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GI AND SURGERY > ACUTE ABDOMEN > Flashcards

ACUTE ABDOMEN Flashcards

1
Q

What can cause acute generalised abdominal pain?

A

Peritonitis
Ruptured AAA
Intestinal obstruction
Ischaemic colitis

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2
Q

What can cause acute RUQ abdominal pain?

A

Biliary colic
Acute cholecystitis
Acute cholangitis
Acute hepatitis

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3
Q

What can cause acute epigastric abdominal pain?

A

Acute gastritis
Peptic ulcer disease
Pancreatitis
Ruptured AAA
Gastric perf
Acute pancreatitis

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4
Q

What can cause acute umbilical abdominal pain?

A

Ruptured AAA
Intestinal obstruction
Ischaemic colitis
Early stages of appendicitis

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5
Q

What can cause acute RIF abdominal pain?

A

Acute appendicitis
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion
Meckels diverticulitis

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6
Q

What can cause acute LIF abdominal pain?

A

Diverticulitis
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion

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7
Q

What can cause acute suprapubic abdominal pain?

A

Lower UTI
Acute urinary retention
PID
Prostatitis

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8
Q

What can cause acute loin-to-groin pain?

A

Renal colic
Ruptured AAA
Pyelonephritis

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9
Q

What can cause acute testicular pain?

A

Testicular torsion
Epididymo-orchitis
Epididymitis
Testicular cancer
Trauma e.g. testicular rupture

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10
Q

What is peritonitis?

A

inflammation of the peritoneum, the lining of the abdomen

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11
Q

What are the signs of peritonitis?

A

Guarding
Rigidity
Rebound tenderness
Coughing test
Percussion tenderness
Pain 10/10 worse with movement or touch
Fever
Tachycardia
Distended abdomen

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12
Q

Whats the difference between localised and generalised peritonitis?

A

Localised peritonitis is caused by underlying organ inflammation, for example, appendicitis or cholecystitis.

Generalised peritonitis may be caused by perforation of an abdominal organ releasing the contents into the peritoneal cavity and causing generalised inflammation of the peritoneum.

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13
Q

What GI related diseases are likely to result in back pain?

A

Pancreatitis
Ruptured AAA
Renal tract disease

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14
Q

What does raised serum amylase suggest?

A

If raised more than 5x normal then acute pancreatitis likely
If raised less than this then it can be any cause of acute abdomen

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15
Q

What does air under the diaphragm on x-ray suggest?

A

Bowel perforation

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16
Q

Outline the epidemiology of appendicitis?

A

6% lifetime incidence
50,000 appendectomies a year
1.4x more common in men
0.1% mortality in the UK

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17
Q

Where is the appendix found?

A

At the posteromedial aspect of the caecum, at the convergence of the taeniae coli
60% are retrocaecal and 30% are pelvic (remaining are pre-ileal, post-ileal, subcaecal or paracaecal)

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18
Q

Outline the pathophysiology of appendicitis?

A

Appendiceal obstruction may result from a variety of causes: faecoliths are most common, lymphoid hyperplasia during infection, impacted stool, foreign body, fibrous stricture, carcinoid tumours

Obstruction of the appendiceal lumen = stasis and resultant bacterial overgrowth = increase in intraluminal pressure = venous and lymphatic congestion. As the pressure rises further, the arterial supply to the appendix becomes compromised = gangrene, perforation + generalised peritonitis.

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19
Q

Why is appendicitis uncommon at the extremes of age?

A

The young have a relatively wide appendiceal lumen, whilst in the elderly, it is almost entirely obliterated.

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20
Q

Outline how the risk of perforation of appendix increases overtime with appendicitis?

A

20% at 24 hours
35% at 72 hours

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21
Q

Outline the clinical features of appendicitis?

A

Colicky, peri-umbilical pain which migrates to the RIF and becomes constant over 24-48 hours. Often worse with movement (children often can’t hop on right leg)
Nausea/vomits once or twice but isnt marked or persistent
anorexia
Constipation
Diarrhoea may be seen but it mild when present

RIF tenderness
Percussion tenderness
Localised guarding
Tachycardia
Mild pyrexia

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22
Q

How may appendicitis present in pregnant woman? Why is this important to know?

A

Pregnant women may have a displaced appendix resulting in flank pain.
A high degree of clinical suspicion is required as delayed treatment results in high morbidity and mortality in both the mother and foetus.

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23
Q

What is Rovsing sign?

A

pain in the RIF on palpation of the LIF
Indicates appendicitis

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24
Q

What is Psoas sign?

A

the patient lies on their left side with knees flexed, positive when there is pain in the RIF on passive extension of the right hip
Indicates appendicitis

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25
Q

What is obturator sign?

A

pain in the RIF on passive internal rotation of a flexed right hip
Indicates appendicitis

26
Q

When is peak incidence of appendicitis?

A

10-20

27
Q

Where is McBurney’s point?

A

a specific area one third of the distance from the anterior superior iliac spine (ASIS) to the umbilicus

28
Q

If you have rebound tenderness and percussion tenderness in appendicitis, what might this suggest?

A

Peritonitis = ruptured appendix

29
Q

Whats the function of the appendicitis?

A

Its precise function is not fully understood. It has a high concentration of GALT, and may act as a reservoir for normal gut flora, allowing the large bowel microbiome to recover after enteric infections

30
Q

What are the risk factors for appendicitis?

A

FHx - associated with nearly a 3 fold increased risk
Summer months
Caucasian
Age 10-30
Males

31
Q

What does it suggest if there is sudden relief of pain from suspected appendicitis?

A

Appendiceal perforation

32
Q

How do you investigate appendicitis?

A

Examine pt - may consider a groin/scrotal/pelvic/rectal examination
FBC, U&E, amylase, group and save, clotting screen, CRP, urine dipstick to rule out UTI, pregnancy test
Abdominal UCC or pelvic UCC
CT

33
Q

What would the FBC show for appendicitis?

A

Neutrophil-predominant leukocytosis in 80-90% of people

34
Q

What are the main key differential diagnoses of appendicitis?

A

Ectopic pregnancy
Ovarian cyst rupture
PID
Ureteric stones
UTI
Pyelonephritis
IBD
Meckels diverticulum
Diverticular disease
Testicular torsion
Epididymo-orchitis
Children - Mesenteric adenitis, intussuseption, constipation, gastroenteritis

35
Q

How do you exclude ectopic pregnancy?

A

Serum of urine hCG

36
Q

Why can meckels diverticulum become painful?

A

It can become inflamed, rupture, cause a volvulus or intussusception

37
Q

What is mesenteric adenitis?

A

Inflamed abdominal lymph nodes

38
Q

What are the symptoms of mesenteric adenitis?

A

RIF abdominal pain. Acute
Fever
Nausea and or vomiting
Diarrhoea

39
Q

What can cause mesenteric adenitis?

A

Usually the cause is a viral infection!
Infections - gastroenteritis, HIV-related infections, TB
Inflammatory conditions - appendicitis, cancers, diverticulitis, IBD, pancreatitis

40
Q

What is the Alvarado score?

A

a clinical scoring system used to predict the likelihood of a diagnosis of appendicitis

41
Q

Outline the Alvarado score?

A

Migratory pain
Anorexia
Nausea/vomiting
Tenderness in RIF (2 points)
Rebound tenderness
Fever >37.3
Leukocytosis (2 points)
Neutrophil shift to left

1-4 unlikely
5-6 possible
>7 likely

42
Q

How can appendicitis be managed conservatively?

A

There is some debate about this…
uncomplicated acute appendicitis may be treated initially with antibiotics (co-amoxiclav is commonly used in the absence of a penicillin allergy)

Note - up to 30% will require surgery within 1 year and beyond this there is likely continued risk of re-developing appendicitis - therefore appendiceal my should remain the standard treatment

43
Q

What is an appendix mass?

A

when the omentum surrounds and sticks to the inflamed appendix, forming a mass in the right iliac fossa.

44
Q

How is an appendix mass treated?

A

Treated conservatively with IV fluids and antibiotics
The pain will subside over a few days and the mass will disappear over a few weeks
Appendicectomy is recommended 6-8 weeks later to prevent further acute episodes

45
Q

How is appendicitis definitively managed?

A

Laparoscopic appendicectomy (with conversion to open surgery when necessary)
Pre-operative prophylactic IV antibiotic therapy - co-amoxiclav

The appendix should routinely be sent to histopathology to look for malignancy (found in 1%, typically carcinoid, adenocarcinoma, or mucinous cystadenoma malignancy).
Also important to check the entirety of the abdomen for other evident pathology, including checking for meckels diverticulum

46
Q

What are the complications of appendicitis?

A

Perforation (mostly in children with delayed presentation)
Surgical site infection
Appendix mass
Pelvic abscess

47
Q

What are the symptoms of ruptured ectopic pregnancy?

A

Sharp, sudden and intense pain in iliac fossa/back/shoulder tip
Syncope
Nausea

48
Q

What is acute salpingitis?

A

Acute inflammation of the fallopian tube

49
Q

What typically causes salpingitis?

A

Neisseria gonorrhoeae and Chlamydia trachomatis infections (ascend from vagina)

50
Q

What are the symptoms of acute salpingitis?

A

Bilateral low abdominal pain
Fever
Vaginal discharge

51
Q

How do you investigate peritonitis?

A

Chest x-ray
Serum amylase for acute pancreatitis
Imaging with USS and/or CT

52
Q

How is peritonitis managed?

A

After adequate resuscitation and re-establishment of good urinary output…
Surgery - peritoneal lavage of abdominal cavity, specific treatment of underlying condition

53
Q

What are the complications of peritonitis?

A

Toxaemia and septicaemia -> multi organ failure
Local abscess formation - commonly pelvic or sub phrenic

54
Q

What are the typical characteristics of biliary colic?

A

RUQ pain provoked by eating a fatty meal
Sudden onset of dull pain that comes and goes and may radiate to the epigastrium/back
Nausea and vomiting
No fever and normal inflammatory markers

55
Q

What are the typical characteristics of acute cholecystitis?

A

Constant RUQ/epigastric pain
Fever and positive inflammatory markers
Positive murphy’s sign

56
Q

What is murphys sign?

A

Arrest of inspiration on palpating of the RUQ

57
Q

What are the typical characteristics of acute cholangitis?

A

Charcots triad - pain in RUQ, fever and jaundice

58
Q

What are the typical characteristics of acute pancreatitis?

A

Upper abdominal pain is very severe that radiates to back
Tenderness on palpating
Fever
Tachycardia
Nausea and vomiting

59
Q

What are the typical characteristics of acute diverticulitis?

A

LLQ colicky pain
Diarrhoea that is sometimes bloody
Fever, raised inflammatory markers and white cells

60
Q

What are the typical characteristics of intestinal obstruction?

A

Vomiting
Absolute constipation
Tinkling bowel sounds

61
Q

What are the typical characteristics of mesenteric ischaemia?

A

Abrupt severe abdo pain out of proportion to clinical findings - diffuse and constant
Fever
Nausea and vomiting
Non-specific tenderness
Metabolic acidosis
History of AF or other CVD

GI AND SURGERY (31 decks)

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