Acute abdomen

Question 1

How does visceral abdominal pain present?

Answer 1

Deep-seated and ill-localized

Question 2

Location of visceral pain for

a) foregut structures (lower oesophagus to second part of duodenum)
b) midgut structures (dueodenum to splenic flexure)
c) hindgut structures (splenic flexure to rectum)

Answer 2

a) epigastrium
b) umbilicus
c) hypochondrium

Question 3

What is the pattern of parietal abdominal pain?

Answer 3

Sharp, well-localized pain with reflex guarding and muscle rigidity

Question 4

What causes colic?

Answer 4

Visceral pain arising from muscular structure with a hollow viscus which is blocked

Question 5

How is the movement of patients affected in colicky pain versus irritation of the parietal peritoneum?

Answer 5

Colicky pain- can’t sit still

Parietal pain- don’t want to move

Question 6

How does irritation of the diaphragmatic peritoneum present differently, depending on the location? (2)

Answer 6

Peripheral diaphragmatic peritoneum-lower spinal nerve distribution
Central diaphragmatic peritoneum- phrenic nerve distriubution (C3, C4, C5, shoulder and neck area)

Question 7

What are the main “surgical” aetiologies of abdominal pain? (4)

Answer 7

Inflammation e.g. appendicitis, diverticulitis
Obstruction e.g. biliary colic, intestinal obstruction
Perforation e.g. peptic ulcer, diverticulum, appendix
Ischaemia e.g. mesenteric ischaemia, torsion

Question 8

Pain which is helped by moving/drawing knees up to chest?

Answer 8

Obstructive colicky pain

Question 9

Pain which comes on very suddenly and is constant?

Answer 9

Perforation

Question 10

Pain on moving/coughing?

Answer 10

Suggests inflammation of the parietal peritoneum

Question 11

Best indicators of peritonism? (4)

Answer 11

Pain on movement/coughing/going over speed bumps
Involuntary guarding
Generalized rigidity
Rebound tenderness

Question 12

What does the loss of liver dullness on percussion suggest?

Answer 12

May represent free intra-peritoneal gas

Question 13

What does “shifting dullness” suggest?

Answer 13

Free fluid in the abdomen (ascites)

Question 14

Absence of bowel sounds over a period of 30 seconds suggests what clinical syndrome?

Answer 14

Ileus

Question 15

Higher volume, frequency and pitch of bowel sounds suggests what clinical syndrome?

Answer 15

Obstruction

Question 16

Catching of the breath when RUQ is palpated during inspiration?

Answer 16

Murphy’s sign- acute cholecystitis

Question 17

Bruising around the umbilicus?

Answer 17

Cullen’s sign- acute pancreatitis

Question 18

Bruising in the left flank?

Answer 18

Grey Turner’s sign- acute pancreatitis

Question 19

Palpation in the left iliac fossa producing pain in the right iliac fossa?

Answer 19

Rosving’s sign- acute appendicitis

Question 20

Patients with sepsis or ischaemic damage are likely to exhibit which bloodgas derangement?

Answer 20

Metabolic acidosis due to elevated lactate

Question 21

Which test should always be requested in a female of child-bearing age with an acute abdomen?

Answer 21

Pregnancy test- can confirm ectopic pregnancy, and is important if radiographs are to be taken

Question 22

Commonest cause of free intraperitoneal gas?

Answer 22

Perforation of the bowel viscera

Question 23

What is the main purpose of contrast abdominal X-rays?

Answer 23

Determining the presence/absence of perforation or obstruction

Question 24

Management of acute appendicitis?

Answer 24

Laparoscopic or open appendicectomy

Pre-operative antibiotics

Question 25

Which condition presents similarly to appendicitis, and may follow a upper respiratory tract infection?

Answer 25

Mesenteric adenitis

Question 26

Visceral afferents from the appendix enter the spinal cord at what level?

Answer 26

T10

Question 27

Female with severe intermittent sharp pain associated with nausea and vomiting

Answer 27

? adnexal/ovarian torsion