Acute Abdomen

Question 1

Define acute abdomen

Answer 1

sudden onset of severe abdominal pain (<24 hours duration) which could indicate acute surgical problem requiring immediate surgical intervention

Question 2

1. What does constant pain usually indicate?
2. Name the 4 types of colic
3. What is indicated by previously colicky pain that has become constant. Give examples

Answer 2

1. inflammatory process
2. biliary, renal, intestina, ureteric
3. inflammation of the organ has occured (e.g. strangulated hernia, ascending cholangitis, salpingitis)

Question 3

1. Name 5 things that sudden onset pain could indicate

2. Name 3 conditions that can present with associated back pain

Answer 3

1. perforation, rupture, tortion, acute pancreatitis, infarction
2. pancreatitis
   AAA rupture
   renal tract disease

Question 4

On Examination:

1. what does guarding and rebound tenderness indicate?
2. What does increased (tinkling) bowel sounds indicate?
3. what do absent bowel sounds indicate?

Answer 4

1. peritonitis
2. obstruction
3. peritonitis due to ischaemia, strangulation or ileus

Question 5

What is the pathogenic mechanism behind acute appendicitis?

Answer 5

1. lumen of appendix becomes obstructed (closed loop obstruction)
2. mucous secretion leads to distension and an increase in intralumenal pressure
3. bacteria within the appendix rapidly multiply
4. pressure in the lumen exceeds venous pressure - engorgement and congestion
5. inflammation involves the serosa and hence parietal peritoneum, causing localised RLQ pain
6. thrombosis of the small arterioles leads to ischaemia, infarction and perforation

Question 6

1. what pain is characteristic of acute appendicitis?

2. What are expected findings on examination?

Answer 6

1. vaguely central abdominal pain that becomes localised to the RIF
2. RIF tenderness
   guarding due to local peritonitis
   possible tender mass in RIF (due to abscess formation

Question 7

1. What type of XR is performed for:
   a) ?perforation
   b) ?obstruction
2. what conditions can USS be useful in diagnosing? (4)
3. What is the most accurate investigation for most acute emergencies?

Answer 7

1a) erect chest
1b) abdominal

2. acute cholangitis, cholecystitis and AAA
   gynae causes
3. CT

Question 8

1. When, after a last known menstrual period is an ruptured ectopic likely to present?
2. What investigation confirms diagnosis of ruptured ectopic?
3. Name 3 other gynaecological causes of acute abdomen

Answer 8

1. 6-8 weeks
2. abdominal and transvaginal ultrasound
3. rupture of ovarian cysts
   tortion of ovarian cysts
   acute salpingitis

Question 9

Describe the onset of peritonitis if the cause is:

1. perforation
2. secondary to inflammation?

Answer 9

1. sudden onset severe abdominal pain; general collapse and shock
2. onset of peritonitis is less rapid. Initial presenting features are of the underlying disease

Question 10

1. Name 5 things which can cause small intestine obstruction

2. Name 3 things which can cause colonic obstruction

Answer 10

1. adhesions, hernia, crohn’s (fibrotic strictures), inussusception, extrinsic compression by tumour
2. colorectal CA; sigmoid volvulus; diverticular disease

Question 11

1. What is open loop obstruction?

2. What is closed loop obstruction?

Answer 11

1. one site of obstruction. There is a proximal outlet for decompression
2. obstruction lacks proximal or distal outlets for decompression
   - can be caused by colonic obstruction against a competent iliocaecal valves
   - pressures can’t be decompressed thus can lead to ischaemia and perforation

Question 12

How does a patient with bowel obstruction typically present?

Answer 12

• abdominal colic
• vomiting
• absolute constipation
• abdominal distension
• increased bowel sounds

Question 13

1. What does the term ruptured viscus otherwise mean?

2. Why must it be managed urgently?

Answer 13

1. GI perforation

2. perforations rapidly progress to septic shock

Question 14

1. What are the 2 most common causes of GI perforation?

2. Name some other causes of GI perforation

Answer 14

1. peptic ulcers and sigmoid diverticulum

2. cholecystitis
    mesenteric ischaemia
    obstruction
    toxic megacolon
    trauma
    cancer - ischaemia or invasion of the bowel wall

Question 15

XRAY ?PERFORATION

1. what is rigler’s sign?
2. What is psoas sign?

Answer 15

1. can see both sides of the bowel wall

2. loss of sharp delineation of the psoas muscle border

Question 16

Describe the three types of Ischaemic Bowel Disease

Answer 16

1. Acute mesenteric ischaemia - sudden decrease in blood supply to the bowel. Further subdivided into embolic, thrombotic or venous ischaemia
2. chronic mesenteric ischameia - type of PVD. Blood suppky gradually deteriorates over time as a result of atherosclerosis. Prognosis more favourable than acute
3. Colonic Ishcaemia

Question 17

Describe the findings to the following tests for ?Ischaemic bowel

1. Serum Lactate
2. Coagulation Panel
3. ABG
4. Erect CXR
5. Abdominal XR

Answer 17

1. raised
2. may demonstrate coagulopathy if cause is embolic/thrombotic; may demonstrate hypercholesterolaemia in chronic ischaemia
3. acidosis; elevated lactate
4. may demonstrate perforation secondary to necrosis
5. dilatation of the bowel and bowel wall thickening (secondary to inflammation)