Acute abdominal pain Flashcards
How does ruptured AAA present?
What are some signs on examination of ruptured AAA?
Presentation of ruptured AAA
- sudden onset severe pain radiating to back, abdomen, groin
- collapse
Signs on examination
-rigid abdomen and PULSATILE, EXPANSILE MASS
-shock-low BP, high HR, poor perfusion (absent femoral pulses)
-signs of ecchymosis (bleeding under skin)
• Cullen’s sign
• Grey-Turners sign
What size dilatation is a AAA categorised as?
When is unruptured AAA big enough to be operated on?
AAA is a permanent dilatation >3cm
<5.5cm = watch and wait
-regular USS monitoring
(3-4.5 do yearly USS
(4.5-5.5 do 3 monthly USS)
-modify risk factors (stop smoking, control HTN (ACEi), DM, chol (statin), Aspiring potentially)
> 5.5cm OR >1cm/yr OR symptoms = surgery
- endovascular stent repair
- or laparotomy with prosthetic graft
What is most common site for AAA?
Infrarenal (just below kidneys)
Risk factors for AAA?
- Over 50 years old (age related changes in elastin + collagen + smooth muscle)
- Male(screened)
- Risk factors for developing atheroma in the aorta:
- Hypertension
- Smoking
- Male
- Hyperlipidaemia
- Obesity
- Genetics
- Marfan’s
- Collagen disorders(Elher’s Danos syndrome)
- Syphilis
Investigations for AAA?
Investigations for AAA
- Urgent USS is diagnostic for AAA - but if it has already ruptured should not waste time doing this
- USS, ECG AND BLOODS: • FBC • group and save and a cross match for 10U or more • amylase • LFTs • Us and Es • Clotting
How should you manage AAA rupture?
AAA management
-CALL THEATRE ASAP (vascular surgeon with experienced anaesthetist)
ABCDE
- High flow oxygen 15L/min via non rebreathe mask
- 2 wide bore cannulas in antecubital fossa
- Bloods - emergency cross matching 10U, FBC, clotting, amylase, U+Es, LFTs
- Give fluids in major hypovolaemia but avoid excess(aim for systolic <100)
-IV morphine(prevent tachycardia and hypertension)- IV antiemetics - 50mg cyclizine
-IV prophylactic antibiotics -METRONIDAZOLE AND CEFUROXIME
Symptoms of appendicitis?
symptoms appendicitis
- INITIAL GENERALISED abdo pain which localised to the RIF just a few hours later
- Nausea and vomiting
- Anorexia
- Constipation or diarrhoea
- Frequent urination (irritation-can mimic UTI)
Signs of acute appendicitis? What are: Rovsigns sign Copes sig/obturator Psoas sign
Signs of acute appendicitis
- Tachycardia, tachypnoea, pyrexia
- Tenderness at McBurney’s point (2/3rds umbilicus to ASIS)
- Guarding (localised peritonitis)
- Rovsigns sign -pain in RIF when pressing on LIF
- Cope/obturator sign - pain on flexion and internal rotation of R thigh
- Psoas sign- get patient to lie on LHS and extend their right leg> PAIN
What causes acute appendicitis?
What should some differentials for acute appendicitis be?
appendicitis CAUSES
- infected faecolith
- gut microorganisms arrive
- causes immune cells to kick off
- inflammation
appendicitis DIFFERENTIALS
- diverticulitis
- gastroenteritis
- acute flare of IBD
- ectopic pregnancy
- ovarian cyst
- mesenteric ischemia (always think about this)
What investigations should be done in acute appendicitis?
Appendicitis investigations
- mainly clinical
- CRP!!!!!!
Bedside
- urinalysis -can be normal (rule out UTI). It is abnormal 50% of the time because bladder is close to appendix- white cells (inflammation)
- pregnancy test (rule out ectopic)
Bloods
- CRP!!
- FBC (increased neutrophils)
- Us Es/LFTs/amylase/crossmatch
Imaging
-not required clinical is enough
can do CT or USS if unsure
How should we manage acute appendicitis in ED?
Appendicitis management
• Obtain IV access and resuscitate if necessary
• Commence fluids if dehydrated
• Antibiotics (metronidazole and cefuroxime) (guidelines)
• IV analgesia and anti-emetics
• Refer to general surgeons for prompt laparoscopic appendectomy
What causes cholecystitis?
- Stone or sludge obstruction of the neck of the gall bladder
- Causing INFLAMMATION of the gall bladder
What are some signs and symptoms of cholecystitis?
Symptoms of cholecystitis
- Continuous epigastric or RUQ pain
- May radiate to right shoulder
- Worse when eating (especially fatty foods)
- Vomiting
Signs
- Fever- the presence of fever distinguishes from just biliary colic
- local 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?
Cholecystitis investigations
- FBC (high WCC)
- LFTs (marginal elevation of ALP, bili and ALT possible - but highly elevated levels might be more suggestive of bile tract obstruction)
- USS might show thick walls and shrunken GB, might see stones and might see a dilated CBD
How should we initially manage cholecystitis in ED?
Cholecystitis management
- NBM
- analgesia
- IV fluids
- IV antibiotics (guidelines) (cefuroxime)
Refer for laparoscopic cholecystectomywithin 7 DAYS
What is ascending cholangitis and how does it differ from cholecystitis?
Treatment for cholangitis?
Cholangitis -This is similar to cholecystitis PLUS JAUNDICE -It's bad! likely septicaemia! -Infection of the gall bladder -CHARCOT'S TRIAD: •RUQ pain •Fever and rigors •Jaundice
Treatment
-antibiotics (cefuroxime and metronidazole) (guidelines)
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
- central distention (less severe than large bowel)
- bilous vomiting will be predominant early symptom
- colic pain +++
Large bowel
- flank distention
- constipation is early sign
- more constant pain
What are some common causes of bowel obstruction? (dynamic and adynamic) give examples of both
Dynamic -> mechanical obstruction •hernias •fecal impaction •volvulus •adhesions •TB
Adynamic -> paralytic ileus (inactivity of the bowel)
•recent abdo surgery
• electrolyte imbalance e.g. loss of K+ after surgery or hypercalceamia
•spinal injury
•pseudo obstruction
How would you approach a patient presenting with ?Bowel obstruction in ED
Bowel obstruction managment (emergency)
- ABCDE approach
- ABDO EXAM and end pieces
- stool
- hernia-femoral more likely to cause obstruction
- rectal exam (1st line)
- urine-cathertise
- BLOODS
- FBC
- UsEs
- LFT
- clotting
- group and save (surgery)
- glucose
- amylase
- calcium,
- Imaging:
- AXR -bigger than 3 (small),6, (caecum) 9 (large)
- CXR erect (pneumoperitomium))
What specific treatment can be done for bowel obstruction?
Bowel obstruction treatment
ABCDE management
-Drip and suck
-IV fluids
-NG ryles tube (reduce contamination of peritonium)
-IV antibiotics
-Correct electrolytes
-Analgesia and antiemetic (if necessary)
-Catheter (monitor fluid input AND output)
-PPI
-Refer to surgery (exploratory laparotomy for patients that are haemodynamically unstable or signs of ischaemia/necrosis)
What is diverticulosis/diviticular disease/diverticulitis?
In which diverticula does diverticulitis most often occur?
What are some complications of diverticulitis?
Increase in lumen pressure>out pouching
Diverticulosis= asymptomatic
Diverticular disease=symptomatic
Diverticulitis (infected)
In the diverticula of the descending/sigmoid colon (LIF)
Complications of diverticulitis
- abscess (swinging fever, WCC)
- perforation -surgery
- haemorrhage
- fistulae
What are some common symptoms of acute diverticulitis?
What are some common signs on examination would you see?
Acute diverticulitis
- SEVERE PAIN IN THE LEFT ILIAC FOSSA (normally relieved by defecation)
- Fever
- Nausea
- Altered bowel habit
- Flatulance
Examination • Febrile • Tachycardia (pain) • Tenderness and guarding in LIF • Localised or generalised peritonism • Diarrhoea ± Bleeding (melaena)
What investigations should be done in patients with diverticulitis?
What score should you use to classify severity?
BLOODS:
•FBC (wcc raised)
•ESR and CRP raised
IMAGING
- CT abdo with IV contrast (can also look for abcess)
- Erect CXR to look for perforation
- Can also do USS: thickened bowel walls and pericolic collections
Hinchey score – severity classification
How should diverticulitis be managed in the ED?
What investigation must you AVOID in acute diverticulitis?
Acute diverticulitis
- Mild attacks an be treated as an outpatient with oral co-amoxiclav
- If they are in considerable abdo pain or cant tolerate oral fluids consider admission for IV fluids, IV co-amoxiclav and analgesics (NBM)
DO NOT DO A COLONOSCOPY IN AN ATTACK OF DIVERTICULITIS(risk of perf)
What are risk factors for ectopic pregnancy?
What are some clinical features of ectopic pregnancy?
Ectopic pregnancy
RISK FACTORS
- endometriosis
- intrauterine contraceptive devise
- pelvic inflammatory disease
- pelvic surgery/edhesions
- PMH ectopic
- IVF
- progesterone only pill
FEATURES
- Collapse/syncope
- Recurrent lower abdominal pain (haemorrhage may cause pain to radiate to shoulder)
- Vaginal bleeding
- Missed period
What investigations should be done with suspected ectopic pregnancy?
What investigation should be AVOIDED?
Ectopic pregnancy
-Trans-vaginal USS
- Urine pregnancy test and serum bHCG in blood
-Bloods: FBC, crossmatch to determine rhesus status
think about other causes (UsEs, LFT, amylase, Ca, glucose)
Do not do bimanual examinationin ectopic pregnancy
How should we manage ectopic pregnancy?
Ectopic pregnancy
- Fluid resuscitation if shocked
- Depends on size and certain factors (B-hCG and FHR)
- Refer to gynaecology
- Watch and wait while measuring Hcg OR Methotrexate (if diagnosed later) OR surgery (heamodynamically unstable)
How might a miscarriage present?
Miscarriage presentation
- Acute vaginal bleeding with or without pain/cramping.
- Sometimes bleeding can be profuse and cause hypotension/collapse/faintness
