Acute Abdo Flashcards by Amy Brown

What are the causes of abdominal perforation?

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

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Name 2 signs on an X-Ray of perforation.

Rigler’s sign

Psoas sign

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How might a retroperioneal perforation present?

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

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What are the complications of perforation?

Infection - peritonitis + sepsis

Haemorrhage

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What are signs of localised peritonitis?

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

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What are causes of localised peritonitis?

Appendicitis, Crohn’s disease, diverticulitis

Cholecystitis, salpingitis

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What are signs of generalised peritonitis?

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

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What causes generalised peritonitis?

Perforation of a viscus

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What are the 2 types of generalised peritonitis?

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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What is the management of generalised peritonitis?

High dose IV Abx

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

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Describe the pathophysiology of pancreatitis.

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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What are the causes of pancreatitis?

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

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Which drugs can cause pancreatitis?

Steroids
Azathioprine, antibiotics
NSAIDs
Diuretics

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How does pancreatitis present?

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

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

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

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

FBC, U&amp;E, CRP
Amylase 
LFTs
Lipase (if trust allows)
ABG 
USS (unless obv cause)

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What is important to remember about amylase?

Levels do not correlate with disease severity

- Falls 24-48 hrs

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

Bowel perforation
Ectopic pregnancy
Mesenteric ischaemia
DKA

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

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

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

ERP and sphincterotomy within 72 hours.

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What scale is used to grade the severity of pancreatitis?

Glasgow scale

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Outline the glasgow scale.

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

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

ARDs is an early complication

Metabolic acidosis is complication associated with poorer prognosis

List systemic complications of pancreatitis.

DIC
Renal failure
Sepsis
ARDS
Hypocalcaemia
Hyperglycaemia
Hypovolaemic shock and MOD

List local complications of pancreatitis.

``` Pancreatic necrosis - prone to infection Fluid collection Pancreatic psueudocyst Pancreatic abscess Haemorrhage ```

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

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

What are additional causes of RIF pain in females?

``` Ruptured ectopic pregnancy Tubo-ovarian abscess Salpingitis/PID Mittelschmerz UTI more likely ```

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

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

What imaging could you do in suspected appendicitis?

USS - will show mass or abscess | CT - accurate

What is the cause of appendicitis?

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

What are 5 positions of the appendix?

``` Retrocaecal Subcaecal Pelvic Pre-ileal Post-ileal ```

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

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

How can appendicitis result in diarrhoea or urinary symptoms?

Pelvic appendix can irritate rectum or ureter

What abdominal sign can be used to help diagnose appendicitis?

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

What complications are associated with appendicitis?

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

Outline the pathophysiology following bowel obstruction.

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

How does bowel obstruction present?

``` Abdo pain Nausea + vomiting Constipation - absolute Abdo distension Anorexia ```

How can small and large bowel differ in their presentation?

Small - vomiting first, then constipation | Large - constipation first, may not vomit, more distension as proximal bowel fills

How is the abdo pain associated with bowel obstruction described?

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

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

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

What are common causes of small bowel obstruction?

Adhesions | Hernias

What are common causes of large bowel obstruction?

Colon Ca Volvulus Constipation Diverticular disease

What are rarer causes of bowel obstruction?

Gallstone ileus Crohns stricture TB Foreign body

How is sigmoid volvulus managed?

Insertion of flatus tube or sigmoidoscopy

What signs might indicate that obstruction is associated with ischaemia?

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

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

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

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

>3cm >6cm >9cm

What is a classic sign of sigmoid volvulus on AXR?

coffee bean sign

What is the conservative management for bowel obstruction?

'Drip and suck' - NBM and insert NG tube to decompress bowel - IV fluids and electrolyte correction - Analgesia and antiemetics

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

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

What are complications of bowel obstruction?

Bowel ischaemia Perforation and faecal peritonitis Dehydration and renal impairment

What 2 pieces of information do you need before CT?

Renal function - creatinine | Allergies to contrast

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

Ascites

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

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