Albert Smith - AAA Flashcards
What does MEDIICAATION stand for and what does it relate to?
When trying to reach a diagnosis
Metabolic Endocrine Degenerative Inflammatory-Infection Congenital Age related Alcohol-Toxic Injury-trauma Oncological Neoplastic
DDx of generalized abdominal pain
- Perforation
- AAA
- Acute Pancreatitis
- Diabetes mellitus
DDx of central abdominal pain
- Early appendicitis
- Subacute Obstruction
- Acute gastritis
- Acute pancreatitis
- Ruptured AAA
- Mesenteric
thrombosis (Mesenteric venous thrombosis (MVT) is a blood clot in one or more of the major veins that drain blood from the intestine)
DDx of epigastric pain
- Peptic Ulceration DU /GU / Oesophagitis
- Biliary Colic
- Acute pancreatitis
- AAA
- Myocardial Infarction (inferior)
DDx of RUQ pain
- Gallbladder disease
- Duodenal Ulcer
- Acute pancreatitis
- Pneumonia
- Subphrenic abscess
DDx of LUQ pain
- Gastric Ulcer
- Pneumonia
- Acute pancreatitis
- Spontaneous splenic
rupture - Subphrenic abscess
DDx of suprapubic pain
- Acute urinary retention
- UTIs
- Cystitis
- PID
- Ectopic pregnancy
- Diverticulitis
DDx of RIF pain
- Acute appendicitis
- Mesenteric adenitis (young)
- Perf DU
- Diverticulitis
- PID
6.Salpingitis - Ureteric colic
- Meckel’s diverticulum
- Ectopic pregnancy
• Crohn’s disease
DDx of loin pain
- Muscle strain
- UTIs
- Renal stones
- Pyelonephritis
- AAA
DDx of LIF pain
- Diverticulitis
- Constipation
- Irritable Bowel Syndrome
- Pelvic Inflammatory
Disease - Rectal Carcinoma
- Ulcerative Colitis
- Ectopic pregnancy
Abdominal pain investigation options
- Pregnancy test
- Urine dipstick
- Plain film (free air, obstruction, air-fluid, foreign bodies)
- Ultrasound (role in trauma)
- CT
Mx steps for abdominal pain
1.ABC’
2. Supplemental oxygen
3. IV access
4. Fluid administration
5. Antiemetics
6. Analgesics
7. Urinary catheterisation
8. Antibiotics
9. Radiology…
10. Re-evaluation with results (Barium Meal, Blood
tests, Arterial Blood Gasses, ECG, radiology)
Risk factors for AAA
- ↑ Age
- Male sex (x 4-8)
- Smoking (x 6)
- Family history (x 4)
- Vascular disease
- Hypertension
- Hypercholesterolaemia
- • Ethnicity
• 50% decreased risk in black men
• 90% decreased risk in Asian men - Genetic disorders: lysil oxidase deficiency
- Connective tissue disorders
• Marfan, Ehlers Danlos - Infective (Mycotic and inflammatory causes)
Protective factors of AAA
- Blacks and hispanics
- Diabetes
- Exercise 1 p/w
- Fruit, veg and nuts
Disease LOB Marfaans
Genetic disorder of connective tissue – tall with long
limbs and long thin fingers
• Autosomal dominant inheritance – Gene FBN1 which
encodes connective protein fibrillin – 1
• Varying penetrance – heart valves, aorta, lungs, eyes,
dura, skeleton, hard palate.
• Fibrillin 1
– A connective protein
– B binds transfroming growth factor beta (TGF-β).
TGF-β has deleterious effects on vascular smooth muscle
development and the integrity of extracellular matrix. Thus
excessive TGF-β weakens the tissues and causes Marfan’s
Disease LOB Ehlers-Danlos syndrome
Group of inherited connective tissue disorders
caused by a defect in the synthesis of type V collagen.
• Typically affects joints, skin and blood vessels.
- Symptoms may include loose joints, stretchy skin,, poor wound healing and abnormal scar formation.
- These can be noticed at birth or in early childhood.
- Complications may include aortic dissection, joint dislocations, scoliosis, chronic pain, or early osteoarthritis.
Pathophysiology of atherosclerosis
See notebook
SS of AAA
- Abdominal pain, back pain, loin pain
- Pulsatile, expansile abdominal mass
- 25% have associated femoral or popliteal aneurysms
- <4cm AAA; clinical examination sensitivity 0.57
- > 5cm AAA; clinical examination sensitivity 0.98
Risk of AAA rupture per by size
– 4 cm.: 1 % / year – 5 cm.: 4 %/ year – 6 cm.: 10 % / year – 7 cm.: 20 % / year – 8 cm.: 40% / year – 10cm.: 100% / year
Most frequent misdiagnosis of AAA
- Renal bleed
- GI bleed
- Diverticulitis
- Back pain
- MI
- Motor vehicle accident
- Sepsis
AAA disease LOB
See notebook
open surgery or EVAR
SEE SLIDE 54 OF mX OF aaa LECTURE (PANOS)
Disadvantages of open repair
Clamping the aorta
• End-organ ischaemia
• Increased SVR (increased pre-load and after-load)
• Reperfusion injury (mediated by inflammatory cytokines)
Massive blood loss
• Transfusion-related coagulopathy
Advantages of EVAR
- Avoids laparotomy
* Avoids aortic clamping
Disadvantages of EVAR
- Wire trauma/access problems
- Endoleak
- Graft migration
- Graft kinking/occlusion
What are the distal branches of the abdominal aorta and what do they supply?
Abdo aorta splits into common iliac arteries which split into ext and int. iliac arteries
Int. iliac supplies pelvis
Ext. iliac continues downward to supply the leg and becomes the femoral artery
Which parameters indicate that the fluid challenge has been successful (i.e. the patient responds positively to fluid)
Heart rate decreases
Mean arterial pressure increases
Arterial pulse pressure increases
Urine output increases
Lactate clearance increases
Cardiac output or stroke volume increase
When is it indicated to give blood glucose?
if < 3 mmol l-1 give glucose
What is the significance of urine output in the sick patient?
Urine output is one of the few signs of end-organ
perfusion
In a sick patient catheterisation should be considered to
allow measurement (and documentation) of hourly urine
volume The weight is essential to get an accurate urine
output.
What is the difference between cholangitis and cholecyctitis?
Cholangitis: infection of the biliary tree, usually arising form a combination of biliary obstruction and presence of bacteria
Cholecystitis: inflammation of the gallbladder, which results from obstruction of the cystic duct by gallstones in 90% of cases
Clinical features:
Cholangitis: Classic triad of fever (>90%), jaundice (65%) and RUQ pain (>40%), although all three occur in <20% of cases.
Cholecystitis: Most have prior history of biliary colic (. Fever, nausea, vomiting often present, RUQ pain/guarding, palpable galbladder in 30% of cases. Jaundice suggests choledocholithasis or Mirizzi’s syndrome (see defs below)
What is biliary colic?
Biliary colic, also known as a gallbladder attack or gallstone attack, is when pain occurs due to a gallstone temporarily blocking the bile duct. Typically, the pain is in the right upper part of the abdomen, and it can radiate to the shoulder. Pain usually lasts from one to a few hours.
Why is the sigmoid colon at highest risk of developing diverticula?
Sigmoid colon has the thinnest diameter therefore according the law of La Place it is subject to increase pressure (pressure is inversely proportional to diameter)
Difference between diverticulosis and diverticulitits
Divertituclosis is outpuching of the colon without inflammation whereas diverticulsis in an inflamed diverticulosis
- Diverticulosis may involve weaking of the vessel within the outpuching and can lead to painless bleeding however diverticulitis does not lead to bleeding as the vessel wall is scarred
Outline a serious potential complication of diverticulosis
Vesicocolonic fistula - rupture of the diverticulosis causes a fistula to be formed in nearby strucutre e.g. the bladder
The leads to fecal matter in the urine - nicht gut
What are the features of mesenteric adentitis
- Usually preceded by viral or bacterial infection
- Diffuse abdo pain > RIF pain
- Can be indistinguishable from appendicitits
- Children > adults
- Precded by URT infection
What is Meckels Diverticulaum
Diverticulum of all layers of the intestinal wall - mucosa, submucosa, muscularis and serosa
As opposed to false diverticula which is just outpuching of the mucosa and submucosa
Congenital remnant of the vetelline
2% population
2 feet from ileocecal valve
2 inches in length
2 x males most likely affect
