Acute abdo Flashcards
Signs of peritonism?
guarding, rebound tenderness , rigidity
Differentials for acute abdo?
Ix for cholecystitis
- FBC
- CRP
- LFT
- USS RUQ
What is Mirizzi syndrome?
Extrinsic compression of the common hepatic duct by a gallstone in the cystic duct or Hartmann’s pouch. Impacted gallstone may erode into the CHD or CBD, creating a cholecystohepatic or cholecystocholedochal fistula; Mirizzi syndrome has an association with gallbladder cancer
Symptoms of cholecystitis
- RUQ pain
- nausea
- anorexia
- fever
What is colelithiasis? Risk factors? Symptoms?
- stones in the GB
- Imbalance of cholesterol, bile salts, and lecithin
- Fat, forty, female, fertile
Symptoms
- Vast majority asymptomatic
- Biliary colic can occur in some
- RUQ pain, spasms, occurs after eating fatty food, wraps around side
- USS will reveal stones
- No inflammatory process
- Elective cholecystectomy
Usually only lasts a few hours
What is the treatement of cholecystitis?
IV abs, analgesia, cholecystectomy
ANTIBIOTICS
- amoxy/ampicillin IV 6 hrly
- IV gentamycin 4-6mg/kg IV daily
What is coledocholithiasis? What is the treatment?
- Stones in the CBD
- Often asymptomatic
- Obstructive jaundice
- Treatment: ERCP +/- stent +/- delayed cholecystectomy
- Ercp = 25% of developing pancreatitis
What is Reynold’s pentad seen in? What are the symptoms and how to treat?
- Cholangitis
- Charcot’s triad/Reynold’s pentad
- Hypotension, confusion, RUQ, jaundice, fever
- High morbidity usually because of rapid sepsis
- Stones in duct, strictures, neoplasm
TREATMENT
- High dose Abx
- ERCP
- Cholecystectomy
What investigations should be done for biliary pathology?
- Bloods
- LFT
- FBC – rise in WCC
- CRP
- Lipase – differentiate between pancreatitis/cholecystitis/choledocholithiasis
- Ranson’s criteria for pancreatitis – what sort of mortality your patient can have
- At 0 and 48 hours
- USS
- Dilation of the common bile duct
- MRCP – will show the distal duct + stone
- Role of CXR in ED setting – stomach and duodenum also in that site, peptic ulcer perforation can mimic biliary pathology
- Air under the diaphragm
- Plural effusion or empyema
What is Ranson’s criteria?
Estimates mortality of patients with pancreatitis, based on initial and 48-hour lab values.
On admission
- WBC > 16k
- Age > 55
- Glucose >200 mg/dL (>10 mmol/L)
- AST > 250
- LDH > 350
48 HRS LATER
- Hct drop >10% from admission
- BUN increase >5 mg/dL (>1.79 mmol/L) from admission
- Ca <8 mg/dL (<2 mmol/L) within 48 hours
- Arterial pO2 <60 mmHg within 48 hours
- Base deficit (24 - HCO3) >4 mg/dL within 48 hours
- Fluid needs > 6L within 48 hours
All worth 1 point
0-2 = 2%
3-4 = 15%
5-6 = 40%
7-8 = 100% mortality
What is Courvoisier’s Sign?
Courvoisier’s Sign
- Palpable, nontender distended gallbladder due to CBD obstruction.
- Present in 33% of patients with pancreatic carcinoma.
- The distended gallbladder could not be due to acute cholecystitis or stone disease because the gallbladder would actually be scarred and smaller, not larger
Non GI causes of acute abdo
- AAA
- MI, IHD
- Pneumonia/PE
- Pregnancy
- Urinary
Special tests for appendicitis
Rovsing’s sign: Press yours fingers in the left lower quadrant and quickly
withdraw your fingers. Pain in the right iliac fossa during left sided pressure
suggests a positive Rovsing’s sign.
Psoas sign: Place your hand above the patient’s right knee and ask the patient
to raise the thigh against your hand. Increased pain during the manoeuvre is a
positive psoas sign
Obturator sign: Flex the patient’s right thigh at the hip and the knee bent; now
internally rotate the leg at the hip. Right hypogastric pain suggests a positive
obturator sign
McBurney’s point: roughly corresponds to the most common location of the base of the appendix where it is attached to the cecum.
