acute abdomen

Question 1

74 y.o. woman presents with severe pain in her LIF

febrile, tachycardic, raised WCC

(a) what systemic clinical syndrome is present as a result of the abdominal problem?

Answer 1

Systemic Inflammatory Response Syndrome (SIRS)

Question 2

on examination, there is peritonism localised to the LIF

(b) list 3 important ddx

Answer 2

1. acute diverticulitis
2. ischaemic colitis
3. sigmoid volvulus
4. IBD
5. locally perforated sigmoid CA
6. pyelonephritis
7. leaking AAA

Question 3

(c) list 4 differential components of your initial mx of this pt

Answer 3

1. assess need for resuscitation using ABCDE
2. analgesia
3. bowel rest i.e. NBM + IV fluids
4. IV broad spectrum abx as per local guidelines

Question 4

(d) what single ix could best clarify the dx?

Answer 4

abdominal CT with contrast

^{NOT colonoscopy / Ba enema in acute phase due to risk of perforating acutely inflamed colon}

Question 5

(e) the following morning, her signs have progressed and she has generalised peritonitis.

at laparotomy, sigmoid colon is found to be the cause of her peritonitis.

what operative procedure is indicated?

Answer 5

Hartmann’s procedure

^{resection of rectosigmoid colon with creation of a colostomy}

Question 6

(f) list 2 features of the pathology of sigmoid diverticular disease

Answer 6

1. false diverticula i.e. herniation of bowel wall that lacks outer coat of muscularis propria
2. muscular hypertrophy of sigmoid

Question 7

A 50 year old woman presents with cramping lower abdominal pain associated with constipation, faeculent vomiting and abdominal distension.

Dx?

Answer 7

large bowel obstruction

Question 8

A 27 year old woman presents with right upper abdominal pain radiating to her back and shoulder tip. She is apyrexial.

Dx?

Answer 8

biliary colic

Question 9

A 35 year old intravenous drug abuser becomes suddenly unwell with a temperature of 37.9°C and marked guarding in the right iliac fossa.

Dx?

Answer 9

acute appendicitis

Question 10

A 73 year old man with known ischaemic heart disease and atrial fibrillation has a three-hour history of severe central abdominal pain. On examination he is shocked and has marked central abdominal tenderness.

Dx?

Answer 10

mesenteric embolism

Question 11

A six month old infant presents to Accident & Emergency with a 12-hour history of sudden bouts of screaming and drawing-up of his legs. He has passed one mucousy, bloodstained stool during this time.

Dx?

Answer 11

intussusception

Question 12

A 75-year-old man is admitted as an emergency under your care with a one-day history of severe generalised abdominal pain. He has no previous relevant history. On examination he is shocked and distressed. His abdomen is rigid, diffusely tender and silent and a chest Xray suggests free intraperitoneal air

(a) What is the most likely diagnosis?

Answer 12

Perforated intra-abdominal viscus

Question 13

(b) Name 2 common causes of this condition?

Answer 13

1. Diverticulitis
2. Peptic ulcer
3. Appendicitis

Question 14

(c) What 3 initial therapeutic measures that should be instituted

Answer 14

1. Intravenous fluids- crystalloid fluids
2. parenteral or effective analgesics
3. Broad spectrum antibiotics

Question 15

(d) Give 2 other measures which you would consider at this stage, explaining how these would help with your investigation/assessment of the patient’s progress?

Answer 15

1. U&E – fluid balance, dehydration, renal function
2. Urinary catheter – fluid balance, renal function
3. Regular monitoring of vital signs (BP, pulse, resp rate, temperature) – Assess stability of patient including response to treatment

Question 16

(e) The patient underwent a laparotomy. Name 2 aims the surgery attempt to achieve?

Answer 16

1. Diagnosis
2. Peritoneal lavage
3. Prevent further peritoneal contamination (eg.appendicectomy, omental patch or Hartmann’s procedure)