Acute Abdominal Presentations Flashcards
what are the 3 main components of bile
cholesterol
phospolipids
bile pigments
- stored in the gallbladder
give 5 risk factors for gallstones
obesity
female
fertility
>40
family history
- also pregnancy and oral contraceptives as oestrogen causes more cholesterole to be secreted into bile
describe the presentation of biliary colic
sudden ,dully, colicky
- RUQ pain but may radiate to epigastrium and/or back
- pain precipitated by consumption of fatty foods
- nausea/vomiting
describe the pathophysiology of biliary colic
- gallbladder neck is occluded
- fatty acids stimulate dudodenum endocrine cells to release CCK which stimulates contraction of gallbladder
what will patients presenting with acute cholecystitis report
constant pain in RUQ or epigastrium + associated signs of inflamm e.g. fever or lethargy
what might you find O/E of a pt w cholecystitis
tender RUQ
- +ve murphy’s sign: apply pressure to RUQ and ask pt to inspire
- halt in inspiration due to pain
give some ddx for RUQ pain
- GORD
- peptic ulceration
- acute pancreatitis
- IBD
what blood tests might be of importance in diagnosing gallstone disease
- FBC/CRP: inflamm response
- LFTS: biliary colic/cholecystisis = raised ALP but normal ALP and bilirubin
- amylase: pancreatitis
- urinalysis + pregnancy test to rule out renal or tubo-ovarian pathology
what is the 1st line investigation into suspected gallstone pathology
trans-abdominal ultrasound
- presence
- gallbladder wall thickness
- bile duct dilatation
what is the gold standard for imaging gallstones
MRCP - magnetic resonance cholangiopancretography
- can show potential defects in the biliary tree, sensitivity approaches 100%
what is the management plan for biliary colic
analgesia: regular paracetamol +/- NSAIDs +/- opiates
- advise about lifestyle factors e.g. low fat diet, weight loss, inc exercise
what is the surgical treatment of biliary colic
laparoscopic cholecystectomy
- should be offered within 6 weeks of first presentation
what should patients with acute cholecystitis be started on
IV ABx e.g. co-amoxiclav +/- metronidazole
- concurrent analgesia + anti-emetics (ondansetron)
what surgical intervention in indicated for acute cholecystitis
laparoscopic cholecystectomy
- within 1 week of presentation but ideally within 72 hours
what can be done if a cholecystitis patient is not fit for surgery and is not responding to abx
percutaneous cholecystostomy to drain the infection
give 4 complications of cholecystitis
- mirizzi syndrome
- gallbladder empyema
- chronic cholecystitis
- bouveret’s syndrome & gallstone ileus
what is mirizzi syndrome
- stone in Hartmanns pouch or in cystic duct can cause compression of the adjacent common hepatic duct
- OBSTRUCTIVE JAUNDICE
- confirm diagnosis by MRCP
- manage with lap chole
what is bouveret’s syndrome and gallstone ileus
inflammation of the gallbladder (typically if recurrent) can cause a fistula to form between the gallbladder wall and the small = cholecystoduodenal fistula
- Bouveret’s Syndrome – a stone impacts in the proximal duodenum, causing a gastric outlet obstruction
- Gallstone Ileus – a stone impacts at the terminal ileum (the narrowest part of the small bowel), causing a small bowel obstruction
what organisms commonly cause cholecystitis/cholangitis
gram -ve bacili
E.Coli, Klebsiella, Enterococcus
(Gentamicin)
what is mesenteric adenitis and what might cause it
swollen lymph nodes in the membrane that connect the bowel to abdo wall
- typically from viral or bac infection, some types of cancer or IBD
what is neutropenic sepsis and what is it caused by
low levels of neutrophils (WCC<2)
- gram +ve pathogens e.g. staph aureus, strep pneumoniae
- HIV, hepatitis, TB, sepsis, Lyme disease
what is the pathophysiology of diverticula formation
- aging bowel naturally becomes weaker over time
- movement of stool in the lumen causes an increase in luminal pressure = outpouching of the mucosa through the weaker areas of the bowel wall
how does diverticulitis arise and what are its consequences
bacteria can overgrow within the outpouchings = inflammation
- can perforate -> diffuse peritonitis, sepsis and death
- chronically can cause fistula formation (colovesical or colovaginal)
most commonly in the SIGMOID COLON
how does acute diverticulitis present
- acute abdo pain LIF
- sharp nature, worsened by movement
- O/E: localised tenderness + systemic upset e.g. dec appetite, pyrexia, nausea
what factors might mask symptoms of diverticulitis
corticosteroids or immunosuppressants
what are complications of diverticulitis
- abscess
- bleeding
- strictures: scarred and fibrotic bowel –> LBO
- fistulae
how is a diverticular abscess managed
<5cm managed conservatively with IV ABX
- radiological drainage
- complicated multi-loculated abscess = surgical intervention via lap washout or Hartmann’s procedure
what is the investigation of choice in suspected diverticulitis
CT abdomen-pelvis
- thickening of colonic wall
- pericolonic fat stranding
- abscess
do NOT perform colonoscopy as risk of perforation
how is acute diverticulitis staged
Hinchey classification
what is a Hartmann’s procedure
a sigmoid colectomy with formation of an end colostomy
what should not be missed in a patient presenting with epigastric pain
MI!!! Request an ECG
- especially in diabetic patients with neuropathy as they will not feel the pain of an MI
what are the 2 syndromes associated with cholangitis
- charcots triad: RUQ, fever, jaundice
- reynold’s pentad: jaundice, fever, RUQ, hypotension and confusion
what is the immediate management of cholangitis
IV fluids + abx e.g. co-amox, metronidazole
- routine bloods + cultures
what is the definitive management of cholangitis
endoscopic biliary decompression
- ERCP
describe the pathophysiology of appendicitis
direct luminal obstruction usually a faecolith or lymphoid hyperplasia
- less commonly by a malignancy e.g. caecal adenocarcinoma or neuroendocrine tumour
- when obstructed, commensal bacteria multiply = acute inflamm
* reduced venous drainage + loc inflamm = inc pressure = ischaemia in appendiceal wall
- left untreated = necrosis - perforate
what are risk factors of appendicitis
- FHx
- ethnicity: caucasians
- environmental: seasonal presentation during summer
what are the clinical features of appendicitis
- dull peri-umbilical pain that is poorly localised (visceral) then migrates to right iliac fossa becoming sharp (parietal)
- vomiting, anorexia, nausea, diarrhoea
- O/E: rebound + percussion tenderness over McBurney’s point
- severe: sepsis, tachycardia, hypotension and pyrexia
what are specific signs of appendicitis
- Rovsing’s sign: RIF pain on palpation of the LIF
- psoas sign: RIF pain with extension of the R hip - retrocaecal appendix abutting the psoas muscle
what are potential ddx for appendicitis
- gynae: ovarian cyst rupture, ectopic pregnancy, PID
- renal: ureteric stones, UTI
- GI: IBD, Meckel’s
- urological: testicular torison, epiddidymo-orchitis
what are important differentials to consider in children presenting with suspected appendicitis
- mesenteric adenitis
- gastroenteritis
- constipation
- intussusception
- UTI
what investigations should be carried out in all patients with suspected appendicitis
urinalysis - assess for renal/urological cause
- pregnancy test in women of reproductive age (serum b-hCG)
- routine bloods
what imaging should be carried out in all patients with suspected appendicitis
- USS
- CT: good sensitivity & specificity
- MRI: 2nd line in children/pregnant women
what is the definitive treatment for appendicitis
lap appendicectomy
- low risk
- allows direct visualisation of other organs
- sent to histo to assess for underlying malingnancy
give 4 possible complications of acute appendicitis
- perforation
- surgical site infection
- appendiceal mass
- abscess formation
what is an important differential for appendicitis in >35s that should not be missed
caecal cancer!
if >35 then do a CT scan to rule out
give 4 causes of pain in the epigastric region
- peptic ulcer disease
- cholecystitis
- pancreatitis
- MI! - important to not miss, order ECG
give 4 causes of pain in the peri-umbilical region
- SBO & LBO
- appendicitis
- AAA
what are the likely diagnoses of acute abdominal pain in those > 50
- biliary tract disease
- NSAP
- appendicitis
- bowel obstruction
what are the likely diagnoses of acute abdominal pain in those < 50
- NSAP
- appendicitis
- mesenteric adenitis
what is pseudo-obstruction
a disorder characterised by dilatation of the colon due to an adynamic bowel in absence of mechanical obstruction
where does pseudo-obstruction most commonly affect
caecum and descending colon
explain the pathphysiology behind pseudo-obstruction
interruption of the autonomic nervous supply to the colon resulting in the absence of smooth muscle action in the bowel wall
what can untreated pseudo-obstruction lead to
increasing colonic diameter –> inc risk of bowel ischaemia and bowel perforation
give 4 possible causes of pseudo-obstruction
- electrolyte imbalance or endocrine disorders e.g. hypercalcaemia
- meds: opioids, CCBs, anti-depressants
- recent surgery, severe systemic illness, trauma
- neuro disease e.g. parkinson’s/MS
what are the clinical features of pseudo-obstruction
- abdo distension
- abdo pain
- absolute constipation
- vomiting: often late due to distal location of the colon
- O/E: distended & tympanic w absent bowel sounds
what investigations should patients with suspected pseudo-obstruction undergo
routine bloods: FBC, U&Es, Ca2+/Mg2+ and thyroid function tests
how can diagnosis of pseudo-obstruction be reached
CT abdo-pelvis + IV contrast: often entire colon is dilated w no obvious narrowing or transition point
- AXR can be performed which will show evidence of bowel distension
how can pseudo-obstruction and mechanical obstruction be differentiated
endoscopic assessment (flexible sigmoidoscopy)
- for firect visualisation and concurrent bowel decompression for symptomatic relief
what is the management for pseudo-obstruction
- aggressive fluid resus as they are often intravascularly fluid deplete
- NGT if vomiting
- urinary catheter for fluid balance assessment
- adequate analgesia
- correct electrolyte abnormalities
what is the management for pseudo-obstruction that does not resolve within 24-48 hours
decompression by flexible sigmoidoscopy and insertion of a flatus tube is required
- if limited resolution can use IV neostigmine (anticholinesterase)
- but must be done in a high-dependency monitored setting due to side effects of severe bradycardia
what is the management for pseudo-obstruction with evidence of bowel ischaemia or perforation
emergency surgery
- laparotomy + subtotal colectomy
