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Burton > Acute Abdo > Flashcards

Acute Abdo Flashcards

1
Q

What are the causes of abdominal perforation?

A 
Stomach or duodenal ulcer
Malignancy 
Fistula - crohns
Infection - appendicitis, diverticulitis
Ischaemia
Obstruction 
Iatrogenic - anastomotic leak, endoscopy
Trauma 
Direct - excessive vomiting
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2
Q

Name 2 signs on an X-Ray of perforation.

A

Rigler’s sign

Psoas sign

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3
Q

How might a retroperioneal perforation present?

A

R shoulder tip pain
Back pain
RIF pain - contents settles in paracolic gutter

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4
Q

What are the complications of perforation?

A

Infection - peritonitis + sepsis

Haemorrhage

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5
Q

What are signs of localised peritonitis?

A

Tender on palpation
Guarding
Rebound tenderness
May have systemic signs of infection

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6
Q

What are causes of localised peritonitis?

A

Appendicitis, Crohn’s disease, diverticulitis

Cholecystitis, salpingitis

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7
Q

What are signs of generalised peritonitis?

A

Abdomen rigid and tender
Cough test +ve
Bowel sends absent - peristalsis stopped

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8
Q

What causes generalised peritonitis?

A

Perforation of a viscus

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9
Q

What are the 2 types of generalised peritonitis?

A

Chemical - bile, stomach or small bowel contents

Bacterial - abscess rupture or faecal contamination from bowel, trauma, surgery or post-surgical leak

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10
Q

What is the management of generalised peritonitis?

A

High dose IV Abx

Urgent laparotomy to find cause and clear material ‘peritoneal toilet’

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11
Q

Describe the pathophysiology of pancreatitis.

A

Inflammation of pancreas.
Vascular permeability and fluid loss (3rd spacing)
Enzyme activation - tryptase
Fat necrosis by lipase, free FA react with calcium to form deposits (hypocalcaemia)
Enzymes can erode blood vessels -retroperitoneal bleeding

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12
Q

What are the causes of pancreatitis?

A 
Iatrogenic/idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune - SLE
Scorpion/snake bite
Hypercalcaemia, hyperlipidaemia, hypothermia
ERCP
Drugs
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13
Q

Which drugs can cause pancreatitis?

A

Steroids
Azathioprine, antibiotics
NSAIDs
Diuretics

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14
Q

How does pancreatitis present?

A 
Sudden onset severe, constant upper abdo pain.
Radiates to back.
Relieved sitting forward 
Vomiting
Abdo distension
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15
Q

What are differential diagnosis for upper abdo pain radiating to the back?

A

Radiating to back:pancreatitis, ruptured AAA, dissecting aorta
Epigastric: peptic ulcer
Biliary colic cholecystitis
Pneumonia, Inferior MI

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16
Q

What investigations would you do in a patient with suspected pancreatitis?

A 
FBC, U&E, CRP
Amylase 
LFTs
Lipase (if trust allows)
ABG 
USS (unless obv cause)
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17
Q

What is important to remember about amylase?

A
  • Levels do not correlate with disease severity

- Falls 24-48 hrs

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18
Q

Other than pancreatitis, what else can cause amylase to be raised?

A

Bowel perforation
Ectopic pregnancy
Mesenteric ischaemia
DKA

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19
Q

When should a CT scan be ordered in a patient with pancreatitis?

A

Only if not improved after 6-10 days and suspect complications such as necrosis.

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20
Q

If gallstone is found to be the cause of pancreatitis, what management should happen?

A

ERP and sphincterotomy within 72 hours.

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21
Q

What scale is used to grade the severity of pancreatitis?

A

Glasgow scale

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22
Q

Outline the glasgow scale.

A 
PaO2 < 8kPa
Age > 55
Neutrophilia > 15x10^9
Calcium < 2 mmol/L
Renal, urea >16 mmol/L
Enzymes, LDH > 600, AST > 200
Albumin < 32 g/L
Sugar - blood glucose > 10 mmol/L

3 or more = severe, ICU for monitoring

23
Q

Why is ABG and acid-base status important in pancreatitis?

A

ARDs is an early complication

Metabolic acidosis is complication associated with poorer prognosis

24
Q

List systemic complications of pancreatitis.

A 
DIC
Renal failure
Sepsis
ARDS
Hypocalcaemia
Hyperglycaemia
Hypovolaemic shock and MOD
25
Q

List local complications of pancreatitis.

A 
Pancreatic necrosis - prone to infection
Fluid collection
Pancreatic psueudocyst
Pancreatic abscess
Haemorrhage
26
Q

What are causes of RIF pain in both males and females?

A 
Appendicitis 
Constipation
Strangulated hernia
Perforated caecum
IBD - Crohn's disease
Renal colic 
Mesenteric adenitis (child)
UTI
Meckel's diverticulitis
27
Q

What are additional causes of RIF pain in females?

A 
Ruptured ectopic pregnancy
Tubo-ovarian abscess
Salpingitis/PID
Mittelschmerz
UTI more likely
28
Q

What investigations should you do for a patient with RIF pain?

A

Urine dip - UTI
Preg test if F
Bloods - FBC, U&E, CRP, amylase

29
Q

What imaging could you do in suspected appendicitis?

A

USS - will show mass or abscess

CT - accurate

30
Q

What is the cause of appendicitis?

A 
Gut organisms (E.Coli) invade lumen following blockage by hyperplasia of lymphoid tissue or faecolith.
Mucosa inflammation, then extends through wall to serosa.
31
Q

What are 5 positions of the appendix?

A 
Retrocaecal
Subcaecal
Pelvic
Pre-ileal
Post-ileal
32
Q

What sign can you use to diagnose appendicitis in a retrocaecal appendix

A

Psoas sign - extension of hip causes pain as appendix irritates the psoas muscle

33
Q

How can appendicitis result in diarrhoea or urinary symptoms?

A

Pelvic appendix can irritate rectum or ureter

34
Q

What abdominal sign can be used to help diagnose appendicitis?

A

Rosvings sign - pain greater in RIF than the LIF when the LIF is pressed.

35
Q

What complications are associated with appendicitis?

A

From op: ileum, infection from wound or intra-abdominal, adhesions/obstruction, incisional hernia.
Perforation
Appendix mass
Appendix abscess

36
Q

Outline the pathophysiology following bowel obstruction.

A

Once occluded, dilatation of proximal bowel and increased peristalsis (to begin with). This leads to large volumes of fluid secretion ‘third spacing’.

37
Q

How does bowel obstruction present?

A 
Abdo pain 
Nausea + vomiting
Constipation - absolute
Abdo distension
Anorexia
38
Q

How can small and large bowel differ in their presentation?

A

Small - vomiting first, then constipation

Large - constipation first, may not vomit, more distension as proximal bowel fills

39
Q

How is the abdo pain associated with bowel obstruction described?

A

Often colicky or crampy to begin with (due to peristalsis), then becomes constant

40
Q

What are the 2 types of bowel obstruction according to their mechanism?

A

Simple - one obstructed point with no vascular compromise

Closed loop - two obstructed points with a loop at risk of ischaemia and perforation e.g. sigmoid volvulus

41
Q

What are common causes of small bowel obstruction?

A

Adhesions

Hernias

42
Q

What are common causes of large bowel obstruction?

A

Colon Ca
Volvulus
Constipation
Diverticular disease

43
Q

What are rarer causes of bowel obstruction?

A

Gallstone ileus
Crohns stricture
TB
Foreign body

44
Q

How is sigmoid volvulus managed?

A

Insertion of flatus tube or sigmoidoscopy

45
Q

What signs might indicate that obstruction is associated with ischaemia?

A

Peritonitic signs - rebound tenderness, guarding, no bowel sounds.

46
Q

What investigations should you do in a pt with suspected bowel obstruction?

A

FBC, U&E, CRP
Group & Save
Venous blood gas - signs of ischaemia (lactate) or metabolic alkalosis from vomiting

AXR

47
Q

What are the diameter for small bowel, large bowel and sigmoid/caecum obstruction?

A

> 3cm
6cm
9cm

48
Q

What is a classic sign of sigmoid volvulus on AXR?

A

coffee bean sign

49
Q

What is the conservative management for bowel obstruction?

A

‘Drip and suck’

  • NBM and insert NG tube to decompress bowel
  • IV fluids and electrolyte correction
  • Analgesia and antiemetics
50
Q

When is surgical intervention rather than drip and suck indicated for bowel obstruction?

A
  • Suspected ischaemia or closed loop
  • Small bowel obstruction in virgin abdomen
  • Cause needs correction - strangulated hernia or tumour
  • Conservative for 48 hours not relieved
51
Q

What are complications of bowel obstruction?

A

Bowel ischaemia
Perforation and faecal peritonitis
Dehydration and renal impairment

52
Q

What 2 pieces of information do you need before CT?

A

Renal function - creatinine

Allergies to contrast

53
Q

Other than obstruction, what is another important differential causing abdo distension?

A

Ascites

54
Q

Why is a CT a useful investigation following AXR for bowel obstruction?

A

Can confirm dilatation of bowel
Point of obstruction
Evidence of metastatic disease cause

Burton (10 decks)

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