Acute abdomen and critically ill ptnt recognition Flashcards
example of abdominal pathology presenting with inner thigh pain?
obturator hernia= Howship-Romberg sign
example of abdominal pathology presenting with shoulder tip pain?
subdiaphragmatic irritation by free blood or pus e.g. ruptured ectopic pregnancy, =Kehr’s sign
acute cholecystitis
why does an obstructed small bowel present initially with central abdominal colic?
small bowel= midgut structure, so pain referred to periumbilical area as viscus receives AN innervation which is poorly localised, in contrast to involvement of parietal peritoneum receiving somatic innervation which allows pain to be localised.
colicky as viscus overactivity in attempt to relieve obstruction.
why might vomiting not occur at all in large bowel obstruction?
ileo-caecal valve prevents vomiting
when does vomiting occur in small bowel obstruction and describe it
early and prominently
proximal obstruction= green vomitus as bile brought up
distal obstruction= more brown as faecal matter contained.
what does abdominal distension indicate in SBO?
obstruction has been of relatively long duration
symptoms of ectopic pregnancy?
acute abdominal pain, possibly shoulder tip pain, missed menstruation with vaginal bleeding
sign on inspection of abdomen indicating peritonitis?
abdomen doesn’t move with respiration, it is rigid-board like rigidity
why is it important to note old scars on abdominal inspection in cases of suspected SBO?
may indicate cause of SBO to be adhesions
exception to acute abdomen presenting with tenderness on palpation?
acute mesenteric infarction- causes exceptional pain but few signs
ultimate investigation for acute abdominal pain dependent on clinical picture?
laparotomy
contrast presentation of peritonitis with biliary, intestinal or renal colic
peritonitis= lie still colic= rolling around in agony
sign visible on supine AXR (occasionally erect CXR) which indicates bowel perforation?
Rigler’s sign= bowel wall clearly defined as free intra-abdominal gas next to gas filled bowel loop.
what should AF with abdominal pain always prompt thoughts of?
mesenteric ischaemia
classical clinical triad of acute mesenteric ischaemia?
acute severe abdominal pain- central and constant, or around RIF (almost always involves small bowel)
no adominal signs
rapid hypovolaemia, leading to SHOCK
degree of illness far out of proportion with clinical signs
investigations for acute mesenteric ischaemia?
increase HB due to plasma loss
WCC increase
Us and Es-baseline for surgery, check for renal disease prior to contrast use in CT angio
modestly raised amylase
raised serum lactate
persistent metabolic acidosis on ABG- HCO3- low
ECG-AF, or evidence of prev MI e.g. pathological Q waves
gasless abdomen on AXR early on, later may be evidence of paralytic ileus with multiple fluid levels and as in mesenteric vein or in bowel wall. thumb printing may be present, espec. if ischaemia of large bowel.
CT angio-absence of contrast medium in mesenteric arteries, or evidence of aortic dissection
laparotomy- nasty necrotic bowel
main life-threatening complics secondary to acute mesenteric ischaemia?
septic peritonitis-bowel perforation*?
progression of SIRS into multi-organ dysfunction syndrome, mediated by bacterial translocation across dying gut wall
tment of acute mesenteric ischaemia?
resuscitation with IV fluids, Abx- gentamicin and metronidazoe, SC LMWH
in very early stages, percutaneous endovascular restoration of mesenteric b.flow by balloon angioplasty, suction embolectomy, thromobolysis and stenting may be successful
laparotomy-pale or gangrenous bowel with poor peristalsis, absence of pulsating vessels in mesenteric arteries, dead bowel MUST be resected before attempts to restore b.supply, then end to end anastomosis or bring out the 2 ends as stomas to skin surface if bowel viability in doubt.
2nd look laparotomy 24hrs after anastomosis to assess bowel viability and carry out further resections
embolectomy catheters-if fail, can do SMA end arterectomy with a patch graft or some sort of bypass
2 potential watershed areas in arterial supply of colon?
splenic flexure- were SMA and IMA meet at marginal artery, or Griffith’s point
at origin of superior rectal artery- Sudeck’s point
diagnoses patients with non-specific abdo pain (NSAP) are commonly discharged from hosp with?
dyspepsia mesenteric adenitis dysmenorrhea constipation gastroenteritis
symptoms and signs of NSAP?
acute onset abdo pain, usually in RIF though may be diffuse
no vomiting or anorexia- assoc. with acute appendicitis
rarely systemic signs e.g. tacycardia, fever, flushing
no signs of peritonism or peritonitis
symtoms usually self-limiting
DD for NSAP in women with no discrete abdominal signs?
endometriosis
which people should not be diagnosed as having NSAP?
elderly- as likely some pathology to account for pain, and even if no cause found, they should be followed up in OPC.
sign on examination of patient with acute appendicitis where palpating LLQ increase pain felt in RLQ?
Rovsing’s sign
signs on examination of peritonitis ptnt?
prostration board like rigidity guarding shock lying still \+ve cough test tenderness +/- rebound/percussion pain no bowel sounds
signs of suspected abscess formation?
swelling
swinging fever
raised WCC
raised CRP
if so, do USS or CT
look for sentinel loop on plain AXR= single loop of dilated bowel adjacent to inflammation, indication of localised ileus e.g. in cholecystitis, pancreatitis, appendicitis or diverticulitis.
ABG is important for diagnosis of which condition causing acute abdomen?
acute mesenteric ischaemia
PLAN for acute abdomen?
treat shock crossmatch 2U blood, or group and save blood culture, then antibiotics- cefuroxime and metronidazole analgesia IVI- 0.9% saline plain AXR CXR if peritonitic or >50 ECG if >50 consent NBM for 2h pre-op
classes of hypovolaemia due to blood loss where blood is also given with crystalloid fluids?
class III and IV
blood loss in class IV hypovolaemia?
>40% (>2L) pulse >140bpm BP decreasing and PP decreasing respirations >35/min negligible urine output lethargic
in surgical abdomen, does pain or vomiting tend to come first?
pain
general signs of acute appendicitis?
fever 37.5-38.5 degrees C tachcardia furred tongue kying still coughing hurts foetor with or without flushing shallow breaths RIF= guarding, rebound and percussion tenderness, PR painful on R side if low lying pelvic appendix
symptoms of acute appendicitis?
periumbilical pain ,omving to RIF
anorexia
vomiting poss, pain precedes vomiting
constipation, sometimes diarrhoea
special tests in acute appendicitis?
rovsing’s sign= pain in RIF > LIF when LIF pressed
psoas sign= pain on hip extension if retrocaecal appendix
cope sign= pain on flexion and internal rotation of R hip in appendix closely related to obturator internus
why might pain be felt in R shoulder in acute cholecystitis?
inflamed GB irritates diaphragm inervated by phrenic nerve- C3-C5, so referred pain.
percussion note if obstruction?
resonant
properties of bowel sounds if peritonitis, and if obstruction?
reduced or absent in peritonitis
high pitched and tinkling if obstruction
what might ptnt do to relieve pain in acute pancreatitis?
sit forwards
prognosis in acute mesenteric ischaemia?
POOR
of those that develop SB infarction, 70-80% die
small number survive left with short bowel syndrome requiring IV nutritional support for wks, mnths or rest of life
