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