Acute abdomen Flashcards
What is biliary colic
This is the most common presentation. Steady non-paroxysmal biliary pain occurs in the epigastrium or right upper quadrant and typically lasts for more than 30 minutes, but less than eight hours.
It is often severe, and may be associated with nausea and vomiting, but is not associated with fever, or abdominal tenderness.
What is acute cholecystitis
Inflammation of the gallbladder. It usually happens when a gallstone blocks the cystic duct.
Symptoms of acute cholecystitis
Classical symptoms and signs are similar to biliary colic, but in addition other classical features are fever and tenderness in the right upper quadrant.
Features of obstructive jaundice
Yellowish discolouration of the skin, dark urine and pale stools.
Features of cholangitis
Typical features, referred to as Charcot’s triad, are diagnostic: fever (often with rigors), jaundice, and upper quadrant abdominal pain.
What is cholangitis
Infection and inflammation of the biliary tree
Features of gallstone pancreatitis
Constant epigastric pain radiating through to the back, and profuse vomiting.
IX for suspected gallstone disease
Abdominal ultrasound
LFTs
MRCP if ultrasound has not detected common bile duct stones
Management of asymptomatic gallstones found in a normal gallbladder and normal biliary tree
Reassure them that they do not need treatment unless they develop symptoms.
Explain that asymptomatic gallstones are very common.
Prophylactic treatments aimed at preventing future complications are not recommended (such as prophylactic cholecystectomy) as the risk of complications from surgical treatment outweighs the potential risk of developing complications from the stones.
When might prophylactic cholecystectomy be considered in asymptomatic gallstones found in a normal gallbladder and normal biliary tree
People with a partially calcified ‘porcelain’ gallbladder.
Management of asymptomatic gallstones found in the CBD
Offer referral for bile duct clearance and laparoscopic cholecystectomy — although they are asymptomatic, there is a significant risk of developing serious complications such as cholangitis or pancreatitis.
Management of symptomatic gallstones
Emergency admission if systemically unwell
Surgical referral
Consider laparoscopic cholecystectomy
When is percutaneous cholecystectomy advised for gallstones
To manage gallbladder empyema when surgery is contraindicated at presentation and conservative management is unsuccessful
Advice regarding diet to help prevent biliary pain
low-fat diet
advice for people with symptomatic gallstones
Avoid food and drink that triggers their symptoms until they have their gallbladder or gallstones removed, but they do not need to avoid this food and drink after surgery.
Seek further advice if eating or drinking triggers existing symptoms or causes new symptoms to develop after they have recovered from having their gallbladder or gallstones removed.
What sign is suggestive of acute cholecystitis
Murphy’s sign
What is Murphy’s sign
Place a hand in RUQ and apply pressure
Ask the patient to take a deep breath in
The gallbladder will move downwards during inspiration and come in contact with your hand
Stimulation of the inflamed gallbladder results in acute pain and sudden stopping of inspiration
What might an abdominal ultrasound scan show in acute cholecystitis
Thickened gallbladder wall
Stones or sludge in gallbladder
Fluid around the gallbladder
Mx of acute cholecystitis
Nil by mouth
IV fluids
Antibiotics (as per local guidelines)
NG tube if required for vomiting
ERCP to remove stones in CBD
Cholecystectomy within 72 hrs of symptoms if required
Complications of acute cholecystitis
Sepsis
Gallbladder empyema
Gangrenous gallbladder
Perforation
What is gallbladder empyema
Gallbladder empyema refers to infected tissue and pus collecting in the gallbladder
Mx of gallbladder empyema
Cholecystectomy (to remove the gallbladder)
Cholecystostomy (inserting a drain into the gallbladder to allow the infected contents to drain)
Two main causes of ascending cholangitis
Obstruction in the bile ducts stopping bile flow (i.e. gallstones in the common bile duct)
Infection introduced during an ERCP procedure
Most common organisms in ascending cholangitis
Escherichia coli
Klebsiella species
Enterococcus species
Acute mx of ascending cholangitis
Nil by mouth IV fluids Blood cultures IV antibiotics (as per local guidelines) Involvement of seniors and potentially HDU or ICU
Diagnosis of cholangitis
Abdominal ultrasound scan
CT scan
Magnetic resonance cholangio-pancreatography (MRCP)
Endoscopic ultrasound
Option for patients who are not suitable for ERCP or where ERCP has failed
Percutaneous transhepatic cholangiogram (PTC) involves radiologically guided insertion of a drain through the skin and liver, into the bile ducts.
The drain relieves the immediate obstruction. A stent can be inserted to give longer-lasting relief of obstruction.
What are most gallstones made of
Cholesterol
Definition of cholelithaisis
gallstone(s) are present
Definition of choledocholithiasis
gallstone(s) in the bile duct
Definition of biliary colic
intermittent right upper quadrant pain caused by gallstones irritating bile ducts
Risk factors for gallstones
The risk factors for gallstones can be remembered with the four F’s mnemonic:
F – Fat
F – Fair
F – Female
F – Forty
Presentation of biliary colic
Severe, colicky epigastric or right upper quadrant pain
Often triggered by meals (particularly high fat meals)
Lasting between 30 minutes and 8 hours
May be associated with nausea and vomiting
Why is it important to avoid fatty foods in gallstones
Fat entering the digestive system causes cholecystokinin (CCK) secretion from the duodenum.
CCK triggers contraction of the gallbladder, which leads to biliary colic.
Patients with gallstones and biliary colic are advised to avoid fatty foods to prevent CCK release and gallbladder contraction.
Key complications of ERCP
Excessive bleeding
Cholangitis
Pancreatitis
Mx of asymptomatic gallstones
Asymptomatic patients with gallstones may be treated conservatively, with no intervention required.
Incision in open cholecystectomy
right subcostal “Kocher” incision
What is post-cholecystectomy syndrome
involves a group of non-specific symptoms that can occur after a cholecystectomy.
They may be attributed to changes in the bile flow after removal of the gallbladder.
Symptoms often improve with time
Symptoms of post-cholecystectomy syndrome
Diarrhoea Indigestion Epigastric or right upper quadrant pain and discomfort Nausea Intolerance of fatty foods Flatulence
What can ischaemia to the lower gi tract result in
acute mesenteric ischaemia
chronic mesenteric ischaemia
ischaemic colitis
Predisposing factors to bowel ischaemia
Age AF(mesenteric ischaemia) Endocarditis,malginancy CVS - HTN, smoking, diabetes Cocaine - ischaemic colitis
Common features of bowel ischaemia
Abdo pain Rectal bleeding Diarrhea Fever Bloods may show WBC raised with lactic acidosis
What is acute mesenteric ischaemia typically caused by
Typically caused by an embolism resulting in occlusion of an artery which supplies the small bowel, for example the superior mesenteric artery
Characteristic feature of acute mesenteric ischaemia
The abdominal pain is typically severe, of sudden onset and out-of-keeping with physical exam findings.
Mx of acute mesenteric ischaemia
Urgent surgery usually
Characteristic feature of chronic mesenteric ischaemia
Colickly, intermittent abdominal pain occurs
Where is ischaemic colitis more likely to occur
‘watershed’ areas such as the splenic flexure that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries.
What is ischaemic colitis
Ischaemic colitis describes an acute but transient compromise in the blood flow to the large bowel.
This may lead to inflammation, ulceration and haemorrhage
IX in ischaemiac colitis
‘thumbprinting’ may be seen on abdominal x-ray due to mucosal oedema/haemorrhage
Mx of ischaemic colitis
Usually supportive
- surgery may be required in a minority of cases if conservative measures fail. Indications would include generalised peritonitis, perforation or ongoing haemorrhage
Bowels typically affected in mesenteric ischaemia vs ischaemic colitis
Mesenteric - small bowel
Ischamic colitis - large bowel
LFTs in acute cholecystitis and what might deranged LFTs indicate
Typically normal
Deranged LFTs may indicate Mirizzi syndrome - a gallstone impacted in the distal cystic duct causing extrinsic compression of the common bile duct
What can be used if diagnosis is uncertain in acute cholecystitis after ultrasound
cholescintigraphy (HIDA scan) may be used
technetium-labelled HIDA (hepatobiliary iminodiacetic acid) is injected IV and taken up selectively by hepatocytes and excreted into bile
in acute cholecystitis there is cystic duct obstruction (secondary to odema associated with inflammation or an obstructing stone) and hence the gallbladder will not be visualised
Factors which increase risk of gallstone formation
Increasing age Family history. Sudden weight loss Loss of bile salts - eg, ileal resection, terminal ileitis(from crohn's) Diabetes Oral contraception
Symptoms of IBS
Diarrhoea Constipation Fluctuating bowel habit Abdominal pain Bloating Worse after eating Improved by opening bowels
Diagnosis of IBS
Normal FBC, ESR and CRP blood tests
Faecal calprotectin negative to exclude inflammatory bowel disease
Negative coeliac disease serology (anti-TTG antibodies)
Cancer is not suspected or excluded if suspected
General advice for IBS
Adequate fluid intake
Regular small meals
Reduced processed foods
Limit caffeine and alcohol
Low “FODMAP” diet (ideally with dietician guidance)
Trial of probiotic supplements for 4 weeks
1st line medication for iBS
Loperamide for diarrhoea
Laxatives for constipation. Avoid lactulose as it can cause bloating. Linaclotide is a specialist laxative for patients with IBS not responding to first-line laxatives
Antispasmodics for cramps e.g. hyoscine butylbromide (Buscopan)
2nd line medication for IBS
Tricyclic antidepressants (i.e. amitriptyline 5-10mg at night)
3rd line medication for IBS
SSRIs antidepressants
Genes associated with coeliac disease
HLA-DQ2
HLA-DQ8
Signs and symptoms of coeliac disease
Chronic/intermittent diarrhoea Nausea/vomiting Fatigue Recurrent abdominal pain Sudden/unexpected weight loss IDA
Complications of coeliac disease
Anaemia Hyposplenism Osteoporosis Lactose intolerance Subfertility
Cancer associated with coeliac disease
enteropathy-associated T-cell lymphoma of small intestine
Mx of rectal prolapse
Gentle digital pressure(sedation and local perianal anaesthesia)
Treat precipitants(constipation/diarrea)
Surgical referral for irreducible prolapse
Subcutaneous circumanal rubber ring may be fitted in elderly where surgery is not appropriate
