Abdominal Pt 2 Flashcards
Give some symptoms seen in hepatitis
- Muscle and joint pain
- High temperature
- N&V
- Fatigue
- General sense of unwell
- Loss of appetite
- Stomach pain
- Dark urine
- Pale poo
- Itchy skin
- Jaundice
Signs seen in hepatitis?
- Hepatomegaly
- Splenomegaly
- Lymphadenopathy
- Ascites
- Encephalopathy
- Jaundice
What is the most common type of viral hepatitis in the UK?
Hep C
Which acute hepatitis infections can lead to chronic hepatitis?
Hep B & Hep C
Transmission of Hep A?
From consuming contaminated food and drink with faecal matter of an infected person (faeco-oral route)
What types of hepatitis are there vaccinations available for?
Hep A & B
Where in the world is Hep A infection commonly seen?
Most common in countries with poor sanitation. Common in Indian subcontinent, Africa, Central and South America, the Far East and eastern Europe.
Prognosis of Hep A infection?
Often self-limiting and passes within a few months. Does NOT caused chronic liver disease or have a chronic carrier state.
Transmission of Hep B?
Blood; sexual contact, sharing needles, vertical transmission (mother to baby)
Risk factors for Hep B?
- Travel to countries where rate is high
- IVDU
- MSM
What complications can chronic hepatitis lead to?
Cirrhosis → hepatocellular carcinoma
Transmission of Hep C?
Blood-to-blood contact with infected person e.g. sharing needles
Who is at the highest risk for Hep C in UK?
IVDU (90% cases)
What % of acute Hep C infections will become chronic?
1 in 4 (25%)
What is fulminant hepatitis?
a clinical syndrome of severe liver function impairment, which causes hepatic coma and the decrease in synthesising capacity of liver, and develops within eight weeks of the onset of hepatitis.
Who specifically does Hep D affect?
Only affects people who are already infected with hepatitis B as it needs the Hep B virus to survive in the body
Where in the world is Hep D more common?
Uncommon in UK but more widespread in Middle East, Africa and South America
Transmission of Hep D?
Blood-to-blood contact or sexual contact
What is the most common cause of acute hepatitis in the UK?
Hep E
Transmission of Hep E?
Consumption of raw or undercooked pork meat, wild boar meat, venison and shellfish
Prognosis of Hep E?
Generally a mild and short-term infection that does not require treatment (but can be serious in immunosuppressed)
Give some causes of hepatitis
- Hep A/B/C/D/E
- Alcoholic hepatitis
- Autoimmune hepatitis
Symptoms of alcoholic hepatitis?
- Often asymptomatic (many people don’t know they have)
- Sudden jaundice and liver failure in some people
Management of autoimmune hepatitis?
Immunosuppressants
What is the most common indication for emergency surgery in paediatric patients?
Appendicitis
Complications of appendicitis?
- Perforation → peritonitis
- Abscess formation
Risk factors for appenditicis?
- Most commonly presents in 2nd decade of life
- Slight predominancy in males vs females
- Children breastfed for <6 months
- Children exposed to tobacco smoke
describe pain in appendicitis
Generalised umbilical pain that localises to right iliac fossa
Give some differentials for appendicitis
- Mesenteric adenitis: usually preceded by a sore throat
- Meckel’s diverticulitis: symptoms include rectal bleeding
- Gastroenteritis: general abdominal pain but will not migrate to right iliac fossa
- UTI: urinary symptoms, urinalysis will show nitrites and WBCs
- Intestinal obstruction
- Biliary colic and acute cholecystitis
- IBD & IBS
- Constipation
- Pancreatitis
Symptoms of appendicitis?
- Acute abdominal pain (approx. 20-30% of children presenting with acute abdominal pain will be diagnosed with appendicitis)
- Typically worse on movement
- N&V
- Low-grade fever
- Right iliac fossa pain
- Umbilical pain
- Diarrhoea
- Anorexia
Signs seen in appenditicis?
- Right iliac fossa tenderness
- RLQ peritonism
- Abdominal distension, guarding, rebound tenderness, absent bowel sounds all suggestive of peritonitis
- Rovsing sign
- Psoas sign
- Obturator sign
- Hop test
- Murphy’s triad
What is Rovsing’s sign?
palpation of the left iliac fossa causes right iliac fossa pain
What is Psoas sign?
extension of the right thigh, in the left lateral position, causes right iliac fossa pain
What is obturator sign?
internal rotation of the flexed right thigh causes pain
Bedside investigations in appendicitis?
- Urinalysis → rule out UTI
- Capillary blood glucose → N&V and anorexia may have caused hypoglycaemia
- Baseline vital signs → low grade fever
Lab investigations in appendicitis?
- FBC → raised WCC
- U&Es → anorexia, N&V can cause deranged renal function in severe cases
- CRP → inflammation
- Group and save
Why is it important to get a group & save in appenditis?
appendicitis management is typically operative and this test is important as a transfusion may be required if there is significant blood loss
Management of appendicitis?
- Appendicectomy: laparoscopic approach is preferred
- However some resolve spontaneously
Is a SBO or LBO more common?
SBO (80%)
Pathophysiology behind a bowel obstruction?
Gross dilatation of the bowel proximal to the blockage occurs, causing increased peristalsis and secretion of large volumes of electrolyte-rich fluid into the bowel.
What is the most common cause of SBO in the developed world?
Intestinal adhesions (bands of fibrous tissue) from previous surgery
Give some causes of bowel obstruction
- Adhesions
- Hernias
- Colon cancer
- IBD
- Diverticulitis
- Twisting of colon (volvulus)
- Impacted faeces
- In children → intussusception is most common
What type of hernias typically cause bowel obstruction? Who is this seen in?
mainly femoral in elderly females
Potential complications of SBO/LBO?
-
Bowel ischaemia leading to tissue death:
- Intestinal obstruction can cut off blood supply to part of intestine
- Tissue death can result in a tear (perforation) which can lead to infection/haemorrhage
- Bowel perforation leading to faecal peritonitis (high mortality):
- Dehydration and renal impairment
Give some differentials for bowel obstruction
- Pseudo-obstruction
- Paralytic ileus
- Toxic megacolon
- Constipation
Symptoms of bowel obstruction?
- Crampy/colicky abdominal pain that comes and goes (2ary to bowel peristalsis)
- Loss of appetite
- Absolute constipation
- Vomiting – occurs early in proximal obstructions and late in distal obstructions
- Inability to have a bowel movement or pass gas
- Abdominal distension
Describe signs seen in an abdo exam in bowel obstruction
- Signs of underlying cause:
- Scars from previous surgery
- Obvious hernia
- Cachexia from malignancy
- Bowel sounds – tinkling or absent altogether
- Tender abdomen – guarding and rebound tenderness on palpation
- Swollen abdomen
- Ascites – 3rd spacing can occur in bowel obstruction
- Percussion – tympanic sounds produced (air filled abdomen)
Describe percussion in bowel obstruction
tympanic sounds produced (air filled abdomen)
Describe bowel sounds in bowel obstruction
tinkling or absent altogether
Why would a VBG be useful in bowel obstruction?
Useful to evaluate signs of ischaemia (high lactate) or for immediate assessment of metabolic derangement (2ary to dehydration or excessive vomiting)
Most accurate imaging in bowel obstruction?
CT scan
Describe an AXR in SBO
- Dilated bowel >3cm (3/6/9 rule!)
- Central abdominal location
- Valvulae conniventes visible (lines completely crossing the bowel)
Describe an AXR in LBO
- Dilated bowel (>6cm or >9cm if at caecum)
- Peripheral location
- Haustral lines visible (not completely crossing bowel)
Why would an erect CXR be useful in bowel obstruction?
assess for free air under the diaphragm to suggest a bowel perforation
Describe each AXR
AXR (1) – SBO with valvulae conniventes crossing a dilated, centrally located bowel
AXR (2) – LBO with peripherally located dilated bowel segments.
Management of bowel obstruction?
Management depends on the aetiology and whether it has been complicated by bowel ischaemia, perforation and/or peritonism.
-
Suck and drip:
- make patient nil by mouth and insert NG tube to decompress bowel (‘suck’)
- fluid resuscitation and correct electrolyte imbalances (‘drip’)
- Urinary catheter & fluid balance
- Analgesia & anti-emetics
What would indicate the need for surgery in bowel obstruction?
if evidence of ischaemia or closed loop bowel obstruction
Most common cause of SBO vs LBO
SBO → adhesions, hernias
LBO → malignancy, sigmoid volvulus
Describe the pain in both SBO and LBO
Diffuse, central, ‘colicky’ pain
Describe vomiting & constipation SBO and LBO
SBO → late constipation, early vomiting (bilious)
LBO → early constipation, late vomiting (faeculent)
Describe abdo distension in SBO and LBO
SBO → less prominent
LBO → marked
Describe progression of SBO vs LBO
SBO → rapid
LBO → Slower
What is a hernia?
The protrusion of a viscus into an abnormal space (i.e. a structure that passes through a space or defect into an abnormal location)
What is a reducible hernia?
When the contents of the hernia can be manipulated back into their original position through the defect from which they emerge
What is an incarcerated hernia (irreducible)?
The hernia is compressed by the defect causing it to be irreducible (i.e. unable to be pushed back into its original position)
What is an obstructed hernia?
Refers mainly to hernias containing bowel** where the contents of the hernia are compressed to the extent that the **bowel lumen is no longer patent and causes bowel obstruction
What is a strangulated hernia?
The compression around the hernia prevents blood flow** into the hernial contents causing **ischaemia of the tissues and associated pain
What are the 2 types of hernias?
- Inguinal (most common)
- Femoral
What is an inguinal hernia?
A protrusion of abdominal contents that ultimately emerges from the superficial inguinal ring
Pathophysiology of a direct inguinal hernia?
- Caused by weakness in the posterior wall of the inguinal canal
- Abdominal contents (usually just fatty tissue, sometimes with bowel) are forced through this defect and enter the inguinal canal
- Contents emerge in the canal medial to the deep ring
Where do direct inguinal hernias emerge in relation to the deep ring?
Medial to deep ring
Which type of inguinal hernia pierces the posterior wall?
Direct
Pathophysiology of an indirect inguinal hernia?
- Does not pierce the posterior wall
- Abdominal contents pass through the deep inguinal ring, passing through the inguinal canal and exiting via the superficial inguinal ring
Which type of inguinal hernia passes through the deep inguinal ring?
Indirect
Is it more common for direct or indirect hernias to emerge within the scrotum after exiting via the superficial ring? Why?
Indirect → this as the path through both anatomical inguinal rings (rather than a muscle defect) has less resistance
How can direct & indirect inguinal hernias be differentiated on an abdo exam?
- Place your finger over the deep inguinal ring
- Can control an indirect inguinal hernia that has been reduced
- If you press the deep ring and the hernia still protrudes, then the hernia is emerging via a defect in the posterior wall medial to this point → direct
Where is the deep inguinal ring located?
just above mid-point of inguinal ligament
Where does the inguinal ligament run between?
Inguinal ligament runs between the ASIS and the pubic tubercle.
What runs in the inguinal ligament?
Within this ligament runs the inguinal canal
Tube enters from the abdominal cavity at the deep inguinal ring and leaves at the superficial inguinal ring
What does the inguinal canal contain (men vs women)?
Provides passage for abdominal contents to exit the abdomen:
- spermatic cord in males
- round ligament in females
- ilioinguinal nerve in both sexes
Where is the deep ring located?
located just above the mid-point of the inguinal ligament
Where is the superficial ring located?
lies just above and lateral to the pubic tubercle
Give some causes of an inguinal hernia
- 1) Increased intra-abdominal pressure
- Chronic cough
- Constipation
- Heavy lifting
- 2) Weakness of the abdominal muscles
- Advanced age
- Obesity
Definitive management of inguinal hernias?
Surgery
Symptoms of inguinal hernia?
- Patients often present with a swelling in the groin/abdomen that is often painless but can become symptomatic
- Pain – particularly when coughing or stooping
- Change in bowel habit
- Constipation
- Burning sensation in the groin
- Scrotal swelling (in males)
When are inguinal hernias treated?
- Only treat if symptomatic e.g. pain, altering bowel habit
- If hernial contents become strangulated or obstructed → surgical emergency
What structures pass under the inguinal ligament?
The femoral nerve, artery and vein (lateral to medial)
What is the femoral canal?
The femoral canal is a space lying medial to the femoral vein
What is the function of the femoral canal?
- Function of the femoral canal is to allow expansion of the femoral vein in order to increase venous return
- Also contains a small amount of fatty tissue and a lymph node (lymph node of Cloquet)
Pathophysiology of a femoral hernia?
The femoral canal can be a defect through which abdominal contents protrude
Who are femoral hernias typically seen in? Why?
Typically seen in elderly women (due to wider bone structure of the female pelvis)
Risk factors for a femoral hernia?
Any activity or condition that increases pressure in the intra-abdominal cavity:
- Obesity
- Heavy lifting
- Coughing
- Straining with urination or defecation
- COPD
- Ascites
Complications of femoral hernias?
Femoral hernias are at high risk of strangulation and obstruction:
- Strangulated femoral hernia → a section of bowel becomes trapped and its blood supply is cut off which can lead to necrosis and gangrene
- Obstructed femoral hernia → part of the intestine becomes intertwined with the hernia, causing a bowel obstruction
Symptoms of a strangulated femoral hernia?
- Extreme tenderness and redness in the area of the bulge
- Sudden pain that worsens in a short period of time
- Fever
- Tachycardia
Management of a strangulated hernia?
Surgical emergency
Symptoms of an obstructed femoral hernia?
severe pain, nausea, vomiting, and the inability to have a bowel movement or pass gas.
Red flags for constipation?
Urgent investigation due to risk of malignancy or serious bowel disorder:
- New constipation in patients >50 y/o
- Anaemia
- Abdominal pain
- Weight loss
- Overt or occult blood in stool
Lifestyle management for constipation?
-
Diet;
- Increase in dietary fibre gradually (to minimise flatulence and bloating)
-
Adequate fluid intake – especially with high fibre diet or fibre supplements
- N.B. this may be difficult for frail/elderly
- Increase exercise
Stepwise pharmacological management of short-term constipation (where dietary measures are ineffective)?
- Bulk forming laxative (ensure fluid intake)
- Add/switch to osmotic laxative
- Add stimulant laxative
What electrolyte imbalance can laxative abuse lead to?
Hypokalaemia
Which Abx are high risk for C. diff infection?
The ‘C’ drugs:
- Ciprofloxacin (quinolone)
- Cephalosporins (cefuroxime, cefotaxime)
- co-amoxiclav
- clindamycin
Risk factos for C. diff infection?
- Abx
- Old age (>65 y/o)
- Hospitalised patients
- Long duration of antibiotic use (>7 days)
- Multiple antibiotic courses
- Severe underlying disease
- Presence of nasogastric tube
- Non-surgical GI procedures
- PPIs
How does Abx use predispose to C. diff infection?
- Broad-spectrum antibiotic use suppresses the normal gut flora, allowing C. difficile to develop
- C. difficile produces an exotoxin which causes intestinal damage, leading to pseudomembranous colitis
What spectrum of Abx predisposes to C. diff?
Broad-spectrum
Severe complication of C. diff?
Toxic megacolon and/or sepsis
Diagnosis of C. diff?
Detecting C. difficile toxin (CDT) in stool
Signs & symptoms of C. diff infection?
- Watery diarrhoea
- Abdominal pain and cramping
- Tachycardia
- Dehydration
- Fever
- Nausea
- Hypotension (severe)
- Increased WCC is characteristic
1st line pharmacological therapy for first episode of C. diff?
Oral vancomycin for 10 days
What is coeliac disease?
T cell mediated inflammatory autoimmune disease affecting the small bowel in which sensitivity to gliadin results in villous atrophy and malabsorption.
How does coeliac disease lead to malabsorption?
If you have celiac disease, eating gluten triggers an immune response in your small intestine. Over time, this reaction damages your small intestine’s lining and prevents it from absorbing some nutrients (malabsorption).
Does coeliac disease affect men or women more?
Females 2x
What allele is coeliac associated with?
HLA-DQ2 allele
GI symptoms of coeliac disease?
- Abdominal pain
- Distension
- N&V
- Diarrhoea
- Steatorrhoea (foul-smelling, greasy, difficult to flush)
Systemic symptoms of coeliac disease?
- Fatigue
- Weight loss/failure to thrive
- Pallor (2ary to anaemia)
- Short stature and wasted buttocks (2ary to malnutrition)
- Features of vitamin deficiency 2ary to malabsorption: e.g. bruising due to vitamin K deficiency
Why can coeliac disease lead to bruising?
Bruising due to vitamin K deficiency
What is the most common dermatological manifestation of coeliac disease?
Dermatitis herpetiformis (pruritic papulovesicular lesions over buttocks and extensor surfaces of arms, legs and trunk)
Give some complications of coeliac disease
- Unexplained iron deficiency
- B12 or folate deficiency
- Hyposplenism
- Osteoporosis (due to impaired vit D)
What can hyposplenism in coeliac disease lead to?
Increase infections
What conditions can be associated with coeliac disease?
- T1DM
- Autoimmune thyroid disease – Grave’s disease or Hashimoto’s thyroiditis
- Enteropathy associated T-cell lymphoma
Gold standard diagnostic investigation in coeliac disease?
OGD and duodenal/jejunal biopsy (patients should be referred after positive serological testing)
Histological features of coeliac disease?
- Sub-total villous atrophy
- Crypt hyperplasia
- Intra-epithelial lymphocytes
Coeliac disease can cause microcytic, normocytic or macrocytic anaemia. Give a cause for each
- May show microcytic anaemia due to iron deficiency
- May show normocytic anaemia due to chronic inflammation
- May show macrocytic anaemia due to B12/folate deficiency
What may LFTs show in coeliac disease?
albumin may be low 2ary to malabsorption
What is the preferred serological test for coeliac disease?
Anti-TTG IgA antibody
What inheritance pattern is Gilbert’s syndrome?
Autosomal recessive condition
What is Gilbert’s syndrome?
decreased activity of the enzyme that conjugates bilirubin with glucuronic acid (glucoronyl transferase)
Which gene is affected in Gilbert’s syndrome?
UGT1A1 gene
Presentation of Gilbert’s syndrome?
During times of stress, fasting, infection, or exercise jaundice can occur.
Blood tests results in Gilbert’s syndrome?
Consider in isolated rise in bilirubin but normal FBC.
What is toxic megacolon?
Occurs when swelling and inflammation spread into the deeper layers of your colon. As a result, the colon stops working and widens. In severe cases, may rupture. This is life-threatening.
3 risk factors for toxic megacolon?
- IBD: Crohn’s or UC that is not well controlled
- Infections of the colon e.g. C. difficile
- Ischaemic bowel disease
In patients with acute IBD flares, what drug can increase the risk of toxic megacolon?
Loperamide
Inflammation in Crohn’s can occur anywhere along GI tract but is nearly always found where?
In the ileocecal region
Signs & symptoms of toxic megacolon?
- Painful, distended abdomen
- Fever (sepsis)
- Diarrhoea (usually bloody)
- Reduced or absent bowel sounds
- Signs of septic shock:
- Tachycardia
- Mental state changes
- Hypotension
Treatment of toxic megacolon?
- Steroids
- Antibiotics
Complications of toxic megacolon?
- Perforation of colon
- Sepsis
- Shock
- Death
What is a faecal occult blood test?
Detection of blood in the faeces which is not visually apparent.
Most common cause of a lower GI bleed?
Diverticulosis
Presentation of diverticular disease bleeds vs diverticulitis associated bleeds?
- Diverticular disease bleeds → classically painless
- Diverticulitis associated bleeds → often painful 2ary to the localised inflammation
Give some differentials for a lower GI bleed
- Diverticular disease/Diverticulosis and Diverticulitis
- Haemorrhoids
- Malignancy
- Ischaemic or infective colitis
- IBD
- Radiation proctitis
What is ischaemic colitis caused by?
Ischaemic colitis is caused by a lack of blood flow through mesenteric vessels supplying the intestines
What is the key risk factor in acute ischaemic colitis?
AF → thrombus forms in LA and mobilises down aorta to SMA
Other risk factors → same as CVS disease
What is exocrine pancreatic insufficiency?
a condition characterised by deficiency of the exocrine pancreatic enzymes, resulting in the inability to digest food properly
What conditions can exocrine pancreatic insufficiency be caused by?
CF, chronic pancreatitis, pancreatic cancer, coeliac disease etc.
Loss of which enzyme is one of the key features in the development of steatorrhea?
Lipase
Give 3 Abx that can cause jaundice
- Co-amoxiclav
- Flucloxacillin
- Nitrofurantoin
What may the presence of bilirubin in the urine indicate?
The presence of bilirubin in the urine may be an early indicator of liver disease.
Give 3 major causes of pre-hepatic jaundice
- Conjugation disorders e.g. Gilbert’s syndrome
- Haemolysis e.g. malaria, haemolytic anaemia
- Drugs e.g. contrast, rifampicin
Give causes of hepatic jaundice
- Viruses e.g. hepatitis, CMV, EBV
- Drugs e.g. paracetamol overdose, halothane, valproate, statins, TB Abx
- Alcohol
- Cirrhosis
- Liver mass (abscess or malignancy)
- Haemochromatosis
- Autoimmune hepatitis
- Alpha-1 antitrypsin deficiency
- Wilson’s disease
Give causes of post-hepatic jaundice
- Primary biliary cirrhosis
- Primary sclerosing cholangitis
- Common bile duct gallstones
- Drugs:
- Flucloxacillin
- Co-amoxiclav
- Nitrofurantoin
- Steroids
- Sulphonylureas
- Malignancy e.g. head of pancreas adenocarcinoma
What 2 severity scales are used to upper GI bleeds?
- Rockall score
- Glasgow Blatchford score
What does the Glasgow Blatchford score estimate?
This estimates the risk of a patient with an upper GI requiring intervention, such as transfusion or endoscopy (0 = low risk)
What does the Rockall score estimate?
This estimates the risk of rebleeding or death in patients with upper GI bleed
What severity score is used in lower GI bleeds?
Oakland score
What does the Oakland score estimate?
This is used to predict whether it is safe to discharge a patient with a lower GI bleed.
Give some risk factors for a hernia that increases intra-abdominal pressure
- Obesity
- Pregnancy
- Chronic coughing/COPD
- Constipation
- Enlarged prostate
- Ascites
- Heavy lifting
Give some risk factors for a hernia that causes weakening of muscle/tissue fibres
- Poor nutrition
- Smoking
- Collagen disorders e.g. Ehlers-Danlos, Marfan’s
- Overexertion
- Trauma
Which 2 congenital disorders can cause weakening of muscle/tissue fibres?
- Marfans
- Ehlers-Danlos
Start and end of inguinal canal?
Start → deep inguinal ring
End → superficial inguinal ring
Contents of the inguinal canal in men?
spermatic cord & ilioinguinal nerve
Contents of the inguinal canal in women?
round ligament of uterus & ilioinguinal nerve
What is the mid-inguinal point?
Halfway between the pubic symphysis and the ASIS
What is the mid point of the inguinal ligament?
Halfway between the ASIS and pubic tubercle
What is found at the mid-inguinal point?
Femoral pulse
What is found at the mid point of the inguinal ligament?
Deep ring
How can you utilise the femoral pulse to locate the deep ring?
The mid point of the inguinal ligament (deep ring) is located lateral to the mid inguinal point (femoral pulse).
Locating the femoral pulse can allow you to locate the deep ring.
