Acute Abdomen Conditions

Question 1

Presentation of Appendicitis

Answer 1

-Most common acute abdominal condition requiring surgery
-Most common 10-20yrs

-Peri-umbilical abdominal pain radiating to the right iliac fossa (RIF) due to localised parietal peritoneal inflammation- worse on coughing or going over speed bumps. Children typically can’t hop on the right leg due to the pain. Moves to RIF
-Vomiting (once or twice)
-Mild pyrexia
-Anorexia

-Generalised/ localised peritonitis if perforation (rebound and percussion tenderness, guarding, rigidity)
-Rovsing’s sign (palpation in LIF causes pain in RIF)
-Right sided tenderness on PR exam

Question 2

Investigation of appendicitis

Answer 2

-Raised inflammatory markers
-Neutrophil-predominant leukocytosis
-Urine analysis= exclude pregnancy, renal colic, UTI (mild leucocytosis normal, look at nitrates)
-Ultrasound useful in females where pelvic organ pathology
-Free fluid on USS always pathological in males, clinical diagnosis in thin male patients

Question 3

Management of appendicitis

Answer 3

-Appendicectomy (laparoscopic)
-Prophylactic IV antibiotics
-Abdominal lavage for perforated appendicitis

Question 4

Presentation of mesenteric adenitis

Answer 4

-Diffuse abdominal pain
-History of recent or current upper respiratory tract infection
-Fever (high)
-Abdominal tenderness not localised to RLQ
-Rhinorrhoea
-Pharyngitis
-Extra mesenteric lymphadenopathy (cervical)
-Children

Question 5

Investigations of mesenteric adenitis

Answer 5

-Abdominal ultrasound (enlarged mesenteric lymph nodes)
-CT scan abdomen and pelvis (enlarged mesenteric lymph nodes)

Question 6

Management of mesenteric adenitis

Answer 6

-No treatment needed
=Analgesia

Question 7

Presentation of perforation

Answer 7

-Generalised peritonitis
=Guarding
=Rigidity
=Rebound tenderness
-Fever
-Nausea and vomiting
-Sepsis

Question 8

Investigations of perforation

Answer 8

-X-ray of chest and abdomen (air under diaphragm)
-CT scan (barium enema?)
-Blood test= infection and blood loss

Question 9

Management of perforation

Answer 9

-Laparotomy
-Abdominal lavage
-IV antibiotics

Question 10

Presentation of intestinal obstruction and ileus

Answer 10

-Abdominal distention/ bloating
-Abdominal pain
-Nausea/ vomiting
-Inability to pass flatus, absolute constipation
-Decreased or hypoactive bowel sounds
-Inability to tolerate oral diet

-RF: Hx malignancy (intraluminal obstruction), previous op (adhesions)

Question 11

Investigations of intestinal obstruction and ileus

Answer 11

-Deranged electrolytes (hypokalaemia, hypo-chloremia, alkalosis, hypermagnesemia)
-Elevated urea and creatinine
-CT abdomen/ pelvis

Question 12

Management of intestinal obstruction and ileus

Answer 12

-Nil-by-mouth initially
-Nasogastric tube if vomiting
-IV fluids to maintain normovolaemic
-Total parenteral nutrition

Question 13

Presentation of ectopic pregnancy

Answer 13

-6-8 weeks (from start of last period, if longer suggest other causes like inevitable abortion) amenorrhoea presents with lower abdominal pain (constant and unilateral) with vaginal bleeding (dark brown)
-Peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination
-Dizziness, fainting or syncope may be seen
symptoms of pregnancy such as breast tenderness may also be reported
-Cervical excitation and adnexal mass (NICE not to examine as increased risk of rupture), abdominal tenderness

Question 14

Ectopic pregnancy RF

Answer 14

-Anything slowing the ovum’s passage to the uterus
=Damage to tubes (pelvic inflammatory disease, surgery)
=Previous ectopic
=Endometriosis
=IUCD
=Progesterone only pill
=IVF (3% of pregnancies are ectopic)

97% tubal (ampulla), more dangerous in isthmus, 3% ovary/cervix/peritoneum

Question 15

Investigations of ectopic pregnancy

Answer 15

-Positive pregnancy test
=Serum bHCG levels >1500
-Transvaginal (gold)/ transabdominal ultrasound

Question 16

Management of ectopic pregnancy

Answer 16

-Surgical management of ruptured ectopic pregnancy
-Salpingectomy
-Methotrexate

-Expectant: size <35mm, unruptured, asymptomatic, no HB, hCG <1000. Monitor over 48 hours for bHCG rise/ symptoms
-Medical: size <35mm, unruptured, no significant pain, no HB, hCG <15000, not suitable if intrauterine pregnancy. Methotrexate, patient attend follow up
-Surgical: size >35mm, can be ruptured, pain, visible HB, hCG >5000. Salpingectomy (no infertility risk)//otomy (infertility risk like contralateral tubal damage)