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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
What is obturator sign?
pain in the RIF on passive internal rotation of a flexed right hip Indicates appendicitis
26
When is peak incidence of appendicitis?
10-20
27
Where is McBurney’s point?
a specific area one third of the distance from the anterior superior iliac spine (ASIS) to the umbilicus
28
If you have rebound tenderness and percussion tenderness in appendicitis, what might this suggest?
Peritonitis = ruptured appendix
29
Whats the function of the appendicitis?
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
What are the risk factors for appendicitis?
FHx - associated with nearly a 3 fold increased risk Summer months Caucasian Age 10-30 Males
31
What does it suggest if there is sudden relief of pain from suspected appendicitis?
Appendiceal perforation
32
How do you investigate appendicitis?
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
What would the FBC show for appendicitis?
Neutrophil-predominant leukocytosis in 80-90% of people
34
What are the main key differential diagnoses of appendicitis?
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
How do you exclude ectopic pregnancy?
Serum of urine hCG
36
Why can meckels diverticulum become painful?
It can become inflamed, rupture, cause a volvulus or intussusception
37
What is mesenteric adenitis?
Inflamed abdominal lymph nodes
38
What are the symptoms of mesenteric adenitis?
RIF abdominal pain. Acute Fever Nausea and or vomiting Diarrhoea
39
What can cause mesenteric adenitis?
Usually the cause is a viral infection! Infections - gastroenteritis, HIV-related infections, TB Inflammatory conditions - appendicitis, cancers, diverticulitis, IBD, pancreatitis
40
What is the Alvarado score?
a clinical scoring system used to predict the likelihood of a diagnosis of appendicitis
41
Outline the Alvarado score?
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
How can appendicitis be managed conservatively?
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
What is an appendix mass?
when the omentum surrounds and sticks to the inflamed appendix, forming a mass in the right iliac fossa.
44
How is an appendix mass treated?
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
How is appendicitis definitively managed?
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
What are the complications of appendicitis?
Perforation (mostly in children with delayed presentation) Surgical site infection Appendix mass Pelvic abscess
47
What are the symptoms of ruptured ectopic pregnancy?
Sharp, sudden and intense pain in iliac fossa/back/shoulder tip Syncope Nausea
48
What is acute salpingitis?
Acute inflammation of the fallopian tube
49
What typically causes salpingitis?
Neisseria gonorrhoeae and Chlamydia trachomatis infections (ascend from vagina)
50
What are the symptoms of acute salpingitis?
Bilateral low abdominal pain Fever Vaginal discharge
51
How do you investigate peritonitis?
Chest x-ray Serum amylase for acute pancreatitis Imaging with USS and/or CT
52
How is peritonitis managed?
After adequate resuscitation and re-establishment of good urinary output… Surgery - peritoneal lavage of abdominal cavity, specific treatment of underlying condition
53
What are the complications of peritonitis?
Toxaemia and septicaemia -> multi organ failure Local abscess formation - commonly pelvic or sub phrenic
54
What are the typical characteristics of biliary colic?
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
What are the typical characteristics of acute cholecystitis?
Constant RUQ/epigastric pain Fever and positive inflammatory markers Positive murphy’s sign
56
What is murphys sign?
Arrest of inspiration on palpating of the RUQ
57
What are the typical characteristics of acute cholangitis?
Charcots triad - pain in RUQ, fever and jaundice
58
What are the typical characteristics of acute pancreatitis?
Upper abdominal pain is very severe that radiates to back Tenderness on palpating Fever Tachycardia Nausea and vomiting
59
What are the typical characteristics of acute diverticulitis?
LLQ colicky pain Diarrhoea that is sometimes bloody Fever, raised inflammatory markers and white cells
60
What are the typical characteristics of intestinal obstruction?
Vomiting Absolute constipation Tinkling bowel sounds
61
What are the typical characteristics of mesenteric ischaemia?
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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