Acute abdominal pain Flashcards
How does ruptured AAA present?
Intermittent or continuous abdominal pain that is radiating to back, iliac fossae, or groin.
COLLAPSE, also note the presence of a rigid abdomen on examination and a PULSATILE, EXPANSILE MASS
Also likely that the patient will be in SHOCK (low BP, high HR, poor perfusion of tissues).
When is unruptured AAA big enough to be operated on?
> 5.5cm - people with known AAA scanned yearly
What is most common site for AAA?
Infrarenal
What causes AAA?
Age (5% of the population >60y), also around 5x more common in men. Men are now screened for it as standard.
Also be aware of other causes such as SYPHILLIS, EHLERS-DANLOS and MARFAN’S SYNDROME (connective tissue disorders)
Investigations for AAA?
- Ultrasound is diagnostic for AAA - but if it has already ruptured should not waste time doing this
- ECG
- BLOODS: amylase and get a group and save and a cross match for 10U or more.
If the patient is stable and you are uncertain if this is the correct diagnosis consider CT but should not delay treatment for this
How should you manage AAA?
- If you suspect ruptured AAA immediately inform theatres and an experienced anaesthetist and then perform the above investigations
- Gain IV access with two wide-bore cannulas and then give the patient some O- blood - DO NOT TRY to boost their blood pressure too much as this might rupture a contained leak: aim for systolic <100
- Get patient to theatre as quickly as possible
Consider prophylactic abx: CEFUROXIME AND METRONIDAZOLE
What are some signs and symptoms of appendicitis?
- INITIAL GENERALISED abdominal pain usually becoming localised to the RIF just a few hours later
- Profuse nausea and vomiting
- Anorexia and acute diarrhoea can occur
- Tenderness in the Right Iliac Fossa with considerable guarding due to localised peritonitis
PSOAS SIGN: extension of the right leg with the person lying down on their left side is painful
What should some differentials for acute appendicitis be?
diverticulitis, ectopic pregnancy, gastroenteritis, ovarian cyst
What causes acute appendicitis?
Usually just due to infected faecolith in the lumen of the appendix. Be aware that the anatomical location of the appendix can vary so still suspect even if presentation is not in classical location
What investigations should be done in acute appendicitis?
- Raised ESR and CRP and WCC can help confirm
- CT is also highly sensitive and specific
USS can also be helpful
How should we manage acute appendicitis in ED?
- Intravenous fluids and antibiotics (refer to guidelines)
Laparoscopic appendicectomy - refer to general surgery
What causes cholecystitis?
Stone or sludge obstruction of the neck of the gall bladder
What are some signs and symptoms of cholecystitis?
- Continuous epigastric or RUQ pain which might also include the R shoulder - this pain might have come on and been made a lot worse by eating - esp fatty food
- Vomiting
- Fever - the presence of fever distinguishes from just biliary colic
- Peritonism
- Tender o/e with possible GB mass with guarding and some rigidity
○ MURPHY’S SIGN (2 fingers over RUQ and ask patient to breath in - only +ve if the same test in the LUQ does not cause pain)
What is the most common cause of cholecystitis?
Gall stones
What investigations should be done in a patient with potential cholecystitis?
- High WCC
- USS might show thick walls and shrunken GB, might see stones and might see a dilated CBD
LFTs: marginal elevation of ALP, bili and ALT possible - but highly elevated levels might be more suggestive of bile tract obstruction
How should we initially manage cholecystitis in ED?
- NBM
- Opioid analgesics
- IV fluids
- IV abx: trust guidelines but consider cefuroxime or tazocin
Surgical management but not a surgical emergency - usually wait for symptoms to settle before operating (outpatient).
What is cholangitis and how does it differ from cholecystitis?
This is similar to cholecystitis PLUS JAUNDICE. Presence of an infection of the gall bladder. The symptoms of cholangitis are made up by CHARCOT’S TRIAD:
- RUQ pain
- Jaundice
- Fever and rigors
What are some symptoms and signs in a patient with a bowel obstruction?
- Vomiting, nausea, anorexia.
If the obstruction is long-term then the faecal contents behind the obstruction might start to ferment and this can cause FAECAL VOMITING - Constipation
- Colic
- Abdominal distension
o/e distension, rigidity, absent or tinkling bowel sounds
What difference will there be between the presentation in patients with small and large bowel obstructions?
Small bowel - vomiting will be predominant symptom
Large bowel - pain and distention more common
What are some common causes of bowel obstruction?
Adhesions, hernias, Crohn’s, Ca, Volvulus, faecal impaction, TB, foreign body
What investigations should be done in a patient with a bowel obstruction?
- AXR
- PR
- Consider CT
- FBC U&E, amylase
- Catheterise
How should we manage a patient with a bowel obstruction in ED?
- NG SUCK TUBE and IV fluids to rehydrate and improve electrolyte balance - DRIP AND SUCK
- Analgesia
Conservative management - does not need surgical review
In which diverticula does diverticulitis most often occur?
In the diverticula of the sigmoid colon
What are some common features of acute diverticulitis?
- SEVERE PAIN IN THE L ILIAC FOSSA
- Fever
- Constipation
O/E: - Febrile
- Tachycardic
- Tenderness and guarding in the LIF
What investigations should be done in patients with diverticulitis?
- BLOODS: ESR and CRP
- USS: thickened bowel walls and pericolic collections
- CT colongraphy might show colon wall thickening
How should diverticulitis be managed in the ED?
- Can be treated as an outpatient with oral cefuroxime and metronidazole
- If they are in considerable abdominal pain consider admission for IV fluids, IV abx and analgesics
What are some clinical features of ectopic pregnancy?
- Collapse
- Recurrent lower abdominal pain which may also extend to the shoulder if there has been bleeding into the abdomen
- Vaginal bleeding
What investigations should be done with suspected ectopic pregnancy?
- Pregnancy test as well as cross match - B-HCG: the levels of this can give us an idea as to how far gone the pregnancy is
- FBC U&E CRP
Trans-vaginal USS
How should we manage ectopic pregnancy?
Depends on size and certain factors (B-hCG and FHR)
Refer to gynaecology
Resuscitate if shocked
Methotrexate or surgery
How might a miscarriage present?
Acute vaginal bleeding with or without pain. Sometimes bleeding can be profuse and cause collapse or faintness
- Abdominal pain and cramping
What causes might there be for a miscarriage?
- Might be spontaneous or might be repeated (infertility)
- Chromosomal abnormalities of fetus
- Uterine malformations (fibroids or cervical changes) - this is more likely to be the cause if the miscarriage is in the second or third trimester
What investigations should be done in a patient with potential miscarriage?
- Vaginal exam (see if os is open or closed) - done by gynae
- Monitor hCG levels
- USS
- Resuscitate if needed
How should miscarriage be managed in the ED?
- Treat pain
- Refer to gynaecology and obstetrics
- Counselling
How might an ovarian cyst present in an acute setting?
- Lower abdominal pain, can be a dull ache or a sharp pain
- Associated frequent need to urinate
- Difficulty going to the toilet
- Bloating or swelling in the abdomen
- Feeling very full after eating very little
- Difficulty getting pregnant
- Very heavy or irregular periods
What are some important causes of ovarian cyst?
Cysts are either:
- FUNCTIONAL - very common and form as part of the menstrual cycle. Usually these are harmless, short-lived and asymptomatic
- PATHOLOGICAL - much less common. They are an abnormal growth and while the majority are benign some can be cancerous.
Can be associated with endometriosis
PCOS
What investigations should be done in people with suspected ovarian cyst?
- USS
- Bloods looking for cancer markers (high levels doesn’t necessarily mean cancer because can be high in a range of things). Ca-125 in ovarian and B-hCG in molar pregnancy
How should we initially manage ovarian cyst in the ED?
- In most cases they will disappear by themselves with no need for treatment
- If the woman is post-menopausal then she might have a slightly higher risk of cancer and so might suggest monitoring over a year
- IV FLUIDS - consider bloods if you suspect blood loss
Consider referring to surgeons - might need surgical repair
What are some clinical features of acute pancreatitis?
First symptoms are usually severe epigastric pain with nausea and vomiting - this can also be the clinical picture with lots of things but acute pancreatitis should always be a differential.
- As the conditions progresses there might be involvement of the peritoneum and the retroperitoneum leading to pain bearing through to the BACK
- If severe: tachycardia, hypotension and oliguria
O/E: will be mostly unremarkable apart from some epigastric tenderness. In severe disease might find some GREY-TURNER’S bruising or some CULLEN’S BRUISING
What are some causes of acute pancreatitis?
GET SMASHED G - Gall stones (38%) E - Ethanol (35%) T - Trauma S - Steroids M - Mumps A - Autoimmune S - Scorpion venom H - Hyperlipidaemia, hypercalcaemia, hypothermia E - ERCP and emboli D - Drugs
What investigations should we do in someone in whom we’re suspecting acute pancreatitis?
- BLOODS: get FBC, U&E LFT and ask for an AMYLASE. Expect it to be raised (>1000) although degree of elevation does not necessarily reflect severity of disease
○ LIPASE is more sensitive and specific - ABG
- AXR: showing NO PSOAS SHADOW (due to high retroperitoneal fluid)
- CXR might help you exclude other causes such as bowel perforation
- CT
- USS
CRP>150
How should we initially manage someone with acute pancreatitis in the ED?
- NBM likely need an NG tube
- Admit
- Analgesia (pethidine or morphine -something strong)
- Keep an eye on obs
ERCP and gall stones removal - call general surgery
What are some clinical features of someone presenting with peptic ulcer disease ?
- Sharp epigastric pain.
○ Might be associated with oesophagitis like pain - sharp central chest pain that is worse with lying and might be accompanies by heart burn, metallic taste in mouth
○ Patients quite often point with a single finger to the point where the pain is - this might help us narrow down the cause to stomach pain rather than more sinister chest pain
○ Might have some relationship with food but this is less clear (duodenal ulcers are the most common and these are made worse by food, gastric ulcers eased by food) - Epigastric pain
- Anorexia and weight loss if it’s been going on a while
- Some nausea and some vomiting although not a lot - vomiting might relieve the pain
What are some important causes of peptic ulcer disease?
- DRUGS: NSAIDs, steroids SSRIs
- H.Pylori
- Blood group O
- Smoking
- Alcohol
- Stress
Aggravating food
What investigations should we do in patients with peptic ulcer disease?
- ECG to rule out cardiac cause of pain
- FBC U&E
- Could test for H.pylori - stool sample of antigen
- Endoscopy for high risk group (>55)
How should we manage peptic ulcer disease initially in ED?
- Get them onto an endoscopy clinic especially if they are over the age of 55 or with other red flag symptoms.
- Give them PPI
- Triple therapy for H.pylori (PPI, Amoxicillin, Clarithromycin)
What are some clinical features of PID?
This is an inflammation of the upper part of the female reproductive tract (ovaries, fallopian tubes, uterus and surrounding pelvis)
- Pelvic and lower abdominal pain
- New or different discharge
- Pain during sex
- Uterine tenderness
- Abdominal abnormalities
What are some important causes of PID?
Associated with sexually transmitted infections such as:
- Gonorrhoea
- Chlamydia
- Bacterial vaginosis increases the risk of developing PID
What investigations should we do in patients with PID?
- USS
- Culture of discharge
- Pelvic exam
- Tissue biopsy
How should we consider managing PID?
- Gynaecological review
- Pain killers
What are some clinical features of renal colic?
- This is when there is intermittent in the flank or the loins or even the groin. Severe and coming and going in waves
○ The pain is in this pattern due to ureteric peristalsis - The patient might be having urinary symptoms as well such as :
○ Anuria or dysuria
○ OR increased frequency, urgency, suprapubic tenderness
○ Change in smell to urine
○ Haematuria
○ Sweating - Nausea and vomiting
What is the most likely cause of renal colic?
Kidney stones (haematuria and raised inflammatory markers)
What investigations should we do in someone with renal colic?
- KUBUSS
- Urine dip - look for blood, leucocytes will be present due to inflammation
- Pregnancy test in woman
- CT
BLOODS: FBC U&E, CRP, WCC
How should we consider managing a patient with renal colic in ED?
- Pain killers (might need IV)
- Fluids - important to keep pt hydrated
What are some clinical features of urinary tract infections?
In terms of abdominal pain in UTI the pain is most likely to be suprapubic, although be aware of possible loin and flank pain as well and consider an upper urinary tract infection (pyelonephritis).
- URINARY SIGNS:
○ Urgency
○ Frequency
○ Feeling of incomplete emptying
○ Haematuria
○ Dysuria
○ Smelly urine
- Fever, rigors and tenderness are also suggestive of an upper UTI
- Confusion in the elderly: could easily be the only presentation in an elderly patient
What are some important causes of UTIs?
- Very common in women, especially those who are sexually active
- Common in the elderly
- Gram negative organisms: E.col
○ Consider immunocompromisation in pt not in high risk group
What investigations should we consider in someone with a UTI?
- Urine dip
- Pregnancy test
- Bloods: FBC, U&E, cultures maybe if pyelonephritis
How can we manage a UTI in the ED?
- Antibiotics (follow guidelines, trimethoprim, nitrofurantoin, pivmecillinam)
○ Cefuroxime if UUTI - Fluids if pt is unwell
- Also advise highly oral intake of fluids
