Acute abdomen

Question 1

What is the definition of acute abdomen?

Answer 1

Sudden severe abdominal pain that has been occurring for less than 8 hours caused by an acute disease or injury that requires surgical intervention

Question 2

What is the approach to a patient with acute abdomen?

Answer 2

1. History
2. Examination
   3.side room investigations
3. laboratory tests
4. imaging studies
   If still unsure after everything then do a re-evaluation after 4-6 hours and consider doing a diagnostic laparotomy

Question 3

How can we classify abdominal pain?

Answer 3

1. visceral
2. parietal
3. referred pain

Question 4

What is visceral pain?

Answer 4

1. The pain signals are transported by the afferent C fibres(nonmyelinised)
   The fibres are stimulated by distension, inflammation,ischemia, and direct infiltration
   -Usually slow onset, gradual, vague and poorly localised

Question 5

With regards with visceral pain in the epigastrium where does it come from?

Answer 5

1. foregut, stomach, duodenum, pancreas and hepatobiliary system

Question 6

If the pain is para-umbilical where is it situated?

Answer 6

the midgut: small bowel and right colon

Question 7

If the pain is suprapubic where does it originate from?

Answer 7

The hindgut: the transverse colon, the descending colon, the sigmoid and the rectum

Question 8

What is parietal pain?

Answer 8

It is impulses conveyed by the A-delta fibres
The pain is acute, sharp and well localised and unilateral
It is caused by irritation of the somatic innervated parietal peritoneum

Question 9

What is referred pain caused from?

Answer 9

The confluence of afferent fibres from different areas in the posterior horn of the spinal cord
Right shoulder: Diaphragm, gallbladder, right pleura and lung, liver capsule
Left shoulder: Diaphragm, spleen, tail of the pancreas, stomach, left pleura and lung
Right scapula pain: gallbladder and biliary tree
Left scapula pain: spleen and tail of the pancreas
Groin and genitalia: kidney, ureter, aorta and iliac arteries
Back midline: pancreas, duodenum, aorta

Question 10

Why would we ask recent travel hx from a patient?

Answer 10

-To determine risk for amebiasis, malaria, echinococcus

Question 11

When a patient presents with colicky pain and is curled up, what would you think of?

Answer 11

visceral

Question 12

When a patient is lying facing up with minimal pain what would you think?

Answer 12

• parietal

- peritonitis

Question 13

What will you hear on auscultation in renal artery stenosis?

Answer 13

bruit over the renal vessels

Question 14

On auscultation what may be a sign of bowel obstruction?

Answer 14

-high frequency bowel sounds with peristaltic rushes

Question 15

What is shifting dullness a sign of?

Answer 15

Ascites

Question 16

On percussion if you hear resonance over the liver what does it indicate?

Answer 16

a perforated viscus- intra-abdominal free air

Question 17

Define voluntary and involuntary guarding:

Answer 17

1. involuntary is when the abdominal wall is rigid and does not relax- board like peritoninitis
2. voluntary is when the abdominal wall relaxes when the patient breathes deeply

Question 18

What is the psoas sign?

Answer 18

Ask the patient to lie on their side and passively extend their upper leg- it is positive when the patient experiences pain

Question 19

What is the obturator sign?

Answer 19

When pain is illicited on internal and external rotation of the flexed hip

Question 20

What is Murphy’s sign?

Answer 20

When we place our hand on the right midclavicular line, just below the costal margin and ask the patient to breath in. Pain illicited on inspiration points towards cholecystits

Question 21

What is costo-vertebral tenderness a sign of?

Answer 21

pyeolonephritis

Question 22

What side room investigations would you do for a patient with abdominal pain?

Answer 22

1. URINE DIPSTICK- leucocytes, nitrites, blood
2. Preganancy test
3. Stool-ova, parasites, bacteria, amoeba

Question 23

What lab tests will you do?

Answer 23

1. FBC
2. CRP
3. ESR
4. Clotting profile in bleeding patient
5. Urea and electrolytes: U&E-hydration and renal failure
6. blood gas: metabolic acidosis to indicate bowel ischaemia
7. Amylase and lipase
8. LFT
9. Cultures of urine stool and blood
10. watson-schwartz test to exclude porphyria

Question 24

Whta imaging can you do for abdominal pain?

Answer 24

1. A chest Xray-To exclude air under the diaphragm
2. AXR- to look for pathological fractures and metastases, calcifications like gallstones, renal stones, faecoliths,chronic pancreatitis and AAA.
3. Abdominal ultrasound or CT: to distinguish between an abscess and mass, can distinguish between whether it is in the biliary tree or the liver
4. CT-Angiography for acute mesenteric ischaemia
5. Contrast studies for oesophageal perforation

Question 25

What does an absent psoas shadow represent?

Answer 25

It can indicate a psoas abscess

Question 26

When may we request a barium enema?

Answer 26

When we suspect volvulus or colonic obstruction

Question 27

What other investigations can we do?

Answer 27

1.Diagnostic laparotomy: especially female in reproductive years
2. HIDA scan for cholecystitis
3.Endoscopy-upper for peptic ulcer disease
ERCP-cholodocholithiasis

Question 28

How will a surgical case present?

Answer 28

Pain for more than 6 hours, well localised and tender