Acute Abdomen/Bleeding

Question 1

Types of pain in acute abdomen? Potential consequences

Answer 1

Severe Pain - visceral, somatic, referred
Visceral - receptors in smooth muscle, poorly localised
Somatic/Referred - receptors in parietal peritoneum/abdominal wall, precise localisation but may be referred

Constant but varying, spontaneous, consider:

• peritonitic
• colic
• body wall

Fluid loss
Bacteraemia/endotoxaemia
> circulatory collapse, death

Question 2

Risk factors and causes of acute abdomen? Differentiating factors of each?

Answer 2

Consider peritonitis, abdominal obstruction

Peritonitis

• perforation
• female GU tract
• penetration of abdominal wall
• haematogenous spread
• generalised peritonitis from rapid/extended contamination

Obstruction

• pain
• vomiting
• distension
• constipation
• borborygmi
• depends on site

Question 3

Investigations in acute abdomen?

Answer 3

History/Examination

Urine test
FBC, U+E, LFTs
Plain radiograph, USS, CT
Laparoscopy/otomy

Observation when diagnosis uncertain/risk of intervention greater

Question 4

Treatment for acute abdomen?

Answer 4

Resuscitation

• restore circulating fluid volume
• ensure tissue perfusion
• enhance tissue oxygenation
• treat sepsis
• decompress gut
• ensure adequate pain relief

Definitive surgery
Act on sepsis

Question 5

Areas of upper GI bleed vs lower GI bleed?

Answer 5

Upper

• oesophagus
• stomach
• duodenum
• (proximal to ligament of Trietz)

Lower

• jejunum
• ileum
• colon
• (distal to ligament of Trietz)

Question 6

Risk factors/causes for upper GI bleeding?

Answer 6

All areas

• ulcers
• inflammation

Oesophagus

• varices
• Mallory-Weiss tear
• Malignancy
• oesophagitis

Stomach

• varices
• malignancy
• dieulafoy
• angiodysplasia

Duodenum
- angiodysplasia

Question 7

Colonic causes of lower GI bleed?

Answer 7

Diverticular disease
Haemorrhoids
Vascular malformations (angiodysplasia)
Neoplasia
Ischaemic colitis
Radiation enteropathy/proctitis
IBD

Diagnosis requires sigmoidoscopy/full colonoscopy

Question 8

Small bowel causes of lower GI bleed?

Answer 8

If upper GI bleed excluded and no colonic cause found

Meckel's diverticulum
Small bowel angiodysplasia
Small bowel tumour/GIST
NSAID ulceration
Aortoentero fistulation - following AAA repair

Question 9

Investigations in GI bleeding?

Answer 9

Colonoscopy/sigmoidoscopy

Lower

• CT angiogram
• Meckel’s scan
• Capsule endoscopy
• Double balloon enteroscopy

Question 10

Symptoms/signs of GI bleed?

Answer 10

Upper

• haematemesis
• malaena
• elevated urea
• associated with dyspepsia, reflux, epigastric pain
• NSAIDs

Lower

• fresh blood/clots
• magenta stools
• normal urea
• typically painless
• more common in advanced age

Question 11

General treatment in GI bleed?

Answer 11

ABCDE

Circulation

• wide bored IV access > IC fluids, transfusion (if Hb <7g/dL)
• urgent blood sample (FBC, U+E, LFTs, coagulation, blood type)
• catheter

HDU
Endoscopy once stable
Withhold/reverse causative medicines
Consider CT angiography, radiology, surgery

Question 12

Peptic ulcer management in GI bleed?

Answer 12

PPI
Endoscopy with endotherapy

If bleeding uncontrollably endoscopically:
Angiograph with embolisation
Laparotomy

Endotherapy

• adrenaline
• thermal
• mechanical
• haemospray
• combination (Adr + thermal/clip) most effective

Question 13

Varices management in GI bleed?

Answer 13

Endotherapy

• oesophageal (band ligation, glue injection)
• gastric (glue injection)
• rectal (glue injection)

Intubation
IV terlipressin
Broad spectrum IV antibiotics

Bleeding uncontrollably:

• Sengstaken-Blakemore tube
• Transjugular intrahepatic porto-systemic shunt