Acute Abdomen Flashcards
Presentation of appendicitis?
Young 5-40 Acute onset Umbilical pain that moves central to RIF Staying still to avoid pain implies peritonitis
Signs for appendicitis?
Rovsings Copes -> pain on progressive flexion and internal rotation of the hip Psoas -> pain on hip extension (retrocaecal appendix) Rebound tenderness -> peritoneum involvement
Appendicitis Ix?
1st line = CT abdo, USS and bloods (leukocytosis and increased CRP) Use alvarado score for signs symptoms and lab values 1-4 = doscharge 5-6 observe and 7-10 = surgery
Management of appendicitis?
Cefotaxime and metronidazole as Abx Appendicectomy
A=
B = Paramedian (kidneys, adrenal, spleen)
C= Subcostal (GB, biliary tract, spleen)
D= chevron (gastrectomy, bilateral adrenealectomy)
E= loin (kidneys)
F = Mcburneys
G = Lanz (appendicectomy with better scar healing)
H = Pfannenstiel (caesarian, Lower GiT, Urinary tract
Complications of appendicitis?
Perforation (common on faecolith + kids)
Appendix mass (inflamed can be covered in omentum)
Appendix abscess
What classification is used for diverticular disease and stages?
Hinchey classification
1a: phlegmon
1b and 2: localised abscess
3: perforation with purulent peritonitis
4: faecal peritonitis
Presentation and aetiology of diverticular disease?
5o -70YO, asymptomatic life, LOW DIETARY FIBRE, smoker, NSAIDS
Bloody stool, fever, N+V, anorexia, urinary symptoms (fistulation to bladder = pneumaturia,faeculuria and recurrent UTIs)
LIF pain and bloating
Most common in sigmoid
Inspection and palpation of diverticular disease?
Tachycardia and low grade pyrexia. peritonits (lying still)
LIF tenderness and guarding, riity and rebound tenderness
Diverticular Ix?
Acute: CT abdo +- erect CXR for perforation
Chronic diverticulosis: barium enerma +- flexi/colonoscopy
Bloods (RBC,CRPclotting)
Dont do barium enema if perfration suspected
Diverticular management?
Mild Itis: PO Abx
Severe Itis: IV Abx + fluids + rest
Surgical = Hartmanns (gives end colostomy and anorectal stump)
Diverticolosis: soluble, high fibre diet and maybe primary anastomosis for surgery (may have a defunctioning loop ileostomy to allow anastamosis to heal). This can also be used for rectal carcinomas and distal large bowel cancers
Complications of diverticular disease?
Diverticulitis, faecal peritonitis, Fistulas and peri-colic abscess, colonic obstruction and perforation
Where do spigelian hernias occur?
On linea semilunaris of the abdomen
Hernia aetiology and presentation?
Age, obseity, constipation, chronic cough, heavy lifting (general increased intra-abdominal pressure)
Lump in groin
Groin pain
Vomiting
Scrotal swelling
Differences between femoral and inguinal hernias?
Femoral more common in femals and more commonly strangulated. Surgery recommended and in lder people
Inguinal more common overall, less commonyl strangulated, can be treated withut surgery and in younger people
Femoral canal borders?
Anterosuperiorly by inguinal ligament
Posterior : pectineal ligament lying anterior to sup. pubic ramus
Medial: lacuna ligamen
Lateral: femoral vein
Inguinal canal borders?
Anterior: aponeurosis of external oblique + internal oblique laterally
Posterior: transversalis fascia
Roof: Transversalis fascia, internal oblique an dtransversus abdominius
FLoor: inguinal ligament thickened medially by lacunar ligament
Where do direct inguinal hernia pass through?
Hesselbachs triangle
Rectus abdominis, inf. epigastric vessels and inguinal ligament
How to check between direct and indirect?
1) reduce hernia
2) place finger over deep inguinal ring(just above midpoint of inguinal ligament)
3) ask patient to cough and see if it re-appears
If not sure = USS
Aetiology and presentation of acute pancreatitis?
GET SMASHED
Gallstone and alcohol intake
Epigastric ain, pain radiates to the back and releived sitting forwar, pain worst n movement
I GET SMASHED?
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion venom
Hyerpcalcaemia,lipidaemia
ERCP
Drugs
Signs of acute pancreatitis?
Epigastric tenderness
Fever
Reduced bowel sounds
Shock, tachycardia and tachypnoea
Cullens (umbilical)
Grey-turners
Ix for acute pancreatitis?
Serum amylase (3x upper limit)
Serum lipase
USS (determine aetiology)
Erect CXR or CT abdo
WHat indicates worse pronosis in acute pancreatitids?
Very low calcium as normal supports hypercalcaemia aetiology
Acute pancreatitis management?
Supportive, enzyme supplementation and diabetes medication
ERCP to remove gallstones
SAME FOR CHRONIC
Chronic pancreatitis aetiology and presentation?
GET SMASHED
Alcohol &0% and idiopathic 20%
Longer symptom Hx than acute
Recurrent epigastric pain (15-30 meals post-prandially)
T2DM
Steatorrhoea
Pain releived sitting ofrward
Chronic pancreatitis IX?
1st line = CT abdo -> pancreatitic calcification
AXR-> pancreatitic calcification (less accurate)
Faecal elastatse
How to differentiate between chronic and acute pancreatitis?
Faecal elastase increased in chronic and normal in acute.
Serum amylase increased in acute and normal in chornic
Causes of intestinal obstruction?
Adhesions, hernias, tumours, volvulus and intussusception
Obstruction aetiology and presentation?
Malignancy Hx, hernia Hx, surgical Hx e.g. scars on exam
Diffuse pain
Constipation
Vomiting (SBO)
ABdo distension
Signs of Obstruction?
Abdo distension and pyrexia, sweting
Tinkling or absent bowel sounds
AXR obstruction signs?
Caecal volvulus = embryo,comma
Sigmoid = coffee bean
Riglers Sign = see lining as air on both sides -> perforation
Intestinal obstruction managment?
Drip and suck (NG)
Rigid sigmoidoscope decompresion (sigmoid volvulus)
Laparatomy
Areas at risk of intestinal ischaemia?
Right colon (poor perfusion from MAD)
Splenic flexure (griffiths) as MAD
Rectosigmoid Junction (sudeks)
Differnces between mesenteric ischaemia and ischaemic colitis?
MI: Small bowel, occlusive > non-occlusive, sudden and severe symptoms, urgery open laparotomy management and high mortality
IC: Large bowel, Non-occlusive>occlusive, transient claudication symptoms, conservative managemnt (fluids and bowel rest) and majority recover
Mesenteric ischaemia presentation and aetiology?
old, CVS disease
Occlsuive: AF, cocaine and smoking
Non-occlusive: trauma
Sudden onset diffuse abdo pain, N&V and diarrhoea
Mesenteric ischaemia and ischaemic colitis Ix?
1st AXR 2nd CT abdo -> perforation, megacolon or dilated
ABD -> lactic acidosis
Angiography
Colonoscopy
ECG
Management of Mesenteric ischaemia?
Occlusive (no gangrene) = thrombectomy or thrombolysis
Non-occlusive (no gangrene) = fluid resuscitation
Gangrene = laparotomy
Ischameic colitis aetiology and presentation?
old, CVS same occlusive and non occlsive reasons
Transient gut claudication, PR bleeding, post-prandial abdo pain and weight loss
Ischaemic colitis management?
Mainly supportive: IV FLuids and drip and suck if ileus
Lapaotomy if severe
