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yr3 > Acute abdomen > Flashcards

Acute abdomen Flashcards

1
Q

Appendicitis presentation

A

Young (5-40yo), acute
= general abdo pain, if staying still; peritonitis
= starts as umbilical pain then moves to RIF

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2
Q

Signs of appendicitis

A

Rovsing’s
= pain greater in RIF than LIF when LIF is pressed

Cope’s
= pain on passive flexion and internal rotation of the hip

Psoas
= pain on extending hip; ONLY for retrocaecal appendix

Rebound tenderness
= if infection involves peritoneum

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3
Q

Ix and mx for appendicitis

A 
Ix
= Alvardo score
= Bloods; increased WCC and CRP
= USS
= CT; most sensitive but takes time

Mx
= appendicetomy
= Abx; cefotaxime, metronidazole

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4
Q

Complications of appendicitis

A

Perforation
- more common when faecolith involved (children)

Appendix mass
- inflamed appendix covered in omentum and forms mass

Appendix abscess

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5
Q

What leads to diverticular disease?

A

Low fibre diet leads to loss of stool bulk thus an increased pressure required to expel stools

This leads to herniations through muscularis weak points, forming outpouchings in colonic mucosa and submucosa throughout large bowel

Common in >40yo

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6
Q

Sx and signs O/E of diverticular disease

A

Can lead to diverticulitis

Sx: bloody stools, fever, LIF pain, urinary sx when fistulation w/ bladder
O/E: general pain, staying still if peritonitis, LIF pain

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7
Q

Ix for ?diverticular disease/diverticulitis

A 
Bloods
Flexible sigmoidoscopy +/-colonoscopy
Acute
- CT + erect CXR
Chronic
- barium enema (do not do on acute presentation, risk of perforation!!)
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8
Q

Mx of diverticular disease

A

Acute/symptomatic
- IV hydration, bed rest

Chronic/asymptomatic
- soluble high-fibre diet, anti-inflammatories (mesalazine)

Surgery if recurrent/complications
- Hartmann’s, primary anastomosis

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9
Q

Complications of diverticular disease

A 
Diverticulitis
Perforation
Faecal peritonitis
Peri-colic abscess
Fistulas
Colonic obstructions
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10
Q

RFs for hernias

A

Chronic cough, constipation, increased age, obesity, heavy lifting, often at weak intestine point in abdo wall

Femoral = more common in women
Inguinal = more common in men
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11
Q

Hernia presentations

A

Lump in groin
Scrotal swelling
Groin pain
Vomiting

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12
Q

Inguinal hernias presentations

A

Superior and medial to pubic tubercle
Often contain bowel
Swells/appears on coughing/may reduce on supination
May be reducible on pressure

Most common type of hernia
Less commonly strangulated
Can be treaed w/o surgery
Younger pts

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13
Q

Femoral hernia presentations

A

Lateral and inferior to pubic tubercle
Often contain omentum
Swells/appears on coughing/may reduce on supination
May be reducible on pressure

Females > males
Older pts
Surgery recommended
More commonly strangulated

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14
Q

Strangulated hernia sx

A

Tender, red, colicky abdo pain, distention, vomiting

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15
Q

Ix and mx for hernias

A 
USS; 1st line
Clinical diagnosis 
---
Elective surgery
Reassurance if left though note strangulation is a potential complication
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16
Q

How to differentiate between direct and indirect hernias?

A

1) Reduce hernia
2) Place finger over deep inguinal ring (just above midpoint of inguinal ligament)
3) Ask pt to cough and if hernia reappears, cannot be indirect hernia (must be direct)

Direct
= goes through weak abdo wall
= medial to inf. epig. vessels
= does NOT descend into scrotum

Indirect
= goes down inguinal canal (test above occludes canal)
= lateral to inf. epig. vessels
= does descend into scrotum

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17
Q

Acute pancreatitis causes

A 
I diopathic
G allstones
E thanol
T rauma
S teroids
M umps, malignancy
A utoimmune
S corpion bite
H ypercalcaemia, hyperlipidaemia, hyperPTH
E RCP
D rugs (thiazides)
18
Q

Acute pancreatitis presentation

A

Hx of gallstones/alcoholism

Epigastric pain, pain worst on movement, relieved by sitting forward, pain radiates to back

Epigastric tenderness, fever, shock, decreased bowel sounds, Cullen’s (umbilical), Gray Turner’s (flank)

19
Q

Acute pancreatitis ix

A 
Bloods
- high amylase (x3), FBC, X-match
USS
- ?gallstones
Erect CXR and AXR
- ?pleural effusion
CT = exclude other causes
20
Q

What score is used for acute pancreatitis?

A

Modified Glasgow Score (>3=severe)

P aO2 < 7.9kPa
A ge > 55yo
N eutrophils > 15 x 10^9/L
C alcium <2mmol/L
R enal function; urea > 16mmol/L
E nzymes; LDH > 600, AST >200
A lbumin <32 g/L
S ugar > 10mmol
21
Q

Mx of acute pancreatitis

A

Fluid balance
Catheter + NG tube if vomiting
Analgeisa, glucose control

ERCP if complications serious

22
Q

Chronic pancreatitis presentation

A

Alcoholism (70%), idiopathic (20%)

Recurrent epigastric pain, pain worst on movement, pain relieved by sitting forward, bloating, steatorrhoea

Epigastric tenderness, Cullen’s, Gray Turner’s, sx of complications

23
Q

Ix of chronic pancreatitis

A 
Bloods
- amylase normal, FBC, x-match
AXR
- pancreatic calcification
ERCP
- early: duct dilation, late: duct strictures
Faeces
- HIGH faecal elastase
24
Q

Mx of chronic pancreatitis

A

Fluid balance
Catheter + Na tube if vomiting
Analgesia, glucose control (chronic pancreatic diabetes)

ERCP to remove gallstones
Further surgery if complications arise

25
Q

Complications of pancreatitis

A

Acute
- pseudocysts, duodenal obstruction, pancreatic ascites

Chronic
- diabetes, steatorrhoea, reduce life expectancy by 10-20 years

26
Q

Intestinal obstruction presentation

A

Hx of hernia, malignancy, surgery (adhesions)

Diffuse pain, constipation, abdo distention, vomiting

Pyrexia, sweating, absent bowel sounds/high pitched bowel sounds

27
Q

Causes of intestinal obstruction

A

Small bowel
- adhesions prior surgeries, malignancy

Large bowel
- colorectal malignancies, sigmoid/caecal volvulus, parailytic ileus/post-op ileus

28
Q

Ix and mx of intestinal obstruction

A 
Bloods; FBC, x-match, U&amp;Es etc
plain AXR + CXR
CT (3/6/9 rule) 
---
Medical
- drip and suck
- conservative if volvulus decompresses
Surgical
- laparotomy, especially if peritonitic
29
Q

What sign may be seen in AXR in bowel perforation?

A

Rigler’s sign
= double-wall sign of air outlining both sides of the bowel wall
= bowel lumen + within peritoneal cavity

30
Q

Intestinal ischaemia presentation

A

Hx may include
= CVD, AF, hypotensive state (car accident), old age, sudden onset diffuse pain

ACUTE:
Diffuse abdo pain, shock signs, normal examination

CHRONIC:
wt loss, blood on DRE, normal abdo examination

31
Q

Ix for intestinal ischaemia

A

Acute + chronic
= AXR; perforation (Rigler’s), megacolon
= ECG; AF, MI
= angiography; blockages

32
Q

Chronic sx of intestinal ischaemia

A 
Intermittent gut claudication
PR bleeding
wt loss
post-prandial pain
Hx of CVD, old age, heart failure
33
Q

What is the cause of the intestinal ischaemia based on the hx of the pt:

a) atherosclerosis +++
b) AF hx
c) hypercoaguable state
d) hypotensive

A

a) arterial thrombosis
b) embolism
c) venous thrombosis
d) non-occlusive disease

34
Q

A nervous 16-year-old college student attends the local A&E department with her boyfriend, complaining of an episode of sudden onset right-sided pain in her abdomen. Physical examination of the patient is unremarkable except from a small scar in the right lower quadrant. What is the most appropriate first line investigation in this case?

A USS of the abdomen
B 𝞫-hCG test
C Full blood count
D CT scan of the abdomen
E No investigations, immediate surgery
A

B 𝞫-hCG test

35
Q

A 26-year-old professional rugby player presents to the A&E department with abdominal pain in the umbilical area. On initial inspection, the gentleman is feverish with a temperature of 38C and a BP of 115/90. The admitting doctor suspects a diagnosis of appendicitis from the history and performs an abdominal physical examination and passively extends the gentleman’s right hip which elicits pain. Which eponymous sign of appendicitis is being demonstrated here and what does it represent?

A Cope’s sign, and a retrocaecal appendix
B Psoas sign, and a retrocaecal appendix
C Psoas sign, and an appendix located next to obturator externus
D Rovsing’s sign, and a retrocaecal appendix
E Rovsing’s sign, and an appendix located next to obturator externus

A

B Psoas sign, and a retrocaecal appendix

36
Q

A feverish 56-year-old woman attends her GP complaining of a sudden appearance of bloody stools. She adds that she has experienced a few episodes of bloody stools before but did not seek medical attention and apart from a fever, she has had no other constitutional symptoms. The GP notes that the patient’s diet is particularly low in fibre and on physical examination, tenderness is found on pressure to the LIF. A DRE shows fresh blood upon removal of a gloved finger. What is the most likely diagnosis?

A Angiodysplasia
B Diverticulosis
C Diverticulitis
D Mallory-Weiss tear
E Gastroenteritis
A

C Diverticulitis

37
Q

A feverish 65-year-old is brought to the local A&E department by her daughter. She complains about nausea, LIF pain and vomiting. The attending doctor takes a full history and performs an abdominal examination and subsequently makes a diagnosis of acute diverticulitis with some associated signs of peritonism. A erect AXR is taken which shows some air under the diaphragm. What is the most appropriate surgical procedure?

A Hartmann’s procedure
B Primary anastomosis
C Colectomy and end-ileostomy formation
D Delorme’s procedure 
E Whipple’s procedure
A

A Hartmann’s procedure

= ACUTE presentation so bowel must be given rest before it is anastamosed

38
Q

A 26-year-old bodybuilder attends the local day-surgical clinic upon referral from his GP due to a groin lump. The general surgical registrar suspects a hernia and so performs a simple test to ascertain the type of hernia to determine the most appropriate management. The doctor reduces the hernia and then places their finger over the deep inguinal ring. The patient is asked to cough and the hernia does not reappear. What is the most likely type of hernia?

A Femoral hernia
B Direct inguinal hernia
C Indirect inguinal hernia
D Spigelian hernia
E Hiatus hernia
A

C Indirect inguinal hernia

39
Q

Which of the following may be raised in chronic pancreatitis?

A Amylase
B Calcium
C Faecal elastase
D Albumin
E Haematocrit
A

C Faecal elastase

40
Q

Which of the following is not a cause of acute pancreatitis?

A Mumps
B Hypocalcaemia
C Thiazide drugs
D Trinidad scorpion bite
E Steroids
A

B Hypocalcaemia

41
Q

An overweight 65-year-old woman visits her general practitioner with discomfort in her right groin. On examination, the suggestion of a reducible groin lump is noted. She is routinely referred to the surgical outpatient clinic with a possible diagnosis of inguinal hernia. However, two weeks later and before her surgical appointment, she again visits her general practitioner, this time with vomiting, diarrhoea, and colicky abdominal pain. What is the next most appropriate management step?

A Administer antibiotics
B Give IV fluids
C Insert an NG tube
D Give IV fluids and insert an NG tube
E Administer an enema
A

D Give IV fluids and insert an NG tube

42
Q

A 70-year-old gentleman presents to the A&E department with sudden-onset severe diffuse abdominal pain. Observations are taken in the ambulance which show an irregularly irregular pulse rate of 130 and a blood pressure of 76/60mmHg. An abdominal X-ray is performed as soon as possible which shows the Rigler sign and the physician diagnoses an acute form of mesenteric ischaemia with perforation. What is the most likely cause for the acute onset of the mesenteric ischaemia?

A Atherosclerotic disease
B Embolism
C Thrombosis
D Polycythaemia vera
E Idiopathic
A

B Embolism

yr3 (32 decks)

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