- ABDOMINAL PRESENTATIONS - Flashcards
Outline the clinical manifestations of GIT bleeding
- Abdominal pain
- Nausea & vomiting
- Jaundice
- Ascites
- Explosive diarrhoea
- Haematemesis
- Malena
- Haematochezia
Outline the clinical manifestations of a bowel obstruction
- vary according to the location of the obstruction
- pain
- colicky cramps (more sever the higher the obstruction)
- vomiting (upper obsruction)
- distention (the lower the more distended)
- altered bowel sounds
- intitially high pitched, hyperactive then hypoactive and absent
Outline the clinical manifestations of Ulcerative colitis
- bloody diarrhoea (up tp 20 times a day)
- abdo pain (lower abdo cramping, generalised - perferetion)
- mucous in stool
- fever
- weight loss
- tachycardia
- dehydration
Outline the clinical manifestations of Chron’s disease
- abdo pain
- diarrhoea
- nausea and vomiting
- weightloss
Outline the clinical manifestations of cholecystitis
- Pain
- Epigastric to RUQ, severe and constant
- May radiate to (R) scapula area / back
- Abdo rebound tenderness and guarding
- Nausea/vomiting
- Fever
- Jaundice if CBD obstructed
- +Murphy’s sign
- Usually no peritoneal signs unless complications
Outline the clinical manifestations of pancreatitis
Range from mild to severe Airway/breathing: – tachypnoea – hypoxaemia – pleural effusion – atelectasis
Circulation: – hypotension – tachycardia – oliguria, renal failure – coagulation abnormalities
Disability: - Low grade fever - Hyperglycaemia - Nausea and vomiting - Hypoactive or absent bowel sounds - Jaundice - Raised WCC - Discoloration of abdominal wall (Cullen’s sign, Grey Turner sign)
- Abdominal pain / distention: – LUQ / epigastric – radiates to back – sudden onset – severe, deep, piercing, continuous – worse with eating – guarding
Outline the clinical manifestations of hepatitis
- jaundice
- fatigue
- abdo pain
- arthralgia
- anorexia
- nausea and vomiting
Outline the clinical manifestations of liver failure
- jaundice
- ascites
- coagulopathy
- hhepatic encephalopathy
- haemodynamic changes
- electrolyte disturbance
- renal failure (hepatorenal failure)
Outline the clinical manifestations of peritonitis
- decreased bowel sounds
- abdo pain
- anorexia
- N,V,D
- tachycardia
- hypotension
- fever
Outline the management of GIT bleeding
Airway/breathing:
– high flow oxygen
– pulse oximetry
– monitor work of breathing
Circulation:
– IV fluids
\+/- packed cells
– cardiac monitoring
– IDC
– nil by mouth
– ECG
Disability – GCS – BGL – temperature – focused abdominal assessment – PR exam / endoscopy
Interventions: • NGT • Medications – Octreotide – Antacids – Histamine-2 receptor antagonists • Cimetidine, Ranitidine, Famotodine etc. – Betablockers • Balloon tamponade ( see slides as for variceal bleeding) • Endoscopic control of bleeding – Adrenaline injection – cautery • Surgical interventions
Outline the management of a bowel obstruction
- history
- physical exam
- x-rays
- NGT
- ?enema if in large bowel and no suspected perferation
- colonoscopy
Outline the management of ulcerative colitis
- FBE, EUC, serum protein and electrolytes
- stool sample (examine for blood and pus then culture
- drug therapy
- scopes
Outline the management of chron’s disease
- in acute phase rest GI tract; fasting or fluids only
- path FBE,EUC,Electrolytes
- dietary management\
- specialist follow-up
- drug therapy
Outline the management of cholecystitis
- path (esp amylase, EUC, billiruben, urine)
- ECG (to exclude cardiac involvement)
- IV crystalioid
- antiemetics
- ?NGT for gastric decompression
- ?IVABS if infection is suspected
- narcotic analgesics
- intake/output
- vitals
- Sx laparotomy or laproscopic cholecystectomy
Outline the management of pancreatitis
• Airway / breathing – monitor respiratory rate – monitor oxygen saturation – treat hypoxaemia with oxygen – maximise lung expansion – chest x-ray
• Circulation: – haemodynamic monitoring – IV access – early aggressive intravenous hydration ( recommendation in ACG Guidelines, 2013) – ? Lactated ringers the preferred choice of crystalloid – manage losses – anti-emetics – correct electrolytes – +/- CVC, IDC – +/- inotropes
• Disability:
– analgesia – opiates, PCA, epidural anaesthesia
• Nutritional support
– in mild AP – oral feeding start immediately ( if no N & V )
– low fat solid diet
– in severe AP – enteral nutrition is recommended
– NG and NJ enteral feeding are both comparable in efficacy
and safety
- Monitor BGL
- Monitor for signs of infection
– antibiotics – no longer recommended as routine
– proton pump inhibitors
– Histamine H2-receptor antagonists
– insulin
Investigations: – pathology (lipase) – chest & abdominal x-ray – abdominal U/S – abdominal CT
Surgery:
– ERCP +/- cholecystectomy
– laparotomy
Outline the management of hepatitis
- treat dehydration
- antipyretics (mindful of paracetamol)
- analgesia
- antiemetics
- cease ETOH
- decrease fatty foods
- antiviral therapy
Outline the management of liver failure
- Path
- ultrasound
- airway protection (vomiting)
- pharmacology (vasoactive drugs)
- sepisis common
- monitor renal function
- lifestyle factors
- ?AWS
Outline the management of peritonitis
- antibiotics
- peritoneal lavage
- laparotomy
- analgesia
- nasogastric decompression
- antiemetics
- volume support
- management of sepsis
Discuss the pathophysiology of pancreatitis
Pancreas:
- inflammation of the pacreas
- back up of pancreatic secretions
- activation and release of enzymes (trypsin, chymeotrypsin, lipase, elastase)
- autodigestion
- Vascular damage, coagulative necrosis, fat necrosis and formation pseudocysts
- oedema
- ischaemia and necrosis
Systemically:
- Pro-inflammatory cytokines & vasoactive peptides released
- Activation leucocytes
- Injury to vessel walls
- Coagulation abnormalities
- third spacing of fluid in the peritoneum
- Vasodilation
- Hypotension
- Shock
- Multisystem failure
- SIRS
Discuss the pathophysiology of Liver failure
- injury to liver (hepatitis, ETOH, drugs, poisoning, obesity, DM, metabolic and genetic disorders)
- inflammation
- immune system stimulation
- increase in oxygen free radicals
- decrease in hepatic perfusion
- hepatic atrophy
- hepatic fibrosis (cirrhosis)
- portal hypertension
- fuild shift
- ascites, peripheral oedema, oesophageal varices
- hepatic decompensation
- renal failure
Discuss the pathophysiology of GIT bleeding
Aetiology Upper GI bleed: – peptic ulcers – Mallory- Weiss tear – drug induced erosions – gastric cancer Lower GI bleed: – haemorrhoids – diverticulitis – colonic polyps – colon cancer – colitis – ulcers – gastritis
Patho:
- injury to the epithelial layer of the GI tract
- GIB
- hypovolaemia
- compensate with peripheral vasoconstriction and increased CO
- Renal Na and water retention
- blood flows to vital organs
- further bleeding or inadequate compensation
- hypovolaemic shock
- insufficient blood to organs
- MODS
- death
Discuss the pathophysiology of a Bowel Obstruction
. - obstruction occurs
- lack of rapid movement of HCI and chyme
- bacteria flourish as a result
- fluiid, gas and intestinal products accumulate proximal to the obstruction
- distal bowel collapses
- distention reduces absorption
- increased pressure leads to increassed capillary permeability and leak of fluid into the peritoneal cavity
- this results in hypotesion and hypovolaemic shock
Define cholecyctitis
- Inflammation of the gallbladder due to obstruction of the CBD by gallstones
- Causes distension of the gallbladder
- pressure decreases blood flow
- bacterial invasion / infection : (E.coli, streptococcus or salmonella)
