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Gastrointestinal > Acute Abdomen > Flashcards

Acute Abdomen Flashcards

1
Q

What is the acute abdomen?

A

An abdominal condition of abrupt onset associated with severe abdominal pain (resulting from inflammation, obstruction, infarction, perforation, or rupture of intra-abdominal organs).

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2
Q

What are the common abdominal emergencies?

A

Mechanical obstruction or to the paralytic ileus of general peritonitis

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3
Q

Describe visceral pain

A
  • It is transmitted by C fibers that are found in muscle, periosteum, mesentery, peritoneum, and viscera.
  • Most painful stimuli from abdominal viscera are conveyed by this type of fiber and tend to be dull, cramping, burning, poorly localized, and more gradual in onset and longer in duration than somatic pain.
  • Because abdominal organs transmit sensory afferents to both sides of the spinal cord, visceral pain is usually perceived to be in the midline, in the epigastrium, periumbilical region, or hypogastrium
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4
Q

Describe abdominal visceral nociceptors

A
  • Abdominal visceral nociceptors respond to mechanical and chemical stimuli.
  • The principal mechanical signal to which visceral nociceptors are sensitive is stretch; cutting, tearing, or crushing of viscera does not result in pain
  • Abdominal visceral nociceptors also respond to various chemical stimuli and are activated directly by substances released in response to local mechanical injury, inflammation, tissue ischemia and necrosis, and noxious thermal or radiation injury.
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5
Q

Describe somatic pain

A
  • Somatic-parietal pain is mediated by A-δ fibers that are distributed principally to skin and muscle.
  • Signals from this neural pathway are perceived as sharp, sudden, well-localized pain, such as that which follows an acute injury.
  • Somatic-parietal pain arising from noxious stimulation of the parietal peritoneum is more intense and more precisely localized than visceral pain.
  • Lateralization of the discomfort of parietal pain is possible because only one side of the nervous system innervates a given part of the parietal peritoneum.
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6
Q

What is referred pain?

A
  • Referred pain is felt in areas remote from the diseased organ
  • This convergence may result from the innervation, early in embryologic development, of adjacent structures that subsequently migrate away from each other.
  • For example, the central tendon of the diaphragm begins its development in the neck and moves craniocaudally, bringing its innervation, the phrenic nerve, with it
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7
Q

What are the GI symptoms?

A
  • Nausea
  • Vomiting
  • Hematemesis
  • Anorexia
  • Diarrhea
  • Constipation
  • Bloody stools
  • Melena stools
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8
Q

What are the GU symptoms?

A
  • Dysuria
  • Frequency
  • Urgency
  • Hematuria
  • Incontinence
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9
Q

What are the Gyn symptoms?

A
  • Vaginal discharge
  • Vaginal bleeding
  • Pain during sexual intercourse
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10
Q

What are the general symptoms?

A
  • Fever

- Lightheadedness

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11
Q

What may come up in a history?

A

-GI
=Past abdominal surgeries, h/o GB disease, ulcers; Fam Hx IBD
-GU
=Past surgeries, h/o kidney stones, pyelonephritis, UTI
-Gyn
=Last menses, sexual activity, contraception, h/o PID or STDs, h/o ovarian cysts, past gynecological surgeries, pregnancies
-Vascular
=h/o MI, heart disease, AF, anticoagulation, CHF, PVD, Fam Hx of AAA (abdominal aortic aneurysms)
-Other medical history
=DM, organ transplant, HIV/AIDS, cancer
-Social
=Tobacco, drugs – Especially cocaine, alcohol
-Medications
=NSAIDs, H2 blockers, PPIs, immunosuppression, warfarin

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12
Q

What diseases present in the RUQ?

A
  • Cholecystitis
  • Biliary colic
  • Cholangitis
  • Hepatitis
  • Hepatic Abscess
  • Pancreatitis
  • Peptic Ulcer
  • Appendicitis (pregnancy)
  • Intestinal Obstruction
  • Inflammatory Bowel Disease
  • Pneumonia
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13
Q

What diseases present in the LUQ?

A
  • Gastritis
  • Peptic Ulcer
  • Pancreatitis
  • Splenomegaly
  • Splenic Rupture
  • Intestinal Obstruction
  • IBD
  • Diverticulitis (splenic fissure)
  • Pneumonia
  • Myocardial ischaemia
  • Pericarditis
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14
Q

What diseases present in the RLQ?

A
  • Appendicitis
  • IBD
  • Diverticulitis (Cecal, Meckel’s)
  • Mesenteric Adenitis
  • Intestinal Obstruction
  • Hernia
  • Ectopic Pregnancy
  • Salpingitis
  • Ovarian Torsion
  • Ruptured Ovarian Cyst
  • Mittelschmerz
  • Nephrolithiasis
  • Pyelonephritis
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15
Q

What diseases present in the LLQ?

A
  • Diverticulitis
  • Appendicitis
  • Intestinal Obstruction
  • IBD
  • Ischaemic colitis
  • Hernia
  • Ectopic pregnancy
  • Salpingitis
  • Ovarian Torsion
  • Ruptured Ovarian Cust
  • Mittelschmerz
  • Nephrolithiasis
  • Pyelonephritis
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16
Q

What are the courses of action for the surgeon?

A
  • Immediate operation
  • Pre-operative preparation and operation
  • Conservative treatment (active observation, IV, antibiotics)
  • Discharge home
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17
Q

What are the clinical patterns?

A
  • Abdominal pain and shock
  • Generalised peritonitis
  • Localised peritonitis (confined to one quadrant of the abdomen)
  • Intestinal obstruction
  • “Medical” illness
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18
Q

What are the main causes of abdominal pain and shock?

A
  • RUPTURED AAA
  • RUPTURED ECTOPIC PREGNANCY (plus hypotension)
  • Acute mesenteric ischemia
  • Severe acute pancreatitis
  • Closed loop intestinal obstruction
19
Q

What are the main causes of generalised peritonitis?

A

-PERFORATED ULCER
-COLONIC PERFORATION
-PERFORATED APPENDICITIS
Enteric contents spillage= chemical reaction= rigid abdomen throughout
-Amylase- mimics peritonitis (imaging)

20
Q

What are the main causes of localised peritonitis?

A
  • ACUTE APPENDICITIS
  • ACUTE DIVERTICULITIS
  • ACUTE CHOLECYSTITIS
  • RUPTURED OVARIAN CYST-OVARIAN TORSION
21
Q

What is the clinical pattern of intestinal obstruction?

A
  • Central, colicky abdominal pain
  • Distension
  • Constipation
  • Vomiting
22
Q

What is the difference between small and large bowel obstruction?

A

-Large= peripheral (diameter 8cm max), presence of haustration
=ASAP, ileocecal valve does not let backflow of contents, so pressure builds up in closed system so perforation

-Small= central (diameter 5cm max), vulvulae convientae, ileum: may appear tubeless
=Managed initially conservatively, unless signs of compromise of blood supply to bowel
=Decompression valve= contents upstream so vomit so pressure alleviated by vomit/ tube in stomach

23
Q

What is a Volvulus?

A

Bowel twists around axis

  • No exit
  • Increases pressure
  • Risk of perforation
24
Q

Example of medical causes of the acute abdomen

A
  • Epigastric pain
  • Obese or hypertensive or diabetic
  • Referred from heart= heart attack
  • Pericarditis
25
Q

What imaging do we use when?

A
  • RUQ pain, lower abdominal pain in female patients => US (ultrasound)
  • Almost all other types of pain => CT
26
Q

Describe diagnostic laparoscopy

A

-Diagnostic laparoscopy may be of utility in the evaluation of
acute abdominal pain, especially in situations in which the
underlying etiology remains unclear despite a thorough clinical
evaluation and radiologic imaging.

-The advantages of diagnostic laparoscopy include its ability to make a definitive diagnosis in 90–98 % of cases and determine whether further intervention is necessary

-A resultant decrease in the negative laparotomy rate—and the fact that if further treatment is indicated that many acute abdominal conditions can be treated laparoscopically—equates to a decrease in morbidity and mortality, a shorter length of stay,
and decreased hospital costs

27
Q

Describe the acute abdomen in elderly patients

A

Elderly patients may lack the febrile response, leukocytosis, and severity of pain expected as a result of the age-dependent decline in immune function along with a delay in pain perception

The atypical presentation may also be attributed to the effects of coexisting medical conditions and medications. For example, beta blockers may blunt the normal tachycardic response to acute abdominal processes while nonsteroidal agents and acetaminophen may prevent the development of a fever.

diagnostic accuracy may be difficult because of the inability to obtain an adequate history from elderly patients with memory and hearing deficits

Increased incidence of complications and increased morbidity and mortality observed in elderly patients presenting with acute abdominal pain.

EXAMPLE:although the incidence of acute appendicitis is lower in this population compared to their younger counterparts, the rate of perforation is significantly higher, reaching almost 70 % in some series

Furthermore, complications of acute cholecystitis occur in more than 50 % of patients aged 65 or older.

28
Q

Describe the acute abdomen in children

A

Diagnosis of the acute abdomen in children challenging, particularly in children who are preverbal or uncooperative.

Further adding to the difficulty is the fact that causes of abdominal pain in children can range from trivial (e.g., constipation) to potentially life-threatening (e.g.,malrotation with midgut volvulus) with little to no difference in their presentation

higher rates of misdiagnosis and complications in the pediatric population as well. In fact, the rate of perforation in childhood cases of acute appendicitis is 30–65 %, which is significantly higher than what is reported for adults

29
Q

Describe the acute abdomen in immuno-compromised patients

A

Challenging diagnosis as a result of conditions such as cancer requiring
chemotherapy, transplantation, HIV, renal failure, diabetes, and malnourishment to name a few.

As a result of their body’s inability to launch a full inflammatory response, these patients may have a delayed onset of fever and other typical symptoms, experience less pain, and have an underwhelming leukocytosis.

these patients may suffer from a variety of atypical infections

neutropenic enterocolitis is a common source of acute abdominal pain in patients with bone marrow suppression secondary to chemotherapy

high index of suspicion for an acute abdominal process if such patients present with persistent abdominal complaints even if seemingly mild in intensity. These patients should undergo prompt diagnostic imaging and the possibility of operative intervention should be considered early.

30
Q

Describe the acute abdomen in the critically ill

A

history and physical exam is often unattainable or unhelpful, especially in those patients who are obtunded, sedated, or intubated

Crucial points: recent abdominal surgery, sudden onset of abdominal pain or distension, changes in laboratory studies ,change in hemodynamic status as indicated by changes in vital signs, an increase in volume requirements, and the need for pressors.

  • CT/USS/bedside DPL/laparoscopy in ITU/LAPAROTOMY
  • Acalculous cholecystitis
  • Abdominal compartment syndrome
31
Q

What is abdominal compartment syndrome?

A

Raised intra-abdominal pressure

32
Q

What are the retroperitoneal causes of raised intra-abdominal pressure?

A
  • Oedema in necrotising pancreatitis
  • Pelvic hematoma
  • Retroperitoneal haematoma
  • Bleeding after aortic surgery
  • Oedema related to resuscitation
33
Q

What are the intraperitoneal causes of raised intra-abdominal pressure?

A
  • Haemorrhage
  • Visceral oedema
  • Abdominal packing
  • Bowel dilation
  • Mesenteric venous obstruction
  • Pneumoperitoneum
  • Acute ascites
34
Q

Describe the acute abdomen in the morbidly obese

A

subtle changes in vital signs, atypical symptoms, and underwhelming physical exam findings

A mildly elevated heart rate, fever, nausea, and malaise may be the only indications to the presence of a serious intra-abdominal process

the time the patient is found to have peritonitis , it is often a late finding with the patient at significant risk for the subsequent development of abdominal sepsis , multisystem organ failure, and death

Imaging studies may be unattainable or more difficult to interpret.

35
Q

Describe the acute abdomen in pregnant patients

A

Delays in presentation, diagnosis, and treatment may occur because many of the presenting signs and symptoms may mimic those normally observed in pregnancy, including abdominal pain, nausea, vomiting, and anorexia.

“Physiologic anemia” in pregnancy in addition to mild leukocytosis. Additionally, there is typically a 10–15 bpm increase in pulse rate as well as relative hypotension

Appendicitis is the most common non-obstetrical cause of the acute abdomen,
complicating 1 in 1500 births . Rate of perforation is higher at approximately 25 %. If and when perforation occurs, risk of fetal/maternal mortality increases significantly.
Pain goes higher as uterus grows!! =>RUQ

USS/CT/MRI: American College of Obstetricians and Gynecologists (ACOG) consensus statement, “Women should be counseled that X-ray exposure from a single diagnostic procedure does not result in harmful fetal effects. Specifically, exposure to less than 5 rad (50 mGy) has not been associated with an increase in fetal anomalies or pregnancy loss” (One CT is 25 mGy)

Acute cholecystitis/pancreatitis

36
Q

What are the exotc causes of acute abdominal pain?

A

-typhoid enteritis
-abdominal tuberculosis
-parasitic infections
=acute intestinal obstructions
=appendicitis
=cholangitis,
=liver abscesses

37
Q

Describe typhoid fever

A

( by Salmonella typhii) is transmitted through fecal contamination of food or water supplies. If not identified and treated in a timely fashion with the appropriate antibiotics, typhoid can result in intestinal hemorrhage or perforation

38
Q

Describe parasitic infections

A

The majority of these were secondary to infections with members of the amoeba family, which can cause colitis and hepatic abscesses, or Ascaris lumbricoides , a species of roundworms that can invade and overwhelm the gastrointestinal and hepatobiliary systems, resulting in intestinal obstruction, appendicitis, pancreatitis, and cholecystitis

39
Q

What is the Montgomery ruling?

A

Any intervention must be based on a shared decision-making process, ensuring the patient is aware of all options and supported to make an informed choice by their healthcare professional

40
Q

What apps are used for risk scoring in EGS?

A

P-POSSUM
NELA SCORE
POTTER CALCULATOR
Risk prediction models developed from large populations of patients take little or no account of the actual surgical diagnosis and may over- or under-estimate the risk for an individual patient.

On occasion the estimate obtained using NELA or other models may differ significantly from an estimate of perioperative death made by experienced clinicians using their judgement alone.

However, clinicians’ judgement in emergency situations may be impaired by the limited time for preoperative assessment and reflection and the potential for information pertinent to risk assessment to go unnoticed.

41
Q

What is fragility?

A

a medical syndrome with multiple causes and contributors that is characterised by diminished strength, endurance and reduced physiologic function that increases an individual’s vulnerability for developing increased dependency and/or death

42
Q

Describe fragility

A

Although the frailty syndrome is not limited to the older population, it is positively associated with ageing

The over 70s represent 60% of the elective colorectal surgical and 45% of the emergency laparotomy population.

Recent studies confirm that frailty is present in a quarter of older adults presenting as a surgical emergency and is associated with poorer outcomes across elective and emergency surgery, including prolonged length of stay, increased level of dependency after surgery and increased morbidity and mortality, irrespective of whether surgery is performed

43
Q

What are the NELA recommendations?

A
  1. Mortality estimation using a risk score by a senior clinician (named by the RCS Eng. as ST3 or greater) and documented on the consent form
pPOSSUM, NELA Score
Lower risk (<5%), High risk (5-10%) and Highest Risk (>10%)
  1. Pre-operative review with Consultant Anaesthetist and Surgeon mortality risk >5%
  2. Rapid access to CT, with report

Prompt treatment of SEPSIS

Timely access to the emergency operating theatre

Consultant Anaesthetist and Surgeon in theatre if mortality risk >5%

Critical Care referral for all patients with mortality risk >5%, direct admission if >10%

Input from specialist Care of the Elderly teams for patients over 70

Gastrointestinal (48 decks)

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