Acute Abdomen Flashcards
What are the differentials for pain in the right hypochondriac region?
- Pancreatitis
- Ulcer (gastric)
- Gallstones
- Biliary Colic
What are the differentials for pain in the Epigastric region?
- Heartburn
- Pancreatitis
- Epigastric hernia
- Gallstones
- Ulcer (gastric)
What are the differentials for pain in the left hypochondriac region?
- Pancreatitis
2. Ulcer (gastric or duodenal)
What are the differentials for pain in the left lumbar region?
- kidney stones
- urinary tract infection
- constipation
- IBD
- Diverticular disease
What are the differentials for pain in the umbilical region?
- Gastric ulcer
- Early stages of appendicitis
- Aortic aneurysm
- Ruptured aortic aneurysm
- Pancreatitis
- IBD.
What are the differentials for pain in the left iliac region?
- Diverticular disease
- IBD
- Ectopic pregnancy
- Ovarian Torsion
- Inguinal or femoral hernias
What are the differentials for pain in the hypogastric region?
- UTI
- Appendicitis
- IBD
- Diverticular disease
What are the differentials for pain in the right iliac region?
- Appendicitis
- Ectopic pregnancy
- Ovarian torsion
- Inguinal or femoral hernias
What are the differentials for pain in the right lumbar region?
- Kidney stones
- UTI
- Constipation
What would make a patient need immediate abdomen in acute abdomen?
- Bleeding
- Perforation
- Ischaemia
Bleeding Presentation
Ruptured AAA
Other causes
- Gastric ulcer
- Ectopic pregnancy
Signs:
- Tachycardia
- Hypotension
- Pale and clammy
- Thready pulse
Perforation Presentation
Peptic ulceration
Bowel obstruction
Diverticular disease
IBD
Signs:
- Peritonitis - laying completely still
- Rigid abdomen with tenderness
- Involuntary guarding
- Reduced or absent bowel sounds
Bowel Ischaemia presentation
Arterial and venous causes
Can be thrombotic or embolic
Most commonly embolic
Think about AF
Signs:
- Severe pain out of proportion is ischaemic bowel until proven otherwise.
- Raised lactate
Involuntary guarding
Tensing even if you ask them to relax they can’t stop guarding.
Ddx anxiety, try asking them to relax if they are anxious they will be able to
True rupture AAA
Where all layers rupture
False rupture
Not all layers rupture - outside doesn’t
Who gets AAA?
Old, fat, white men with Marfan’s who smoke
Whos AAA rupture?
old, fat, white women who smoke.
Triple AAA triad + signs
- Abdominal/back pain, pulsatile mass + hypotension
Back pain, then collapse then hypotension.
Triple A triad + signs
- Abdominal/back pain, pulsatile mass + hypotension
Back pain, then collapse then hypotension.
Investigations AAA
ABCDE
- US abdomen - FAST scan, quick and easy
- CT angiography
Treatment of AAA
Stabilise: FBC, U&E, cross match (if giving blood right now)
Urgent surgical repair - EVAR preferred even in rupture.
Right upper quadrant pain
Predominantly HPB causes
Intermittent = biliary colic secondary to gallstones
constant with fever = cholecystitis
constant with fever + jaundice = ascending cholangitis
palpable liver + jaundice = hepatitis
None of the above - consider pneumonia or pylonephritis
Epigastric
Upper GI problems
Bleeding - gastric ulcer
pain better by leaning forward - pancreatitis
N+V, diarrhoea and light coloured stools? Pancreatitis
ERCP = pancreatitis
gallstones or abuse alcohol = pancreatitis
LUQ
Bleeding - Gastric ulcer
Urinary symptoms - pyelonephritis
Colic = Ureteric colic (never crosses the midline - renal related)
Rest signs - pneumonia
Peri-umbilical
AAA and bowel
Vomit first and profuse = small bowel
Constipation then vomit = Large bowel
Electrolyte imbalances can be present in both (due to obstruction and oedema, which sucks in water and electrolytes)
First line investigation AXR and upright CXR (perforation)
LLQ
Bowel: Diverticulitis, IBD, Hernia, Cancer
Renal: Ureteric colic or UTI
Genitourinary: Torsion or ectopic
RLQ
Bowel: Appendix, IBD, Hernia or cancer
Renal: Ureteric colic or UTI
Genitourinary: torsion or ectopic
Appendicitis
Umbilical pain then RLQ (laproscopic) then ruptures you get peritonitis (laparotomy at that point)
Investigations of acute abdomen
History
Examination: Abdo + PR
Bedside: Urine dip (+pregnancy test) + ECG
ABG: Lactate + Hb info
Bloods: FBC, U&E, LFT, CRP and amylase (pancreatitis - lipase is now being used more)
IMAGING:
Biliary or ovary - US
Calculi - CT KUB
Bowel - AXR + erect CXR
If they are going to have an operation, they get a CT
Abdo Xray - small bowel
Partial SBO: Gas throughout abdomen and into rectum
Complete SBO: No distal gas, staggered air-fluid levels
Complicated SBO: free air under diaphragm OR thumb printing
Rigler’s sign - air either side of the bowel. Changes
pneumoperitonism
Pneumoperitoneum is pneumatosis (abnormal presence of air or other gas) in the peritoneal cavity, a potential space within the abdominal cavity.
369 rule
> 3 - small bowel
6 - large bowel
9 - caecum or sigmoid
obstruction, high risk of perforation.
Toxic megacolon
Complication of UC, distended bowl and swollen, risk of perforation.
Caecum volvulus
Can move in any direction (looks a bit like a question mark)
More common in young people
Operation
Sigmoid volvulus
Can only move upwards and goes to the RUQ (coffee bean sign)
More common in older people
Drip and suck
Drip and Suck
Fluids and NG tube
Management
Acute:
- IV access
- NBM
- Analgesia +/- antiemetics
- VTE prophylaxis (TED stockings, express sleeves and anticoag - LMWH unless renal problems then give UFH)
- Catheter (and fluid balance)
Definitie:
- operation
- Drip and suck (sigmoid)
- Abx and fluids (diverticulitis)
- Palliation
Types of scar
Lanz scar = old appendix Grid iron scar = Kidney transplant Kocher scar = old gallbladder approach Rooftop scar = Thoracic surgery Mercedes-Benz = Liver Tx or Whipple Midline = Laparotomy Ports = Laparoscopy (various) Pfannelnsteil = C-section
