Abdominal pain- core conditions 2 Flashcards
Murphys sign
Examiners hand is at the middle inferior border of the liver. Patient is asked to take deep inspiration, if positive patient will experience pain and will stop short of full inspiration. Done for acute cholecystitis
Causes and risk factors for acute choleystitis
Cause of acute cholecystitis: inflammation of the gallbladder, usually due to an impacted stone.
Risk factors: female, fat, forty, fair (family history, frequent weight loss)
Symptoms of acute cholecystitis
• RUQ pain- Murphey’s sign
• Tachycardic
• Fever
• Nausea, vomiting and anorexia
• History of fatty food ingestion one hour or more before the initial onset of pain
• Shoulder tip pain
Diagnosis, Management and Complications of acute cholystitis
Diagnosis: fever, increased WCC, positive USS (CT and MRCP are also used). USS is the best for imaging gallstones as not all stones will appear on CT
Management: IVT, analgesia, IV abx, lap cholecystectomy (within one week). Can also have a cholecystostomy.
Complications- bile duct injury, gallstone ileus, fistulas
Acute diverticulitis pathology
Acute diverticulitis is due to inflammation. Peak incidence 50-70yrs, commonly found in the sigmoid colon. Diverticulitis is due to microscopic or macroscopic perforation of a diverticulum due to diverticular inflammation and focal necrosis.
Diverticular disease- symptoms and diagnosis
Symptoms
• LIF pain
• Nausea and vomiting
• Fever
• Change in bowels
Diagnosis: increased WCC and CRP, positive CT
Uncomplicated diverticular disease- treatment
• Offer oral antibiotics to a patient with uncomplicated acute diverticulitis who is systemically unwell, has signs of systemic inflammation, is immunosuppressed, or has significant comorbidities.
• If the patient is systemically well, consider not prescribing antibiotics. Instead offer analgesia and advise to return if symptoms worsen
• If fever and leukocytosis persist after 72 hours or symptoms of acute diverticulitis or acute abdomen present, the patient should be admitted to hospital and given intravenous antibiotics used until clinical improvement
• Surgical intervention may be considered for diverticular disease that fails to respond to medical management and for complications, including recurrent diverticulitis, abscess, perforation, fistulae, and obstruction.
Complicated diverticular disease is defined by
• Bowel obstruction
• Abscess formation
• Fistula
• Perforation
Complicated diverticular disease: Management
• IVT, analgesia, IV abx, intervention
• Guided drainage of abscess (>3cm)
• Laparoscopic washout (Hinchey I-III)
• Hartman’s procedure (surgical resection)
• Consider flexible sigmoidoscopy as an outpatient
Small bowel obstruction: causes
• Adhesions (60%), Hernia (20%), volvulus, cancer, inflammatory stricture, intussusception, faecolith, gallstones/FB
• Most common cause of large bowel obstruction is colorectal cancer
• Caecal vovlus will need to go to theatre
• Pseudo obstruction- old frail patients, manage conservatively
Small bowel obstruction: symptoms, diagnosis
Symptoms: generalised pain, distention, not opening bowels, nausea and vomiting
Diagnosis: history, CT
Small bowel obstruction: Management
• NG (drip and suck)
• IVT (Intravenous therapy- fluid)
• Analgesia
• IV abx
• Conservative
• Laparotomy -> NBM (Nil by mouth)
Small bowel obstruction: Nasogastric tube
• Fine bore feeding tube- feeding
• Ryle’s tube for gastric drainage- draining
Small bowel obstruction: Confirmation of NG placement
• NG tube should remain in the midline down to the level of the diaphragm
• The NG tube should bisect the carina
• The tip of the NG tube should be clearly visible and below the left hemidiaphragm
• The tip of the NG tube should be approximately 10cm beyond the COJ i.e. within the stomach
PR bleeding: history
• When did it start?
• How much?
• Consistency - ?clots
• COLOUR – dark red/brown/bright red
• Mixed in with stool vs separate from stool vs on paper when wiping
• Passing stool at the same time vs purely passing blood
• Painful vs painless
• Happened before?
Causes of PR bleeds
• Polyps
• Bowel cancer
• Post-procedure
• Anti-coagulation medication
• Diverticular disease
• Inflammatory bowel disease: Crohn’s, Ulcerative colitis, infection (i.e. colitis/proctitis)
• Stomach/duodenal ulcers
• Angiodysplasia
• STI- injury from anal sex
• Anal fistula
• Anal fissures
• Haemorrhoids
Associated symptoms of PR bleeding
• Abdominal pain
• Nausea and vomiting
• Fevers
• Tensmus
• Incontinence
• Bloating
• Reflux
• Urinary symptoms
• Weight loss
• Eating and drinking
PR bleeding: drug history and social history
Drug history: anti-coagulants
Social history: smoker/alcohol, independent
Fluid replacement: The 5 R’s
• Routine maintenance
• Rescusitation
• Replacement
• Redistribution
• Reassessment
Fluid replacement: routine daily requirement
• 25-30 mL/kg/day H20: use ideal body weight if obese, use more conservative targets if old or comorbidities like renal or cardiac disease
• 0.5-1.0 mmol/kg/day of potassium: do not replace potassium at rates >10mmol/hr. Do not give potassium at concentrations >40mmol/L
• 1-2mmol/kg/day sodium and chloride
• 50-100 g/day glucose
Conditions in which you’ll need to assess the fluid status
CKD, Liver disease, diarrhoea, vomiting, pyrexial, tachypnoea, sepsis, DKA, burns, hyperosmolar hyperglycaemic state, heart failure, pancreatitis, bleeding
Examinations for assessing fluid status
Heart rate, pulse, JVP, Capillary refill time, Mucus membrane, Skin turgor, Oedema, Chest auscultation
Monitoring of fluid status
Clinical monitoring of fluid status: NEWS score, Fluid balance chart, Daily weights
Assessing fluid status blood tests: Full blood count, Haematocrit, Urea, Magnesium, Serum creatinine, Osmolarity, sodium, potassium, calcium
Fluid balance in the textbook human (70kg body mass)
• 1750-2100mls H2O
• 35-70mmol K+
• 70-140mmol Na+ and Cl-
Fluid regimen for the textbook human
• 1L Hartmann’s + 1L 5% glucose with 40mmol K+
• 1L 0.9% NaCl + 1L 5% glucose with 40mmol K+
• 1L 5% glucose + 1L 0.9% NaCl with 40mmol K+
Replacement fluids
• If their insensible losses (vomiting diarrhorea) are greater than normal, factor this into your maintenance fluid calculation
• Vomit and GI secretions contain lots of electrolytes so keep a close eye on these with monitoring blood tests and replace them as necessary
Red flags for fluid resuscitation
• SBP <100mmHg
• HR >90bpm
• Capillary refill >2 seconds
• Cool peripheries
• Respiratory rate >20
What should you give for resuscitation fluids
Give a fluid bolus (a ‘fluid challenge’)
• Only use 0.9%NaCl or Hartmann’s for fluid resuscitation
• Never use glucose
• 500mls over 15 minutes (i.e. ‘STAT’)
• Consider comorbidities and frailty – if elderly, frail or comorbid cardiac/renal disease, consider an initial 250ml fluid bolus
Causes of Hyperkalaemia: Ineffective elimination
• Renal insufficiency: AKI or CKD
• Medications which interfere with urinary excretion: ACE inhibitors, ARBS, potassium sparking diuretics (amiloride, spironolactone, eplerenone), NSAID’s, Calcineurin inhibitors (ciclosporin, tacrolismus), Trimethoprim, Pentamidine
• Mineralocorticoid deficiency or resistance: Addisons disease, Aldosterone deficiency, Type IV renal tubular acidosis, Heparins (unfractionated and low molecular weight), beta blockers
Causes of Hyperkalaemia: Excessive release from cells
• Rhabdomyolysis, burns, tumour lysis syndrome
• Massive blood transfusion or massive haemolysis
• Acidosis
• Insulin deficiency (DKA)
• Digoxin overdose
• Suxamethonium
Causes of Hyperkalaemia: Excessive intake
• Diet, oral, IV supplements
• Potassium containing salt substitutes
• Potassium containing drugs
Artefatual hyperkalaemia
• The secretion of calcium in vitro from an excessive number of abnormally activated platelets
• Difficult venepuncture- haemolysis, fist clenching
• Thrombocythaemia
• Delayed analysis
• Potassium EDTA contamination from FBC bottle if collected first
What separates the upper and lower gastrointestinal tract (GIT)
The ligament of Treitz (suspensory muscle of the duodenuma)
Causes of upper GI bleeds
• Peptic ulcer disease
• Gastroesophageal varices
• Upper GI cancers (oesophageal and gastric)
Causes of lower GI bleeds
• Diverticulitis
• Colitis: Inflammatory (IBD), Ischaemic (reduced blood supply to the colon), Infective (i.e. Clostridium difficile), colorectal cancers
• Haemorrhoids
• Anal fissure
Chronic diarrhoea
Lasting more than 4 weeks
Blood in diarrhoea
Blood in the stool is a red flag for diarrhoea. Blood mixed in with the stool suggests bleeding from the GI tract, whereas blood just on the toilet paper could suggest a rectal or anal problem such as haemorrhoids
Red flag symptoms for diarrhoea
• Unexplained weight loss
• Associated abdominal pain
• Waking in the night to open your bowels
• Fevers, tachycardia, hypotension, dehydration
• Blood in your stools
• A change in bowel habit over the age of 50
• Abdominal mass, rectal mass
• Iron deficiency anaemia- linked to IBD and colon cancer
• Raised inflammatory markers
Chronic diarrhoea: Associated symptoms
1) Linked to food, bloating, wind
2) Apthous mouth ulcers are linked to crohns disease.
3) Dermatitis herpetiformis are linked with Coeliac diasease, they are blisters filled with watery fluid that are intensely itchy
4) Erythema Nodosum (bruised knees) are linked to Inflammatory bowel disease.
Investigations into diarrhoea: Bloods
• FBC: checks for anaemia which points towards IBD, raised white cell count suggests inflammation or infection
• Urea and electrolyte: check patient isn’t dehydrated if they have diarrhoea, chronic diarrhoea causes electrolyte disturbances
• TSH: Hyperthyroidism is a cause of chronic diarrhoea
• Tissue transglutaminase antibody (anti tTG): screening tool for coeliac disease, patient needs to be eating gluten for it to be accurate
• Liver function test: low albumin is a marker of systemic disease
• CRP/ESR: are raised in inflammatory bowel disease
Investigations into diarrhoea: stool
• Faecal calprotectin: marker of intestinal inflammation, positive in IBD, negative in IBS. Done on patients <40 years
• Stool for Ova, Cysts and parasites: only done if there is a history of exotic travel
Faecal Calprotectin
• Negative test rules out IBD but a positive test does not diagnose it, patients with a positive test should go on to have a colonoscopy
• Faecal calprotectin may not be raised with cancer so should be used with caution in older patients (>50 years)
Colonoscopy is used to diagnose Crohns disease
Red flags for acute diarrhoea
• Blood in the stool- suggests a bacterial infection like campylobacter or another serious pathology
• Recent hospital treatment or antibiotic treatment
• Weight loss
• Evidence of dehydration
• Nocturnal symptoms
Other questions to ask about acute diarrhoea
• Been abroad?- expands differentials to tropical diseases
• Vomiting?- makes a viral gastroenteritis more likely
• Any recent antibiotics?- can lead to clostridium difficile associated diarrhoea which is a serious bowel infection
• Anyone else unwell?- viral gastroenteritis tends to spread through a family
Risk factors for C.difficile
• Antibiotic exposure
• >65
• Hospital/institutional care
• Multiple existing illnesses
• Immunocompromised status
• PPI therapy
What antibiotics pose the biggest risk with C.difficile
Clindamycin, Cephalosporin like antibiotics, Carbapenems, Fluoroquinolones
Sepsis: Systemic Inflammatory Response Syndrome (SIRS) criteria
• Temperature: <36 or >38
• Heart rate: >90 beats per minute
• Tachypnoea: >20 breathes per minute or PaCO2 <32mm Hg
• WBC: <4,000 or >12,000 or >10% immature (band) forms
What is classified using the SIRS criteria
• Systemic Inflammatory Response Syndrome (SIRS): >2 criteria
• Sepsis: SIRS plus confirmed or presumed infection
• Severe Sepsis: sepsis plus organ dysfunction
• Septic shock: severe sepsis plus refractory hypotension
• Multiple organ dysfunction syndrome: evidence of >2 organs failing
Sepsis 6
• Give high flow oxygen
• Take blood cultures
• Give IV antibiotics
• Give a fluid challenge
• Measure lactate
• Measure urine output
Sepsis investigations: Bedside and other tests
Bedside: ECG
Other tests
•Stool MC&S: to check for an infective cause of diarrhoea
• Stool C diff + toxin: to check for C diff infection
Sepsis: Bloods
• Full Blood Count: This would look for signs of infection, such as a raised WCC.
• Urea & Electrolytes: This would show any signs of dehydration secondary to her profuse diarrhoea, or any electrolyte abnormality.
• Lactate: As part of the Sepsis 6. This looks for tissue hypoperfusion.
• Blood Cultures: Although she is not febrile, she still meets the Sepsis 6 criteria, so therefore should have cultures taken.
• CRPA: non-specific marker of inflammation that can show the severity of the infection.
• LFT: To monitor the function of the liver.
What measure should be made in hospital for patients with infections
• Staff should use soap and water to wash their hands (not alcohol hand gel)
• Wear gloves and gowns
• Isolate the patient in a single room
• Monitor the patients fluid input and output
• Send off a stool sample
Tests for C.difficile
Detecting Clostridium difficile in the stool (a positive culture) does not prove the diarrhoea is caused by C diff, as the bacteria may be present in some people’s bowels without causing symptoms. These people would be high risk for developing C diff associated diarrhoea (CDAD), but may not need to be treated.
If the C.diff toxin is present it confirms that the diarrhoea is caused by C.diff. A negative toxin does not completely rule out CDAD as the toxin is unstable and may have degraded before reaching the labs, a second sample may be needed.
Two week wait referral
Request from the GP to the hospital asking for an urgent appointment when cancer is the likely diagnosis
Red flag symptoms for bowel cancer
• Anaemia (iron deficiency)
• Weight loss
• Change of bowel habit- intermittent constipation and diarrhoea
• Blood per rectum- bleeding associated with pain is rarely a symptom of cancer and indicates other conditions like haemorrhoids or anal fissure
• Bowel obstruction
