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Surgery > Acute abdomen > Flashcards

Acute abdomen Flashcards

1
Q

Appendicitis definition

A

Inflammation of vermiform appendix

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2
Q

Pathophysiology of appendicitis

A
  1. Lumen distal to obstruction starts to fill with mucous & fluid; acts as closed-loop obstruction
  2. Distention & increased intraluminal and intramural pressure
  3. Resident bacteria in appendix multiply -
  4. inflammation
  5. Congestion/rising intraluminal pressure
  6. Vascular compromise
  7. Ischaemia
  8. Necrosis
  9. Perforation & Abscess
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3
Q

Clinical features of appendicitis

A
  • Periumbilical pain moving to RIF
  • N&V
  • Anorexia
  • Constipation
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4
Q

Physical examination of appendicitis

A

Tachycardia, low grade fever
Lying still, coughing hurts
Flushing
Guarding RIF, rebound and percussion tenderness
Rosvings, psoas sign and Mcburney’s sign positive.

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5
Q

Management for appendicitis

A
  1. Surgical consult
  2. 2 large bore IV cannulae
  3. Investigations
  4. Analgesia and antiemetic
  5. Keep NBM
  6. IVF
  7. Amoxycillin + gentamicin + metronidazole
  8. Consent and book for appendisectomy
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6
Q

Alvarado/MANTREL’s score for appendicitis

A 
Higher the score out of 10= higher chance
MANTRELS
Migration to RLQ
Anorexia
Nausea and vomiting
Tenderness in RLQ (2)
Rebound tenderness
Elevated temperature
Leukocytosis (2 points)
Shift of WBC count to left
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7
Q

Consenting for Lap appendix

A
  1. Explain diagnosis->appendicitis, inflammation of appendix, very common
  2. Treatment->only recommended treatment is surgery. Key-hole->three incisions, while under a GA, will image organs, remove appendix even if doesn’t appear inflamed. Once removed, sutured, dissolvable.
  3. Risks
    a. GA->NV, difficulty passing urine. Muscle ches, temporary nerve, blood clot leg, chest infection, allergy/shock, hyperthermia, stroke, MI, death->rare
    b. Procedure->Lung collapse (pain relief and antibiotics), DVT/PE, wound infections/dishiscience, hemorrhage
    c. Appendectomy->removal of normal appendix, injury to bladder/bowel/ureter, iA abscess, paralytic ileus, bowel perforation
  4. No other treatment options, can lead to infection and death if not treated.
  5. After surgery->encouraged to move ASAP. Most of normal activities in 2 weeks, normal in one month.
  6. Question, signed for both, fill in other information
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8
Q

DDx for: Severe abdo pain with rigidity of entire abdominal wall and prostration (exhaustion)

A
  • Perforated peptic ulcer
  • Perforation of other intra-abdominal organ
  • Dissecting aneurysm
  • Severe pancreatitis
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9
Q

Tenderness and rigidity in right hypochondrium

A 
Cholangitis 
Acute cholecystitis 
Subphrenic abscess 
Pleurisy 
RLL pneumonia 
Hepatitis 
Acute pyelonephritis, nephrolithiasis 
Perforated peptic ulcer
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10
Q

Tenderness and rigidity in left hypochondrium

A 
Pancreatitis 
Subphrenic abscess 
Diverticulitis 
Splenic rupture 
Acute pyelonephritis, nephrolithiasis 
Leaking aneurysm of splenic artery 
Acute gastric distention
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11
Q

Tenderness and rigidity in left lower quadrant

A 
Diverticulitis 
Ulcerative colitis 
Colon cancer 
Pelvic peritonitis 
Ovarian cyst/torsion
Ectopic pregnancy 
Sigmoid volvulus
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12
Q

Signs of peritonism

A 
Guarding
Rigidity
Rebound tenderness 
Abnormal bowel sounds 
Red flags
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13
Q

Urgent considerations

A 
Surgical consult
Abnormal vitals->fluids and blood
2 large IV cannula
Group and hold
Fluid resuscitation
0 negative blood
Oxygen
If perforation/appendictis->broad spectrum antibiotics
Pregnancy test
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14
Q

Abdominal pain out of proportion to physical examination

A

Suspect mesenteric ischaemia - older, smoking, peripheral vascular disease, AF

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15
Q

Right Scapula pain

A

Gall bladder
Liver
Irritation of right hemidiaphragm -> pneumonia

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16
Q

Definition of Diverticulosis

A

Herniation of mucosa and submucosa through muscular layer of colon

17
Q

Complications of diverticulosis

A 
Diverticulitis 
Segmental colitis 
Lower GI bleeding 
Infection 
Abscess 
Perforation 
Peritonitis 
Fistula
18
Q

Most common location of diverticulitis

A

Sigmoid colon

19
Q

Pathophysiology of diverticulitis

A

Low fibre diet= + transit time, decreased stool volume, + intraluminal pressure and colonic segmentation
Between taenia coli where the vasa recti penetrate the colonic wall
Fecal particles may lead to infection->+intraluminal pressure->inflammation, ischemia, necrosis->perforation

20
Q

Risk factors for diverticulosis

A 
Low dietary fibre 
>50 
Western diet 
Obesity 
NSAIDs
21
Q

Presentation of diverticulitis

A 
LLQ pain, quarding, tenderness 
Leukocytosis, fever 
Rectal bleeding (uncommon) 
Bloating 
Constipation 
Pelvic tenderness on PR
22
Q

Investigations for Diverticulitis

A

FBC ->leukocytosis
CXR ->normal
CT ->thickening of bowel wall, mass, abscess, streaky mesenteric fat

NEVER perform sigmoidoscopy/colonscopy as . increased risk of perforation (perform >6 weeks post)

23
Q

Initial management for diverticulitis

A
  1. Mild w/o markers of systemic involvement (no fever, N WCC):
    Can be treated at home
    Bowel rest (fluids only)
    Analgesia
  2. Moderate/severe
    If cannot take oral fluids/pain not controlled, systemic involvement evidence->Admit
    NBM, low residue diet after
    IV fluids
    IV antibiotics->gentamicin + amoxycillin + metronidazole
    Analgesia
    Consider CT percutaneous drainage if abscess formation
    Erect CXR/CT contrast
    Consider for surgery
24
Q

Causes of rectal bleeding

A 
Diverticulosis 
Colorectal cancer 
Hemorrhoids 
Crohns, UC . 
Perianal disease 
Angiodysplasia 
Trauma
Ischemia colitic 
Radiation proctitis
25
Q

Indications for surgery in diverticulitis

A

Generalised peritonitis
Uncontrolled sepsis
Perforation
Clinical deterioration

26
Q

Causes of perforation

A
  • Peptic ulcer disease
  • Small bowel obstruction
  • Large bowel obstruction
  • Diverticular disease
  • IBD
27
Q

Main investigation for ischemic bowel

A

CT with IV contrast

28
Q

General acute abdomen treatment

A 
Largely depends on cause 
- IV access 
- NBM
- Analgesia +/- antiemetics 
- Imaging 
- VTE prophylaxis 
- Urine dip 
- Bloods 
- IV fluids 
\+/- urinary catheter 
\+/- NGT
29
Q

Complications of appendicitis

A

Perforation (if untreated)
Surgical site infection
Appendix mass/adherance
Pelvic abscess

30
Q

Diverticulitis classification

A

Hinchey

  1. Diverticulitis with pericolic abscess
  2. Diverticulitis with distant abscess
  3. Diverticulitis with ruptured abscess (purulent peritonitis)
  4. Diverticulitis, free communication with peritoneum, generalised fecal peritonitis = feculent peritonitis
31
Q

Complications of diverticulitis

A

1) pericolic abscess
2) Fistula
3) bowel obstruction

32
Q

Indication for surgery in diverticulitis

A
  1. unstable patient
  2. Hinchey 3-4
  3. 3+ episodes
  4. Becomes immunocompromised
  5. Complications - perforation, abscess, fistula, obstruction, haemorrhage, failure of medicines to work, cannot rule out malignancy
33
Q

What is Hartmans procedure and indication

A

removal of the sigmoid colon +/- rectum with end colostomy formation in the acute setting (usually for perforated diverticular disease or an obstructing cancer)

34
Q

Complication of hartmans procedure

A 
Infection 
Rectraction of stoma 
Bleeding 
Ileal paralysis 
Renal insufficiency 
Pneumonia 
Stroke 
Reaction to anaesthetic
35
Q

What is abdominal compartment syndrome and its etiology?

A 
Increased intra-abdominal pressure 
Caused by:
Decreased wall compliance 
Increased intra-luminal pressure 
Increased abdominal contents 
Capillary leakage
36
Q

What are complications of abdominal compartment syndrome?

A 
GI - ischaemia & thrombosis 
Neuro - increased ICP 
Resp - decreased ventilation and compliance 
Renal - Ischaemia and AKI 
CV - increased CVP
37
Q

Management of abdominal compartment syndrome?

A

Improve abdominal compliance

  • Paralyse - neuromuscular blockade
  • Remove constriction
  • Sedate with analgesia

Evacuate luminal contents

  • NGT decompression
  • Rectal decompression
  • Minimise enteral nutrition

Evacuate abdominal fluid

  • Paracentesis
  • Surgical evacuation

Correct positive fluid balance

  • Avoid overloading
  • Diuretics
  • Colloids
38
Q

What is Ogilvie’s syndrome?

A

acute dilation of colon in absence of any mechanical obstruction in severely ill patients (acute colonic pseudo-obstruction). cecum >10cm and right colon dilation

Surgery (9 decks)

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