ACUTE ABDOMEN Flashcards
What is the scoring system used for appendicitis?
Alvarado score
Which medications is it important to give prior to surgery for appendicitis?
IV metronidazole and IV cefuroxime
What key differential for appendicitis should you always mention?
Meckels diverticulum
What are the 3 main types of bowel ischaemia?
- Acute mesenteric ischaemia
- chronic mesenteric ischaemia
- ischaemic colitis
What are the anatomical landmarks of the foregut, midgut and hindgut?
- foregut- distal oesophagus to ampulla of vator
- ampulla of vator to 2/3 along transverse colon
- 2/3 transverse colon to rectum
What is the supply to the foregut, midgut and hindgut?
- foregut- coeliac trunk
- midgut- superior mesenteric artery
- hindgut- inferior mesenteric artery
What is the gold standard for diagnosing acute mesenteric ischaemia?
Angiography
What is the triad of acute mesenteric ischaemia?
- Gut emptying
- Cardiac disease
- Acute abdo pain
What are the two common medical options for acute mesenteric ischaemia?
- thrombolytics via an angiogram catheter
- heparin for mesenteric venous thromboembolism
Chronic mesenteric ischaemia is often referred to as bowel angina. Name 3 options for surgical management of CMI
- Transaortic endarterectomy of the coeliac or superior mesenteric artery
- bypass grafting
- angiography and stenting
What is the definition of ischaemic colitis?
Caused by compromise of the blood supply to the colon, most commonly affecting the splenic flexure
What is the most common cause of ischaemic colitis?
Atheroma of the mesenteric arteries
Is ischaemic colitis often managed medically or surgically?
Medically, except in cases of necrosis
Bowel obstruction can be broadly differentiated into what two classifications?
- Static BO occurs due to a failure of peristalsis
- Dynamic occurs due a failure of passage
What anatomical marking can be seen on the small bowel? Does it traverse the entirety of the bowel?
Valvulae conniventes
Yes
What anatomical markings can be seen on the large bowel?
Do they traverse the entire distance?
- Haustra
- No
The causes of mechanical obstruction can be divided into what?
- Extraluminal
- Transmural
- Intraluminal
Give two causes of
- intraluminal
- transmural
- extraluminal
mechanical obstruction
- intraluminal
- foreign body
- faecal impaction
- transmural
- neoplasm
- stricture
- fistula
- extraluminal
- adhesion
- neoplasm
- pregnancy
- hernia
- volvulus
Give 3 common causes of small bowel obstruction
- adhesions
- hernias
- strictures
- foreign bodies
Give 3 common causes of large bowel obstruction
- neoplasm
- stricture
- faecal impaction
- sigmoid or caecal volvulus
What is a closed loop bowel obstruction and why is it dangerous?
Closed loop bowel obstructions occur where the ileo-caecal valve remains competent, therefore there can be no decompressionof bowel contents into the small bowel, This is more dangerous as it is more likely to perforate
Give 3 causes of a paralytic ileus
- post-op
- peritonitis
- trauma
- other acute abnormalities
What are the 4 cardinal features of intestinal obstruction?
- vomiting (may be faecalent)
- colicky pain, this is usually diffuse and central. In paralytic ileus pain is usually absent
- complete constipation
- distension
What is the classic ward based management of bowel obstruction?
- Ng tube insertion for decompression
- Copious IV fluids
In acquired diverticulosis the lack of collagen weakens the (1), meaning that there are small herniations of (2) through the (3). This is typically adjacent to (4) and (5)
- muscularis propria
- mucosa
- muscularis
- terminal artial branches
- taenia coli
WHat 3 imaging studies should be acquired in suspected diverticulitis?
- erect CXR
- axr
- Contrast enhanced CT
What is the primary management option for acute uncomplicated diverticulitis? (3 components)
- IV broad spec ABx (co-amoxiclav)
- NBM
- Analgesia
Why is Hartmann’s generally preferred in cases of diverticulitis induced perforation?
Colostomy reversal
What is the defintion of a hernia?
- protrusion of a viscus through its containing wall into an abnormal position
What is the relation of the femoral hernia to the pubic tubercle?
Inferolateral
The iguinal canal runs parallel to what other structure?
the inguinal ligament
the internal ring of the inguinal canal lies at what anatomical point?
The mid-inguinal point
the inguinal canal will contain which structures in a male?
- spermatic cord
- testicular artery
- vas deferens artery
- genital nerve
- ilioinguinal nerve
- pampiniform plexus
- vas deferens
- lymphatics
the inguinal canal will contain which structures in a female?
- round ligament
- genital branch of genitofemoral nerve
- iliolingual nerve
Which is more common: indirect or direct inguinal hernias?
Indirect
Through which anatomical area do direct hernias puncture through? What are it’s borders?
- Hasselbach’s triangle
- rectus, inguinal ligament, inferior epigastric artery
Which type of inguinal hernia rarely goes into the scrotum?
Direct
What simple physical exam can be used to distinguish direct vs indirect inguinal hernias?
- reduce the hernia
- occlude the deep inguinal ring
- indirect hernias will not represent
- direct hernias will
What are the anatomical borders of Calot’s triangle?
- Calot’s triangle is orientated so that its apex is directed at the liver. The borders are as follows:
Medial – common hepatic duct.
Inferior – cystic duct.
Superior – inferior surface of the liver.
- What are the 3 types of gallbladder stones? what are their relative percentages?
- Cholesterol 80%
- Pigment 10%
- Mixed 10%
What is the most common site of obstruction in acute cholecystitis?
The neck contains a mucosal fold, known as Hartmann’s Pouch. This is a common location for gallstones to become lodged, causing cholestasis.
What is the gold standard investigation for cholecystitis?
- USS RUQ
As well as surgery wat medical management should be initiated in patients in acute cholecystitis?
- broad spec abx (ceftriaxone) + gram negative cover (metronidazole)
- Pain relief
patients should present in what period of time to get an urgent cholecystectomy? If they wait beyond this time how long will hey have to wait for an elective cholecystectomy?
- 72 hours
- 6 weeks
ca19-9 is a useful cancer biomarker for what two intra-abdominal malignancies?
- cholangiocarcinoma
- pancreatic cancer
What is Charcot’s triad?
What is it indicative of?
- ruq pain, jaundice, fever/rigor
- cholangitis
If surgery is contraindicated in cases of cholecystitis what treatment can be offered?
medical dissolution of cholesterol stones using MTBE ( direct infusion into the gallbladder) or ursodeoxycholic acid (oral)
What is SIRS?
What is the criteria to diagnose SIRS?
The introduction of SIRS was intended to define a clinical response to a non-specific insult, either infectious or non-infectious in origin. SIRS is defined as 2 or more of the following:
- Fever >38◦C or < 36◦C
- Heart rate >90 beats per minute
- Respiratory rate >20 breaths per minute or PaCO2 <32 mm Hg
- Abnormal white blood cell count (>12,000/mm3 or <4,000/ mm3 or >10% bands)
SIRS can be incited by ischemia, inflammation, trauma, infection or a combination of several “insults”. SIRS is not always associated with infection. These terms suggest organ dysfunction or refractor hypotension not related to an infectious etiology, but rather an ischemic, traumatic or inflammatory process. .
What test is commonly used to make a diagnosis of acute pancreatitis?
What test should be used?
- Amylase
- Lipase (often not available)
What is the scoring criteria for pancreatitis?
What scores correlate to mild moderate and severe pancreatitis?
- Glasgow score
- Mild 0-1
- Moderate 2
- Severe >3
Outline the basic principles of managing pancreatitis
- Analgesia- usually morphine
- Antiemetics
- IV crystalloid fluids (2L in 2 hours) + input/output fluid monitoring
- Oxygen
- Enteral nutrition whenever possible but TPN when required
- Alcohol aetiology- chlordiazepoxide + pabrinex
- Abx such as meropenem in cases where there is concurrent acute cholecystitis
Name at least 3 immediate complications of acute pancreatitis
Hypoglycaemia
Hypocalcaemia
AKI
ARDS
Name at least 3 complications of acute pancreatitis which may present 5-7 days following onset of symptoms
Acute haemorrhage
Pancreatic necrosis
Pseudocyst
pancreatic abscess
Sepsis
VTE
name at least 3 delayed complications of acute pancreatitis
- pseudocyst
- chronic pancreatitis
- diabetes mellitus
Name at least 4 causes for the development of peptic ulceration
- H pylori infection
- medications (NSAIDs, steroids, SSRIs)
- Smoking and alcohol
- Stress
- Zollinger Ellison syndrome (gastrinoma)
What are the indications for upper GI endoscopy in GORD?
- age > 55 years
- symptoms > 4 weeks or persistent symptoms despite treatment
- dysphagia
- relapsing symptoms
- weight loss
What two options are there for assessing if a patient has h pylori infection?
- Urea breath test
- stool antigen test
what is the gold standard investigation for nephrolithiasis?
Helical CT KUB Non-enhanced
What are the 5 main types of kidney stones?
- Calcium based
- struvite
- urate
- cysteine
- infection
Which 3 points are especially likely to lodge a kidney stone?
The ureteropelvic junction (UPJ), the ureteral crossing of the iliac vessels, and the ureterovesical junction (UVJ).
Which investigation is recommended for patients with first time renal colic?
Stone analysis
What are the principles of management for renal colic? What is the size cut off of stone?
Patients with renal stones will often be dehydrated, secondary to reduced oral fluid intake +/- vomiting, so ensure adequate fluid resuscitation if required.
For the majority of cases, renal stones will pass spontaneously without further intervention*, especially if in the lower ureter or <5mm in diameter. Ensuring patients have sufficient analgesia is paramount, specifically opiate analgesia and NSAIDs per rectum typically being the most effective.
Any evidence of significant infection or sepsis present warrants intravenous antibiotic therapy and urgent referral to the urology team.
*Use of alpha receptor antagonists, such as Tamsulosin, largely has a limited benefit in ureteric stones and is no longer routinely prescribed
Patients with any evidence of obstructive nephropathy or significant infection may warrant stent insertion or a nephrostomy. For these patients, the obstruction must be immediately relieved to avoid renal damage; neither options are definitive, however can temporarily relieve the obstruction prior to definitive management.
Retrograde stent insertion is the placement of a stent within the ureter, approaching from distal to proximal via cystoscopy (Fig. 4). It allows the ureter to be kept patent and temporarily relieve the obstruction.
A nephrostomy is a tube placed directly into the renal pelvis and collecting system, relieving the obstruction proximally (Fig. 5). If required, an anterograde stent can subsequently be passed via the same tract made.
Name 3 definitive management options for nephrolithiasis
- Extracorporeal Shock Wave Lithotripsy (ESWL) involves targeted sonic waves to break up the stone, to then be passes spontaneously. This is typically reserved for small stones (<2cm), performed via radiological guidance (either X-ray or ultrasound imaging). Contra-indications include pregnancy or stone positioned over a bony landmark (e.g. pelvis).
- Percutaneous nephrolithotomy (PCNL) is used for renal stones only, being the preferred method for large renal stones (including staghorn calculi). Percutaneous access to the kidney is performed, with a nephroscope passed into the renal pelvis. The stones can then be fragmented using various forms of lithotripsy.
- Flexible uretero-renoscopy (URS) involves passing a scope retrograde up into the ureter, allowing stones to be fragmented through laser lithotripsy and the fragments subsequently removed.
What special advice should be given to individuals with the following types of renal stones?
- Oxalate
- Calcium
- Urate
- Cystine
- Oxalate stone formers should be advised to avoid high purine foods and high oxalate foods (such as nuts, rhubarb, and sesame)
- Calcium stone formers should have PTH levels checked to exclude any primary hyperparathyroidism and avoid excess salt in their diet
- Urate stone formers should be advised to avoid high purine foods (such as red meat and shellfish) and may need to be considered for urate-lowering medication (e.g. allopurinol)
- Cystine stone formers may warrant genetic testing for underlying familial disease
What is the management of simple UTI?
Nitrofurantoin 50mg QDS 3/7
What is the management of uncomplicated pyelonephritis?
Ciprofloxacin 500mg BD for 1/52
What is the management in patients with complicated pyelonephritis?
- Crystalloid fluids
- Adequate analgesia
- IV ABx (IV aminopenicillin +/- aminoglycoside or IV cephalosporins)
What is the size definition of an AAA?
>3cm
How frequent are ultrasounds for AAA<5.5cm?
3/12
Give 3 indications for elective surgery on a AAA
- AAA>5.5cm in men
- AAA>5 in women
- AAA growing by >0.5cm/y
What are the 3 management options for ectopic pregnancy?
- Watchful waiting (rare)
- Methotrexate IM
- Surgical removal
Which two antibiotics are given in suspected or confirmed mild-to-moderate PID?
Doxicycline and ceftriaxone
