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MBBS 3: Surgery > Acute Abdomen > Flashcards

Acute Abdomen Flashcards

1
Q

What is an acute abdomen?

A

The acute abdomen implies presentation of a patient with a history of undiagnosed abdominal pain lasting less than one week

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2
Q

Causes of acute abdomen pain?

A
  1. Non specific abdominal pain
  2. Acute choleycystitis
  3. Renal colic
  4. Perforation
  5. Acute diverticular disease
  6. Acute appendicitis
  7. Small bowel obstruction
  8. Gynaecological
  9. Acute pancreatitis
  10. Others
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3
Q

What to take in history of acute abdomen?

A
  1. Pain
  2. Associated symptoms
  3. Previous history
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4
Q

Physical examination?

A
  1. General Examination
    - mood
    - Nutrition state
    - vital signs
  2. Abdominal Examination
    - inspection (look)
    - auscultation (listen)
    - palpation (feel)
    Note: don’t forget the hernia orifices
  3. DRE
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5
Q

Investigations?

A
  1. FBC (WBC↑ in peritonitis)
  2. ECXR
  3. AXR
  4. USS
  5. Sigmoidoscopy
  6. CT
  7. MRI
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6
Q

What is peritonitis?

A

Inflammation of the peritoneum, with exudations of serum, fibrin, cells, and pus
- Usually accompanied by abdominal pain and tenderness, constipation, vomiting, and moderate fever

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7
Q

Causes of peritonitis?

A
  1. Appendicitis (70%)
  2. Postoperative
    - anastomotic leakage (80%)
  3. Stomach & Duodenum
    - ulcer perforation
  4. Jejunum & Ileum
    - strangulated hernia, adhesions, thypoid
  5. Caecum & Rectum
    - perforation/obstruction
    - sigmoid volvulus
  6. Gallbladder & Pancreas
    - perforated cholecystitis
    - necrotizing pancreatitis
  7. Pelvis
    - pelvic inflammatory disease, CS
  8. Post traumatic
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8
Q

Biological causes of peritonitis?

A
  1. Special forms
    - TB,
    - syphillis,
    - gonorrhoea
    - chlamydial
    - mycotic
  2. Parasitic
    - echonococus,
    - ascaris
  3. Iatrogenic
    - talcum,cellulose,other foreign bodies
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9
Q

What is primary peritonitis?

A

acute peritonitis where an infection arises from within the peritoneum

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10
Q

Epidemiology of primary peritonitis?

A
  • well recognized entity in children
  • less common in adults
  • more often seen in the female (if no known risk factors)
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11
Q

Route of infection of peritonitis?

A
  1. ascending from the female genital tract
  2. transdiaphragmatic lymphatic spread
  3. translocation of bacteria from GIT
  4. spread from the UTI
  5. haematogenous/lymphogenous
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12
Q

5 risk factors for primary peritonities?

A
  1. apparently otherwise healthy individuals
  2. cirrhosis with ascites
  3. nephrotic syndrome
  4. immunocompromised patients
  5. in association with Fitz-Hugh-Curtis syndrome (gonorrhoea/chlamydiae: perihepatitis)
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13
Q

Treatment of peritonitis?

A
  1. resuscitation before any surgery
    - IVI (NS/RL)
    - NGT
    - urine catheter
    - laboratory
    - Abx
  2. surgery
    - treat the cause of peritonitis
    - wash out
    - drainage of abdomen
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13
Q

What is acute appendicities?

A

inflammation of the appendix
SURGICAL EMERGENCY!
The most common cause of emergency abdominal surgery in childhood

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14
Q

Clinical findings of acute appendicitis?

A
  1. Low-grade fever
  2. periumbilical abdominal pain, which then localizes to the right lower quadrant (McBurney’s Point)
  3. signs of peritoneal irritation
  4. Anorexia
  5. Vomiting
  6. sometimes constipation or diarrhea
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15
Q

How to diagnose acute appendicitis using an abdominal film?

A

look for an appendicolith
- precipitation of mucous, rich in calcium and phosphate onto inspissated feces or other matter

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16
Q

What is acute pancreatitis?

A

rapid onset of inflammation of the pancreas.

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17
Q

Epidemiology of pancreatitis?

A
  • annual incidence in the U.S. is 18/100,000
  • Prevalence in the US is 80,000 cases/ yr
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18
Q

Common causes of pancreatitis?

A

I GET SMASHED
I - idiopathic
G - gallstone pancreatitis
E - ethanol (alcohol)
T - trauma
S - steroids
M – mumps: paramayxovirus, EBV, CMV
A - autoimmune diseases
S - scorpion sting / snake bite
H - hypercalcemia, hyperlipidemia, hypetriglyceridemia, hypothermia
E -ERCP (Endoscopic Retrograde Cholangio-Pancreatography: a form of endoscopy)
D – drugs (steroids & sulfonamides, azathioprine, NSAIDS, diuretics)

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19
Q

Pathogenesis of pancreatitis?

A

Trypsinogen → active trypsin.
- responsible for auto-digestion of the pancreas
- causes the pain and complications of pancreatitis

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20
Q

Investigations used to diagnose acute pancreatitis?

A

FBC,RFT,LFT
Serum calcium
Serum amylase and lipase
Arterial blood gases
ECXR
AXR
- “sentinel loop” dilated duodenum sign
- gallstones : radioopaque in 10%
CT abdomen

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21
Q

Treatment for acute pancreatitis?

A

Supportive for shock - IVF.
Pain relief
surgery

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22
Q

Indications for surgery for acute pancreatitis?

A
  1. infected pancreatic necrosis
  2. diagnostic uncertainty
  3. complications.
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23
Q

Systemic complications of acute pancreatitis?

A

ARDS
MODS
DIC
Hypocalcemia
Hyperglycemia
IDDM

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24
Q

Locoregional complications of acute pancreatitis?

A

pancreatic pseudocyst
phlegmon / abscess formation
splenic artery pseudoaneurysms
hemorrhage from erosions into splenic artery and vein
thrombosis of the splenic vein, superior mesenteric vein and portal veins
duodenal obstruction
common bile duct obstruction
, progression to chronic pancreatitis

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25
Q

What is cholecystitis?

A

inflammation of the gallbladder that occurs due to obstruction of the cystic duct
- 90% cases involve stones in the cystic duct (ie, calculous cholecystitis)
- 10% representing acalculous cholecystitis
- bile cultures are positive for bacteria in 50 - 75% of cases

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26
Q

Classification of cholecystitis?

A
  1. calculous - involve stones
  2. acalculous - does not involve stones
27
Q

Risk factors for cholecystitis?

A
  1. increasing age
  2. female sex
  3. certain ethnic groups
  4. obesity or rapid weight loss
  5. drugs
  6. pregnancy.
28
Q

Acalculous cholecystitis is associated with?

A
  1. biliary stasis
  2. debilitation
  3. major surgery
  4. severe trauma
  5. sepsis
  6. long-term total parenteral nutrition (TPN)
  7. prolonged fasting.
29
Q

Conditions associated with acalculous cholecystitis?

A

sickle cell disease; Salmonella infections; diabetes mellitus; cytomegalovirus, cryptosporidiosis, microsporidiosis infections in patients with AIDS.

30
Q

Epidemiology of cholecystitis?

A

10-20% of Americans have gallstones
-⅓ of these people develop acute cholecystitis.
-Cholecystectomy: ≈ 500,000 operations annually.
less common in the sub-Saharan Africa and Asia.

31
Q

Clinical features of cholecystitis: history?

A
  1. Epigastric pain,
  2. Signs of peritoneal irritation
  3. the pain may radiate to the right shoulder.
  4. N and v, fever
32
Q

Clinical features of cholecystitis: physical examination?

A
  1. fever, tachycardia, tenderness in the RUQ or epigastric region, often with guarding or rebound.
    A palpable gallbladder or fullness of the RUQ: 30-40% of cases.
    Jaundice : 15% of patients.
    Murphy sign.
33
Q

Investigations to diagnose cholecystitis?

A
34
Q

Conservative treatment of cholecystitis?

A

bowel rest
-intravenous hydration
-analgesia
-intravenous antibiotics

35
Q

Surgical treatment of cholecystitis?

A

Laparoscopic cholecystectomy

36
Q

Complications of cholecystitis?

A
  1. Bacterial proliferation - empyema of the organ.
  2. gallstone ileus
  3. Emphysematous cholecystitis
  4. Sepsis
  5. Pancreatitis
  6. Perforation occurs in up to 15% of patients
37
Q

What is peptic ulcer disease?

A
38
Q

Infectious causes of peptic ulcer disease?

A

H. pylori (80-90%)

39
Q

What medications cause PUD?

A

NSAIDS
Corticosteroids

40
Q

Stress causes of PUD?

A
  1. Head trauma (Cushing’s Ulcer)
  2. Burns (Curling’s Ulcer)
41
Q

Systemic illnesses that cause PUD?

A
  1. Diabetes mellitus
  2. Sickle cell disease
  3. Cystic fibrosis
  4. Crohn’s Disease
42
Q

Hyperacidic conditions that cause PUD?

A
  1. Zollinger-Ellison Syndrome
  2. G-Cell Hyperplasia
  3. Mastocytosis
43
Q

Risk factors for perforation in PUD?

A
  1. NSAIDs
  2. Alcohol abuse
  3. Age >60yrs
  4. Smoking
  5. Post-op stress
44
Q

Clinical features of PUD?

A
  1. Pain
    - Sudden onset
    - Epigastric
    - Radiation to whole abdomen
    - Continuous
    - Aggravated by mvt
  2. Vomiting
45
Q

What is seen in physical examination of PUD?

A

Not in shock / toxic
Generalised guarding (board-like rigidity)
Tenderness
Loss of liver dullness

46
Q

Diagnosis of PUD?

A
  1. Clinical
  2. Plain radiograph
    - Erect abdominal
    - CXR
  3. X-ray with Contrast
    - Gastrografin meal
47
Q

Initial management of PUD?

A
  1. NG tube
  2. Analgesia
  3. Blood samples
  4. I.V. fluids – crystalloids
48
Q

Conservative management of PUD?

A

Nasogastric aspiration
I.V. fluids
Antisecretory drugs
Antibiotics

49
Q

Operative management of PUD?

A
  1. Lap. + Peritoneal toilet
  2. Deodenal Ulcer
    - Simple closure
    - Gastrojejunostomy
  3. Gastric Ulcer
    - Gastrectomy
50
Q

Complications of PUD?

A

Peritonitis
Abscess formation
Shock
Atelectasis

51
Q

What is pyloric stenosis?

A
52
Q

Epidemiology of pyloric stenosis?

A

3/1000 births
M:F = 4:1 (1st born white)
Age: 1-18 wks (3wks)

53
Q

Etiology of pyloric stenosis?

A

Unknown
- multifactorial (? Genetic)

54
Q

Pathophysiology of pyloric stenosis?

A

> Hypertrophy+ hyperplasia of circular muscle
Gastric antrum narrowing
Outflow obstruction

55
Q

History of pyloric stenosis?

A
  1. Vomiting
  2. Usually don’t have diarrhoea
  3. Often hungry afterwards
  4. Weight loss or inadequate weight gain
56
Q

Examination of pyloric stenosis?

A
  1. Dehydration
  2. Jaundice (1-2%)
  3. gastric peristalsis
  4. pyloric mass
    - “olive”
  5. Signs may be more obvious following a feed
57
Q

Investigations of pyloric stenosis?

A
  1. Clinical diagnosis
  2. Bloods: FBC, U&Es, glucose, biliubin
  3. USS abdomen
  4. Barium meal
58
Q

Management of pyloric stenosis?

A
  1. Correct hypochloraemic alkalosis
  2. NGT suction
  3. Sx – Rammstedt’s pyloromyotomy
  4. Post-op: Rapid recovery
59
Q

Complications of pyloric stenosis?

A
  1. Undetected mucosal perforation
  2. Bleeding
  3. Post-op
    - Pyrexia
    - Infections
  4. Mortality < 0.5%
60
Q

What is intussusception?

A
61
Q

History of intussusception?

A
  1. Abdominal pain
    - Vomiting
  2. Bloody diarrhea
    - “Redcurrant jelly”
  3. Lethargy, distended abdomen, Diarrhea, Fever
62
Q

Examination of intussusception?

A
  1. sausage” mass
  2. PR:
    - Mucoid bloody stool
    - Empty
  3. Signs of obstruction
  4. fever
63
Q

Investigations for intussusception?

A

Bloods: FBC, U&Es, ESR

Plain abd Xray

Barium enema

Abd USS
‘target’ transverse
‘Psuedokidney’ longitudinal

64
Q

Management of intussusception?

A
  1. Resuscitate
  2. Hydrostatic reduction (contrast vs air)
  3. laparoscopy
  4. Laparotomy
  5. Appendectomy
65
Q

Complications of intussusception?

A
  1. intestinal wall ischaemia
  2. Perforation
  3. Peritonitis

MBBS 3: Surgery (42 decks)

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