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General Surgery > Acute Abdomen > Flashcards

Acute Abdomen Flashcards

1
Q

What are the differences in presentation between mesenteric ischaemia and ischaemic colitis?

A

Mesenteric ischaemia = sudden onset of severe pain due to total loss of blood supply, caused by thromboembolism. Managed operatively.

Ischaemic colitis = gradual onset of diarrhoea, PR bleeding and pain due to transient loss of blood supply (due to collateralisation). Managed conservatively or operatively.

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2
Q

What is cholecystitis?

A

When a gallstone becomes impacted in Hartmann’s pouch –> inflammation + oedema –> infected.
Increased pressure causes distension + pain

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3
Q

What are the symptoms of cholangitis?

A

Charcot’s triad: jaundice + RUQ pain + fever/ rigors

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4
Q

What is Reynold’s Pentad?

A

Charcot’s triad (jaundice, RUQ pain, fever/ rigors) + confusion + hypotension

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5
Q

What happens when a stone gets stuck in the CBD?

A

Initially, causes biliary colic (pain).
Then, with complete obstruction, causes obstructive jaundice.
Then, with inflammation, causes cholangitis (pain + jaundice + fever/ rigors)

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6
Q

What is the pattern of pain in appendicitis?

A

Initially localised to umbilical region, then migrates to RIF

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7
Q

What are the UNMISSABLE diagnoses of acute abdomen?

A

AI PUPPET:
-AAA
-Ischaemia - mesenteric or MI

-Perforation
-Ulcer
-Pancreatitis
-Pneumonia
-Ectopic
-Torsion - ovarian or testicular)

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8
Q

What are the systems/ diagnoses to consider depending on area of pain in the abdomen?

A

RUQ = HPB system
LUQ = stomach + spleen
Epigastric = pancreas + ulcer
Lower abdomen = bowel, pelvic organs + kidneys
RIF = appendix
LIF = bowel (diverticulitis)

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9
Q

Which diagnoses typically cause RLQ?

A

Appendicitis
Mesenteric adenitis (due to inflammation of lymph nodes)
Meckel’s diverticulitis (congenital outpouching of lower intestine, leftover umbilical cord)

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10
Q

What is Rovsing’s sign?

A

Indicative of appendicitis:
slowly pressing into LLQ and gradually releasing causing pain in RLQ

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11
Q

What is Murphy’s sign?

A

Indicative of cholecystitis:
inhaling whilst applying pressure to RUQ causing pain (hand comes into contact with inflamed gallbladder)

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12
Q

What is McBurney’s point?

A

Indicative of appendicitis:
maximal pain 2/3rd of way from navel to right ASIS

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13
Q

Which scores can be used to quantify likelihood of appendicitis?

A

Alvarado and AIR (on MDCalc)

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14
Q

What is the Psoas test?

A

Indicative of appendicitis for retrocaecal appendix
= actively flexing hip causing pain (as appendix sits on psoas muscle)

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15
Q

What is the Obturator sign/test?

A

Indicative of appendicitis
= flexing hip, passively internally rotating the hip to cause pain

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16
Q

What are the risk factors associated with peptic ulceration?

A

H. Pylori
Smoking, alcohol
NSAID’s + steroids

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17
Q

How is bowel obstruction classified by time?

A

Acute = short-term, in a patient who has not previously had abdominal surgery, therefore less likely to settle with conservative Mx
Sub-acute = short-term, in a patient who HAS previously had abdominal surgery, therefore more likely to settle with conservative Mx as more likely to be incomplete/ due to adhesions
Chronic = long term; typically seen in patients with incompetent ileo-caecal valve

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18
Q

What are the cardinal features of bowel obstruction?

A
  1. Vomiting - as an early sign, indicative of SMALL BO. Worrying if ++ or faeculent
  2. Colicky abdominal pain - upper = small; lower = large
  3. Abdominal distension
  4. Absolute constipation - passing no stool or flatus
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19
Q

What are the causes of bowel obstruction?

A

Commonest for SBO: hernias, adhesions, cancer
Commonest for LBO: neoplasm, volvulus, diverticular disease

Others: intussusception, IBD

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20
Q

What are the potential complications of bowel obstruction?

A

Bowel ischaemia
Bowel perforation –> faecal peritonitis
Strangulation –> necrosis
Dehydration + renal impairment

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21
Q

What is the conservative management in bowel obstruction?

A

‘Drip + suck’ = NGT to decompress + IVI inc. KCl
Analgesia, anti-emetics, VTE prophylaxis
Urinary catheter + fluid balance chart

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22
Q

Where are inguinal and femoral hernias sited?

A

Femoral = below and lateral to pubic tubercle (through femoral canal/ ring)
Inguinal = above and medial to pubic tubercle

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23
Q

What is an incarcerated or strangulated hernia?

A

Incarcerated = becomes trapped in the hernia sac and is irreducible, but still viable
Strangulated = vascular supply becomes compromised

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24
Q

What is an indirect inguinal hernia?

A

The most common inguinal hernia, usually in young males.
When fatty tissue or bowel passes through the deep ring, down the canal, and out the superficial ring. Neck of hernia lateral to inferior epigastric vessels. Usually descends into the scrotum (‘complete’ if it does)

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25
Q

What is a direct inguinal hernia?

A

Usually in older population, who have weaker abdominal walls
When fatty tissue or bowel passes through the weakness in the abdominal wall (Hesselbach’s triangle) to bulge through the superficial ring. Neck of hernia medial to inferior epigastric vessels.

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26
Q

What is a pantaloon inguinal hernia?

A

When a direct and indirect inguinal hernia occur on same side of the groin. Two hernia sacs divided by inferior epigastric vessels, so looks like a pair of pantaloons

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27
Q

What is a Lichtenstein procedure?

A

Open mesh repair of hernias (usually for inguinal)

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28
Q

How are haemorrhoids classified?

A

1st degree = symptomatic
2nd degree = prolapse but returns spontaneously
3rd degree = prolapse requiring manual reduction
4th degree = prolapse that cannot be reduced

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29
Q

What are the management options for haemorrhoids?

A

1st degree = conservative - high-fibre diet, good hydration, bulking agents (ispaghula husk), stool softeners (docusate, senna)
2nd degree = para-surgical - injection sclerotherapy, band ligation, topical cryotherapy
3rd-4th degree = surgical - haemorrhoidectomy, stapled haemorrhoidopexy/ PPH, trans-anal haemorrhoidal de-arterialisation,

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30
Q

What is an anal fissure?

A

A tear or open sore (ulcer) that develops in the lining of the large intestine, near to the anus

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31
Q

What are the symptoms of an anal fissure?

A

Pain
Discharge/ bleeding
Recurrent perianal abscess

32
Q

What are the causes of an anal fissure?

A

Constipation
IBD
Complication during childbirth

33
Q

How are anal fissures managed?

A

Conservative options (to relax the sphincter muscle) = GTN, Nifedipine, Diltiazem, and Botulinim Toxin

Surgical options = lateral internal sphincterotomy or advancement flap

34
Q

What are the symptoms of a peri-anal fistula?

A

PR bleeding/ discharge
Perianal discharge
Perianal abscess

35
Q

What are the causes of a peri-anal fistula?

A

Cryptoglandular infection
Crohn’s disease
Malignancy
Obstetric
Radiation

36
Q

What are the types of peri-anal fistulas?

A

Intersphincteric (between internal and external anal sphincters)
Trans-sphincteric (through both)
Supra-sphincteric
Extra-sphincteric (rectum to skin without involving sphincters)

37
Q

?How is H. Pylori detected

A

Serology
Urea breath test
Faecal antigen test

38
Q

What is the H. Pylori eradication regimen?

A

PPI + two antibacterials

39
Q

Which score is used pre-endoscopy for UGI bleeds?

A

Glasgow-Blatchford score
0 = consider early discharge
< 2 = consider outpatient endoscopy
> 6 = 80% of these patients require endoscopic treatment

40
Q

What is an upper GI bleed?

A

Bleeding from GI system proximal to the ligament of Treitz (between duodenum and jejunum)

41
Q

What are the symptoms of an UGI bleed?

A

Haematemesis
Melaena
Haematochezia
Coffee-ground vomiting
Symptoms of anaemia - fatigue, pallor, dyspnoea, dizziness, palpitations

42
Q

What are the causes of an UGI bleed?

A

Peptic ulcer disease
Peptic inflammation - oesophagitis/ gastritis/ duodenitis
Oesophageal or gastric varices
Portal hypertensive gastropathy
Malignancy
Mallory Weiss tear
Vascular malformation

43
Q

What is a lower GI bleed?

A

GI bleed distal to the ligament of Treitz (jejunum, ileum, colon)

44
Q

What are the causes of a lower GI bleed?

A

Diverticular disease
Haemorrhoids
Mesenteric ischaemia
Colitis
Cancer
Rectal ulcers
Radiation

45
Q

What are diverticulae and where do they most often occur?

A

Herniations of the mucosa and muscularis propria through the colon wall.
Mainly in sigmoid colon

46
Q

Which score is used post-endoscopy for UGI bleeds?

A

Rockall

47
Q

Which transfusions are considered in UGI bleeds?

A

RBC transfusion if Hb < 70
Platelet transfusion is platelets < 50
Prothrombin complex concentrate if actively bleeding and taking warfarin

48
Q

Which medication changes are made if suspecting/ treating UGI bleed?

A
  • Continue aspirin, stop all other antithrombotics
  • If cirrhosis/ suspected variceal bleed, give terlipressin 2mg TDS 5/7 and antibiotics (local protocol)
  • Do not offer PPI or H2 antagonist pre-endoscopy (offer afterwards)
49
Q

When should endoscopy be offered in UGI bleeds?

A

If unstable with severe acute UGI bleed, immediately after resuscitation.
All other patients with UGI bleed should have endoscopy within 24 hours of admission.

50
Q

What is the management post-OGD for different diagnoses?

A

For ulcers or inflammation: H. pylori eradication therapy, PPI + repeat in 6-8 weeks for gastric ulcers to ensure healing/ check not malignant and need biopsy (don’t have to do for duodenal ulcers as less likely to be malignant)

For varices: beta-blocker to reduce portal pressure, sequential banding procedure/ TIPS/ liver transplant

51
Q

What risks come with massive blood transfusions?

A

Lethal triad (high mortality rate) = acidosis, hypothermia + coagulopathy
Fluid overload
Electrolyte abnormalities

52
Q

Which bug causes traveller’s diarrhoea?

A

ETEC (Entero-Toxigenic E. Coli) - this secretes a toxin to drive secretion from the intestinal crypts

53
Q

What are the types of ulcerative colitis?

A

Proctitis = affecting rectum; suppositories can be used
Left colitis = up to the splenic flexure; enemas can be used
Pancolitis = the entire colon; oral medications required

54
Q

What are the symptoms of ulcerative colitis?

A

Diarrhoea and urgency
Blood in stool
Fatigue
Weight loss

55
Q

Which test is used to diagnose IBD?

A

Faecal calprotectin = an inflammatory marker expressed by cells in the gut lining

56
Q

What are the symptoms of Crohn’s disease?

A

Most typical site = terminal ileum - causes post-prandial colicky pain
Altered bowel habit
PR bleeding
Weight loss
Fistula/ abscess (as a transmural disease)

57
Q

What are the extra-intestinal manifestations of IBD?

A
  • Mouth ulcers
  • Erythema nodosum
  • Iritis and uveitis
  • Primary sclerosing cholangitis
  • Peri-anal disease
  • Joint arthropathies
58
Q

What are the risk factors for CRC?

A

Age
Obesity
Physical inactivity
Alcohol consumption
IBD, particularly pancolitis
Family history
Polyposis syndromes - FAP, Lynch syndrome, Juvenile polyposis, Peutz-Jegher syndrome, Gardner syndrome
Diet - low fibre, high red meat consumption

59
Q

What is PJS?

A

Peutz-Jegher Syndrome
= a genetic condition causing intestinal polyps and pigmentation of hands, feet and mouth

60
Q

What is Gardner syndrome?

A

A subtype of FAP where multiple polyps develop throughout the bowel in addition to extracolonic tumours

61
Q

What are the red flags associated with CRC?

A

Unintentional weight loss
PR bleeding
Change in bowel habit to looser/ more frequent stools > 6 weeks in age > 60; or nocturnal diarrhoea
Abdominal or rectal mass
Anaemia
Family history - of bowel or ovarian Ca
Inflammatory markers +ve for IBD

62
Q

What is Duke’s classification?

A

Of CRC:
Stage A = confined beneath muscularis mucosa
Stage B = extension through muscularis mucosa
Stage C = involvement of regional lymph nodes
Stage D = distant metastases

63
Q

What are the causes of chronic liver disease/ cirrhosis?

A

Commonly - alcohol-related, NAFLD, viral Hepatitis C
Autoimmune - autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis
Metabolic - Wilson’s disease, haemochromatosis

64
Q

What are the causes of jaundice and the symptoms associated?

A

Pre-hepatic e.g. haemolysis - excess unconjugated bilirubin causing jaundice but not filtered through kidneys, so urine remains normal

Hepatic e.g. cirrhosis, hepatitis - conjugated bilirubin filtered through kidneys, so urine is darker

Post-hepatic i.e. obstruction - bile is refluxed along with bile salts, causing jaundice, pruritus, pale stools and dark urine

65
Q

What is ERCP?

A

Endoscopic Retrograde Cholangio-Pancreatography

66
Q

What are the symptoms of Wernicke’s Encephalopathy?

A

Ophthalmoplegia
Confusion
Ataxia

67
Q

What is Mirizzi syndrome?

A

In cholecystitis, when the gallstone is impacted at the cystic duct, causing compression of the CBD and therefore jaundice

68
Q

What is Courvoisier sign?

A

Painless jaundice + palpable gallbladder - indicative of mass at head of pancreas

69
Q

What are the causes of pancreatitis?

A

GET SMASHED:
Gallstones
Ethanol (alcohol)
Trauma

Steroids
Mumps
Autoimmune pancreatopathy
Scorpion bites
Hypertriglycidaemia/ lipidaemia
ERCP (iatrogenic)
Drugs (sodium valproate, azathioprine, opiates, thiazides, anti-retrovirals)

70
Q

How do we score the severity of pancreatitis?

A

Glasgow-Imrie Score

71
Q

How can you tell an ileostomy and colostomy apart?

A

Colostomy = usually in LIF (sigmoid colostomy is most common); flush to skin; formed contents
Ileostomy = usually in RIF; ‘spouted’ 2cm from skin as ileal contents can cause skin irritation; semi-liquid contents

72
Q

What are the types of colostomy?

A

End colostomy = created from one end of the bowel

Loop colostomy = (usually temporary) - when a loop of bowel is brought to the skin; one end is from the functioning part of the bowel, where waste exits into the bag; one end is the inactive bowel to the anus

Double barrel colostomy = the above, but with two separate stomas (the colon is completely separated)

73
Q

Which surgeries are used for treatment of CRC?

A

Right hemicolectomy = for caecal, ascending or proximal transverse colon tumours

Left hemicolectomy = for distal transverse or descending colon tumours

Sigmoid colectomy

Anterior resection = for low sigmoid or high rectal tumours

AP (abdomino-perineal) resection = for low rectal tumours - permanent colostomy + removal of rectum and anus

Hartmann’s = for emergency bowel obstruction, perforation or palliation

Endoscopic stenting = for palliation in malignant obstruction

74
Q

What is a Hartmann’s procedure?

A

resection of rectosigmoid colon, with closure of anorectal stump and formation of end colostomy

75
Q

What are the signs of haemorrhage associated with pancreatitis?

A

(Retroperitoneal haemorrhage)
Cullen’s sign = peri-umbilical bruising
Grey-Turner’s sign = bruising in the flanks

General Surgery (4 decks)

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