Acute Abdomen Flashcards
1
Q
What is the definition of an acute abdomen?
A
Recent or sudden onset of unexpected signs or symptoms, including abdominal pain.
Potential for life-threatening infection or fluid/blood loss
2
Q
Reminder: what are the features of visceral pain?
A
Stimulation of receptors in smooth muscle by:
- ischaemia
- distension/stretching
- tension
Often colicky.
Conducted by ANS.
Poorly localised to midline.
Associated with malaise, N&V, and sweating.
3
Q
Reminder: what are the features of somatic pain?
A
Stimulation of pain receptors in parietal peritoneum.
Conducted by segmental somatic nerves.
Accurately localised.
Usually overrided by the early visceral component.
5
Q
Give some examples of causes of generalised and localised peritonitis.
A
Generalised peritonitis:
- perforated viscus
- primary infective peritonitis
- rupture of cyst
Localised peritonitis:
- appendicitis
- cholecystitis
- pancreatitis
- diverticulitis
- abscesses
- salpingitis/ruptured ectopic pregnancy
6
Q
Give some examples of causes of ischaemia in the acute abdomen.
A
- mesenteric angina
- splenic infarction
- torsion of ovarian cyst/testicle/omentum
- tumour necrosis (hepatoma, fibroid)
7
Q
Give some examples of extra-abdominal causes of acute abdomen.
A
Thoracic: pleurisy, pneumonia, IHD, oesophageal disease
Neurological: herpes zoster, spinal arthritis, radiculopathy from tumours, tabes dorsalis, abdominal epilepsy
Metabolic: diabetes mellitus (DKA), chronic renal failure, porphyria, acute adrenal insufficiency
Toxins: snake/insect bites, lead poisoning, strychnine
Other: peptic ulcer, IBD
8
Q
What are the key questions for assessing the acute abdomen?
A
Severity
Character:
- ?colicky
- sharp, severe, well localised or dull, vague, deep
Location:
- ?localised to quadrant
- ?midline
- ?radiation of pain
Aggravating/relieving factors:
- diffuse peritonitis
- colic due to bowel obstruction
Urinary features:
- frequency
- urgency
- pain
- haematuria
Gynae features:
- last menstrual period
- discharge
GI features:
- appetite
- N&V
- distension
- bowel habit changes
- weight loss
- blood/mucus in stool
History of trauma
Past medical and surgical history:
- clotting/blood disorders
- cancer (abdo. mets)
- previous abdominal surgery (adhesions)
- previous surgery (?anaesthesia reaction)
Medications/allergies
FHx:
- bowel cancer
- hereditary disorders
- anaesthetic problems
SHx:
- alcohol (detox, gastritis, cancer, liver disease)
- recreational drugs
- smoking (cancer, increased coagulation, peptic ulcers)
- diet
- occupation
- carers
- living arrangement
- exercise
Systems r/v:
- cancer
- cardiorespiratory
- GU (?pregnancy)
- urinary (?UTI)
Last meal: Nil by mouth
9
Q
Compare the differentials of acute abdomen according to timeframe.
A
Sudden (secs):
- perforation/rupture of AAA/duodenal ulcer
- MI
- acute mesenteric occlusion
Rapidly accelerating (min):
- biliary colic
- ureteric colic
- small bowel obstruction
Gradual (hrs):
- inflammatory
- obstructive
- mechanical
10
Q
What are the time limits for nil by mouth?
A
Food - 6hrs
Breast milk - 4hrs
Clear liquids - 2hrs (non-fizzy to prevent reflux and regurgitation)
11
Q
What are the features of acute abdomen caused by malignancy?
A
Intermittent pain lasting >48hrs
Alteration of bowel habit
Mass felt
Weight loss
Abdominal distension
12
Q
What are the features of acute abdomen caused by intestinal obstruction?
A
Colicky severe pain
No aggravating factors
Vomiting/constipation (depending on level of obstruction)
Abdominal distension
High pitched bowel sounds
Previous surgery
13
Q
What are the features of acute abdomen caused by a perforated viscus?
A
Sudden onset of pain
Constant severe pain
Pain aggravated by moving/coughing
Diffuse tenderness
Silent, rigid abdomen
14
Q
What are the key examinations in an acute abdomen?
A
- ABCDE
- bedside: vomit bowls, IVs, Abx
- general: appearance (unwell, pain, consciousness), vital signs (obs chart, EWS)
- abdo. inspection: distension, discolouration (rashes, Grey Turner’s/Cullen’s, erythema ab igne), scars, visible peristalsis, masses (hernias, tumours, varices)
- abdo. palpation: light (?tenderness), deep (?masses), guarding/rigidity (peritonitis), palpable masses, hernial orifices, rebound tenderness (peritonitis releasing stretches peritoneum)
- abdo. percussion
- abdo. auscultation: bowel sounds (peritonitis causing ileus has no bowel sounds, obstruction has tinkling bowel sounds)
- PR +/- PV, testicles: PID, testicular torsion, indirect inguinal hernia, bowel obstruction, rectal bleeding
- systems r/v: cardiorespiratory, vascular
15
Q
What are the key investigations in an acute abdomen?
A
- Bedside: BM, urinalysis, pregnancy test, temperature, spO2, BP +/- stool samples +/- ECG
- FBC: anaemia, infection
- Clotting: DIC (sepsis), drugs, liver pathology
- G&S: identify blood type and cross-match
- U&Es: hypokalaemia (vomiting), renal function
- amylase (serum/urinary): pancreatitis
- ABG: acid-base balance, lactate
- CRP
- CXR: bowel perforation
- AXR: obstruction (dilated bowel)
- US
- contrast studies
- CT scan: perforation
- laparoscopy/(exploratory) laparotomy
16
Q
What is the general management of an acute abdomen?
A
- NBM
- IV fluids (dehydration)
- ?frequency of observations
- tubes: catheter (monitor fluid output), NG (vomiting, obstruction)
- thromboprophylaxis: TEDs, dalteparin (VTE assessment)
- analgesia (IV morphine)
- antiemetics
- ?Abx
- theatre workup (bloods, ECG, put on theatre list)
17
Q
Reminder: what are the different regions of the abdomen according to the digestive tract?
A
EPIGASTRIC:
Stomach —> 2nd part of duodenum
Liver/biliary tree
Pancreas & spleen
PERIUMBILICAL:
2nd part of duodenum —> proximal 2nd-3rd of transverse colon
SUPRAPUBIC:
Distal transverse colon to anal verge
18
Q
What is the aetiology of acute appendicitis?
A
1/400 incidence Peak incidence 15-25yrs Majority of appendices are retrocaecal (63%) - 33% vermiform - pre- and post-ileal - subcaecal - paracaecal
19
Q
Describe the pathophysiology of acute appendicitis.
A
Causes of lumen obstruction:
- faecolith
- foreign body
- tumour
- trichobezoar
- worms
- trauma
- lymphadenitis
Inflammation —> increased intraluminal pressure/onbstruction —> lymphoid swelling, decreased venous drainage, thrombosis, bacterial invasion —> abscess —> gangrene —> perforation —> peritonitis
20
Q
What are the signs and symptoms of acute appendicitis?
A
- severe constant pain; starts as diffuse periumbilical pain and then moves to McBurney’s point
- fever
- unwell; flushed
- anorexia
- N&V
- lymphadenopathy (mesenteric adenitis)
- diarrhoea
21
Q
Constrat the prevalence of diagnoses of acute abdomen.
A
- nonspecific (34%)
- mesenteric adenitis = children following infection
- acute appendicitis (28%)
- acute cholecystitis/biliary colic (10%)
- peptic ulcer perforation/bleeding (4%)
- small bowel obstruction (4%)
- gynaecological cause (4%) = ovarian cyst rupture/torsion, PID, ectopic, dysmenorrhoea
- acute pancreatitis (3%)
- renal/ureteric colic (3%)
- malignant disease (2%)
- acute diverticulitis (2%) = usually left-sided (sigmoid) but can be right-sided if bowel is long and looping
- dyspepsia (1%)
- IBD = “fat-wrapping” around affected bowel
22
Q
What is the scoring system for acute appendicitis diagnosis?
A
MANTRELS
Migratory pain +1 Anorexia +1 Nausea +1 Tenderness (RIF) +2 Rebound tenderness +1 Elevated temp. +1 Leucocytosis +2 Shift to left (blood film; indicates neutrophilia) +1
7 or above indicates acute appendicitis diagnosis
23
Q
What is Rovsing’s sign?
A
Light palpation of LIF causes pain in the RIF caused by displacement of appendix against peritoneum.
Specific to appendicitis
24
Q
What is psoas sign?
A
Patient lies on left side —> hyperextend right thigh —> abdo. pain as iliopsoas contracts
e.g. inflamed appendix lying near iliopsoas, extrapelvic abscess
25
Q
What are some of the investigations which may be appropriate in acute appendicitis?
A
BEDSIDE: BP, bpm, spO2, urine dip. (leucocytes)
BLOODS:
- U&Es: dehydration
- FBC: thrombocytosis, leucocytosis, anaemia
- pregnancy
- CRP
- INR
- G&S
- blood culture
IMAGING:
- CXR: ?perforation
- US: if female to check repro. tracts before op.
- abdo. CT
- AXR: ?bowel obstruction
26
What are the sepsis six?
1. Deliver high flow O2
2. Take blood cultures
3. Empirical IV Abx
4. Measure serum lactate & FBC
5. IV fluid resuscitation
6. Commence accurate urine output measurement
27
What is the management of acute appendicitis?
- ABCDE: 3.0-3.5l of Hartmann's/saline over 24hrs
- book OR for open/diagnostic lap +/-/appendicectomy
- anaglesia: morphine, IV paracetamol
- NBM
- DVT prophylaxis: dalteparin
- ?Abx: can complicate diagnosis unless sepsis is diagnosed
- monitoring
- senior review
- laparoscopy
28
When is an open appendicectomy indicated?
- suspicion of adhesions
- young (small abdomen)
- difficult access
- surgeon incapable of lap. appendicectomy
29
Should the appedix be removed in an appendicectomy if it looks normal?
Yes
- prevent future appendicitis
- microscopic inflammation
30
Give some extramural causes of intestional obstruction.
- adhesions, fibrous bands
- herniae (internal and external)
- compression by tumour e.g. ovarian, peritoneal metastases
31
Give some intramural causes of intestinal obstruction.
- IBD
- tumours e.g. adenocarcinoma, lymphoma, carcinoid
- structures e.g. IBD, colitis, surgery (anastomosis), diverticular, ischaemia
- volvulus
- intussusception (adults: adhesions, strictures; babies: Henoch-Schonlein purpura, enlarged lymph nodes)
32
Give some intraluminal causes of intestinal obstruction.
- faecal impaction
- swallowed foreign bodies
- bezoars
- gallstone ileus
33
What are the most common causes of small intestinal obstruction?
Adhesions (50%-75%) = fibrous tissue usually resulting from prev. surgery causes "kinks" in bowel
Hernias (7%-25%)
- femoral = high risk of strangulation (sharp, tough, borders ---> venous swelling ---> incarceration)
- inguinal = low risk of strangulation
34
Give some causes of functional obstruction of the intestines.
- paralytic ileus following surgery/electrolyte imbalance
- pseudocolon: elderly, mental disorders, electrolyte imbalance
- Hirschsprung's disease
35
What are the less common causes of small intestinal obstruction?
Primary malignancy: GIST, carcinoid syndrome, lymphoma, caecal carcinoma
Seconday malignancy: ovarian, colorectal, stomach; causes multiple level obstruction (surgery not indicated ---> permanent ileostomy)
Volvulus around fibrous band adhesion ---> closed-loop ---> fluid moves in ---> distension
Mesenteric infarction
Gallstone ileus
Intussusception
36
What are the signs and symptoms of small intestinal obstruction?
- colicky abdo. pain (rolling around, paroxysms every 4-5min) which progresses to constant pain (lying still)
- (faeculant) vomiting
- late absolute constipation
- failure to pass flatus
- abdo. distension
- visible peristalsis
- visible hernias, scars
- high-pitched, tinkling bowel sounds
- dehydration
- sepsis: tachycardia, hypotension, fever,
37
What are some investigations which may be appropriate in small intestinal obstruction?
BEDSIDE:
BLOODS:
- U&Es: vomiting
- LFTs: ?gallstone ileus, ?metastases
- FBC: ?anaemia, WCCs
- clotting
- G&S
- ABG
- serum amylase: ?pancreatitis
- lactate: ?sepsis, ?necrotic bowel
IMAGING
- AXR
- erect CXR
- MRI: ?Crohn's
- CT scan
- barium meal
note: normal X-ray does not exclude (fluid-filled small bowel due to obstruction not visible on X-ray)
38
What is the management of small intestinal obstruction?
- resuscitation: 0.9% saline/Hartmann's fluid boluses (10-20ml/kg)
- NG tube placement
- catheterise
- conservative: adhesional obstruction resolves 60%-70% of the time
- surgical: non-adhesional obstruction, adhesional obstruction with evidence of bowel ischaemia e.g. fever, marked tenderness, failure of resolution, imaging shows perforation
39
What are the most common causes of large intestinal obstruction?
Colorectal carcinoma (65%)
Diverticular disease (20%)
- acute diverticulitis
- chronic: fibrotic diverticular strictures
- pericolic abscess
- ischaemic colitis causing strictures
- IBD causing strictures
Volvulus (10%)
40
Reminder: what are diverticula? Give some examples of true and false diverticula.
Outpouchings of hollow or fluid-filled structures (tend to occur where blood vessels pierce wall)
TRUE: invovle all layers of the structure
- Meckel's diverticulum
FALSE: do not involve all layers of the structure
41
What are the signs and symptoms of large intestinal obstruction?
- colicky abdo. pain (longer paroxysms than small bowel) which progresses to constant in peritonitis
- early absolute constipation
- failure to pass flatus
- rectal examination may reveal mass
- visible peristalsis
- high-pitched, tinkling bowel sounds
- dehydration
- signs of sepsis: tachycardia, hypotension, fever,
42
What are some appropriate investigations in large bowel obstruction?
BEDSIDE:
BLOODS:
- U&Es: vomiting
- LFTs: ?gallstone ileus, ?metastases
- FBC: ?anaemia, WCCs
- clotting
- G&S
- ABG
- serum amylase: ?pancreatitis
- lactate: ?sepsis, ?necrotic bowel
IMAGING
- AXR
- erect CXR
- MRI: ?Crohn's
- CT scan
- barium meal
note: normal X-ray does not exclude (fluid-filled small bowel due to obstruction not visible on X-ray)
43
What is the management of large intesintal obstruction?
- resuscitation: 0.9% saline/Hartmann's fluid boluses (10-20ml/kg)
- catheterise
- conservative: sigmoid volvulus resolves in 90%
- surgical: resectionof infarcted bowel/stenting (not possible in complete obstruction; usually used palliatively in tumours)
44
What is the aetiology, presentation, and examination findings in pelvis sepsis?
Aetiology: after acute appendicitis, salpingitis, diverticulitis, anaestomotic dehiscence
Presentation: pelvic discomfort, diarrhoea, tenesmus, fever, lassitude, sweats, rigors, pyrexia
DRE: +/- tender, boggy swelling high in pelvis
45
Describe the characteristics of biliary colic.
Caused by transient obstruction of the cystic duct by a gallstone.
RUQ/epigastric pain (colicky - every 10-30min - but never goes away completely)
Abrupt onset, possibly exacerbated by (fatty) food
Associated with nausea and vomiting
No associated systemic response
Elevated ALP and bilriubin
Cessation spontaneous or post-analgesia
46
Describe the characteristics of acute cholecystitis.
Same cause as biliary colic but associated with inflammation and involvement of the parietal peritoneum.
Localised tenderness with localised peritonism (+ve Murphy's sign)
Associated with a systemic response i.e. leucocytosis, pyrexia
47
Describe the aetiology of gallstones.
80% asymptomatic.
Up to 30% of pop. may have gallstones.
8% of males and 17% of females (fiar, fat, female, fertile, forty)
48
Give examples of some distant complications of acute cholecystitis.
- choledocholithiasis: stones within common bile duct; presents with elevated bilirubin and cholangitis
- cholangitis: infected bile ---> Charcot's triad (fever, RUQ pain, jaundice)
- Reynold's pentad: Charcot's triad + mental obtundation + shock
- pancreatitis: deranged LFTs and elevated amylase
49
Give examples of some local complications of acute cholecystitis.
- mucocoele: failure to relieve cystic duct obstruction causes gallbladder necrosis
- empyema: same as above but with more infection
- gangrene
- perforation
- fistula: into duodenum/colon (gallstone ileus)
- Mirizzi syndrome: external compression of common bile duct by stone impacted in Hartmann's pouch
50
Give examples of causes of pre-hepatic jaundice.
Unconjugated bilirubin elevated
- haemolysis
- Gilbert's syndrome: reduced liver uptake of unconjugated bilirubin
- Crigler-Nagler syndrome: reduced conjugation of bilirubin due to enzyme defect
51
Give examples of causes of hepatic jaundice.
- viral hepatitis
- alcoholic hepatitis
- drug induced
- cirrhosis
52
Give examples of causes of post-hepatic jaundice.
Conjugated bilribuin elevated
- gallstones
- biliary stricture
- sclerosing cholangitis
- autoimmune pancreatitis associated sclerosing cholangitis
- congenital choledochal cysts
- malignancy
53
What history, examinations, and investigations are appropriate in post-hepatic jaundice?
Hx:
- abdo. pain
- fever
- itching
- alcohol
- drugs
O/E:
- abdo. masses
- hepatomegaly
- splenomegaly
- stigmata of liver disease
- ascites
- caput medusae
```
Ix:
BLOODS:
- FBC
- U&Es
- LFTs: elevated in liver damage
- ALP: elevated
- bilirubin: elevated
```
IMAGING:
- US abdomen to confirm (if -ve: hepatitis serology, autoimmune screen)
- CT (periampullary)
- MRCP
54
What is the management of post-hepatic jaundice?
CBD stones: ERCP, lap./open exploration
Benign strictures: hepaticojejunostomy
Autoimmune: steroids, ERCP and balloon dilatation of dominant stricture
Malignancy: resection (10%-20%) or palliative
55
Reminder: what are the endocrine and exocrine enzymes released by the pancreas.
Endocrine:
- insulin
- glucagon
- somatostatin
- pancreatic polypeptide
Exocrine:
- trypsinogen
- HCO3-
- amylase
- prolipase
- chymotrypsinogen
56
What is the presentation of pain due to acute pancreatitis?
Constant epigastric pain, maximal intensity several hours after onset
50% radiate to back
Aggravated by movement, relieved by sitting up, worst when flat (inflamed pancreas resting on spine)
Associated with nausea and vomiting
57
What are the causes of acute pancreatitis?
I GET SMASHED
```
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion/spider bite
Hyperlipidaemia
ERCP
Drugs e.g. azathioprine, metronidazole
```
58
What are the indications for ERCP?
- choledocholithiasis in high risk patients (recent cholangitis, recent acute pancreatitis, abnormal LFTs)
- acute pancreatitis due to biliary obstruction, sphincter of Oddi dysfunction, idiopathic
- diagnosis of pancreatic/biliary malignancy
- palliative procedures e.g. drainage
- dilatation of benign strictures
59
What are the examination findings in acute pancreatitis?
- epigastric tenderness
- abdo. distension
- fever
- tachycardia
- Grey-Turner's/Cullen's sign (3%)
- jaundice
60
What are the appropriate investigations in acute pancreatitis?
BLOODS:
- FBC
- U&Es
- LFTs
- amylase
- lipase
- calcium
- ABG
IMAGING:
- CXR/AXR: exclude perforation, sentinel loop
- US abdo.: rule out gallstones, check for pseudocysts
- CT: assess for pancreatic necrosis
61
What are some differentials for acute pancreatitis?
- perforated duodenal ulcer
- mesenteric infarction
- MI
- AAA
- cholecystitis/cholangitis
62
How is acute pancreatitis scored?
```
Glasgow scale (Imrie): PANCREAS
PaO2 < 8.0kPa (+1)
Age > 55yrs (+1)
Neutrophils > 15 x 10^9 (+1)
Calcium < 2.0 (+1)
Urea > 16 (+1)
LDH > 600 (+1)
Albumin < 32 (+1)
Glucose > 10 (+1)
```
2< severe pancreatitis likely
(also Balthazar score)
63
Outline the management of acute pancreatitis.
- IV fluids
- catheter: monitor urine output
- correct eletrolytes
- can eat and drink
- etOH withdrawal prophylaxis if appropriate
- identify and treat cause
- +/- Abx
- +/- ERCP
- central line if necessary
64
Give some examples of complications of acute pancreatitis.
SYSTEMIC
- SIRS/shock
- pulmonary insufficiency
- hypocalcaemia/magnesium/albumin
- DIC
LOCAL
- pancreatic necrosis
- pancreatic abscess
- pancreatic pseudocyst
- pancreatic ascites
- pancreatic fistulae
- pancreatic duct stricture
- pancreatic haemorrhage
65
Give some examples of complications of ERCP.
- pancreatitits (2%-9%)
- infection
- bleeding
- perforation of duodenum
- failure to remove gallstone
- stent occlusion
- pancreatic duct obstruction
- pseudocyst formation
66
Outline the causes and presentation of chronic pancreatitis.
Causes:
- alcohol
- trauma
- pancreas divisum (single pancreatic duct splits)
- familial
Presentation: recurrent/persistent abdominal pain with evidence of exocrine or endocrine pancreas insufficiency
67
What are the examination findings and investigations in suspected chronic pancreatitis?
O/E:
- recurrent epigastric pain radiating to back
- anorexia
- weight loss
- steatorrhoea
- diabetes
- naroctic abuse
Ix:
- radiological evidence of calcification, fibrosis of pancreas, duct dilatation
- faecal elastase
68
What is the management of chronic pancreatitis?
- Creon to counteract exocrine dysfunction
- opiate analgesia & coeliac axis block
- give up alcohol
- diabetic control
- ERCP and pancreatic duct stenting
- resection
- drainage
69
Give some differentials for pain in the epigastric region.
- acute/chronic peptic ulceration
- acute cholecystitis
- perforated peptic ulcer
- acute pancreatitis
- IBS
- gastric volvulus
- Boerhaave's syndrome
- ruptured AAA
- Curtis-Fitz-Hugh syndrome
- acute hepatitis
- liver mets
- spleen infarction
- acute appendicitis
- MI
- pericarditis
- pre-eclampsia
- gastric carcinoma
- pancreatic cyst/tumour
70
Give some differentials for pain in the right hypochondrium.
- MI
- pericarditis
- lower lobe pneumonia
- PE
- pleurisy
- cholecystitis
- pre-eclampsia
- HELLP syndrome
- duodenal ulcer
- retrocaecal appendicitis
71
Give some differentials for pain in the left hypochondrium.
- MI
- pericarditis
- lower lobe pneumonia
- PE
- pleurisy
- splenic rupture
- splenic abscess
- acute splenomegaly
- oesophagitis
- gastritis
- peptic ulcer
- oesophageal/gastric cancer
72
Give some differentials for pain in the umbilical region.
- small bowel obstruction
- large bowel obstruction
- intestinal infarction/ischaemia
- small bowel volvulus
- small bowel perforation
- intussusception
- Crohn's
- AAA
- mesenteric adenitis
- Meckel's diverticulum
- mesenteric ischaemia/infarction
- acute pancreaitis
- pancreatic cyst/tumour
- lymphoma
- lymph mets
73
Give some differentials for pain in the right lumbar region.
- AAA rupture/dissection
- renal calculi
- pyelonephritis
- renal tumour
- retrocaecal appendicitis
- diverticulitis
- ovarian cyst/torsion/rupture
- cholecystitis
- retroperitoneal haemorrhage
- mesenteric ischaemia
74
Give some differentials for pain in the left lumbar region.
- AAA rupture/dissection
- renal calculi
- pyelonephritis
- renal tumour
- diverticulitis
- ovarian cyst/torsion/rupture
- pancreatitis
- retroperitoneal haemorrhage
- mesenteric ischaemia
75
Give some differentials for pain in the hypogastric region.
- distended bladder
- IBS
- UTI
- constipation
- diverticulitis
- IBD
- large bowel obstruction
- colon tumour
- ectopic pregnancy
- PID
- ovarian cyst/torsion/rupture
- ovulation pain (Mittelschmerz)
- endometriosis
- miscarriage
- labour
- placental abruption
76
Give some differentials for pain in the right iliac fossa.
- constipation
- acute appendicitis
- Meckel's diverticulitis
- mesenteric adenitis
- Crohn's (terminal ileum)
- acute gastroenteritis
- intussusception
- colon/caecal carcinoma
- solitary caecal diverticulum
- acute sigmoid diverticulitis
- TB
- actinomycosis
- Yersinia pestis
- pseudo-TB
- testicular torsion
- perforated peptic ulcer
- hernias
- ovarian cyst/torsion/rupture
- endometriosis
- PID
- ureteric calculus
- ectopic pregnancy
- ovulation pain (Mittelschmerz)
- pyelonephritis/cystitis
77
Give some differentials for pain in the left iliac fossa.
- IBS
- diverticulitis/pericolic abscess
- large bowel obstruction/perforation
- colon carcinoma +/- pericolic abscess
- IBD
- ectopic pregnancy
- PID
- endometriosis
- ovulation pain (Mittelschmerz)
- ischaemia
- Crohn's colitis
- toxic colon
- testicular torsion
- ureteric colic/pyelonephritis
- hernia
- constipation
78
Contrast cholangitis and asc. cholangitis.
Cholangitis = bile stasis above obstruction ---> superimposed infection of biliary tract
Asc. cholangitis = propagation of biliary infection proximally into intrahepatic ducts ---> liver abscess
79
What is Borchardt's triad?
Sudden onset epigastric pain + intractable retching + passing NG tube difficult = indicates gastric volvulus (giant hiatus hernia req.)
80
Which flank should Grey-Turner's sign be?
Haemorrhagic pancreatitis ---> LEFT
Intraperitoneal haemorrhage e.g. AAA ---> RIGHT
81
Describe the features of carcinoid syndrome.
Carcinoid tumour (tumour on liver/beyond portal system, otherwise 5-HT would be metabolised by liver e.g. small intestine, appendix, proximal large bowel) secreting 5-HT.
Causes symptoms of flushing, diarrhoea, abdo. pain, palpitations, hypotension, wheezing
82
What are the six Fs of abdominal distenstion?
Fat, Fluid, Faeces, Flatus, Foetus, Fibroids
83
Give some examples of causes of GI haemorrhage.
COMMON (80%):
- acute peptic ulceration
- gastric erosions
- chronic peptic ulceration
UNCOMMON (5%): oesophageal varices
OTHER:
- bleeding disorders
- Meckel's diveritculum
- jejunal diverticulum
- intussusception
- angiodysplasia
- Peutz-Jegher's syndrome = hereditary intestinal polyposis
- Osler-Rendu-Weber syndrome = hereditary haemorrhagic telangiectasia
- oesophagitis
- GIST tumours
- gastric adenocarcinoma
- Mallory-Weiss tear
- aortic-enteric fistula
- haemobilia
- Dieulafoy syndrome = large torturous arteriole in stomach wall
- Henoch-Schonlein purpura
84
What is the cause and presentation of empyema of the gallbladder?
Complication of acute cholecystitis.
- fever
- pain
- tender mass under liver, moves with palpation
Treat by cholecystectomy
85
Contrast the conservative and urgent management of a cholecystitis.
CONSERVATIVE = send home after pain subsides, book for elective lap. cholecystectomy in 6-8wks
URGENT = acute attacks, biliary peritonitis
86
What is acanthosis nigricans?
Thickened, hyperpigmented skin, predominantly on flexures, warty/velveted appearance
Young/obese = increased insulin (pseudo-acanthosis nigricans)
Older = malignancy (esp. GI)
Hyperandrogenism in females
87
Contrast true and pseudo macroglossia.
TRUE = definitve histological findings
- primary: hypertrophy/plasia e.g. hypothyroidisim, lymphangioma, haemangioma, Down's, idiopathic, metabolic, amylodosis
- secondary: infiltration of normal tissue with anomalous elements
PSEUDO = relative enlargement of tongue secondary to small mandible with no definitive histological findings
88
What is Light's criteria for exudate?
TRANSUDATE EXUDATE
Clear Cloudy
Lower specific gravity Higher specific gravity
Lower protein content Higher protein content
Higher albumin content Lower albumin content
Lower cholesterol content Higher cholesterol content
