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Abdominal Pain Flashcards

1
Q

What is a abdominal aortic aneurysm/

A

Localised permanent dilatation of the aorta >3cm

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2
Q

What are the risk factors for AAA?

A

> 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
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3
Q

How are most AAA found?

A

Most are asymptomatic and found on routine abdominal examination, AXR or USS

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4
Q

What sign can be found on examination of AAA?

A

Pulsatile and expansile mass

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5
Q

How does a ruptured AAA present?

A

Sudden onset of severe pain in back/abdomen/loin/groin

Collapse

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6
Q

What signs would be found on examination of ruptured AAA?

A 
Tachycardia
Hypotension
Cullen's sign
Grey-Turner's sign
Absent femoral pulses
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7
Q

What investigation must be done in ?AAA?

A

Urgent abdominal USS

Bloods - FBC, clotting, crossmatch, LFTs, U&Es

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8
Q

What size AAA requires/does not require treatment?

A

<5.5cm - watch a wait, regular USS monitoring

>5.5cm - surgery (endovascular stent repair or insertion of graft)

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9
Q

What is the acute management of a ruptured AAA?

A

ABCDE

  1. High flow oxygen 15L/min via a non-rebreathe mask
  2. 2 wide bore cannulas in the antecubital fossae
  3. Bloods - emergency crossmatching, FBC, U&Es, glucose, coagulation, LFTs
  4. Give fluids in major hypovolaemia but avoid excess
  5. IV morphine
  6. IV antiemetics - 50mg cyclizine
  7. IV antibiotics (prophylactic) - 1.5g cefuroxime + 500mg metronidazole
  8. Call vascular surgeon and anaesthetist for aortic cross clamping and insertion of Dacron graft
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10
Q

What is the commonest surgical emergency?

A

Appendicitis

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11
Q

What causes appendicitis?

A

Lumen of appendix becomes obstructed with:
- Faecolith
- Lymphoid hyperplasia
- Filarial worms
Then gut organisms invade the appendix wall

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12
Q

How does appendicitis present?

A

Acute abdominal pain that starts in epigastric/umbilical area then localises to the right iliac fossa
Nausea, vomiting, diarrhoea
Anorexia
Fever

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13
Q

What signs can be found in appendicitis?

A
  • 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
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14
Q

What are some complications of appendicitis?

A

Electrolyte imbalance from vomiting
Perforation
Ileus

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15
Q

What are some differentials for appendicitis?

A

Acute terminal ileitis from Crohn’s
Ectopic pregnnacy
Ruptured ovarian cyst
Inflamed Meckel’s diverticulum

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16
Q

How is appendicitis diagnosed?

A

Clinical diagnosis

Bloods - raised WCC, CRP, ESR
Urinalysis to rule out UTI
Pregnancy test to rule out ectopic

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17
Q

How is appendicitis treated?

A 
Nil by mouth 
IV fluids
IV analgesia + anti-emetics
IV Abx (cefuroxime 1.5g/8hr plus metronidazole 500mg/8hr)
Laparoscopic appendectomy
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18
Q

What does bile consist of?

A

Cholesterol
Bile pigments
Phospholipids

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19
Q

What causes acute cholecystitis?

A

Stone or sludge impaction in the neck of the gallbladder

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20
Q

How does acute cholecystitis present?

A
  • RUQ/epigastric pain
  • Refers to right shoulder
  • Local peritonism, vomiting, fever (these differentiate it from biliary colic)
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21
Q

What sign is classic in acute cholecystitis?

A

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
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22
Q

What causes biliary colic?

A

Gallstones passing into the common bile duct or obstructing the cystic duct (without infection)

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23
Q

How does biliary colic present?

A
  • RUQ pain

- Jaundice (only if obstructing CBD)

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24
Q

What investigation can diagnose gallstones?

A

USS

  • thickened gallbladder wall
  • shrunken gallbladder
  • dilated CBD
  • stones
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25
Q

What is the treatment for acute cholecystitis?

A

Lap chole

IV Abx - cefuroxime 1.5g/8hr

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26
Q

What is a bile duct infection called?

A

Cholangitis

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27
Q

How does cholangitis present?

A

Charcot’s Triad

1) RUQ pain
2) Jaundice
3) Rigors/fever

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28
Q

What are the LFTs like in obstructive jaundice?

A

ALP +++
ALT +/normal
Bilirubin +++

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29
Q

What can be used for prophylaxis of gallstones in high risk patients?

A

Ursodeoxycholic acid

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30
Q

What is the treatment for cholangitis?

A

Cefuroxime 1.5g/8h IV + metronidazole 500mg/8h IV

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31
Q

What can cause small bowel obstruction?

A

Adhesions
Hernias
Crohn’s

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32
Q

How does small bowel obstruction present?

A
  • Early vomiting
  • Severe colicky abdominal pain
  • Late constipation
  • Central distention
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33
Q

What can cause large bowel obstruction?

A

Volvulus
Carcinoma
Constipation
Diverticular strictures

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34
Q

How does large bowel obstruction present?

A
  • Later vomiting
  • More constant pain
  • Earlier constipation
  • Possible absolute constipation = no faeces or flatus
  • Distention around flanks
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35
Q

What are the 2 classifications of bowel obstruction?

A

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
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36
Q

What would an abdominal X-ray of bowel obstruction look like?

A

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)

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37
Q

What are the normal sizes of bowel on AXR?

A

<3cm - small bowel
<6cm - large bowel
<9cm - caecum

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38
Q

How can you determine the level of obstruction in bowel obstruction?

A

Barium swallow

Barium enema

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39
Q

What is the management for acute bowel obstruction?

A

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
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40
Q

What parts of the colon are most commonly affected by diverticulitis?

A

Descending

Sigmoid

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41
Q

What is the main risk factor for diverticulosis?

A

Lack of dietary fibre

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42
Q

How does diverticulitis present?

A 
Localised lower quadrant abdominal, relieved by defecation 
Fever
Nausea 
Bloating, flatulence 
Painless PR bleeding
43
Q

What bloods should be done in ?diverticulitis?

A

FBC - raised WCC
CRP - raised
ESR - raised

44
Q

What imaging should be done in ?diverticulitis?

A

CXR - pneumoperitoneum
AXR - perforation, free fluid, collections
CT contrast - more accurate in complicated disease

45
Q

What must not be done in acute attack of diverticulitis?

A

Colonoscopy

46
Q

How do you treat a mild attack of diverticulitis?

A

Bowel rest - fluids only

Antibiotics - cefuroxime and metronidazole

47
Q

What are some signs of abscess formation in diverticulitis?

A

Swinging fever
Leucocytosis
Localising signs

48
Q

What are signs of perforation in diverticulitis?

A

Ileus
Peritonitis
Shock

49
Q

Where do ectopic pregnancies mostly occur?

A

96% fallopian tube
2% interstitial part of uterus
1.5% intra-abdominally

50
Q

How does an ectopic pregnancy usually present?

A

Sudden, severe lower abdominal pain
Collapse/syncope
Vaginal bleeding

51
Q

What must you assume in all women with abdo pain?

A

They are pregnant until proven otherwise

52
Q

What investigations should be done in ?ectopic pregnancy?

A

Pregnancy test

Bloods - serum b-HCG levels, FBC and cross match for rhesus status

53
Q

What should not be done in ectopic pregnancy?

A

Bimanual examination

54
Q

What is the treatment for ectopic pregnancy?

A

Fluid resuscitate
Methotrexate then refer to gynae
Significant haemorrhage requires urgent surgery

55
Q

What is the definition of miscarriage?

A

Foetus dies before 24 weeks gestation

56
Q

What are the risk factors for miscarriage?

A 
Chromosomal anomalies in more than 50%
First pregnancy
Maternal disease
Age > 30 years
Uterine abnormalities
Drugs - especially isotretinoin 
Cervical incompetence
Trauma
57
Q

How do miscarriages present?

A

Pelvic pain due to early uterine contractions - pain is associated with lower chance of foetal survival
Vaginal bleeding
Hypotension/shock

58
Q

What is a threatened miscarriage?

A

Closed os
Vaginal bleeding
50% will miscarry
Presents with light, crampy pain

59
Q

What signs might be found on examination of miscarriage?

A

Abdominal tenderness
Cervical dilatation
Products in the os

60
Q

What investigations should be done in ?miscarriage?

A

Ultrasound scan to exclude ectopic pregnancy
Pregnancy test - remains positive for several days after foetal death
Rhesus status
Baseline b-HCG
Crossmatch

61
Q

What should be done if cervical shock present?

A

Remove products from cervical os using sponge forceps

62
Q

What should be done if severe bleeding continues in miscarriage?

A

Administer IM oxytocin/ergometrine 500mcg

63
Q

What kind of cysts are most ovarian cysts?

A

Corpus luteum cysts

Follicular cysts

64
Q

What are risk factors for ovarian cysts?

A 
Early menarche
Irregular periods
Obesity
Tamoxifen
PID
PCOS
65
Q

How do chronic ovarian cysts present?

A

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

66
Q

How do ruptured or twisted ovarian cysts present?

A

Sudden severe sharp pain in pelvic area
Vomiting
Vaginal bleeding
Shock

67
Q

What investigations should be done in ?ovarian cyst?

A

Pregnancy test to exclude ectopic
USS - confirms diagnosis
CA125 for ovarian cancer
Urinalysis to exclude UTI if urinary symptoms present

68
Q

When should a laparoscopic cystectomy be considered?

A

If the ovarian cysts are:

  • Large (>5cm)
  • Symptomatic
  • Cancerous (95% are benign)
  • Signs of torsion - urgent laparoscopy
69
Q

What can cause pancreatitis?

A

GET SMASHED

Gallstones
Ethanol
Trauma
Surgery
Mumps
Autoimmune
Scorpion sting
Hypercalcaemia, hyperlipidaemia, hypothermia
ERCP
Drugs (azathioprine, didanosine, pentamidine)
70
Q

How does pancreatitis present?

A

Severe constant epigastric pain radiating to the back that is relieved by sitting forwards
Pain is aggravated by alcohol
Vomiting +++
Shock

71
Q

What signs might be found on examination of pancreatitis?

A 
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)

72
Q

What bloods must be requested in ?pancreatitis?

A 
Serum amylase - 3x the normal level is diagnostic
Serum lipase - raised; more specific 
FBC - raised WCC
U&amp;Es - raised urea, low calcium 
Glucose - low 
LFTs - LDH, AST
73
Q

What imaging should be done in ?pancreatitis?

A

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

74
Q

What is seen on USS abdomen if there is bile duct obstruction from gallstones?

A

Dilated intrahepatic ducts

75
Q

What is done to remove bile duct stones in gallstone-related pancreatitis?

A

ERCP

76
Q

What is the criteria for predicting the severity of pancreatitis?

A

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

77
Q

What is the acute management for pancreatitis?

A

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
78
Q

What medication is best avoided in pancreatitis?

A

Morphine - could increase pancreatic ductular hypertension by causing Sphincter of Oddi contraction

79
Q

What are the possible complications of pancreatitis?

A

PAIN

Peri-pancreatic fluid
Abscess
Infection
Necrosis

80
Q

What is included under the term pelvic inflammatory disease?

A 
Includes infection which has spread from:
- Cervix to uterus = endometritis 
- Fallopian tubes = salpingitis
- Ovaries = oophoritis
- Adjacent peritoneum 
= peritonitis
81
Q

What complications can arise from PID?

A

Abscess formation
5x increased risk of ectopic pregnancy
Infertility

82
Q

What are the main causes of PID?

A

90% due to STI
Terminations
Dilatation & curettage

83
Q

Who is most at risk of PID?

A

Sexually active women
Ages 15-20
Many sexual partners
History of STI

84
Q

What organisms cause PID?

A

Chlamydia trachomatis = most common
Neisseria gonorrhoea
Mycoplasma hominis
Ureaplasma urealyticum

85
Q

How does PID present?

A 
Bilateral lower abdominal tenderness - may be constant or intermittent
Dyspareunia 
Painful, irregular periods
Vaginal discharge
Dysuria
86
Q

What signs might be found on examination of PID?

A

Cervical motion tenderness

87
Q

What investigations should be done in ?PID?

A

High vaginal and cervical swabs to test for STIs
Urinalysis to exclude UTI
USS to exclude abscess
FBC - high WCC

88
Q

What is the antibiotic therapy for PID?

A

Low-risk gonorrhoea = ofloxacin 400mg BD PO + metronidazole 400mg BD PO for 14 days

High-risk gonorrhoea = ceftriaxone IM + doxycycline + metronidazole

89
Q

What are the most common causes of peptic ulcers?

A
  1. Helicobacter pylori - bacteria produces ammonia to neutralise stomach acid which is toxic to epithelial cells
  2. NSAIDs - inhibit prostaglandin synthesis which reduces the production of alkaline mucus
90
Q

What are the alarm symptoms for peptic ulcers?

A

ALARMS

Anaemia (iron deficiency)
Loss of weight
Anorexia
Recent onset
Meleana/haematemesis
Swallowing difficulty
91
Q

How do stomach/duodenal ulcers present?

A

Stomach

  • Pain worse just before eating/on eating
  • Haematemesis

Duodenal (4x commoner)

  • Pain relieved by eating
  • Pain wakes patient up in the night
  • Meleana
92
Q

What investigations test for H. Pylori?

A

Stool antigen test = diagnostic

Carbon-13 urea breath test = to check if eradication was successful

93
Q

What is the treatment for H Pylori?

A

Triple therapy

Amoxicillin/metronidazole 1g + clarithromycin 500mg + PPI (all taken twice daily for 1 week)

94
Q

What are the different types of renal calculi in order of how common they are?

A
  1. Calcium oxalate (75%)
  2. Struvite - magnesium ammonium phosphate (15%)
  3. Urate
  4. Hydroxyapatite (usually do to UTI)
  5. Cysteine (usually due to renal tubular defect)
95
Q

What metabolic disorders predispose you to urinary tract calculi?

A

Hypercalcaemia (hyperthyroidism, hyperparathyroidism, neoplasia, sarcoidosis, lithium)
Renal tubular acidosis
Gout
Cysteinuria

96
Q

How do renal calculi present?

A
  1. 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
  2. Infection - fevers, rigors
  3. Haematuria
  4. Proteinuria
  5. Sterile pyuria
  6. Anuria
97
Q

What signs might you find on examination of renal stones?

A

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

98
Q

What investigations can be done for imaging stones?

A

CT scan of KUB
USS or Doppler in pregnant patients
IV urography

99
Q

How do you treat stones <5mm?

A

Increase fluid intake - 90% pass spontaneously
Analgesia - diclofenac PO then ketorolac IV
Antibiotics - penicillin/gentamicin if infection

100
Q

How do you treat stones >5mm?

A

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

101
Q

What can cause different odours in urine?

A

Sweet - DKA
Pungent - infection
Ammonia - alkaline
Diet changes

102
Q

What can cause discolouration of urine?

A

Brown: bile pigments, myoglobin, methaemoglobin, drugs (levodopa, metronidazole, anti-malarials, nitrofurantoin)

Green/blue: pseudomonas, amitryptiline

Orange: bile pigments, phenothiazines

Red: haematuria, porphyria, beetroot, rifampicin

103
Q

What can cause haematuria?

A

ONNIT

Obstruction - calculi 
Neoplasm - TCC, RCC, prostate
Nephritic syndrome - glomerulonephritis
Inflammation - UTI
Trauma
104
Q

What can cause ketonuria?

A 
Starvation/low carb diet
Diabetes/DKA
Alcoholism
Pregnancy
Hyperthyroidism

False negatives can occur from:

  • Dehydration
  • L Dopa
  • Sodium valproate

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