Acute Abdomen Flashcards
Peritonitis aka
Causes 4
Presentation 5 Presentation features 1 Clinical FInding 5 signs of infections 1 crude test
Investigations
Bedside- 4
Bloods- 6
Imaging- 3
Management - cause dependant
intitial management -5
if unwell- 3
What presents similarly to this but doesn’t require a laparotomy?
‘Hot Belly’
Causes: Perf. peptic/duo ulcer Diverticulum Appendicitis Cholecystitis
Presentation:
- rebound tenderness
- guarding (invol tensing of abdo)
- prostration (position knees and head on ground)
- no bowel sounds
- Abdo distention + rigid
- board-like abdo
- inc. HR, inc. BP, Fever, Dehydration, Anorexia
Test = +ve cough test (pain when ask to cough)
Investigations
bedside: Urine Dip, Preg, VBG/ ABG, ALWAYS ECG!
bloods: FBC, LFTs, CRP, Amylase, GROUP + SAVE, Blood Cult
Imaging: Erect CXR (gas under diaphragm), Ultrasound, CT abdo
Management
IV access + bloods, NBM, Analgesia, Urine dip, Consider imaging
unwell: IV fluids, Catheter, NG tube
extra- Pancreatitis
Acute Appendicitis Classical Presentation (2)
Classic infection 6
3 signs and what they are
Differential Diag (M+F) G- 3 R- 3 G- 4 U- 2
Investigations
Bedside- 2
Bloods- 2
Imaging- 2
Management 2
Complications 3
Classical Presentation:
- Periumbilical pain which moves to RIF
- To Mcburney’s Point (between umbilicus + Ant Sup il sp)
- Tachy
- Fever
- Peritonism -> guarding + rebound tenderness or percussion tenderness
- Anorexia is important!
- Constipation (usual)
- Vom is rare
- Rovsing’s Sign - Palp LIF causes RIF pain
- Psoas Sign- RIF pain with ext. of right hip
- Cope Sign- Pain on flexion and internal rotation in right, if appendix is close to obturator internus
DD
- Gynae: ovarian cyst rupt, ectopic preg, pelvic inflammatory disease
- Renal: UTI, ureteric stones, polynephritis
- GI: IBD, Meckel’s Diverticulum/ Diverticular disease, Cholecytsitis, Perforated ulcer
- Urological: Test torsion, epididymo-orchitis
Investigation
Bedside- preg test, urinanalysis
Bloods- FBC (neutrophil leukocytosis/ inc. CRP
Imaging- USS not always useful, CT good diag but not always needed
Management
- Laparoscopic appendicectomy (gold standard)
- Antibiotics- piptaz = pipercillin/ tazobactam
Complications
- perforation
- appendix mass: when the omentum covers so surgery/ antibiotics needed but rule out colonic tumour
- Appendix abscess: if mass isn’t resolved this can occur, needs draining/ surgery or antibiotics
Acute Pancreatitis
What is it? 2
Causes: I GET SMASHED
Presentation - - Eases with? - Exam 3 including 2 signs and why!
-
-
Investigations
- What to measure?
Modified GCS for severity- Called?
- PANCREAS
- …. indicates pancreatitis
- mortality % (4)
- When is the test done?
Management
- initial 4
- concepts of later 1
Complications
- Local LATE 4/6
- Systemic EARLY 4/6
- Self- perpetuated pancreatic enzyme- mediated autodigestion, odema, fluid shift -> Hypovolaemia
- Extra-cellular fluid trapped in gut, peritonium and retroperitonium
Causes
I-Idiopathic S- Steroid
M- Mumps (virus: HIV, Coxsachie)
G- Gallstones A- Autoimmune
E- Ethanol S- Scorpion venom
T- Trauma H- Hyper.. lipidamia, calcamia,
hypothermia
E- ERCP or Emboli
D- Drugs (thiazide diuretics,
azathioprine)
Could also be preg, anatomical defect
Presentation
- Epigastric pain WHICH RADIATES TO BACK
- Eases with sitting forward or fetal position
- Nausea and vom assoc
Examination
- Epigastric tenderness +/- guarding
- Cullens Sign: Bruising around umbilicus
- Grey- Turners Sign: Flank bruising
from retroperitoneal haemorrhage or vessel autodigestion
Complications?
- ARDS
- Hypovolaemia leading to AKI
- Pleural effusions
Investigations
- Lipase is more sensitive than amylase but not as readily available
- Amylase x3 upper limit of normal is very suggestive
Modified GCS- Glasgow Imrie (gallstones or alcohol) P- PaO2 < 8kPa A- Age >55y/o N- Neutrophilia WBC > 15 x10^9 /L C- Calcium <2 mmol/L R- Renal Funct Urea> 16mmol/L E- Enzymes LDH> 600iu/L AST> 200iu/L A- Albumin < 32g/L S- Sugar Blood Glucose > 10mmol/L - 3+ indicates pancreatitis - mortality 0-2 2%, 3-4 15%, 5-6 40%, 7-8 100% - at 48 hours
Management Initial: Analgaesia (opioid) Fluid resus (crystalloid), Monitor fluid balance (catheter) NBM -> NG tube
- concepts of later: treat underlying cause ERCP
Complications
Local: LATE > 1 week
- Pancreatic Pseudocyst- collection of enzymes, blood, necrotic tissue surrounded by fibrotic/ vascular wall, forms weeks after episode and can be incidental or mass found
- Pancreatic Necrosis- Inflamm causing inchaemia/ infarct of pancreas. suspect of persistent systemic inflam >7days
- Bleeding -> eroded major vessel eg splenic artery
- Thrombosis-> splenic or gastroduo artery, or colic branches SMA
- Abscess
- Fistulae
- Recurrent oedematous pancreatitis
Systemic:
- Disseminated Intravascular Coag (DIC)
- Acute Resp. Distress Synd (ARDS)
- Hypocalcaemia
- Hyperglycaemia
- Sepsis
- Renal Failure
Diverticular Disease Definitions - Diverticulum - Diverticulosis - Diverticulitis - Diverticular bleed - Diverticular disease
Presentation - Diverticular disease 4
Presentation- Diverticulitis 6
Complications 5/7
Surgical Management of diverticulitis? main procedure? and 4 stages
- two more managments to complications
Non-surgical Management of diverticulitis 5
mild attack 2
not tolerated 4/5
Definitions
- Diverticulum- outpouching of bowel, usually sigmoid affected but can affect whole bowel.
- Diverticulosis- symptoms arising from diverticula
- Diverticulitis- inflam of diverticula
- Diverticular bleed- erosion into vessel causing large vol painless bleed.
- Diverticula disease- symptoms arising from diverticula
Presentation - Diverticular disease
- Intermittent lower abdo pain
- Colicky
- Relieved by defecation
- Altered bowel habit (nausea/ flatulence)
Presentation- Diverticulitis
- Acute abdo pain, sharp
- LIF
- Worse on movement
- Localised tenderness
- Systemically unwell (pyrexia, inc WBC, ESR, CRP)
perforation- localised or general guarding
Complications
- Colovesical fistuala: tract between bowel + bladder
- Colovaginal fistula: ‘’ bowel + vagina
- Perforation
- Haemorrhage: large rectal bleed painless
- Post-infection from suture
- Abscess: persistent with swinging fever, leukocytosis, local sign such as rectal mass but if not then pus can be under diaphragm
Surgical Management: Sigmoid colectomy with formation of end colostomy or Hartmanns procedure
Stage 1: pericolic/ mesenteric abcsess NOT
Stage 2: walled off/ pelvic abscess SOMETIMES
Stage 3: Generalised purulent peritonitis SURGERY
Stage 4: faecal peritonitis SURGERY
- If haemorrhaging embolization is needed
- If abscess then will need draining under CT
Non-surgical Managment Mild attack: home with bowel rest (fluid only) and antibiotics PO Not tolerated: admit with - IV Fluids - Analgaesia - NBM - IV antibiotics - (Antispasmodic eg mebeverine)
Biliary Disease
-Draw anatomy of biliary system
- Different types of gallstones
1) Not as common and what causes it?
2) Most common and what causes it?
3) - Different conditions caused by gall stones. WHERE IS THE STONE? (3 name and def.)
- Presentation and management for each
1) Presentation 5 Management 3
2) Presentation 4 + 1 Sign! Management 3
3) Presentation TRIAD + 3 due to… Management 3
L/R hepatic duct, common hepatic duct, cystic duct joins, common bile duct, pancreatic duct joins, Ampulla of Varter +Sphincter of Oddi into 2nd portion of Duo
Types
- Pigment stones: small, friable, irreg cause- haemolysis
- Cholesterol Stones: large, yellow, usually solitary
cause = excess cholesterol, 3Fs: Fat, forty, female
- Mixed Stones: faceted (calcium salt pigment, cholesterol)
3 conditions caused by gall stones
- Biliary Colic- Gallstones impacts neck of gallbladder
- Acute Cholecystitis- Inflam of gallbladder
- Acute Cholangitis- Stone blocks CBD
Presentation
- Biliary Colic: AFTER EATING, Dull, colicky pain, RUQ, assoc nausea + vom.
Manage: Analgesia, Lifestyle (low fat, weight loss, exercise), Elective laparoscopic cholecystectomy
-Acute Cholecystitis: systemic features (lethargy, fever), constant RUQ pain +/- Guarding, Murphy’s +ve! (large inhale and palpate RUQ +ve is pain)
Manage: Antibiotics, Analgesia, Laparoscopic cholecystectomy within 1 week
- Acute Cholangitis: Charcot’s triad Fever, Jaundice, RUQ pain, Itching, pale stool, dark urine due to obstructive jaundice! ( Reynold’s Pentad + Hypotension + Delerium/ Confusion)
Management: IV anti-biotics + treat sepsis, ERCP (endoscopic Retrograde Cholangiopancreatography- endoscopic removal of stone), Laparoscopic cholecystectomy
Know the difference in blood results for the 3 biliary conditions:
- WCC, CRP, Bilirubin, ALT, ALP what is happening with each?
Presentation table (Simple Revision tool)
- Biliary Colic
- Acute Cholecystitis
- Acute Cholangitis
Imaging for Biliary Disease 2
Biliary Colic: WCC, CRP, Bilirubin, ALP, ALT NORMAL
Acute Cholecystitis: Inc WCC + Neut, Inc CRP but Bilirubin, ALP, ALT normal
Acute Cholangitis: Inc WCC + Neut, CRP, Bilirubin, Inc. Inc. ALP, ALT Inc./ normal
Presentation
- Biliary Colic: RUQ pain but NO fever or jaundice
- Acute Cholecystitis: RUQ and Fever but NO jaundice
- Acute Cholangitis: ALL 3!
USS (cant see if passed to CBL) so…
MRCP (MRI of biliary)
Small Bowel Obstruction
5 Cardinal Presentations of Obstructions
3 Presentation specific to Small Bowel
Two main types:
Mechanical-
Functional-
Causes:
- Intrinsic 5
- Extrinsic 4 (The big two are within here!)
- Intraluminal 3
Investigations:
- Bedside 1
- Bloods 4
- Imagery 1
Early non-surgical management of small bowel obstruction 4
Provide a broad overview of the surgical options for managing a patient with small bowel obstruction **
Small Bowel Presents: Cardinal Signs of Obstruction: - Vom + Nausea - Annorexia - Constripation - Abdo distention Small Bowel - vomiting occurs early - less distention - pain higher
Two main types:
Mechanical- A blockage within the lumen
Functional- No block in the lumen, no peristalsis
Causes:
Intrinsic:
- Inflammatory stricture (Crohns, Gasteroenteritis, TB)
- Neoplasia (Primary= adenocarcinoma, lymphoma, GIST or secondary)
- Vascular lesion
- Hematoma (coag, trauma, blood dyscrasias)
- Intussusception
Extrinsic:
- ADHESION (75%) (fibrous scar tissue which joins two surfaces but are usually separate due to surgery)
- Hernias (external or internal)
- Endometriosis
- Heamatoma
Intraluminal:
- Gallstone ileus
- Bezoars- collection of partially digested material that collects in the GI
- Foreign Body
Investigations:
- Bedside: AXR
- Bloods: FBC, Amylase, U+E (monitor electrolytes), Group and save
- Imagery: CT abdo with gastrografin (iodine contrast)
Non- surgical management early
- ‘Drip and Suck’ (NG tube and Fluid resus) Analgaesia, catheterise
Surgery
- laperotomy or laperscopic removal
Large Bowel Obstruction presentation 1 Identify the causes of large bowel obstructions Mural 2 (big one) Intramural/ within lumen 1 Extramural 2
Provide a broad overview of the surgical options for managing a patient with large bowel obstruction **
Definitions
What is Ileus? and what examination finding?
Mechanical
Simple
Closed loop What is it and a complication?
Strangulated What is it and 3 presentations?
Paralytic ileus
What is it?
4/6 causes SHUT PAS
Psuedo- obstruction
What is it? And what else is it called?
Sigmoid Volvulus
What is it? Key clinical fact?
Presentation:
- pain constant
- Distension
Causes
Mural:
- Colorectal Cancer
- Diverticular Stricture
Intramural:
- Faecal impaction
Extramural:
- Hernia
- Volvulus - sigmoid volvulus looks like coffee bean as it twists on its mesentry
Surgical Options Large bowel
- Endoscopic stent (for malignancies)
Ileus- functional obstruction from dec. motility, bowel sounds abscent
eg paralytic ileus- caused by abdo surgery, pancreatitis, spinal injury, hypokalaemia, hyponatrraemia, ureamia, peritoneal sepsis, drugs (trycyclic anti-depressants)
Mechanical- Physical block within the lumen of bowel
Simple- one ob point and no vascular compromise
Closed loop- two ob points, therefore distended, could perforate
Strangulated- Blood supply comp, sharper + localised pain (peritonism), could also have fever, inc WCC, bowel ischaemia signs
Paralytic ileus- no peristalsis causes include: abdo surgery, spinal injury, tricyclic antidepressant, hypokalaemia, uraemia, peritoneal sepsis
Psuedo- obstruction- resembles mech. bowel ob but no lesion and called Ogilvie’s Syndrome
Sigmoid Volvulus- bowel twists on its own mesentry, severe rapid strangulation obstruction in elderly, constipated and looks like coffee bean on AXR
Glasgow Imrie used for Pancreatitis
Write it out
Interpret results
When is the test done?
Causes of drug-induced pancreatitis
FATSHEEP pneumonic
Modified GCS- Glasgow Imrie (gallstones or alcohol) P- PaO2 < 8kPa A- Age >55y/o N- Neutrophilia WBC > 15 x10^9 /L C- Calcium <2 mmol/L R- Renal Funct Urea> 16mmol/L E- Enzymes LDH> 600iu/L AST> 200iu/L A- Albumin < 32g/L S- Sugar Blood Glucose > 10mmol/L
Results
- 3+ indicates pancreatitis
- mortality 0-2 2%, 3-4 15%, 5-6 40%, 7-8 100%
Done at 48 hours
Causes of drug-induced pancreatitis
A good mnemonic for drug-induced pancreatitis is FATSHEEP:
Furosemide Azathioprine/Asparaginase Thiazides/Tetracycline Statins/Sulfonamides/Sodium Valproate Hydrochlorothiazide Estrogens Ethanol Protease inhibitors and NRTI (Nucleotide Reverse Transcriptase Inhibitors) used in HIV
