Acute Abdomen Flashcards by Ben Moore

Presentation of appendicitis?

Young 5-40 Acute onset Umbilical pain that moves central to RIF Staying still to avoid pain implies peritonitis

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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

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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

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Management of appendicitis?

Cefotaxime and metronidazole as Abx Appendicectomy

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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

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Complications of appendicitis?

Perforation (common on faecolith + kids)

Appendix mass (inflamed can be covered in omentum)

Appendix abscess

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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

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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

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Inspection and palpation of diverticular disease?

Tachycardia and low grade pyrexia. peritonits (lying still)

LIF tenderness and guarding, riity and rebound tenderness

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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

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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

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Complications of diverticular disease?

Diverticulitis, faecal peritonitis, Fistulas and peri-colic abscess, colonic obstruction and perforation

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Where do spigelian hernias occur?

On linea semilunaris of the abdomen

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Hernia aetiology and presentation?

Age, obseity, constipation, chronic cough, heavy lifting (general increased intra-abdominal pressure)

Lump in groin

Groin pain

Vomiting

Scrotal swelling

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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

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Femoral canal borders?

Anterosuperiorly by inguinal ligament

Posterior : pectineal ligament lying anterior to sup. pubic ramus

Medial: lacuna ligamen

Lateral: femoral vein

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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