Acute abdomen Flashcards
Acute abdo
What is appendicitis?
Inflammation of the appendix
What is the typical presentation of appendicitis?
Peri-umbilical pain that moves to the RIF (peritonitis)
Acute onset
5-40 yrs old
what is the aetiology of appendicitis?
Gut organisms invade the appendix after luminal obstruction
Leads to oedema, ischaemic necrosis, and perforation
What are the signs of appendicitis?
Epigastric pain (early) RIF pain (late) Peritonitis Rovsing's sign Cope's psoas sign Cope's obturator sign Rebound tenderness
What are the signs of peritonitis?
Keeps very still
Abdo pain upon movement
Rigid abdomen
Rebound tenderness- more pain on lifting up than pushing down
What is Rovsing’s sign?
Pain in RIF upon palpation of LIF
What is Cope’s psoas sign?
Pain upon extending the hip
seen only in retrocaecal appendices
What is Cope’s (obturator) sign?
Pain on passive flexion and internal rotation of the hip
What are the investigations for appendicitis?
Can be a clinical diagnosis
- USS – first line (especially transvaginal) if the differential includes gynaecological pathology
- CT- sensitive + specific, exclude other Ddx
- Bloods- leukocytosis, CRP
What is the scoring system for appendicitis?
ALVARADO SCORE for acute appendicitis
Looks at obs, pain and bloods
- discharge 1-4
- observe 5-6
- surgery 7-10
What is the management for appendicitis?
Appendectomy
Abx: Metronidazole and Cefotaxime
If appendiceal mass, antibiotic therapy is favoured, with an interval appendectomy 6-8 weeks later
What are the complications of appendicitis?
Perforation- more common with feacolith involvement (children)
Appendix mass- inflamed appendix becomes wrapped in omentum and forms a mass (wait to die down pre-surgery)
Appendix abscess- infected appendix walls off and forms an abscess
What is diverticular disease?
Diverticulosis associated with complications
What is diverticulosis?
Presence of diverticulae outpouchings of the colonic mucosa and submucosa throughout the large bowel
What is diverticulitis?
Acute inflammation and infection of a diverticulae
What is the classification of diverticular disease?
Hinchey classification Ia: phlegmon Ib/II: localised abscess III: perforation with purulent peritonitis IV: faecal peritonitis
What are the symptoms of diverticular disease?
Bloody stool LIF pain +/- bloating Fever N+V, anorexia Urinary symptoms- if there is a bladder fistula Peritonism- lying very still
What are the signs of diverticular disease?
LIF tenderness +/- bloating
Guarding, rigidity + rebound tenderness (peritonism)
Tachycardia, low grade pyrexia
What are the investigations for acute diverticulitis? What musn’t you do?
- CT abdomen
- erect CXR (?perforation- pneumoperitoneum)
- G+S/cross-match - if suspect surgery required
- bloods (FBC, CRP, clotting)
NEVER do barium enema in acute presentation- increased risk of perforation
What is are the 2 treatment options for an acute presentation of diverticular disease? (diverticulitis)
MILD = IV antibiotics + fluids + bowel rest
SEVERE (recurrent attacks/complications) = surgery
= Hartmann’s procedure
What is the treatment for a chronic presentation of diverticular disease?
(diverticulosis)
Soluble high-fibre diet
Anti-inflammatories eg. mesalazine
Surgery (if recurrent attack/complications)
-Primary anastamosis
What is Hartmann’s procedure?
Resection of the diseased bowel and an end-colostomy formation, with an anorectal stump.
When primary anastamoses are not possible ( inflammation)
What is a primary anastamosis? When is it contraindicated?
Resection of the diseased bowel and anastamoses of the two resected ends
To protect the anastomosis and allow it to heal, adefunctioning(loop) ileostomymay be used to divert bowel contents away from the primary anastomosis
contraindicated in acute infection/inflammation- oedema in bowel –> anastamoses will leak when inflammation subsides
What are the complications of diverticular disease?
Diverticulitis (high recurrence rate) Faecal peritonitis Fistulas Peri-colic abscess (faecolith) Colonic obstruction Perforation
What is the definition of a hernia?
a condition in which part of an organ is displaced and protrudes through the wall of the cavity containing it
What are the symptoms of a hernia?
Groin lump
Groin pain
Vomiting
Scrotal swelling
What is a strangulated hernia?
An ischaemic hernia due to a constriction around the vasculature
RF for hernias
male sex
old age
smoking
family history
increasing intra-abdominal pressure: obesity, chronic cough, heavy lifting, constipation
connective tissue disorders (Marfan, Ehlers-Danlos)
Which hernia is more often strangulated, hence requiring surgery?
Femoral hernias
What are the signs of a hernia?
Appears/swells on coughing
Reducible via supination/pressure
STRANGULATED HERNIA: tender, red, colicky, abdo pain, distension, vomiting
What are the borders of Hesselbach’s triangle?
LATERAL: Inferior epigastric vessels
INFERIOR: Inguinal ligament
MEDIAL: Lateral border of rectus abdominis
What are the differences between direct and indirect inguinal hernias?
Direct:
- medial to the IE vessels
- enters through Hesselbach’s triangle (weakness in abdominal wall)
Indirect:
- lateral to the IE vessels
- passes through the inguinal canal due to a failure of embryonic closure of the processus vaginalis
How can you clinically differentiate between a direct and indirect inguinal hernia?
- Reduce the hernia
- Place a finger over the deep inguinal ring (just above midpoint of inguinal ligament)
- Ask patient to cough and if the hernia re-appears, it cannot be an indirect hernia (must be direct)
What are the investigations for a hernia?
Mostly a clinical diagnosis
Can do USS
What is the management for a femoral hernia?
Surgical repair- mesh
femoral = emergency, inguinal = elective
What is the management for an inguinal hernia?
Reassurance
Elective surgery
What is pancreatitis?
Inflammation of the pancreas, can be both acute or chronic
What are the symptoms of acute pancreatitis? (give on differential)
Epigastric pain Radiating to the back Relieved on sitting forwards Pain worst on movement (DDx = AAA- except no hypovolaemic signs)
What are the causes of acute pancreatitis?
GET SMASHED
Gallstones- most common Ethanol- most common Trauma Steroids Mumps/Malignancy Autoimmune Scorpion venom Hyperlipidaemia/calcaemia/parathyroidism ERCP Drugs eg. thiazides
What are the signs of acute pancreatitis?
Epigastric tenderness
Fever
Shock
Tachycardia/tachypnoea
Reduced bowel sounds (peritonitis, ileus)
Cullen’s sign + grey-Turner’s sign (due to intra-abdominal bleeding from pancreatic inflammation)
What is Cullen’s sign?
Umbilical bruising
What is Grey-Turner’s sign?
Flank bruising (have to turn to see it)
What is Fox’s sign?
Bruising over the inguinal ligament
What are the investigations for acute pancreatitis?
Bloods- amylase, lipase, FBC, X-match
USS- aetiology- gallstones
Erect CXR/AXR- ?pleural effusion, perforations
CT- exclude other causes
What is the scoring system for pancreatitis?
Modified Glasgow Score
What does PANCREAS stand for in the Modified Glasgow Score and what is the minimum score for a severe rating?
PaO2: <7.9kPa Age: >55 Neutrophils: >15x10^9/L Calcium: <2mmol/L Renal function: >16mmol/L Enzymes: LDH >600U/L; AST >200U/L Albumin: <32g/L Sugar: >10mmol
Severe: >3
Management of acute pancreatitis
MEDICAL:
Supportive: Fluid balance, catheter and NG tube, analgesia, glucose control
enzyme supplementation
diabetes medications
SURGERY:
ERCP for gallstones
Catheter drain/necrosectomy
What are the symptoms of chronic pancreatitis?
Recurrent post-prandial epigastric pain Relieved on sitting forwards T2DM WL, bloating, steatorrhoea note: symptoms may be acute on chronic
What are the signs of chronic pancreatitis?
Epigastric tenderness Cullen's sign Grey-Turner's sign Fox's sign Signs of complications
What are the investigations for chronic pancreatitis?
1st line- CT abdo- look for pancreatic calcification (pathoneumonic)
AXR- pancreatic calcification (less sensitive)
Faecal elastase (raised- normal in acute)
Serum amylase will be NORMAL
What is the management of chronic pancreatitis?
As for acute (supportive, analgesia)
May be more dependent on enzyme supplementation _ diabetes medications
ERCP if gallstone aetiology
What are the complications for chronic pancreatitis?
Pseudocysts Duodenal obstruction Pancreatic ascites Pancreatic necrosis- due to autodigestionof pancreatic tissue by pancreatic enzymes Systemic – diabetes, steatorrhea
What are the symptoms of intestinal obstruction?
Diffuse pain
Constipation
Vomiting (SBO)
Abdominal distension
What are the risks for intestinal obstruction?
SBO
- Adhesions from prior operations (most common cause in western world)
- Malignancy
- Hernia- strangulated/incarcerated
LBO
- Colorectal malignancies
- Sigmoid/caecal volvulus
- Paralytic Ileus
- Postoperative ileus
What are the signs for intestinal obstruction?
Abdominal distension
Pyrexia/sweating (potential perforation/infarction)
High pitched, tinkling bowel sounds on auscultation
OR absent bowel sounds
What are the investigations for an intestinal obstruction?
- AXR- ?volvulus, ?malignancy
- CT to confirm
- Bloods- FBc, U+E, X-match
what is the rule for normal bowel sizes?
3, 6, 9
3cm- small bowel
6cm- large bowel
9cm- caecum
What is the management for an intestinal obstruction?
Drip and suck (IV drip and NG tube- not a feeding tube, Rile’s tube is stiffer)
Rigid sigmoidoscope decompression
(sigmoid volvulus)
Conservative if volvulus decompresses
Laparotomy (caecal volvulus, other SBO/LBO)
What is intestinal ischaemia?
Impaired bloodflow to the intestine, resulting in ischaemia of the bowel wall
What are the symptoms of acute intestinal ischaemia?
Sudden onset diffuse pain
N+V
diarrhoea
What are the risk factors of acute intestinal ischaemia?
Old age
Cardiovascular disease
OCCLUSIVE
- AF- most common- thromboemboli
- Thrombus from atherosclerosis
- Cocaine use
- Smoking
NON-OCCLUSIVE
- Trauma causing hypotensive state -eg. car accidents
- Mesentery take between 20-25% of CO –> very prone to ischaemia with hypovolaemia
What are the signs of acute intestinal ischaemia?
Can be NORMAL
Diffuse abdo pain
Shock signs
What are the investigations for acute intestinal ischaemia?
AXR- perforation, megacolon, Rigler sign, dilation
ABG- lactic acidosis
Angiography- use dye to show blockages
Colonoscopy- ischaemic bowel + rule out other pathology
ECG- look for MI/AF
What are the symptoms of chronic intestinal ischaemia?
Intermittent gut claudication
Post-prandial pain
PR bleed
Weight loss - due to malabsorption
What are the risk factors of chronic intestinal ischaemia?
Old age
Cardiovascular disease
Heart failure
What are the signs of acute intestinal ischaemia?
Can be normal
PR bleed on DRE
What are the investigations for chronic intestinal ischaemia?
1st AXR, 2nd CT abdo (perforation, megacolon, dilated) ABG Angiography ECG colonoscopy (same as acute really)
A nervous 16-year-old college student attends the local A&E department with her boyfriend, complaining of an episode of sudden onset right-sided pain in her abdomen. Physical examination of the patient is unremarkable except from a small scar located near the inguinal ligament. What is the most appropriate first line investigation in this case?
A. USS of the abdomen B. 𝞫-hCG test C. Full blood count D. CT scan of the abdomen E. No investigations, immediate surgery
B. 𝞫-hCG test
Scar indicates likely appendectomy Hx
Risk of pregnancy
1st line investigation in female with acute abdo is pregnancy test
A 26-year-old professional rugby player presents to the A&E department with abdominal pain in the umbilical area. On initial inspection, the gentleman is feverish with a temperature of 38C and a BP of 115/90. The admitting doctor suspects a diagnosis of appendicitis from the history and performs an abdominal physical examination and passively extends the gentleman’s right hip which elicits pain. Which eponymous sign of appendicitis is being demonstrated here and what does it represent?
A. Cope’s sign, and a retrocaecal appendix
B. Psoas sign, and a retrocaecal appendix
C. Psoas sign, and an appendix located next to obturator externus
D. Rovsing’s sign, and a retrocaecal appendix
E. Rovsing’s sign, and an appendix located next to obturator externus
B. Psoas sign, and a retrocaecal appendix
A feverish 56-year-old woman attends her GP complaining of a sudden appearance of bloody stools. She adds that she has experienced a few episodes of bloody stools before but did not seek medical attention and apart from a fever, she has had no other constitutional symptoms. The GP notes that the patient’s diet is particularly low in fibre and on physical examination, tenderness is found on pressure to the LIF. A DRE shows fresh blood upon removal of a gloved finger. What is the most likely diagnosis?
A. Angiodysplasia B. Diverticulosis C. Diverticulitis D. Mallory-Weiss tear E. Gastroenteritis
C. Diverticulitis
A feverish 65-year-old is brought to the local A&E department by her daughter. She complains about nausea, LIF pain and vomiting. The attending doctor takes a full history and performs an abdominal examination and subsequently makes a diagnosis of acute diverticulitis with some associated signs of peritonism. A erect AXR is taken which shows some air under the diaphragm. What is the most appropriate surgical procedure?
A. Hartmann’s procedure B. Primary anastomosis C. Colectomy and end-ileostomy formation D. Delorme’s procedure E. Whipple’s procedure
A. Hartmann’s procedure
in acute, cannot do a primary anastamoses
C is an alternative but this would be overkill to remove entire colon
Whipple is for pancreatic cancer
A 26-year-old bodybuilder attends the local day-surgical clinic upon referral from his GP due to a groin lump. The general surgical registrar suspects a hernia and so performs a simple test to ascertain the type of hernia to determine the most appropriate management. The doctor reduces the hernia and then places their finger over the deep inguinal ring. The patient is asked to cough and the hernia does not reappear. What is the most likely type of hernia?
A. Femoral hernia B. Direct inguinal hernia C. Indirect inguinal hernia D. Spigelian hernia E. Hiatus hernia
C. Indirect inguinal hernia
placing finger over deep inguinal ring obstructs channel.
Which of the following may be raised in chronic pancreatitis?
A. Amylase B. Calcium C. Faecal elastase D. Albumin E. Haematocrit
C. Faecal elastase
Which of the following is not a cause of acute pancreatitis?
A. Mumps B. Hypocalcaemia C. Thiazide drugs D. Trinidad scorpion bite E. Steroids
B. Hypocalcaemia
An overweight 65-year-old woman visits her general practitioner with discomfort in her right groin. On examination, the suggestion of a reducible groin lump is noted. She is routinely referred to the surgical outpatient clinic with a possible diagnosis of inguinal hernia. However, two weeks later and before her surgical appointment, she again visits her general practitioner, this time with vomiting, diarrhoea, and colicky abdominal pain. What is the next most appropriate management step?
A. Administer antibiotics B. Give IV fluids C. Insert an NG tube D. Give IV fluids and insert an NG tube E. Administer an enema
D. Give IV fluids and insert an NG tube
A 70-year-old gentleman presents to the A&E department with sudden-onset severe diffuse abdominal pain. Observations are taken in the ambulance which show an irregularly irregular pulse rate of 130 and a blood pressure of 76/60mmHg. An abdominal X-ray is performed as soon as possible which shows the Rigler sign and the physician diagnoses an acute form of mesenteric ischaemia with perforation. What is the most likely cause for the acute onset of the mesenteric ischaemia?
A. Atherosclerotic disease B. Embolism C. Thrombosis D. Polycythaemia vera E. Idiopathic
B. Embolism
Name the incisions used in appendectomy
McBurney’s/gridiron: oblique incision made two thirds of the way from the umbilicus to the right anterior superior iliac spine
Lanz: transverse incision across McBurney’s point (better scar healing)
Diverticulitis RF
50-70yo Asymptomatic life Low dietary fibre Smoker NSAIDs
Investigations for chronic diverticulosis
- barium enema
2. +/- flexible sigmoidoscopy/colonoscopy
Indications for loop ileostomy?
Divert bowel contents way from distal bowel anastamoses
allows bowel to rest + heal
eg after cancer/diverticulae resection
Explain the aeitiology of diverticulitis
A low fibre diet can lead to loss of stool bulk, consequently high pressures are required to expel the stool, leading to herniations through the muscularis at weak points
Pathogenesis: most common in sigmoid colon; can be obstructed with stool, leading to bacterial overgrowth, injury and diverticulitis
Urinary complication + signs of diverticulitis
Diverticular fistulation into the bladder:
pneumaturia
faecaluria
recurrent UTIs
Define hiatus hernia
protrusion of intra-abdominal contents through an enlarged oesophageal hiatus of the diaphragm
Define Spigelian hernia
hernia occurs on the linea semilunaris of the abdomen
Most common type of hernia
inguinal
which hernia is more common in females?
femoral
which hernia is more commonly strangulated?
femoral- therefore surgery recommended
When is a hernia classified as strangulated?
the compression around the hernia prevents blood flow into the hernial contents causing pain + ischaemia to the tissues
define incarcerated hernia
the hernia is compressed by the defect causing it to be irreducible (i.e. unable to be pushed back into its original position)
define obstructed hernia
refers mainly to hernias containing bowel
contents of the hernia are compressed to the extent the the bowel lumen is no longer patent
causes bowel obstruction
How to we discern between femoral and inguinal hernias?
FEMORAL = lateral & inferior to pubic tubercle INGUINAL = superior & medial to public tubercle
contents of femoral versus inguinal hernia
FEMORAL = omentum INGUINAL = bowel
2 enzymes tested for in acute pancreatitis
serum amylase- >3x upper limit normal (normal in chronic)
serum lipase - more sensitive/specific
Which electrolyte/mineral drops in acute pancreatitis and why?
serum calcium drops in acute pancreatitis due the sequestering of free Ca2+ by free fatty acids
What 2 things does a low calcium in pancreatitis tell us?
very low Ca2+ has a worst prognosis
normal Ca2+ supports an aetiology of hypercalcaemia causing the pancreatitis
How may the history of chronic pancreatitis be different to that of acute?
chronic = 70% alcoholic acute = more likely gallstones
Longer symptom history, recurrent episodes
Prognosis chronic + acute pancreatitis
Chronic = reduces life expectancy by 10-20 years
Acute =
20% run severe course with 70% mortality
80% run milder with 5% mortality
What might you see on AXR in intestinal obstruction?
Rigler’s sign- indicated pneumoperitoneum
Volvulus- caecal/sigmoid (folding of abdomen)
How do you differentiate between large and small bowel on AXR?
SBO = valvulae conniventes (mucosal folds full width of bowel). CENTRAL LBO = haustra (pouches protruding partway across lumen). PERIPHERAL
Comma sign indicates what?
caecal volvulus
coffee bean sign indicates what?
sigmoid volvulus
Rigler’s sign indicates what?
air both sides of the bowel wall (pneumoperitoneum) –> perforation
Prognosis SBO
Mortality at 25% with delayed surgery >36 hours; drops to 8% at <36 hours
Name the terms given to small versus large bowel ischaemia
Small bowel = mesenteric ischaemia
Large bowel = ischaemic colitis
Which 3 blood vessels supply the bowels?
Coeliac trunk (oesophagus, stomach and duodenum) SMA: duodenum, jejunum, ileum, large colon up to splenic flexure IMA: descending colon to rectum
Differentiate between mesenteric ischaemia and ischaemic colitis in terms of : causes symptoms management prognosis
MESENTERIC ISCHAEMIA more commonly occlusive cause (thromboembolic) acute, severe onset surgical emergency (open laparotomy) ^ mortality
ISCHAEMIC COLITIS
more commonly non-occlusive cause (hypoperfusion, hypercoagulable states)
transient claudication (eg post prandial)
conservative management- bowel rest, fluids
good prognosis- majority recover
What spinal levels are the IMA and SMA at?
SMA- L1 (duodenum –> splenic flexure)
IMA- L3 (everything else)
Which part of the bowel are most vulnerable to ischaemia due to hypoperfusion?
SPLENIC FLEXURE(Griffith’s point)
marginal artery of Drummond is occasionally tenuous here and is absent in 5% people
(means small area has no vasa recta)
RIGHT COLON
supplied by marginal artery of Drummond (underdeveloped in 50% population)
RECTOSIGMOID JUNCTION
Sudek’s point - most distal connection to collaterals
Management of mesenteric ischaemia (occlusive vs non-occlusive)
OCCLUSIVE, NO GANGRENE
thrombectomy, thrombolysis
NON-OCCLUSIVE, NO GANGRENE
fluid resuscitation- they have hypoperfusion causing the ischaemia
GANGRENE- laparotomy. Bowel is dead.
Management of ischaemic colitis
supportive (mainly medical, unlike mesenteric ischaemia)…
IV fluids
drip and suck (if ileus)
If gangrene- laparotomy
