Acute abdomen Flashcards
Appendicitis presentation
Young (5-40yo), acute
= general abdo pain, if staying still; peritonitis
= starts as umbilical pain then moves to RIF
Signs of appendicitis
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
Ix and mx for appendicitis
Ix = Alvardo score = Bloods; increased WCC and CRP = USS = CT; most sensitive but takes time
Mx
= appendicetomy
= Abx; cefotaxime, metronidazole
Complications of appendicitis
Perforation
- more common when faecolith involved (children)
Appendix mass
- inflamed appendix covered in omentum and forms mass
Appendix abscess
What leads to diverticular disease?
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
Sx and signs O/E of diverticular disease
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
Ix for ?diverticular disease/diverticulitis
Bloods Flexible sigmoidoscopy +/-colonoscopy Acute - CT + erect CXR Chronic - barium enema (do not do on acute presentation, risk of perforation!!)
Mx of diverticular disease
Acute/symptomatic
- IV hydration, bed rest
Chronic/asymptomatic
- soluble high-fibre diet, anti-inflammatories (mesalazine)
Surgery if recurrent/complications
- Hartmann’s, primary anastomosis
Complications of diverticular disease
Diverticulitis Perforation Faecal peritonitis Peri-colic abscess Fistulas Colonic obstructions
RFs for hernias
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
Hernia presentations
Lump in groin
Scrotal swelling
Groin pain
Vomiting
Inguinal hernias presentations
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
Femoral hernia presentations
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
Strangulated hernia sx
Tender, red, colicky abdo pain, distention, vomiting
Ix and mx for hernias
USS; 1st line Clinical diagnosis --- Elective surgery Reassurance if left though note strangulation is a potential complication
How to differentiate between direct and indirect hernias?
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
Acute pancreatitis causes
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)
Acute pancreatitis presentation
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)
Acute pancreatitis ix
Bloods - high amylase (x3), FBC, X-match USS - ?gallstones Erect CXR and AXR - ?pleural effusion CT = exclude other causes
What score is used for acute pancreatitis?
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
Mx of acute pancreatitis
Fluid balance
Catheter + NG tube if vomiting
Analgeisa, glucose control
ERCP if complications serious
Chronic pancreatitis presentation
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
Ix of chronic pancreatitis
Bloods - amylase normal, FBC, x-match AXR - pancreatic calcification ERCP - early: duct dilation, late: duct strictures Faeces - HIGH faecal elastase
Mx of chronic pancreatitis
Fluid balance
Catheter + Na tube if vomiting
Analgesia, glucose control (chronic pancreatic diabetes)
ERCP to remove gallstones
Further surgery if complications arise
Complications of pancreatitis
Acute
- pseudocysts, duodenal obstruction, pancreatic ascites
Chronic
- diabetes, steatorrhoea, reduce life expectancy by 10-20 years
Intestinal obstruction presentation
Hx of hernia, malignancy, surgery (adhesions)
Diffuse pain, constipation, abdo distention, vomiting
Pyrexia, sweating, absent bowel sounds/high pitched bowel sounds
Causes of intestinal obstruction
Small bowel
- adhesions prior surgeries, malignancy
Large bowel
- colorectal malignancies, sigmoid/caecal volvulus, parailytic ileus/post-op ileus
Ix and mx of intestinal obstruction
Bloods; FBC, x-match, U&Es etc plain AXR + CXR CT (3/6/9 rule) --- Medical - drip and suck - conservative if volvulus decompresses Surgical - laparotomy, especially if peritonitic
What sign may be seen in AXR in bowel perforation?
Rigler’s sign
= double-wall sign of air outlining both sides of the bowel wall
= bowel lumen + within peritoneal cavity
Intestinal ischaemia presentation
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
Ix for intestinal ischaemia
Acute + chronic
= AXR; perforation (Rigler’s), megacolon
= ECG; AF, MI
= angiography; blockages
Chronic sx of intestinal ischaemia
Intermittent gut claudication PR bleeding wt loss post-prandial pain Hx of CVD, old age, heart failure
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) arterial thrombosis
b) embolism
c) venous thrombosis
d) non-occlusive disease
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
B 𝞫-hCG test
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
B Psoas sign, and a retrocaecal appendix
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
C Diverticulitis
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 Hartmann’s procedure
= ACUTE presentation so bowel must be given rest before it is anastamosed
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
C Indirect inguinal hernia
Which of the following may be raised in chronic pancreatitis?
A Amylase B Calcium C Faecal elastase D Albumin E Haematocrit
C Faecal elastase
Which of the following is not a cause of acute pancreatitis?
A Mumps B Hypocalcaemia C Thiazide drugs D Trinidad scorpion bite E Steroids
B Hypocalcaemia
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
D Give IV fluids and insert an NG tube
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
B Embolism
