Abdominal pain: Core conditions Flashcards
Diabetes
A chronic metabolic disorder characterised by chronic hyperglycaemia due to insulin resistance and/or insulin deficiency.
Types of diabetes
• Type 1 Diabetes Mellitus (5 – 10%)
• Type 2 Diabetes Mellitus (90%)
• Endocrinopathies – Cushing’s Syndrome, Acromegaly, Phaeochromocytoma
• Secondary Diabetes due to Pancreatic Disease
• Genetic – MODY, Mitochondrial Diabetes Mellitus
• Gestational Diabetes Mellitus
Symptoms of diabetes
Abdominal pain, change in appetite, weight loss/gain, indigestion, nausea/vomiting, change in bowel habit (diarrhoea/constipation), change in colour of stools, change in urinary habits, polyuria/polydipsia
Core symptoms for type 1 diabetes mellitus
Weight loss, change in urinary habit, polyuria/polydipsia
Diagnosis of type 1 diabetes mellitus
• Additional symptoms: constitutional (malaise, fatigue), blurred vision, infections (genitourinary)
• Time frame: recent onset > months
• Younger 20-30
• Slim, not overweight
• FHx of T1 or autoimmunity (Coeliac, Addisons, Thyroid)
Type 2 diabetes mellitus
• Insulin resistance and deficiency
• Intracellular lipid accumulation in liver and pancreas
• Hepatic insulin resistance causes more insulin to be secreted by the pancreas, more fat disposition in both, cycle of worsening insulin effect and production
Diagnosis of type 2 diabetes
• Additional symptoms: malaise, fatigue, blurred vision
• Time frame- months, years
• Older 40+
• Overweight, obese
• PMHX- hypertension, hyperlipidaemia
• FHx of T2
Pancreatic (T3c) diabetes mellitus symptoms
Weight loss, change in urinary habit, polyuria/polydipsia, nausea and vomiting, abdominal pain, change in bowel habit (diarrhoea/constipation), change in colour of stools.
Making a diagnosis of Pancreatic (T3c) diabetes mellitus
• Time frame: rapid onset in pancreatic disease, slow in chronic disease
• Risk factors for pancreatitis: ETOH, gallstones (GETSMASHED)
• Upper/epigastric abdominal pains are present in acute presentation
Diabetes investigations
• Random blood glucose (capillary or venous)
• Blood or Urine Ketones
• Arterial/Venous blood gas
• Fasting plasma glucose
• Oral Glucose Tolerance Test
• Glycated Haemoglobin (HbA1c)
• Autoantibodies
Diagnosis of acute presentation of diabetes and T3c
Acute presentation e.g. A/E Random BG +/- ketones/gas (+/- tests if T1 suspected from history) – want to make sure DKA not present
T3c= Then amylase/LFTs/lipase/calcium - + imaging (US/CT/MRCP), faecal elastase
Tests for diabetes
• Fasting plasma glucose >7.0 mmol/L
• 2hr oral glucose tolerance test >11.1 mmol/L
• Random plasma glucose >11.1 mmol/L
• HbA1c >48 mmol/mol (6.5%)
Management of diabetes
• Dietary changes and weight loss
• Oral and injectable medication
• Insulin- immediately start on T1 even if unsure
• Pancreatic disease- standard management
Rapid acting insulin (human insulin)
Onset: 5-15min
Peak: 30-90min
Duration:3-5hr
Examples: Novorapid, Humalog
Rapid acting (analogue insulin)
Onset:20-40 min
Peak: 2-3hr
Duration: 5-8hr
Examples: Actrapid, Humulin S
Intermediate acting (human insulin)
Onset: 2-4hr
Peak: 8-12hr
Duration: 12-16hr
Examples: Insulatard, Humulin I
How many insulin injections are needed
T1DM are usually on 4-5 injections whilst T2 is more likely to be on 2 injection.
GKI and VRII
• Glucose potassium insulin (GKI) infusions works well and needs less intensive monitoring meaning its easier to use on wards
• Variable rate intravenous insulin infusions (VRII) are only used in acute wards
• VRII is used in the treatment of DKA and HHS
• GKI is a step down from VRII, its used as pre-op management or for patients unwell with nausea and vomiting who are type 1
• GKI is safer than VRII and is less intensive for ward nurses
How do I transfer the patient from a GKI or VRII infusion back to subcutaneous insulin
• The effects of IV insulin in a GKI or VII will only last for about 3 minutes after the infusion is switched off
• So, you must give a subcutaneous insulin injection 60 minutes before stopping the GKI to ensure the subcutaneous insulin has been absorbed.
Diabetes medication
• Biguanide – Metformin
• Sulphonylurea – Gliclazide
• DPP4 inhibitors – Sitagliptin
• SGLT2 inhibitor – Empagliflozin
• GLP-1 analogue – Liraglutide
Metformin- oral
• Enhances insulin sensitivity
• Dose: 500/850/1000mg twice- three times daily with meals
• Contraindications: CKD/ liver/ heart failure
• Gi side effects
Gliclazide
• Enhances insulin secretion by beta cells of the pancreas
• Dose 40/80/120/160mg once- twice daily with meals
• Hypoglycaemia risk, weight gain
• Other drugs in the same class- Glimepiride
Sitagliptin
• Inhibits DPP4-induced breakdown of GLP-1
• Dose: 100mg once daily
• Other drugs in same class – Linagliptin (5mg), Saxagliptin (5mg)
Empagliflozin
• Inhibits glucose uptake in kidney proximal tubule
• Dose – 10 – 25mg once daily
• Other drugs in same class – Canagliflozin (100mg/300mg), Dapagliflozin (5mg/10mg)
- Benefits: weight loss, reduced cardiovascular risk, reduces progression of chronic kidney disease
Liraglutide- injectable
• GLP-1 analogue
• Dose- 0.6/1.2/1.8mg once daily
• Other drugs in the same class: Exenatide, Lixisenatide, Semaglutide, Dulaglutide
• GI symptoms
• Pancreatitis contra-indications, weight loss
- Benefits: weight loss, reduced cardiovascular risk
The acute abdomen exclusion tests
Urine dip, pregnancy test, FAST scan
GI causes of abdo pain
• Reflux (GORD)
• Gastritis
• Perforation (anywhere)
• Pancreatitis
• DKA
• Biliary= Gallstones, Cholecystitis, Cholangitis
• Hepatitis
• Adhesions obstruction/SBO
• Appendicitis
• Colitis (infective, Crohn’s, UC)
• LBO, volvulus, toxic megacolon
• Diverticulitis
• Incarcerated/strangulated hernia
Genitourinary causes of Abdo pain
• Pyelonephritis
• Renal/ureteric calculi
• Urinary retention
• UTI
• Prostatitis/prostate Ca
• Testicular torsion
• Ovarian torsion
• Pelvic inflammatory disease
• Ruptured cyst
• Endometriosis
• Retrograde menstruation
• Pregnancy (ectopic)
Vascular / non-abdominal causes of abdominal pain
MI, pneumonia, ruptured spleen, mesenteric ischaemia, ruptured aneurysm
What is an acute abdomen
• Rapid onset (or worsening on background of a few days)
• Severe pain
• Systemically unwell: shock/sepsis
• Common things to suspect: Infection, Inflammation, Obstruction, Vascular
Peritonism
The collection of symptoms of acute abdominal pain, N&V, unwell. Peritonitis is inflammation of the peritoneum of the abdomen caused by underlying inflammatory triggers (inflamed viscera, blood, perforated bowel contents, necrosis, ischaemia).
How pain presents in the abdomen
In order of severity:
• Tenderness
• Rebound tenderness
• Guarding
• Localised peritonism
• Generalised peritonism
Associated symptoms of abdominal pain
• Nausea and vomiting
• Diarhoea/ Constipation/ Change in bowel habit
• Bloating
• Passing blood PR/PU
• Problems swallowing
• Fevers
• ‘Off food’
• Weight loss
• Lethargy
The big 5 for abdominal issues
• Eating
• Drinking
• Opening bowels
• Passing urine
• Pain
Abdominal pain history
• Past medical Hx: previous abdo surgery, appendix, gallbladder, other medical condition
• Drug Hx: anticoagulants, allergies
• Social Hx: other people unwell, travel, smoking/alcohol
Conditions which cause pain in different parts of the abdomen
• Right Hypochondriac: Cholecystitis, Cholangitis, Pyelonephritis, Renal stone, Lung pathology
• Epigastric region: Peptic ulcer disease, Cholecystits, Pancreatits, MI
• Left Hypochondriac: Gastric ulcer, Splenic pathology, Pyelonephritis, Renal stone, Lung pathology
• Umbilical region: Appendicitis, Small bowel obstruction, Large bowel obstruction, AAA
• Right iliac: Appendicitis, IBD, renal stone, ovarian pathology
• Left iliac: Diverticulitis, IBD, renal stone, ovarian pathology
Different abdominal areas
• Right Hypochondriac: Liver, gallbladder, right kidney, small intestine
• Epigastric region: stomach, liver, pancreas, duodenum, spleen, adrenal glands
• Left Hypochondriac: Spleen, colon, left kidney, pancreas
• Right lumbar: gallbladder, liver, right colon
• Umbilical region: umbilicus (navel), parts of the small intestine, duodenum
• Duodenum: Descending colon, left kidney
• Right iliac: Appendix, Cecum
• Hypogastric region: urinary bladder, sigmoid colon, female reproductive organs
• Left iliac: descending colon, sigmoid colon
Abdominal examination- SHRUG
• Stool sample
• Hernia orifice
• Rectal examination (PR)
• Urinalysis
• Genitalia
Abdominal pain- investigations
• Bloods- FBC, U&E, LFT, CRP, Amylase, Coag, G&S
• ABG- if unwell
• Urine dip- including betaHCG
• Blood culture- if septic and planning to start Abx
• Imaging: USS, erect CXR, CT abdo/pelvis
• You always need to rule out an ectopic pregnancy so you can CT the patient
Types of CT scan
• CAP (chest abdomen pelvis)
• Angiogram
• KUB (kidneys, ureter, bladder)
Early management in ED/wards for abdominal pain
• IV fluids Hartman’s: fluid bolus challenges 500ml stat, will need multiple challenges
• O2 15L/min: until bloods gas/saturations are available
• IV antibiotics: Co-amoxacillin/Tazocin
• Analgesia: IV morphine 5-10mg, IV paracetamol 1g PRN
• Antiemetics
• Catheterise- need to monitor fluid resuscitation
• NBM
Onwards/Preoperative management of abdominal pain
• ECG, CXR
• Goal directed fluid management
• Correction of electrolyte abnormalities
• Blood sugar management- VRII/GKI
• Group and save if going to theatre
• NG if obstruction
• Steroid replacement
Acute kidney injury
• Abrupt (<48h) reduction in kidney function; ↑ serum creatinine >26.4mml/l, or
• >1.5 – fold increase from baseline, or
• A reduction in urine output (oligura) of <0.5ml/kg/h for >6h
• Pre-renal/ renal/ post-renal causes
• Hyperkalaemia and pulmonary oedema are the life threatening complications
Appendicitis
One of the most common causes of acute abdominal pain. Most common presentation age 10-30. Male>female.
The progression of appendicitis
Inflammation -> Localised ischaemic -> Perforation -> Perforation/abscess -> Peritonitis
Appendiceal obstruction may be caused by
• Fecaliths (hard faecal masses)
• Calculi
• Lymphoid hyperplasia
• Infectious processes (worms)
• Benign or malignant tumour
Pathology of appendicitis
When obstruction of the appendix is the cause of appendicitis, the obstruction leads to an increase in luminal and intramural pressure, resulting in thrombosis and occlusion of the small vessels in the appendiceal wall, and stasis of lymphatic flow. As the appendix becomes engorged, the visceral afferent nerve fibers entering the spinal cord at T8 to T10 are stimulated, leading to vague central or periumbilical abdominal pain.
Symptoms of appendicitis
• Right lower quadrant abdominal pain- McBurneys point, Rovsings signs, Psoas sign
• Anorexia
• Nausea and vomiting
• Fever
The different signs in appendicitis
• Mcburneys point- a point 1/3 of the way along a line drawn from the hip to the umbilicus, the point of maximum sensitivity in acute appendicitis
• Positive Rovsing’s sign: when there is tenderness in the RLQ when palpating the LLQ
• Psoas sign- pain in hip extension
• Obturator sign- pain during rotation of the right flexed hip
Appendicitis: Investigations, Management and Complications
• Investigations: raised WCC + CRP, urine dip, ultrasound in women to rule out gynae cause, CT if over 40 or raised CRP
• Management: diagnostic laparoscopy and appendectomy, with or without antibiotics
• Complications- Perforations, appendicular mass, collections
Causes of Pancreatiti
I GET SMASHED
• Idiopathic
• Gall stones
• Ethanol (alcohol)
• Trauma
• Steroids
• Mumps/malignancy
• Autoimmune
• Scorpion stings
• Hypercalcaemic/Hypertryglyceridaemia
• ERCP
• Drugs
Panncreatitis pathology and risk factors
Inflammation caused by hypersecretion or backflow (due to an obstruction) of exocrine digestive enzymes causing autodigestion of the pancreas.
Risk factors: Male, Age, Obestity, Smoking
Pancreatitis- symptoms and categories
Symptoms
• Epigastric pain: severe, radiates to the back
• Nausea and vomiting
• Anorexia
Acute pancreatitis can be divided into two broad categories: edematous, interstitial acute pancreatitis and necrotizing acute pancreatitis.
Pancreatitis- diagnosis
• Amylase >300 (3x limit of normal)
• +ve imaging (USS, CT, MRCP)
Categories of acute pancreatitis- Atlanta criteria
• Mild - characterised by the absence of organ failure and local or systemic complications
• Moderate - characterised by no organ failure or transient organ failure (<48 hours) and/or local complications
• Severe - characterised by persistent organ failure (>48 hours) that may involve one or multiple organs
Try and delay CT till 72h to help clarify severity
Management of pancreatitis
• IVT
• Analgesia
• Monitoring (catheter, repeat imaging)
• Nutrition: enteral vs parenteral
• Management of cause: Cholecystectomy, ERCP, stop drinking
Complications and outlook for pancreatitis
Complications- ARDS, pseudocyst, necrosis, infected necrosis
The severity of acute pancreatitis should be assessed by clinical examination to assess for early fluid losses, organ failure and systemic inflammatory response syndrome (SIRS) score. Can use GCS. In patients with mild pancreatitis, recovery generally occurs quickly, making it unnecessary to initiate supplemental nutrition
