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Gen surg > Acute abdomen > Flashcards

Acute abdomen Flashcards

1
Q

What is biliary colic

A

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.

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2
Q

What is acute cholecystitis

A

Inflammation of the gallbladder. It usually happens when a gallstone blocks the cystic duct.

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3
Q

Symptoms of acute cholecystitis

A

Classical symptoms and signs are similar to biliary colic, but in addition other classical features are fever and tenderness in the right upper quadrant.

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4
Q

Features of obstructive jaundice

A

Yellowish discolouration of the skin, dark urine and pale stools.

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5
Q

Features of cholangitis

A

Typical features, referred to as Charcot’s triad, are diagnostic: fever (often with rigors), jaundice, and upper quadrant abdominal pain.

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6
Q

What is cholangitis

A

Infection and inflammation of the biliary tree

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7
Q

Features of gallstone pancreatitis

A

Constant epigastric pain radiating through to the back, and profuse vomiting.

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8
Q

IX for suspected gallstone disease

A

Abdominal ultrasound
LFTs
MRCP if ultrasound has not detected common bile duct stones

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9
Q

Management of asymptomatic gallstones found in a normal gallbladder and normal biliary tree

A

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.

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10
Q

When might prophylactic cholecystectomy be considered in asymptomatic gallstones found in a normal gallbladder and normal biliary tree

A

People with a partially calcified ‘porcelain’ gallbladder.

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11
Q

Management of asymptomatic gallstones found in the CBD

A

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.

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12
Q

Management of symptomatic gallstones

A

Emergency admission if systemically unwell

Surgical referral

Consider laparoscopic cholecystectomy

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13
Q

When is percutaneous cholecystectomy advised for gallstones

A

To manage gallbladder empyema when surgery is contraindicated at presentation and conservative management is unsuccessful

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14
Q

Advice regarding diet to help prevent biliary pain

A

low-fat diet

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15
Q

advice for people with symptomatic gallstones

A

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.

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16
Q

What sign is suggestive of acute cholecystitis

A

Murphy’s sign

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17
Q

What is Murphy’s sign

A

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

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18
Q

What might an abdominal ultrasound scan show in acute cholecystitis

A

Thickened gallbladder wall
Stones or sludge in gallbladder
Fluid around the gallbladder

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19
Q

Mx of acute cholecystitis

A

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

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20
Q

Complications of acute cholecystitis

A

Sepsis
Gallbladder empyema
Gangrenous gallbladder
Perforation

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21
Q

What is gallbladder empyema

A

Gallbladder empyema refers to infected tissue and pus collecting in the gallbladder

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22
Q

Mx of gallbladder empyema

A

Cholecystectomy (to remove the gallbladder)

Cholecystostomy (inserting a drain into the gallbladder to allow the infected contents to drain)

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23
Q

Two main causes of ascending cholangitis

A

Obstruction in the bile ducts stopping bile flow (i.e. gallstones in the common bile duct)

Infection introduced during an ERCP procedure

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24
Q

Most common organisms in ascending cholangitis

A

Escherichia coli
Klebsiella species
Enterococcus species

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25
Q

Acute mx of ascending cholangitis

A 
Nil by mouth
IV fluids
Blood cultures
IV antibiotics (as per local guidelines)
Involvement of seniors and potentially HDU or ICU
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26
Q

Diagnosis of cholangitis

A

Abdominal ultrasound scan
CT scan
Magnetic resonance cholangio-pancreatography (MRCP)
Endoscopic ultrasound

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27
Q

Option for patients who are not suitable for ERCP or where ERCP has failed

A

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.

28
Q

What are most gallstones made of

A

Cholesterol

29
Q

Definition of cholelithaisis

A

gallstone(s) are present

30
Q

Definition of choledocholithiasis

A

gallstone(s) in the bile duct

31
Q

Definition of biliary colic

A

intermittent right upper quadrant pain caused by gallstones irritating bile ducts

32
Q

Risk factors for gallstones

A

The risk factors for gallstones can be remembered with the four F’s mnemonic:

F – Fat
F – Fair
F – Female
F – Forty

33
Q

Presentation of biliary colic

A

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

34
Q

Why is it important to avoid fatty foods in gallstones

A

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.

35
Q

Key complications of ERCP

A

Excessive bleeding
Cholangitis
Pancreatitis

36
Q

Mx of asymptomatic gallstones

A

Asymptomatic patients with gallstones may be treated conservatively, with no intervention required.

37
Q

Incision in open cholecystectomy

A

right subcostal “Kocher” incision

38
Q

What is post-cholecystectomy syndrome

A

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

39
Q

Symptoms of post-cholecystectomy syndrome

A 
Diarrhoea
Indigestion
Epigastric or right upper quadrant pain and discomfort
Nausea
Intolerance of fatty foods
Flatulence
40
Q

What can ischaemia to the lower gi tract result in

A

acute mesenteric ischaemia

chronic mesenteric ischaemia

ischaemic colitis

41
Q

Predisposing factors to bowel ischaemia

A 
Age 
AF(mesenteric ischaemia) 
Endocarditis,malginancy 
CVS - HTN, smoking, diabetes 
Cocaine - ischaemic colitis
42
Q

Common features of bowel ischaemia

A 
Abdo pain 
Rectal bleeding 
Diarrhea 
Fever 
Bloods may show WBC raised with lactic acidosis
43
Q

What is acute mesenteric ischaemia typically caused by

A

Typically caused by an embolism resulting in occlusion of an artery which supplies the small bowel, for example the superior mesenteric artery

44
Q

Characteristic feature of acute mesenteric ischaemia

A

The abdominal pain is typically severe, of sudden onset and out-of-keeping with physical exam findings.

45
Q

Mx of acute mesenteric ischaemia

A

Urgent surgery usually

46
Q

Characteristic feature of chronic mesenteric ischaemia

A

Colickly, intermittent abdominal pain occurs

47
Q

Where is ischaemic colitis more likely to occur

A

‘watershed’ areas such as the splenic flexure that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries.

48
Q

What is ischaemic colitis

A

Ischaemic colitis describes an acute but transient compromise in the blood flow to the large bowel.

This may lead to inflammation, ulceration and haemorrhage

49
Q

IX in ischaemiac colitis

A

‘thumbprinting’ may be seen on abdominal x-ray due to mucosal oedema/haemorrhage

50
Q

Mx of ischaemic colitis

A

Usually supportive

  • surgery may be required in a minority of cases if conservative measures fail. Indications would include generalised peritonitis, perforation or ongoing haemorrhage
51
Q

Bowels typically affected in mesenteric ischaemia vs ischaemic colitis

A

Mesenteric - small bowel

Ischamic colitis - large bowel

52
Q

LFTs in acute cholecystitis and what might deranged LFTs indicate

A

Typically normal

Deranged LFTs may indicate Mirizzi syndrome - a gallstone impacted in the distal cystic duct causing extrinsic compression of the common bile duct

53
Q

What can be used if diagnosis is uncertain in acute cholecystitis after ultrasound

A

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

54
Q

Factors which increase risk of gallstone formation

A 
Increasing age
Family history.
Sudden weight loss
Loss of bile salts - eg, ileal resection, terminal ileitis(from crohn's) 
Diabetes 
Oral contraception
55
Q

Symptoms of IBS

A 
Diarrhoea
Constipation
Fluctuating bowel habit
Abdominal pain
Bloating
Worse after eating
Improved by opening bowels
56
Q

Diagnosis of IBS

A

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

57
Q

General advice for IBS

A

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

58
Q

1st line medication for iBS

A

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)

59
Q

2nd line medication for IBS

A

Tricyclic antidepressants (i.e. amitriptyline 5-10mg at night)

60
Q

3rd line medication for IBS

A

SSRIs antidepressants

61
Q

Genes associated with coeliac disease

A

HLA-DQ2

HLA-DQ8

62
Q

Signs and symptoms of coeliac disease

A 
Chronic/intermittent diarrhoea 
Nausea/vomiting 
Fatigue 
Recurrent abdominal pain 
Sudden/unexpected weight loss 
IDA
63
Q

Complications of coeliac disease

A 
Anaemia 
Hyposplenism 
Osteoporosis 
Lactose intolerance 
Subfertility
64
Q

Cancer associated with coeliac disease

A

enteropathy-associated T-cell lymphoma of small intestine

65
Q

Mx of rectal prolapse

A

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

Gen surg (24 decks)

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