Abdominal Pain Flashcards
What is the presentation of ruptured AAA?
Severe ‘Ripping’ abdominal or back pain, syncope and shock. Tachycardic and hypotensive
Classic triad - flank pain, hypotension and a pulsatile abdominal mass
what is the classification of an AAA, where are they commonly found?
diameter of 3cm of more (normal diameter is 2 cm)
Found below the level of the renal arteries
Risk factors for AAA
Male, atherosclerosis, FH, smoking, age, HTN, COPD, inflammatory disease, connective tissue disease, infection
Investigations for suspected ruptured AAA
A-E approach
Obs - hypotensive, tachycardic
Bloods - FBC, Group and save, cross match, U&Es (baseline for surgery)
Imaging - Abdo XR or CT will confirm diagnosis
ECG - is chest pain presentation
Management fo ruptures AAA
A-E approach. Surgical emergency
15L O2
Large bore canula and rapid fluid resuscitation
Prep for surgery - if stable to CT w/ contrast.
if not stable to laparotomy.
Presentation of appendicitis
abdominal pain moving to RIF. Pain aggrevated by moving, localised tenderness, may have rovsings sign.
N/V, constipation, fever
Signs: Gaurding, rebound tenderness, tachycardia.
Most common cause of acute abdomen?
appendicitis. Most common in young people, can occur at any age.
Differentials of acute abdominal pain presentation
Appendicitis Bowel obstruction Pancreatitis Perforated ulcer Diverticulitis DKA Renal Colic Constipation Ectopic pregnancy Ovarian cyst Testicular torsion
Scoring system used to rate symptoms of suspected appendicitis?
Alvadro score - RIF pain, Anorexia, N/V, RIF tenderness, rebound tenderness, Fever, Leucocytosis, Neutropihils.
Investigations for suspected appendicitis?
Exclusion of differentials: Urine dip, Pregnancy test.
Bloods: FBC, CRP, U&E
Imaging: USS, CT is gold standard for diagnosing.
Management of acute appendicitis
A-E approach Fluids and analgesia Pre-operative antibiotics NBM Prepped and wait for surger - lapraroscopic appendectomy.
What is Charcots Tirad?
Fever, jaundice, RUQ pain
Triad indicating Cholangitis (inflammation and infection of biliary tree)
what causes cholangitis?
obstruction of the gall bladder by stones, tumour, stenosis, infections., prodecudres (eg ERCP)
Presentation of cholangitis
Fever, jaundice, RUQ pain, puritis, change in stool colour - clay coloured.
Investigations for suspected cholangitis
Bloods: FBC, CRP, LFTs, U&Es, amylase, Blood culture
Imaging: liver USS, Contrast CT of clinical suspicion of diagnostic uncertainty
What changes in LFTs would you see in cholangitis
obstructive jaundice
increased bilirubin, increase ALP and transaminase.
Management for cholangitis
Stabilise - may need fluids and analgesia
Give IV antibiotics once cultures have returned.
Will need aerobic and gram negative coverage metronidazole, ceftriaxoe or ciprofloxacin.
If no improvement, can do endocopic biliary drainage.
Monitor LFTs, U&Es, vitimain absorption.
Presentation of bowel obstruction
Colicky abdominal pain.
N/V. failure to mass bowel motion
abdominal distenstion, tympanic ‘tinkly’ bowel sounds.
Signs: tachycardic, hypotensive, dehydrated, pyrexia.
Causes of bowel obstruction
constipation, malignancy, strangulated hernias, IBD, CF, Volvulus., neurological damage causing paralytic ileus
What is a paralytic ileus and what causes it?
Obstruction due to no peristalsis, part of the bowel becomes paralysed.
Caused by: Stroke, MI, AKI, DKA, Chest infections, electrolyte disturbance, MS, Parkinson’s, neurological impairment are at risk.
What type of obstruction is more common, how does it present?
Small bowel obstruction: presenting with vomiting and abdominal pain.
if not passing faeces this is a late sign.
How to tell the difference between small and large bowel obstruction on XR
Look for dilated bowel loops
Small: Valvulae starch entire way across the bowel loop
Large: haustra stretch only part of the way across the bowel
Investigations and Management for suspected bowel obstruction
A-E approach
ensure Pt is stable. give O2 is needed.
ECG - if electrolyte abnormalities
Bloods: FBC, group and save, crossmatch, glucose, ABG ( look at lactate)
Fluid resuscitation and electrolyte replacement - monitor fluid balance, will need catheter.
Imaging - abdominal XR. May need non-contrast CT
Emergency surgery - can have decompression with stents endoscopically, or may need laparotomy.
Complications of bowel obstruction
perforation, ischaemia, electrolyte disturbance, AKI, shock.
What is diverticulitis?
Herniation of GI mucosa through colonic muscle in the sigmoid or descending colon (diverticula) which then become inflamed.
Presentation of diverticulitis
LLQ abdominal pain, which can be intermittent or associated with bowel habits.
Pyrexia, N/V, tachycardia.
Localised tenderness, reduced bowel sounds, palpable mass.
Complications of diverticula disease
obstruction, perforation, abscess formation, peritonitis, haemorrhage - can present acutely with lower GI bleed.
Risk factors for diverticulitis?
Older age, low fibre diet, smoking chronic NSAID use, obesity
Investigations for diverticulitis?
Bloods: BFC, LFT, U&Es, CRP Abdominal XR CT w/contrast Urinalysis (exclusion of renal cause) NOT endoscopy due to risk of perforation
Management of diverticulitis
Fluids and analgesia
Broad spectrum Abx - ned to cover anaerobes. Co amox, ciprofloxacin or metronidazole.
Can use mesalamine to reduce severity of bowel symptoms and prevent recurrence.
Surgery if: perforation, peritonitis, uncontrolled sepsis, obstruction.
Pancreatitis causes
I GET SMASHED Idiopthic / Infective Gall stones Ethanol Trauma Steriods Mumps/malignancy Autoimmune Scorpion Hypercalceamia Ercp Drugs
Presentation of pancreatitis
Severe epigastric pain penetrating to the back.
Jaundice, ascities.
N/V, tachycardic and hypotensive.
May have grey turners and Cullen’s sign (bruising around umbilicus and flank)
Investigations for suspected pancreatitis
Bloods: ABG/VBG, FBC, LFT, U&E, glucose, amylase (will be 3x normal values)
CXR - look for signs of perforation
AXR - look for perforation or obstruction
CT with contrast - not needed f patient is stable and diagnosis is highly likely, only needed us diagnostic uncertainty.
Severity assessment tool used in pancreatitis
Glasgow prognostic score -
PANCREAS P - PaO2 A- Age N- Neutrophils C- Calcium R- Renal function E- Enzymes A - Albumin S- Sugar
a score of 3 or more indicates a severe attack
Management of Pancreatitis
A-E approach
If identify a cause - treat!
mild - analgesia. (not morphine), IV fluids, NG if vomiting, Abx if signs of infection.
if Severe - if evidence of necrosis IV abx, drainage of ascites, surgery only need if infection or necrosis.
necrosis = raised CRP requiring surgical intervention.
Why can’t morphine be used in pancreatitis?
can cause spasm of sphincter of oddi.
ectopic pregnancy presentation
usually atypical. abdominal/pelvic pain, amenorrhoea, bleeding, syncope, urinary symptoms, N/V.
signs of shock if ruptured.
Investigations for suspected ectopic pregnancy
Pregnancy test
Transvaginal USS
serum hcg in women with pregnancy in unknown location
Management of ectopic pregnancy
Expectant: if hcg <1000, pain free, mass <3mm
Medical: single dose of methotrexate. serum hcg of >1500, mass <35mm, no heartbeat, no Intrauterine pregnancy.
contraception needs to be used for 3-6months after
Surgical: if significant pain, mass over 35, fetal heart beat, hcg >5000.
Presentation of ovarian cyst
Asymptomatic and incidental finding
Dull lower abdominal/back pain, intermittent, dyspareunia, heavier menstruation. May have ascites (malignancy), pressure effects eg urinary frequency, oedema.
Rupture - severe pain, fever, peritonitis, shock.
Causes of ovarian cyst formation
70% benign - epithelial cysts (either serous (older women) or mucinous(younger women, more likely to rupture)), neoplastic benign tumours eg fibroma.
24% functional cyst - luteal cysts or follicular cysts
6% malignant
Investigations for suspected ovarian cyst
Pregnancy test
Bloods: FBC (look for infection or haemorrhage signs), Ca125 (NOT in pre-menopausal women), LDH, ADP, hCG - all tumour markers.
Imaging: Pelvic USS, transvaginal preferred. CT only if USS is not definitive.
What system if used to assess the likelihood of an ovarian cyst being malignant?
RMI - Risk of Malignancy Index.
Measures, menopausal status, USS features of cysts, Serum Ca125. score a point for each and X together to get overall score.
Management of ovarian cysts
Expectant: watch and wait, for cysts smaller than 5 cm. Oral contraceptives should be stopped. analgesia for pain control. May need yearly USS check ups, cyst should disintegrate.
Surgical: if expectant management fails, if larger than 5 cm, or if complication (torsion, rupture, haemorrhage).
Presentation of miscarriage, what are the risk factors?
Heavy vaginal bleeding, pain.
Risk factors: stress, increased of very young age, recent infections smoking, alcohol, Low BMI, fertility problems, poorly controlled diabetes.
Classification of miscarriage
Threatened: cervical os closed, little bleeding. May keep the pregnancy
Inevitable: cervical os open, lots of bleeding, will precede to have a complete miscarriage.
Incomplete: cervical os open, products of conception partially expelled.
Complete: after bleeding stops, no sign of pregnancy on USS.
Investigations for suspected miscarriage
VE examination
Transvaginal USS - detection of heartbeat or products of conception
Bloods: serum hCG, (to exclude ectopic) progesterone (if low can rule out viable pregnancy)
Management of miscarriage
Expectant: with support, urine PT 7 days after to see if miscarriage has resolved.
Medical: analgesia. Vaginal or oral misoprostol (prostaglandin analogue). Bleeding can continue for three weeks.
Surgical: if persistent bleeding, haemodynamic instability, Manual cavum aspiration or surgical management under GA.
Presentation of PID
infection of upper genital tract, bilateral lower abdominal pain, deep dyspareunia, vaginal bleeding, purulent discharge, pyrexia, N/V
O/E, cervical motion tenderness.
Causes of PID
infection from cervix, chlamydia or gonorrhoea. or polymicrobial, caused by endogenous vaginal flora and aerobic strep.
Investigations for PID
PT and urinalysis
Swabs: endocervical, vulvovaginal NAAT.
Bloods: FBC, CRP
USS may be needed to exclude masses and cysts.
Management of PID
analgesia
Abx - do not delay since can increase likelihood of scarring and future fertility problems.
Board spectrum, may need IV, ceftriaxone then doxycycline.
avoid unprotected sex, screen sexual partners for STI.
Presentation of peptic ulcer
upper abdominal/chest pain, dyspepsia, pain is postprandial, N/V, bloating, reflux, symptoms resolved by antacids.
Investigations for suspected peptic ulcer
Bloods: FBC
H.Pylori screen - carbon urea breath test or stool antigen test.
Endoscopy - only required if risk factors for severe disease or malignancy
indications for needing an endoscopy with dyspepsia presentation
over 55, have iron deficient anaemia, weight loss, bloods loss, vomiting, epigastric mass or dysphagia
Management of peptic ulcer disease
Modify current medications
Antacid relief
if H.Pylori treat - PPI and Ranitidine
Presentation of renal colic
severe back pain moving towards the groin, intermittent pain. Dysuria, haematuria, N/V, signs of dehydration.
Tender, reduced bowel sounds, may be hypotensive.
Causes of renal colic
stones form due to saturated urine with acid, salt and struvite.
Risk factors: male, obesity, hypertension, gout, dehydration, calcium supplements.
Investigations for suspected renal colic
Urinalysis - look for WCC, nitrates, pH (acidic if stones), RBC
Bloods: BC, U&Es, CRP, Calcium, urate, creatinine, phosphate
CT - non-contrast
USS or Abdo XR can be useful
Management of renal colic
analgesia
antiemetic
fluid control - balance risk of hydroneohrosis with dehydration.
Most stones pass spontaneously within 1-3 weeks
Further interventions/hospital management if fever, uncontrolled pain, dehydration.
Medical - nifedipine or Tamsulosin to facilitate stone passing
Surgical - ablation or stenting.
Presentation of UTI
abdominal pain, dysuria, urinary frequency, nocturia, haematuria, confusion, fever, N/V
Causes and risk factors of UTI
E.coli infection, either to bladder (cystitis) or kidney (pyelonephritis)
RF: women, pregnancy, catheter use, incomplete bladder emptying, sexual intercourse, diabetes
Management of UTI
Cystitis uncomplicated: oral Abx - trimethoprim or nitrofurantoin for 3 days.
If pyelonephritis- cefalexin (oral) or co-amoxiclav (IV) for 7-10 days.
Investigations for UTI
Simple UTI:
Urinalysis - look for raised nitrates and leukocytes, may also have protein and blood.
Send for culture and sensitivity
If worried about sepsis - do BUFALO!
