Follicular cysts
What are risk factors for ovarian cysts?
Early menarche Irregular periods Obesity Tamoxifen PID PCOS
How do chronic ovarian cysts present?
Dull/achy lower abdominal/pelvic pain that may radiate to lower back
Pain worse on intercourse
Bloating/swollen abdomen
Urinary symptoms if pressing onto bladder
How do ruptured or twisted ovarian cysts present?
Sudden severe sharp pain in pelvic area
Vomiting
Vaginal bleeding
Shock
What investigations should be done in ?ovarian cyst?
Pregnancy test to exclude ectopic
USS - confirms diagnosis
CA125 for ovarian cancer
Urinalysis to exclude UTI if urinary symptoms present
When should a laparoscopic cystectomy be considered?
If the ovarian cysts are:
- Large (>5cm)
- Symptomatic
- Cancerous (95% are benign)
- Signs of torsion - urgent laparoscopy
What can cause pancreatitis?
GET SMASHED
Gallstones Ethanol Trauma Surgery Mumps Autoimmune Scorpion sting Hypercalcaemia, hyperlipidaemia, hypothermia ERCP Drugs (azathioprine, didanosine, pentamidine)
How does pancreatitis present?
Severe constant epigastric pain radiating to the back that is relieved by sitting forwards
Pain is aggravated by alcohol
Vomiting +++
Shock
What signs might be found on examination of pancreatitis?
Tachycardia + hypotension = shock Fever Jaundice if gallstone obstruction is the cause Rigid abdomen/guarding Ileus/decreased bowel sounds Cullen's sign = periumbilical Grey Turner's sign = flank
(Cullen’s and Grey Turner’s are due to blood vessel autodigestion and retroperitoneal haemorrhage)
What bloods must be requested in ?pancreatitis?
Serum amylase - 3x the normal level is diagnostic Serum lipase - raised; more specific FBC - raised WCC U&Es - raised urea, low calcium Glucose - low LFTs - LDH, AST
What imaging should be done in ?pancreatitis?
CXR - to exclude gastroduodenal perforation (also causes raised serum amylase)
USS abdomen - identify gallstones
CT with contrast - perform after 72hr to assess extent of pancreatic necrosis
MRI - identifies gallstones in biliary tree
What is seen on USS abdomen if there is bile duct obstruction from gallstones?
Dilated intrahepatic ducts
What is done to remove bile duct stones in gallstone-related pancreatitis?
ERCP
What is the criteria for predicting the severity of pancreatitis?
Glasgow Score
PaO2 < 8 kPa Age > 55 years Neutrophilia Calcium < 2mmol/L Renal function (urea > 16) Enzymes (high LDH, AST, ALT) Albumin < 32g/L Sugar (glucose > 10mmol/L)
3+ points within first 48hrs = severe acute pancreatitis - transfer to ICU
What is the acute management for pancreatitis?
VACCINES
Vital signs monitoring - give oxygen if necessary Analgesia (pethidine IV) and antibiotics (cefuroxime) Catheter/calcium gluconate if required Cimetidine IV access and fluids NBM - insert NG tube for suction ERCP Surgery if required/senior review
What medication is best avoided in pancreatitis?
Morphine - could increase pancreatic ductular hypertension by causing Sphincter of Oddi contraction
What are the possible complications of pancreatitis?
PAIN
Peri-pancreatic fluid
Abscess
Infection
Necrosis
What is included under the term pelvic inflammatory disease?
Includes infection which has spread from: - Cervix to uterus = endometritis - Fallopian tubes = salpingitis - Ovaries = oophoritis - Adjacent peritoneum = peritonitis
What complications can arise from PID?
Abscess formation
5x increased risk of ectopic pregnancy
Infertility
What are the main causes of PID?
90% due to STI
Terminations
Dilatation & curettage
Who is most at risk of PID?
Sexually active women
Ages 15-20
Many sexual partners
History of STI
What organisms cause PID?
Chlamydia trachomatis = most common
Neisseria gonorrhoea
Mycoplasma hominis
Ureaplasma urealyticum
How does PID present?
Bilateral lower abdominal tenderness - may be constant or intermittent Dyspareunia Painful, irregular periods Vaginal discharge Dysuria
What signs might be found on examination of PID?
Cervical motion tenderness
What investigations should be done in ?PID?
High vaginal and cervical swabs to test for STIs
Urinalysis to exclude UTI
USS to exclude abscess
FBC - high WCC
What is the antibiotic therapy for PID?
Low-risk gonorrhoea = ofloxacin 400mg BD PO + metronidazole 400mg BD PO for 14 days
High-risk gonorrhoea = ceftriaxone IM + doxycycline + metronidazole
What are the most common causes of peptic ulcers?
- Helicobacter pylori - bacteria produces ammonia to neutralise stomach acid which is toxic to epithelial cells
- NSAIDs - inhibit prostaglandin synthesis which reduces the production of alkaline mucus
What are the alarm symptoms for peptic ulcers?
ALARMS
Anaemia (iron deficiency) Loss of weight Anorexia Recent onset Meleana/haematemesis Swallowing difficulty
How do stomach/duodenal ulcers present?
Stomach
- Pain worse just before eating/on eating
- Haematemesis
Duodenal (4x commoner)
- Pain relieved by eating
- Pain wakes patient up in the night
- Meleana
What investigations test for H. Pylori?
Stool antigen test = diagnostic
Carbon-13 urea breath test = to check if eradication was successful
What is the treatment for H Pylori?
Triple therapy
Amoxicillin/metronidazole 1g + clarithromycin 500mg + PPI (all taken twice daily for 1 week)
What are the different types of renal calculi in order of how common they are?
- Calcium oxalate (75%)
- Struvite - magnesium ammonium phosphate (15%)
- Urate
- Hydroxyapatite (usually do to UTI)
- Cysteine (usually due to renal tubular defect)
What metabolic disorders predispose you to urinary tract calculi?
Hypercalcaemia (hyperthyroidism, hyperparathyroidism, neoplasia, sarcoidosis, lithium)
Renal tubular acidosis
Gout
Cysteinuria
How do renal calculi present?
- Pain - fast onset of excruciating colicky loin to groin pain causing them to roll around (if it was peritonitis they would stay still); nausea + vomiting from pain
- Infection - fevers, rigors
- Haematuria
- Proteinuria
- Sterile pyuria
- Anuria
What signs might you find on examination of renal stones?
Renal angle tenderness - especially on percussion if there is retroperitoneal inflammation
Reduced bowel sounds (as in any severe pain)
Severe pain in testis but not tender on palpation
What investigations can be done for imaging stones?
CT scan of KUB
USS or Doppler in pregnant patients
IV urography
How do you treat stones <5mm?
Increase fluid intake - 90% pass spontaneously
Analgesia - diclofenac PO then ketorolac IV
Antibiotics - penicillin/gentamicin if infection
How do you treat stones >5mm?
Medical expulsive therapy
- Nifedipine (calcium-channel blocker) or tamsulosin (alpha blocker) to relax smooth muscle of bladder and ureter
- Extracorporeal shockwave lithotripsy (ultrasound waves shatter the stone)
- Uteroscopy
Percutaneous nephrolithotomy = keyhole surgery to remove stones if complex
What can cause different odours in urine?
Sweet - DKA
Pungent - infection
Ammonia - alkaline
Diet changes
What can cause discolouration of urine?
Brown: bile pigments, myoglobin, methaemoglobin, drugs (levodopa, metronidazole, anti-malarials, nitrofurantoin)
Green/blue: pseudomonas, amitryptiline
Orange: bile pigments, phenothiazines
Red: haematuria, porphyria, beetroot, rifampicin
What can cause haematuria?
ONNIT
Obstruction - calculi Neoplasm - TCC, RCC, prostate Nephritic syndrome - glomerulonephritis Inflammation - UTI Trauma
What can cause ketonuria?
Starvation/low carb diet Diabetes/DKA Alcoholism Pregnancy Hyperthyroidism
False negatives can occur from:
- Dehydration
- L Dopa
- Sodium valproate
