Acute abdomen -CBL 4

Question 1

The acute abdomen- whats important?

Answer 1

Hospitalised within a few hours of onset of pain. Some need laparotomy.
Medical conditions appearing as acute abdo:
DKA, MI, and pneumonia. IBS can also be severe.

Hx + gynae hx. Points to it.
Intermittent (colicky pain) - mechanical obstruction- e.g. Ureteric calculus or bowel obstr. - peristalsis starts and stops- assc sx- abdo distention, vomittinh and absolute constipation. (Some gas passes through)
OR

Continuous pain- occurs in any abdo condition.

O/E:
Shock? (Pale, cool peripheries(hypotension), tachycardia) suggest organ rupture e.g. Aortic abeurism, ruptired ectopic pregnancy.
Later stages of generalised peritonitis from bowel perforation.

Fever- common in acute inflamatory conditions
Peritonitis and bowel obstruction- specific signs. Examine hernial orfices just in case of a strangulated hernia.
Rectal and pelvic exam done in most cases.
Kids no rectal

Investigations:
Bloods- WCC⬆️ in inflammation , ⬆️ serum amylase in abdo conditions but x5 indicates acute pancreatitis.
Imaging- erect CXR- air under D- perforated viscus.
Plain Abdo XR- dilated loops of bowel and fluid levels in obstruction.
USS- dx acute cholecystitis (shows dilation) , appendicitis and gynae conditions.

Surgery- laparoscopy or laparotomy may, depend on dx.

Question 2

What are some common causes of mechanical bowel obstruction?

Answer 2

Constriction from the outside- adhesions, bowel trapped in hernia, volvulus esp sigmoid.

Bowel wall disease: crohns, carcinoma, diverticular disease.
Intra luminal obstruction- foreign body, gall stones

Question 3

Whats biliary pain?

Answer 3

Not true colic resulting from obstruction of GB bile duct,
Usually constant upper abdo pain.
High intensity, just lowering down, but never stops.

Question 4

How do we describe constant pain?

Answer 4

Onset: sudden, gradual
Sudden: perforation of viscus, DU, rupture of organ (AA), or torsion (ovarian cyst) . Acute pancreatitis also.

Site? Upper abdo pain-> pathology of upper abdo viscera e.g. Acute cholecystitis, acute pancreatitis, or stomach, duodenum.
Pain of small bowel usually in centre of abdomen.
Commonest: acute RIF pain= acute appendicitis.

Radiation to back: acute pancreatitis, ruptire of aortic aneurism, renal tract disease.

Question 5

What are the signs of peritonitis?

Are there any bowel sounds in generalised peritonitis?

Answer 5

Tenderness
Guarding- involuntary contraction of abdo muscles when abdo palpated.
Rigid on palpation
May be localised or generalised

No bowel sounds in generalised one.

Question 6

What are the signs of bowel obstruction?

Answer 6

Mechanical BO: distention and active “tingling” bowel sounds.
Strangulated hernia: –> obstruction so hernial orfices always examined.

Question 7

Acute appendicitis- what happens?

Answer 7

When lumen of appendix obstructed by faecolith.
Affects all age groups but rare in very young or very old.
CF:
Onset of central abdo pain, the localised to RIF assc w/ anorexia, pyrexia, maybe vomitting and diarrhoea + tenderness + guarding in RIF

Inv- clinical, ⬆️ WCC and USS. CT if time.

Ddx- many conditions mimic it- non specific mesenteric lymphadenitis, terminal ileitis due to Crohns or Yersina infx, acute salpingitis, Meckels Diverticulum and functional bowel d.

Mx- surgical removal - open or laparoscope. Appendicectomy
Complications: from gangrene and perforation leading to localised abscess formation or generalised peritonitis.
Tx: obtain IV access and ressuscitate if necessary. IV opiod and antiemetic (slow IV metoclopramide 10mg)
Keep NBM and refer to surgeon.
Appendicectomy: pre-op antibiotics: cefuroxime and metronidiazole - ⬇️ risk of infective complications.

Question 8

Acute peritonitis- what happens?

Answer 8

Localised- w/ all acute inflammatory GI conditions .
Generalised: as a result of rupture of an abdo viscus e.g. Perforated DU, perforated appendix. Sudden onset of abdo pain which rapidly becomes generalised.
Patient is shocked and lies still. ⚽️ -😠 . Plain XR -> air under D. Amylase done to exclude acute pancreatitis.

Question 9

Intestinal obstruction- what happens?

Answer 9

Either mechanical of functional
Mech- bowel above level of obstr is dilated so ⬆️ secretions into lumen. Pt complains of colicky abdo pain, assc w/ V + absolute constipation. O/E distention amd tinkling bowel sounds. Small bowel obstruction may settle for conservative tx- NG suction and IV fluids to maintain hydration- large bowel- surgery.

Functional: with paralytic ileus - often seen post -op stage of peritonitis or major abdo surgery or in assc w/ opiod tx (axute colonic pseudo obstruction- Ogilvie’s syndrome. )
Also when nerves or muscles of intestines are damaged causing intestinal pseudo obstruction.
Unlike mechn obstr, pain not present, sounds be be decreased.
Plain Abdo XR- gas throughout the bowel.
Mx- conservative.

Question 10

What is the peritoneum? What pathologies affect it?

Answer 10

Peritoneal cavity- closed sac lined by mesothelium. Contains a little fluid to allow abdo contentns to move freerly.
Conditions affe ting peritoneum:
Infective: (peritonitis)
2o to gut disease- appendicitis, perforation,
Chronic peritoneal dialysis
Spontaneous assc w/ ascites
Tuberculous

Neoplasia
2o deposits eg from ovary
1o mesothelioma

Vasculitis- connective tissue disease

Question 11

What are some nutrition requirements of man?

Answer 11

Energy provision!
Female: 8100kJ or 1940kcal , male: 10600kJ or 2550kcal per day.
50% carbs, 35% fat, 15% protein, +- alcohol.
Emergy req ⬆️ during rapid growth: adolescents, pregnancy, lactation, AND Sepsis.

Nutritional support for:
Sever malnourished on admission: BMI-

Question 12

Whats enteral nutrition and TPN?

Answer 12

Enteral- food given by: mouth, fine bore NG tube for short term enteral nutrition,
Percutaneous endoscopic gastroscopy (PEG) ✔️ for pts needing feeding >2 weeks.
Percutaneous jejunostomy- tube inserted into jejunum either endoscopically or laparotomically.
Full fiet- crohns( elemental diet- amino acids, glucose and Fatty acids)

Total parenteral nutrition:
Via feeding catheter placed in peripheral vein or a silicone catheter placed in Subclavian vein.
Central catheters- only by experienced clinicians in asceptic conditions and sterile env. If these catheres only used for food and not administration of drugs ot bloods then infection risk ⬇️.
Peripheral feeding tubes- last only 5 days- reserved for when feeding short.
Central lines can last for months to years.

Question 13

What are some complications of TPN?
Whats refeeding syndrome?
What pts are at risk of refeeding syndrome?

Answer 13

Catheter related: sepsis, thrombosis, embolism, pneumothorax.
Metabolic- hyperglycaemia, hypercalcaemia
Electrolyte disturbances
Liver dysfunction

Refeeding sx:
Occurs within first days of refeeding y oral, enteral ot parenteral route.
Under recognised and can be fatal . It involves a shift from the use of fat as energy source during starvation to the use of carbs an ebergy source during refeeding.
Re intro of carbs by any source- insulin release augmented-> rapid intracellular passage of phosphate, Mg2+, and K+ –> hypophosphatasmia, hypomagnesaemia and hypokalemia.
HPO3- important ! - def- organ dysfx (muscle weakness, rhabdomyalisis, Cardiac F, haemolytic anaemia, hallucinations, gits, thrombocytopenia, coma. )
Thiamine deficiency can be precipitated.
Pts at risk:
Underweight, (anorexia nervosa, chronic alcoholism) or those w/ recent rapid wt loss (5% w/ proceding month)
+ pts after tx of morbid obesity.

At risk pts should receive:
Pabrinex.

Question 14

What are some causes of RIF mass?

Answer 14

Appendix mass
Caecal carcinoma
Crohns
Ovarian mass
Pelvic kidney
Iliac lymphadenotis
Psoas abscess
Retroperitoneal tumor
Actinomycosis
Common iliac artery aneurysm
Spligeliam hernia

Question 15

What are some causes of acute pancreatitis?

Answer 15

5 per 100,000, middle aged and elderly
Causes:
I get smashed
Idiopathic/ Infection (glandular fever, mumps, infc hepatitis, cozsaxkie

Gall stones (38%)
Ethanol (35%)
Tumours

Surgery&trauma
Mumps
Autoimmune
Scorpion venom
Hyperlipidaemia, hypercalcaemia, hypothermia, hyperparathyroidism
ERCP/Emboli
Drugs(steroids, azathioprine, thiazides and statins)

Commonest- gall stones and alcohol.
PC- severe constant epigastric pain radiating to the centre of back (cz its a retroperitoneal organ) w/ assc N+V

Signs: distressed, sweaty, midly pyrexial. Look for shock- rescusitation? Abdo tenderness max in epigastrium +- guarding. After several days: Grey Turners sign- bluish discolouration in loins -rare

Question 16

How do we asses the severity of pancreatitis?

Answer 16

Secerity criteria: PANCREAS
P- PaO2. 55Y
N- neutrophilia. WBC >15x109/L
C- Ca2+. 16mmol/L
E- enzymes. LDH >600iu/L, AST >200iu/L
A- Albumin. 10mmol/L serum

Question 17

How would u investigate and treat acute pancreatitis?

Answer 17

BMG - cap glucose bedsite and SpO2, serum amylase ⬆️⬆️x 5, consider urinary amylase.
FBC may reveal ⬆️ WCC
U+Es, Ca2+, LFTs, glucose- hypocalcaemia common
Coagulation screen
CXR, ECG, ABG- consider lactate if unwell.

Tx:ABC
O2, provide IV access and resuscitate with IV fluids if necessary
IV analgesia, morphine + antiemetic- cyclizine 50mg or metoclopramide slow IV.
Insert NG tube
Isert urinary catheter to monitor UO
CVline to monitor the CVP and guide fluid therapy in seriously ill + elderly.
ICU contact.

Question 18

What are some complications of acute pancreatitis? What hapoens in chronic pancreatitis?

Answer 18

Mortality
AKI, DIC, hypocalcaemia, ARDS,
Later: pancreatic abscess and pseudo cysts.
RFs : Glascow coma scale
Severe disease: 3 out of more in 48hrs of admission: PANCREAS.

CHRONIC PANCREATITIS
permanent pancreatic damage
Due to alcohol Xs . Some present to A+ E often requesting opiod analgesia.

Question 19

What biliary tract problems could cause an acute abdomen?

Answer 19

Gallstones both solitary cholesterol and multiple mixed GS common amongst middle aged and elderly. Pigment stones-> less common- hereditary spherocytosis (kamnei bales) malaria, and haemolytic anaemia.

Complications of GS: acute and chronic cholecystitis, biliary colic, obstructive jaundice,mascending cholangitis,mucocoele, empyema, acute pancreatitis, gallstone ileus, carcinoma of the gall bladder.

Question 20

Acute cholecystitis: what happens?

Answer 20

Hx- impaction of gall stones with acute inflammatiom of the GB, R hypochondrial pain radiating to the right side of back +/- V.
O/E
Look for acute inflammation features: fever, R hypochondrial tenderness esp on inspiration (Murphys sign) +- palpable mass - also feature of mucocoele and empyema. –> high Fever, extreme tenderness and septic shock.

Mx:
IV analgesia + antiemetics
FBC- WCC ⬆️, U+Es, amylase, LFTs. CXR and ECG just in case of atypical presentation MI

USS- ultrasonic Murphys sign confirms dx
Commence Antibiotics- cefotaxime IV + refer to surgeon.

Question 21

What happens in a biliary colic/ chronic cholecystitis

Answer 21

Sometimes known GS- PC: short loved recurrent episodes of epigastric/right hypochondrial pain +- radiation to the back .
Ddx PUD. Pain gone? Dismiss and arrange w/ GP.

Common bile duct stones:
Acute pancreatitis, obstructive jaundice, ascending infx.

Obstructive jaundice: biliary obstruction ⬆️ jaundice w/ pale stools and dark urine(epidi to bilirubin paei sto aima je metabsta kisneys)+- pain
Acute hep + pancreatic carcinom present similarly. Palpable GB–> pancreatic carcinoma ( courvoisiers law: in presence of jaundice, if GB papable, stone unlikely)

Ascending cholangitis: biliary stasis predisposes to infx, characterised by Charcots triad (abdo pain, jaundice, fever) ❌❌ VERY ILL, resuscitation for septic shock.

Question 22

PUD

Answer 22

Perforated DU or GU very painful. Sudden localised pain “pt thinks indigestion” Pain worse on moving and may radiate to shoulder tip.
O/E
Distresseed, lie still. Howver some in extreme pain roll about, unable to keep still for examination. As time passes… Abscent bowel sounds, shock, generalised peritonitis and fever.

Inv
Erect CXR free gas under D -75% perforated PU- if not fit- Left, lateral decubitus XRay. Contrast CT might help.
U+Es, glucose, amylase (slightly ⬆️) , FBC (WCC slighly ⬆️) , SpO2, ABGs , ECG/ troponin.

Tx
O2+ analgesia- titrate morphine + antiemetic (slow IV metoclopramide 10mg)
Rescusitate w/ IV 0.9% saline
Refer to surgeon and give IV antibiotics (cefotaxime 1g and in late PC metronidiazole 500mg as well.

Question 23

What happens in intestinal obstructions?

Answer 23

Mechanical or paralytic (functional) - rare in A+E - post op ileus, electrolyte disturbance (hypoK) and pseudoobstr.

Abdo pain, absolute cosntipation, vomitting,mdiatention
Inv- U+Es, glucose, anylase, FBC, LFTs, clotting , G+S
CXR and supine abdo xray or erect abdo film. Y shaped gas shadow in R hypovhondrium- fistula b/w bowel and GB allows gas into biliary tree.
ECG if pt middle aged or elderly
ABGs if pt shocked, check SpO2 and lactate

Mx
Insert IV cannula and start IV 0.9% saline
Shock? Resuscitate w/ O2 and IV fluids and insert urinary catheter .
Invovle ICu specialist early. Insert CVLine to guide rescusitation.
Provide anelgesia IV morphine titrated ro response and cyclizine 50mg
Insert NG tube, refer to surgery

Question 24

Mesenteric ischaemia/ infraction

Answer 24

Acute mesenteric infraction:
Abrupt blockade- IRRIVERSIBLE gangrene of bowel rapidly. High mortality.

Patho: 
Mesenteric arterial embolism assc w/ AF
Mesenteric arterial thrombosis
⬇️ mesenteric arterial blood flow- hypotension 2o to MI
Mesenteric venous thrombosis
Most: arterial embolism OR thrombosis

Hx
Middle aged or elderly. Severe,msudden onset, diffuse abdo pain. Severity far exceeds assc physical signs initially. Pain may radiate to back (cz intestine is hiding)
Some pts- mesenteric ischaemia w/ pain after meals and wt loss. Often assc vascular disease elsewhere. Intermittent claudication.

O/E
Shock, absent bowel sounds, abdo distention and tenderness -Late signs. Initially- tenderness and diffuse abdo pain. If suspected, search for an embolic source: AF, recent MI w/ high risk of mural thrombus, aortic valve disease or valve prosthesis, recent cardiac catheter.

Inv
u+Es, BMG (glucose cap), + lab glucose 
Amylsae ⬆️
FBC ⬆️ WCC
Coagulation screen, G+S
ABG- severe metabolic acidosis and LDH ⬆️
XRAy- non specific dilatation of bowel loops and in advanned cases gas i. Hepatic portal venous system. 
ECG- AF?
USS, CT, angiography? Sureon decides. 

Mx
Rescusitation with O2 and IV fluids, provide anelgesia IV morphine titrated,
Broad spec antibiotics,
Refer urgently to surgeon.

Question 25

What hapoens in ischaemic colitis?

Answer 25

Chronic arterial imsufficiency affects mucosa and submucosa typically at splenic flexure- junction of supplu- superior and inferior mesenteric a.

PC:
Abdo pain, start in LIF. Loose stools w/ blood +-
May had prev episodes, or CVS disease.
O/E
Low grade pyrexian, tachycardia, and colonic tenderness with blood PR.

Check FBC, U+Es, G+S, ECG, CXR. XRay plain- thumb printing- submucosal colonic oedema typs at splenic flexure. Provide IV fluods + analgesia , refer to surgical team.

Question 26

What are some pitfalls of abdo pain?

Answer 26

Steroids, NSAIDS or obesity- less obvious physical sx
B blockade may mask signs of shock
Abscence of fever does not exclude infx- esp in elderly, very ill or immunosuppressed.
When severe abdo pain in out of proportion to the physical findings consider torsion of ovarian cyst, ruprture of AA/ dissection, acute pancreatitis, mesenteric infracyion.
Splenic rupture can occur aftertrivial trauma in pts w/ glandular fever or haematological dx.
- consider pregnancy in any woman with child bearing age. Perform pregnancy test.
WCC may be normal im established peritonitis/sepsis.
Amylase may be normal in acute pancreatitis. Conservly ⬆️ amylase may be due to acute cholecystitis, perforated pud, mesenteric infraction.