Acute abdominal pain

Question 1

Appendicitis

Answer 1

History of migratory pain, fever, anorexia, right iliac fossa tenderness, mild pyrexia
Ix - differential white cell count, pregnancy test, CRP, amylase, urine dipstick
Mx - appendectomy

Question 2

Mesenteric adenitis

Answer 2

Usually recent upper respiratory tract infection, high fever, generalised abdominal discomfort - true localised pain and signs are rare
Ix - full blood count (may show slightly raised white cell count), urine dipstick often normal, abdominal ultrasound scan (usually no free fluid)
Mx - conservative management

Question 3

Mittelschmerz

Answer 3

Mid menstrual cycle supra-pubic pain, usually occurs two weeks after last menstrual period and subsides over a 24-48 hour period
Ix - full blood count (normal), urine dipstick (normal), abdominal and pelvic ultrasound (may show a trace of pelvic free fluid)
Mx - conservative management

Question 4

Fitz-Hugh Curtis syndrome

Answer 4

Disseminated infection with Chlamydia, usually seen in females.
PID together with peri-hepatic inflammation and subsequent adhesion formation.
Ix - abdominal ultrasound scan (may show free fluid), high vaginal swabs (may show evidence of sexually transmitted infections)
Mx - doxycycline or azithromycin

Question 5

Abdominal aortic aneurysm (ruptured)

Answer 5

Sudden onset of abdominal pain radiating to the back in older adults, collapse
May be moribund on arrival in casualty, more stable if contained haematoma
Careful clinical assessment may reveal pulsatile mass
Ix - if haemodynamically stable should have a CT scan
Mx - unstable patients, patients with evidence of contained leak on CT or increasing unruptured aneurysmal size should undergo immediate surgery

Question 6

Perforated peptic ulcer

Answer 6

Sudden onset of pain (usually epigastric) with a history of upper abdominal pain that soon develops into generalised abdominal pain.
On examination may have clinical evidence of peritonitis.
Ix - erect CXR (may show free air), CT if still unsure
Mx - laparotomy

Question 7

Intestinal obstruction

Answer 7

Colicky abdominal pain and vomiting (the nature of which depends on the level of the obstruction).
Abdominal distension and constipation (depending upon site of obstruction).
Features of peritonism may occur where local necrosis of bowel loops is occurring.
Ix - plain abdominal film, CT if still unsure
Mx - laparotomy

Question 8

Mesenteric infarction

Answer 8

Embolic events present with sudden pain and forceful evacuation.
Acute on chronic events have a longer history and previous weight loss.
On examination the pain is typically greater than the physical signs would suggest.
Ix - arterial pH and lactate, arterial phase CT scanning is the most sensitive test
Mx - immediate laparotomy and resection of affected segments