Acute Abdomen

Question 1

definition of the acute abdomen

Answer 1

sudden onset of severe abdominal pain <24 hours duration

Question 2

main differentials for RUQ pain

Answer 2

biliary colic acute cholecystitis acute cholangitis

Question 3

main differentials for Right Iliac Fossa pain

Answer 3

acute appendicitis ectopic pregnancy ovarian cyst diverticulitis

Question 4

main differentials for left iliac fossa pain

Answer 4

ectopic pregnancy ovarian cyst diverticulitis

Question 5

main differentials for epigastric pain

Answer 5

pancreatitis peptic ulcer disease AAA

Question 6

main differentials for central/generalised pain

Answer 6

AAA intestinal obstruction ischaemic colitis

Question 7

main differentials for suprapubic pain

Answer 7

acute urinary retention pelvic inflammatory disease

Question 8

main differentials for pain radiating loin to groin

Answer 8

renal colic (kidney stones) pyelonephritis

Question 9

what laboratory investigations should patients receive

Answer 9

Urine dipstick + pregnancy test in females

FBC, LFTs, U+Es, CRP, Amylase

• consider measuring serum calcium in suspected pancreatitis

ABG

Blood cultures if suspected infection

Question 10

imaging for patients with acute abdomen

Answer 10

ECG- to exclude MI

USS:

• KUB: for suspected renal tract pathology
• Biliary tree + liver: suspected gall stone diseae
• Ovaries, fallopian tube, uterus: for suspected gynae problem

Radiological:

Erect CXR to look for bowel perforation

Question 11

dull peri-umbilical pain that then becomes sharp and localised to right iliac fossa

Answer 11

appendicits

Question 12

symptoms of appendicitis

Answer 12

migratory pain - begins peri-umbilical and localises to RIF - pain worse on moving/laughing/coughing nausea, vomiting anorexia

Question 13

examination findings in appendicitis

Answer 13

tachycardia, tachypnoea, pyrexia rebound tenderness: increasing pain when releasing deep palpation guarding Rovsings sign

Question 14

what is Rovsings sign? what condition is it seen in?

Answer 14

palpation of LIF causes pain in RIF appendicitis

Question 15

what differential diagnoses need to be excluded in appendicitis

Answer 15

ectopic pregnancy – pregnancy test UTI – urinalysis

Question 16

definitive management of appendicitis

Answer 16

laparoscopic appendectomy

Question 17

what is a diverticulum? what part of colon is most commonly affected?

Answer 17

out pouching of the bowel wall - most common in sigmoid colon

Question 18

difference between: - diverticulosis - diverticulitis - diverticular disease

Answer 18

diverticulosis = presence of diverticula with no inflammation. Often incidental finding, asymptomatic. diverticulitis = inflammation of diverticula diverticula disease = symptoms arising from presence of diverticula

Question 19

symptoms of diverticular disease

Answer 19

lower abdominal pain altered bowel habit nausea flactulence

Question 20

presentation of acute diverticulitis

Answer 20

sharp abdominal pain - usually LIF - worse on movement nausea, anorexia, pyrexia bloody diarrhoea tenderness / guarding on examination

Question 21

risk factors for the formation of diverticulum

Answer 21

age low fibre diet obesity smoking NSAID use family history

Question 22

1st line imaging for suspected diverticulitis - what might be seen?

Answer 22

CT abdo-pelvis - thickening of colonic wall - pericolonic fat stranding - abscesses - air bubbles / free air

Question 23

why should colonoscopy be avoided in acute diverticulitis

Answer 23

high risk of perforation

Question 24

scoring system used to classify acute diverticulitis

Answer 24

Hinchey classification

Question 25

management of acute diverticulitis

Answer 25

IV fluids, analgesia, antibiotics (cefotaxime + metronidazole) Hartmanns procedure indicated if: - failure to respond to treatment - perforation - overwhelming sepsis

Question 26

what does this CXR show?

Answer 26

Air under diaphragm (pneumoperitoneum)

• strongly suggests bowel perforation