Acute Abdomen

Question 1

Differentials for epigastric pain?

Answer 1

Intrathoracic: myocardial infarction, pericarditis, pleurisy, basal pneumonia, PE,
oesophagitis, oesophageal perforation

• Upper GI: peptic ulcer, GORD, pancreatitis

Question 2

Differrentials for upper quadrant pain?

Answer 2

Intrathoracic: myocardial infarction, pericarditis, pleurisy, basal pneumonia, PE
- Kidney: pyelonephritis, renal stones
- On the right, symptoms can be due to the liver or biliary tree: gallstone complications,
hepatitis, liver abscess/cyst, hepatic congestion
- On the left, symptoms can be due to the spleen: rupture, abscess, acute splenomegaly

Question 3

Differentials for lower quadrant and central pain?

Answer 3

Bowel: mesenteric adenitis (viral lymphadenopathy of the mesentry), diverticulitis,
obstruction, hernia complications, perforation, colitis (IBD, ischaemia, pseudomembranous)
- Gynaecological: mittelschmerz, salpingitis, tubo-ovarian abscess, ruptured ectopic
pregnancy, ovarian torsion, PID, endometriosis
- Kidney: pyelonephritis, renal stones
- Musculoskeletal: psoas abscess
- On the right, symptoms can be due to: appendicitis, Meckel’s diverticulitis

Question 4

Vascular causes of an acute abdomen?

Answer 4

AAA, Mesenteric Iscaemia

Question 5

Medical causes of abdominal pain?

Answer 5

DKA, Septicaemia, shingles, sickle cell crisis and infection

Question 6

Most severe causes of acute abdomen?

Answer 6

Haemorrhage
Peritonitis
Closed loop obstruction
inflammation
open loop intestinal obstruction

Question 7

How long should they be NBM?

Answer 7

6 hours food 2 hours clear fluids

Question 8

Why does appendicitis happen? When is it most common?

Answer 8

btw ages of 10-20. Gut organisms invade the wall of the appendx after luminal obstruction. Then get oedema and ischaemic necrosis, Lumen can be obstructed by faecolith, worms or lymphoid hyperplasia.

Question 9

How will appendicitis present?

Answer 9

Colicky, periumbilical pain until it localises to the RIF when peritoneum becomes inflamed.
- McBurney’s point: 2/3rd of the way from the umbilicus to ASIS
Also tachycardia, fever, anorexia, constipation, and (in some cases, after pain onset)
vomiting

Question 10

What signs may you find on examination of appendicitis?

Answer 10

Tender in the RIF and there is potentially rebound tenderness/
guarding

Rovsing’s sign may be present, where pressing on the LIF elicits pain in the RIF
There can also be psoas sign (pain on hip extension) and Cope sign (pain on flexion and
internal rotation of the hip)

Question 11

What ix should you do in appendicitis?

Answer 11

• Urine dip incl BHCG in women and routine blood tests, will show a neutrophillia and raised CRP

Ultrasound is useful, CT is rarely used due to delaying treatment but has high diagnositic accuracy if uncertain

Question 12

What scoring system is used in appendicitis?

Answer 12

Alvorado scoring system
Out of 10:
<4- unlikely
5-6 ? CT
7+ operate

Looks at clinical and Lab criteria
Pain migration 1 
Anorexia 1 
Nausea/ Vomiting 1 
RLQ Tenderness 2

Rebound Tenderness 1
Temp >37 1
Neutrophils >75% 1
WCC >10 2

Question 13

What treatment is used in appendicitis?

Answer 13

Treatment is prompt appendicectomy, which can be laporoscopic or open

• Open appendicectomy can be Gridiron or Lanz. The Lanz incision is lower and more
  horizontal)
• IV antibiotics are important, usually metronidazole and cefuroxime. These should be given
  prior to surgery

Question 14

Where does visceral pain refer to?

Answer 14

Foregut (oesophagus to 2nd duodenum, liver, pancreas) is epigastric

• Midgut (2nd duodenum to 2/3rd transverse colon) is umbilical
• Hindgut (2/3rd transverse colon to rectum) is suprapubic

Question 15

What are the complications of appendicitis?

Answer 15

perforation

appendix mass (inflamed appendix covered with omentum) (conservative then later appendicectomy)

appendix abscess (where an appendix mass is left unresolved)- will require percutaneous drainage and abx with later appindecectomy

Question 16

What is Merckels diverticulum?

Answer 16

congenital vestigial remnant of the vitellointestinal duct in the
distal ileum containing gastric mucosa

(rule of 2s)
Complications will occure in around 2%

Question 17

What are the complications of meckels diverticulum?

Answer 17

Intestinal obstruction, this may be due to intussusception or volvulus

• Diverticulitis
• Perforation
• Neoplasia
• Haemorrhage, typically painless fresh PR bleeding in a child <2

(if occur, resect)

Question 18

What is the blood supply of the digestive system?

Answer 18

branches of the abdominal aorta,
The foregut is supplied by the celiac trunk

The midgut is supplied by the branches of the superior mesenteric artery

The hindgut is supplied by the branches of the inferior mesenteric artery

Question 19

What is acute mesenteric ischaemia?

Answer 19

umbrella term for impaired blood flow to the intestine wit bacterial relocation to normally sterile tissue and SIRS

Question 20

Causes of acute mesenteric ischaemia?

Answer 20

Mesenteric arterial embolus and thrombus
o Mural thrombus following MI, septic emboli from IE, AF

• Mesenteric venous thrombus
  o Hypercoagulability disorders, tumours causing venous compression, infection,
  venous trauma
• Non-occlusive mesenteric ischaemia
  o Hypotension, vasopressive drugs (including cocaine)

Question 21

How do patients with acute mesenteric ischaemia present?

Answer 21

Patients usually present with moderate-to-severe colicky pain that is poorly localised

• Physical findings are out of proportion to the degree of pain, and there may be no features
  of tenderness or peritonitis
• Hypovolaemia and shock occur rapidly

Question 22

What ix are important in acute mesenteric ischaemia ? (initial and further)

Answer 22

A to E assess and stabilise the patient
- Give high flow oxygen through a non-rebreathe mask, the patient will be breathless due to
lactic acidosis (perform ABG)

• Gain IV access and commence fluid resuscitation
  o Bloods to include FBC, U&Es, LFTs, coagulation profile, and G&S

o ECG

Plain AXR and erect CXR can be used to exclude differentials, AXR may show thumb-printing

• Abdominal CT can show some features
• Angiography is the gold standard for diagnosis
• Echocardiogram can show valvular pathology leading to embolism

Question 23

Management of acute mesenteric ischaemia?

Answer 23

• Initial resus with fluids and oxygen as A to E
• Also ABX such as ceftriaxone or anything with enteric cover as bacteria can translocate

-If no evidence of perf, can use thrombolytics down the angiogram catheter eg papaverine (or heparin in MVT)

Surgery may be required such as embolectomy, angioplasty or laparotomy and resection of any dead bowel.

Question 24

What is chronic mesenteric ischameia?

Answer 24

occurs when there is atherosclerotic disease affecting the vessels that supply the intestine

Question 25

How does chronic mesenteric ischaemia present?

Answer 25

postprandial colicky pain due to claudication, this often leads to weight loss as eating is uncomfortable - Chronic mesenteric ischaemia is often called intestinal angina for this reason - Patients will also often have associated vascular disease e.g. TIA, angina On examination patients may have an upper abdominal bruit

Question 26

What ix should be donw in chronic mesenteric ischaemia?

Answer 26

Routine bloods and ECG should be carried out to assess CVD risk factors and exclude malnutrition Diagnostic investigation is imaging - Angiography is gold standard

Question 27

Management of chronic mesenteric ischaemia?

Answer 27

MEdical: limited, only in pts not suitable for surgery and is usually with nitrates Surgical: Transaortic endarterectomy of coeliac os SMA, bypass grafting or angiography and stenting

Question 28

What is Ischaemic colitis and what causes it?

Answer 28

Caused by compromise of the blood supply to the colon, commonly affecting the splenic flexure The most common cause is atheroma of the mesenteric arteries - Certain factors can predispose to ischaemic colitis, these factors are similar to mesenteric ischaemia

Question 29

HOw does ischaemic colitis present?

Answer 29

with acute onset abdominal pain, usually in the LIF | - There is often nausea, vomiting, and loose stools containing dark or fresh blood

Question 30

Ix in ischaemic colitis?

Answer 30

loods should be the same as in mesenteric ischaemia. Following this there can be further imaging - Erect CXR and AXR - CT can indicate likely ischaemic colitis, further to this there can be either o Colonoscopy can show blue, swollen mucosa with contact bleeding o Barium enema shows thumb-printing with a similar appearance to UC and Crohn’s

Question 31

Management of ichaemic colitis?

Answer 31

Bowel ischaemia often resolves once the cause of hypoperfusion has been alleviated, therefore it is important to give IV fluids and rest the bowel - Surgery is rarely required, and used to correct perforation, necrosis and strictures

Question 32

How can bowel obstruction be divided?

Answer 32

Static and dynamic causes. Dynamic is mechanical, static is a failure of peristalsis eg ileus

Question 33

How can you distinguish btw small and large bowel on xray?

Answer 33

Small bowel obstruction can be identified by multiple dilated (>3cm) loops of central bowel, completely traversed by valvulae conniventis - Large bowel obstruction can be identified by dilated (>6cm or >9cm at the caecum) loops of peripheral bowel, incompletely traversed by haustra

Question 34

What are the cases of mechanical bowel obstruction?

Answer 34

Intraluminal Foreign body Faecal impaction Gallstone Transmural Neoplasm Stricture (e.g. Crohn’s disease, radiotherapy, diverticular disease, post-operative) Fistula Extraluminal ``` Adhesion (post-operative, infection, inflammation, congenital) Neoplasm Pregnancy Volvulus hernia ```

Question 35

COmmonest causes of small bowel obstruction?

Answer 35

Adhesions - Hernias - Other causes e.g. foreign bodies, tumours (most commonly benign polyps), strictures, gallstone ileus

Question 36

COmmonest causes of large bowel obstruction?

Answer 36

Neoplasm (usually primary malignancy) - Structures (usually diverticular) - Faecal impaction - Sigmoid or caecal volvulus o Volvulus is rotation of the gut on its mesenteric axis, more commonly sigmoid o This can produce a severe, rapid, strangulated obstruction

Question 37

What is a closed loop obstruction?

Answer 37

ileo-caecal valve remains competent, therefore there can be no decompression of bowel contents into the small bowel. This is much more dangerous, and likely to perforate Perforation occurs due to increasing pressure leading to decreased venous return, oedema, and decreased arterial supply. This causes necrosis of the bowel wall - Another effect of decreased venous return and oedema is bacterial translocation, risking peritonitis in the absence of perforation

Question 38

WHat are the causes of paralytic ileus?

Answer 38

Post-operative - Peritonitis or viscus perforation - Trauma - Metabolic and electrolyte disturbances e.g. uraemia, hypokalaemia - Other acute abnormalities e.g. chest infection, MI, stroke, AKI, DKA, hypothyroidism, pancreatitis

Question 39

How will intestinal obstruction present?

Answer 39

There are four cardinal features of intestinal obstruction. 1. Vomiting, which may be faeculant 2. Colicky pain, this is usually diffuse and central. In paralytic ileus, pain is absent 3. Complete constipation i.e. no flatus or faeces 4. Distension On examination there may be tenderness, highly active ‘tinkling’ bowel sounds on auscultation and hyper-resonant percussion. It is important to check for hernias Severe pain and tenderness suggests ischaemia or perforation

Question 40

What ix should be done in bowel obstruction?

Answer 40

Therefore fluid charts are essential to monitor intake and output, and catheterisation may be needed for an accurate calculation of requirements (lots of third space losses) Routine bloods : clotting, group and save, and cross match as surgery may be required - AXR, looking for air-fluid levels and distention (>3cm in small bowel, >6cm in large bowel, and >9cm in the caecum) - Erect CXR where perforation is suspected - CT scanning can be used where there is diagnostic uncertainty

Question 41

Management of Bowel Obstruction?

Answer 41

keep patients NBM and ensure they are catheterised Drip and suck NG tube -decompresses the bowel and reduces the risk of perforation, but also alleviates vomiting - After initial NG placement there should be aspiration of fluid, and then the tube should be left on free drainage

Question 42

How is volvulus managed?

Answer 42

Conservative passage of a flatus tube

Question 43

When is surgery indicated in bowel obstruction?

Answer 43

strangulation, perforation, or closed-loop large bowel obstruction. For other cases, usually conservative measures will be trialled for 24 – 48 hours before consideration of surgery to alleviate the obstruction

Question 44

What can be done in bowel obstruction for pts not suitable for surgery?

Answer 44

Endoscopic stenting