acute abdo ddx Flashcards
define acute abdo
sudden severe abdo pain <24hr duration
how to tell if its an acute surigcal probelm [needing prompt surgical intrevention + urgent med therapy]
10 sec end-o-bed-o-gram
> obs
> are they talking to u
- if yes: breathe
- if no: shit. give o2, call for help, take hx and exam
3 acute situ’s needing urgent surgical rx
- bleeding [HYPOVOLEMIC SHOCK S/S]
- AAA = most serious- urgent vasc rx needed
- ruptured ectopic preg
- gastric ulcer
- trauma
- perforated viscus [peritonitic s/s]
- peptic ulceration
- SBO/LBO
- diverticular disease
- IBD
- ischemic bowel [severe pain out of proportion with clinical signs has bowel ischemia until proved otherwise]
hypovolemic shock s/s
tachycardia
hypotension
pale, clammy
cool to touch
thready pulse
peritonitic s/s
lie completely still [nb: bilarary colic- they’re restless]
look unwell
high HR, low BP
rigid ‘washboard’ abdomen
involuntary guarding- tense muscles upon palpation
increased/absent bowel sounds
s/s, ix, rx of ischemic bowel
- acidemic
- high lactate
- physiologically compromised
- diffuse constant pain
- o/e- oft unremarkable
IX: confirmed w/ CT WITH IV CONTRAST
RX: EARLY SURGICAL INVOLVEMENT
Less acute ‘acute abdo’ situ’s
1. colic
= abdo pain that crescendos- gets v severe- then goes away
eg. ureteric obstruction/ bowel obstruction
nb: biliary colic is not true colic, here the pain waxes and wanes…
2. peritonism
= localised inflammation of peritoneum
[inflammed viscus irritates viscerae + parietal peritoneum]
s/s:
- pain starts in one place then moves to another place/ gets more generalised eg. acute appendicitis
ddx of acute RUQ pain
BADHAD
DAPS
- biliary colic pain - constant, nonparoxysmal pain which rapidly increases in intensity then plateaus, lasts four to six hours, occasionally radiates to the right subscapular area
- acute cholecystitis - longer lasting (more than six hours) biliary pain with tenderness, fever, and/or leukocytosis
- dyspepsia - bloating, nausea, belching, intolerance to fatty foods
- duodenal ulcer - pain two hours after meals, relieved by taking food or antacids
- hepatic abscess - pain associated with fever and chills; palpable liver and subcostal tenderness
- acute myocardial infarction - right upper quadrant or epigastrium discomfort; may be similar to biliary pain (1)
Other possible causes of right upper quadrant pain include:
- duodenal ulcer
- acute pancreatitis
- pneumonia
- subphrenic abscess
Ddx of LUQ pain
- gastric ulcer
- pneumonia
- acute pancreatitis
- spontaneous splenic rupture
- leaking splenic artery aneurysm
- acute perinephritis
- subphrenic abscess
ddx of RIF pain
- acute appendicitis
- mesenteric adenitis in the young
- diverticulitis
- pelvic inflammatory disease
- salpingitis
- inflamed Meckel’s diverticulum
- ectopic pregnancy
- Crohn’s disease
- inguinal hernia
- testicular torsion
ddx LIF pain
Causes of left iliac fossa pain include:
- diverticulitis
- constipation
- irritable bowel syndrome
- pelvic inflammatory disease
- rectal carcinoma
- ulcerative colitis
- ectopic pregnancy
ddx of epigastric pain
- duodenal ulcer
- gastric ulcer
- oesophagitis
- acute pancreatitis
- cholecystitis
- MI
- abdominal aortic aneurysm
ddx abdo pain radiating to back
Abdominal pain which radiates to the back can have a variety of aetiologies; an important additional question is whether it radiates through or round to the back.
Conditions causing pain which radiates round to the back include:
- cholecystitis
- biliary colic
- renal colic
Conditions causing pain which radiates through to the back include:
- abdominal aortic aneurysm
- pancreatitis
- aortic dissection
- duodenal ulcer
ddx of periumbilical pain
Causes of central abdominal pain include:
- early appendicitis
- small intestinal obstruction
- acute gastritis
- acute pancreatitis
- ruptured abdominal aneurysm [AAA]
In isolated central abdominal pain with no other features, it is often best to repeat the examination after two or three hours have passed; by this time other symptoms may have emerged which help the examiner to come to a firm diagnosis.
Rarer causes may include:
- mesenteric thrombosis
ddx of suprapubic pain include:
- acute urinary retention
- urinary tract infection
- cystitis
- pelvic inflammatory disease
- ectopic pregnancy
- diverticulitis
ddx loin pain
Loin pain is most frequently due to:
- muscle strain
- urinary tract infection
Other conditions which should be considered include:
- renal calculus
- pyelonephritis
- Very rarely in pregnancy listeriosis may present with loin pain.
Investigation of loin pain should include:
- urine dipstick testing
- mid-stream urine
- radiology of kidneys, ureters and bladder
- ultrasound scan if pain persists
ix of acute abdo
IN ACUTE SETTING: UBEX
- urine dip [infection [high WCC], haematuria, mc+s, preg test
- bloods- ABG in bleeding + septic pt’s = vital
- ph, p02, pco2
- signs of tissue hypoperfusion
-
rapid Hb
- MAY ALSO SEND OFF BLOOD CULTURES [if infection is potential diagnosis]
- ECG - rule out MI.
- XRAY [ie. imaging]
- non radiological
- US -KUB in suspected renal tract pathology
- biliary tree/liver- suspected gallstone disease
- ovaries/FT/uterus- suspected tubo-ovarian pathology
- radiological
- CXR- erect if level of bowel perf
- CT- best discuss with senior
- non radiological
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Blood tests:
- full blood count - haemoglobin and white cell count
- serum amylase - pancreatitis[if >3x upper limit= pancreatitis. if just high, could be perf bowel, ectopic preg, dka]
- urea and electrolytes
- glucose
- blood group and cross match, group and save [in case surgery is needed..]
- blood gases - adult respiratory distress syndrome, particularly in pancreatitis
- pregnancy test, if available, in women of child bearing age, if there is any possibility they may be pregnant.
Other blood tests:
- liver function tests and calcium - pancreatitis and acute biliary disease
- clotting studies - acute pancreatitis, septicaemia and disseminated intravascular coagulation, history of bleeding disorders, on anticoagulant therapy, liver disease
Urine tests:
- stick test
- microscopy
- culture and sensitivity
- if ureteric colic then strain urine for stones
- pregnancy test, if a blood test is not available
Radiology:
- chest radiology, erect - looking for gas under the diaphragm
- plain abdominal radiology, supine
- ultrasound, for example in suspected pancreatitis or gynaecological pathology
- IVU - if suspecting renal / ureteric colic
mx of serious acute abdomen
depends mainly on cause
always start adequete resus!
iv access
nbm
analgesia + antiemetics
imaging
urine dip
bloods
consider: catheter/NGT
iv fluids + fluid balance
