Acute abdomen Flashcards
What is the definition of acute abdomen?
Sudden severe abdominal pain that has been occurring for less than 8 hours caused by an acute disease or injury that requires surgical intervention
What is the approach to a patient with acute abdomen?
- History
- Examination
3.side room investigations - laboratory tests
- imaging studies
If still unsure after everything then do a re-evaluation after 4-6 hours and consider doing a diagnostic laparotomy
How can we classify abdominal pain?
- visceral
- parietal
- referred pain
What is visceral pain?
- 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
With regards with visceral pain in the epigastrium where does it come from?
- foregut, stomach, duodenum, pancreas and hepatobiliary system
If the pain is para-umbilical where is it situated?
the midgut: small bowel and right colon
If the pain is suprapubic where does it originate from?
The hindgut: the transverse colon, the descending colon, the sigmoid and the rectum
What is parietal pain?
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
What is referred pain caused from?
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
Why would we ask recent travel hx from a patient?
-To determine risk for amebiasis, malaria, echinococcus
When a patient presents with colicky pain and is curled up, what would you think of?
visceral
When a patient is lying facing up with minimal pain what would you think?
- parietal
- peritonitis
What will you hear on auscultation in renal artery stenosis?
bruit over the renal vessels
On auscultation what may be a sign of bowel obstruction?
-high frequency bowel sounds with peristaltic rushes
What is shifting dullness a sign of?
Ascites
On percussion if you hear resonance over the liver what does it indicate?
a perforated viscus- intra-abdominal free air
Define voluntary and involuntary guarding:
- involuntary is when the abdominal wall is rigid and does not relax- board like peritoninitis
- voluntary is when the abdominal wall relaxes when the patient breathes deeply
What is the psoas sign?
Ask the patient to lie on their side and passively extend their upper leg- it is positive when the patient experiences pain
What is the obturator sign?
When pain is illicited on internal and external rotation of the flexed hip
What is Murphy’s sign?
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
What is costo-vertebral tenderness a sign of?
pyeolonephritis
What side room investigations would you do for a patient with abdominal pain?
- URINE DIPSTICK- leucocytes, nitrites, blood
- Preganancy test
- Stool-ova, parasites, bacteria, amoeba
What lab tests will you do?
- FBC
- CRP
- ESR
- Clotting profile in bleeding patient
- Urea and electrolytes: U&E-hydration and renal failure
- blood gas: metabolic acidosis to indicate bowel ischaemia
- Amylase and lipase
- LFT
- Cultures of urine stool and blood
- watson-schwartz test to exclude porphyria
Whta imaging can you do for abdominal pain?
- A chest Xray-To exclude air under the diaphragm
- AXR- to look for pathological fractures and metastases, calcifications like gallstones, renal stones, faecoliths,chronic pancreatitis and AAA.
- Abdominal ultrasound or CT: to distinguish between an abscess and mass, can distinguish between whether it is in the biliary tree or the liver
- CT-Angiography for acute mesenteric ischaemia
- Contrast studies for oesophageal perforation
What does an absent psoas shadow represent?
It can indicate a psoas abscess
When may we request a barium enema?
When we suspect volvulus or colonic obstruction
What other investigations can we do?
1.Diagnostic laparotomy: especially female in reproductive years
2. HIDA scan for cholecystitis
3.Endoscopy-upper for peptic ulcer disease
ERCP-cholodocholithiasis
How will a surgical case present?
Pain for more than 6 hours, well localised and tender
