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Semester 1 ( 3rd Year) > Case 11: Central/lower abdominal pain > Flashcards

Case 11: Central/lower abdominal pain Flashcards

1
Q

dermatomes for the foregut

A

T5-T9

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2
Q

dermatomes for the midgut

A

T10-T11

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3
Q

dermatomes for the hindgut

A

L1-L2

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4
Q

what small bowel diameter suggests bowel obstruction

A

over 3cm

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5
Q

what caecum diameter suggests bowel obstruction

A

over 9cm

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6
Q

what colon diameter suggests bowel obstruction

A

over 6cm

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7
Q

which structures will cause central abdominal pain

A

intra-abdominal structures- midgut

retroperitoneal structures- duodenum, pancreas, aorta

abdominal wall- hernia, muscle, skin

referred pain- from back, base of lung, inferior heart

rarely medical causes- DKA, porphyria

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8
Q

what are the midgut structures

A

form the opening of the bile duct to proximal 2/3 of transverse colon:

distal duodenum
jejunum
ileum
caecum
appendix
ascending colon
proximal 2/3 transverse colon

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9
Q

how does referred pain happen

A

the visceral pain of the organ is referred to the site on the skin which is supplied by that dermatome

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10
Q

where is foregut pain perceived

A

epigastric region

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11
Q

where is midgut pain perceived

A

umbilical region

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12
Q

where is hindgut pain perceived

A

suprapubic/hypogastric region

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13
Q

possible diagnoses for continuous abdominal pain radiating to the back

A

symptomatic abdominal aortic aneurysm (AAA)
pancreatitis

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14
Q

possible diagnoses for colicky abdominal pain which is now constant

A

bowel obstruction with/without hernia
IBS

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15
Q

possible diagnoses for colicky abdominal pain associated with diarrhoea

A

gastroenteritis
IBD

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16
Q

possible diagnoses for central abdominal pain which has now shifted to the right iliac fossa

A

appendicitis
rarely perforated duodenal ulcer

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17
Q

possible diagnoses for sudden severe pain radiating to the back, flank and/or groin

A

AAA until proven otherwise
renal colic

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18
Q

possible diagnoses for severe generalised pain with shoulder tip pain

A

diaphragm irritation by free fluid/blood within the abdomen

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19
Q

typical presentation of AAA

A

central abdominal pain
no link to food
palpable pulsatile/expansile mass especially if tender

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20
Q

typical presentation of acute appendicitis

A

classic central (visceral) abdominal pain that localises to right iliac fossa when the inflamed appendix irritates the peritoneum locally

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21
Q

typical presentation of duodenal perforation

A

background of epigastric pain and clear relationship to eating

can cause high central abdominal pain and leak of duodenal content will track across the root of mesentery into right iliac fossa localising the pain to that side

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22
Q

what does colicky pain that becomes constant suggest

A

that there is a partial obstruction of a hollow viscus (bowel, bile duct, ureter) which has become complete

needs urgent intervention to prevent perforation or major complications

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23
Q

what suggests infection/inflammatory process in one organ

A

pyrexia
localised tenderness
guarding

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24
Q

what is mcburneys point

A

point of maximum tenderness in appendicitis (base of the appendix)

1/3 the line between the anterior superior iliac spine to umbilicus

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25
Q

important interventions for appendicitis

A

analgesia (morphine)

NBM

IV fluids- to maintain hydration and to treat hypotension

antibiotics for the sepsis

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26
Q

what can septic shock also present with with acute abdominal pathology

A

hypothermia

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27
Q

what part of the large intestine is the appendix attached to

A

caecum

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28
Q

official name for appendix and why

A

vermiform appendix- means worm shaped

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29
Q

what is the most common surgical emergency for the abdomen

A

appendicitis

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30
Q

causes of appendicitis

A

most common is obstruction:
fecalith- faecal rock
undigested seeds
pinworm infection
lymphoid hyperplasia

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31
Q

what leads to the pathophysiology of appendicitis

A

there is an increase in pressure- prolonged increase in pressure can compress the blood vessels suppling the appendix which can lead to ischaemia)

gut flora multiplies (e.coli, bactericides fragilis)

immune system causes an increased which cell count

fever, nausea and vomiting

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32
Q

why might you get peritonitis with appendicitis

A

the increase in pressure can weaken the walls of the appendix

this can lead to the appendix rupturing

the contents which are full of bacteria can irritate the peritoneum causing peritonitis

this will cause guarding and rebound tenderness especially at mcburneys point

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33
Q

what is a AAA

A

dilation of the abdominal aorta

the diameter is over 3cm

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34
Q

what is the mortality of a ruptured abdominal aortic aneurysm

A

80 percent

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35
Q

are men or women more at risk of AAA

A

men are affected more often and at a younger age

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36
Q

risk factors for AAA

A

men
increasing age
smoking
hypertension
family history
existing cardiovascular disease

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37
Q

screening process for AAA

A

all men at 65 are offered an ultrasound to detect an asymptotic AAA

women aren’t routinely offered screening as they are at a much lower risk (may be screened at 70 if they have lots of risk factors)

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38
Q

how does referral for AAA work following screening

A

if diameter is more than 3cm refer to vascular
urgent referral if more than 5.5cm

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39
Q

typical presentation of AAA

A

most asymptomatic

can be detected during routine screening, after rupture, or an incidental finding on x-ray, ultrasound or CT

non-specific abdominal pain

pulsatile and expansile mass

40
Q

diagnosis of AAA

A

ultrasound

a CT angiogram will be performed to get a more detailed picture and it helps guide elective surgery

41
Q

classification of AAA

A

normal= less than 3cm

small= 3-4.4cm

medium= 4.5-5.4cm

large= over 5.5cm

42
Q

management of AAA

A

treat reversible risk factors- smoking cessation, healthy diet and exercise, optimise hypertension, diabetes and hyperlididaemia

follow-up scans- yearly if 3-4.4cm or every 3 monthly if 4.5-5.4cm

elective repair- if symptomatic, growing more than 1cm per year or if over 5.5cm

43
Q

how is the surgery for AAA done

A

a graft is inserted

can be either open repair (laparotomy)

or

endovasuclar aneurysm repair (EVAR) which is inserted via the femoral arteries

44
Q

DVLA advice for AAA

A

must inform the DVLA if over 6cm
must stop driving if over 6.5cm

45
Q

presentation of ruptured AAA

A

severe abdominal pain which radiates to the back and groin

haemodynamic instability:
hypotension
tachycardia
pulsatile and expansile mass
collapse
loss of consciousness

46
Q

what blood pressure technique is done when managing ruptured AAA

A

permissive hypotension
(don’t want to increase BP as it will lead to more blood spilling into the abdominal cavity)

47
Q

common misdiagnosis of ruptured AAA

A

renal colic
diverticulitis
GI bleed
MI
muscular or mechanical back pain

48
Q

how can clinical examination for AAA be limiting

A

only picks up 40-50%
can be difficult in obese
false positives in thin individuals due to transmitted pulse vs expansile mass

49
Q

what happens to the legs with ruptured AAA

A

bilateral leg ischemia (if in one leg think of dissection or significant peripheral vascular disease)

50
Q

in which patients should you always suspect ruptured AAA

A

men older than 60 with first presentation of renal colic

51
Q

what is a hernia

A

protrusion of an organ through its containing wall and into a different cavity (can be acquired or congenital)

52
Q

what is the most common type of hernia

A

inguinal

53
Q

other types of hernias

A

umbilical/paraumbilical
femoral
incisional
epigastric

54
Q

what is a reducible hernia

A

hernia can be manually pushed back or reduced into the abdominal cavity

55
Q

what is a irreducible hernia

A

the hernia sac and its content cannot be pushed back into the abdomen

56
Q

what is a stangulated hernia

A

the neck of the sac is quite tight leading to cut off the blood supply to the organ that herniated

57
Q

what is a obstructed hernia

A

the bowel loop trapped within the sac causes bowel obstruction, with further oedema it can become strangulated

58
Q

what investigation is always done when there is peritonitis

A

CT

59
Q

what is conservative management of appendicitis

A

can be treated with antibiotics but has a significant failure rate due to ongoing sepsis and also has high recurrence rate

may be an option for those not fit for surgery or those who are pregnant with mild symptoms and no sepsis

60
Q

complications of appendectomy that the patient needs to be counselled on

A

conversion to open surgery

post-operative wound infection or intra-abdominal collection

bleeding

others- pain, postoperative ileus, lower respiratory tract infections/pneumonias, DVT, PE, adhesions and incisional herniasconversion to open surgery

61
Q

what would warrant and urgent referral for ovarian cancer

A

2 week wait if:

ascites
pelvic/abdominal mass (which is not obviously uterine fibroids)

62
Q

what is the CA125 blood test

A

protein in the blood
raised levels may indicate/help monitor ovarian, fallopian tube, or primary peritoneal cancer

63
Q

when would CA125/ultrasound be indicated

A

in women (especially 50+) who experience the following frequently (more than 12 times per month):

persistant abdominal distention
early satiety and/or loss of appetite
pelvic/abdominal pain
increased urinary urgency and/or frequency
new onset symptoms suggestive of IBS (IBS rarely presents for the first time in women of this age)
unexplained weight loss
fatigue
changes in bowel habit (though colorectal cancer will be the most likely malignant cause)

64
Q

what would prompt urgent referral for investigation of colorectal cancer

A

any age with abdominal/rectal mass

40 and over with unexplained weight loss and abdominal pain

50 and over with unexplained rectal bleeding

60 and over with iron deficiency anaemia

65
Q

symptoms and signs of strangulated hernia

A

acute, severe pain delectable on examination as a non-reducible mass in groin or anterior abdominal wall

66
Q

what is overflow diarrhoea and what would you find on examination

A

can occur in severe constipation
there would be impacted stool in the rectum

67
Q

what age most commonly presents with inflammatory bowel disease

A

15-40

68
Q

signs and symptoms of inflammatory bowel disease

A

abdominal pain
bloating
bloody diarrhoea
weight loss
extreme tiredness

69
Q

pathophysiology of irritable bowel syndrome

A

functional disorder of the bowel
related to the way the bowel and the brain interact, causing increased sensitivity of the bowel to normal stimuli and abnormal motility

70
Q

most common age diagnosis of IBS

A

20-40

71
Q

are men or women more likely to have IBS

A

women are twice as more likely to be affected by men

72
Q

symptoms of IBS

A

diarrhoea
constipation
alternation between both of the above
abdominal pain
diurnal bloating
mucus in the stool
tiredness

73
Q

what can affect the symptoms of IBS

A

hormonal fluctuations during the menstrual cycle- often worse during the progesterone dominant premenstrual phase

emotional stress is a trigger

can also occur after an episode of gastroenteritis

74
Q

pathophysiology of diverticulitis

A

diverticula are small bulges/pouches in the lining of the large intestine- usually incidental findings on scans/colonoscopy and occur with advancing age

occurs when these pouches becomes infected/inflamed

75
Q

what is diverticulosis

A

presence of diverticula (they are asymptomatic and not inflamed)

76
Q

signs and symptoms of diverticulitis

A

severe pain ofter in LLQ
bloating
fever
bloody diarrhoea
severe pain which worsens over several days

77
Q

pathophysiology of coeliac disease

A

autoimmune condition triggered by sensitivity to gluten, repeated gluten exposure causes inflammation of the small intestine

78
Q

signs of symptoms of coeliac disease

A

abdominal pain
bloating
tiredness
diarrhoea
constipation
anaemia
weight loss
skin rashes (specifically dermatitis herpetiformis)

79
Q

pathophysiology of lactose intolerance

A

deficiency in lactase enzyme which is produced by the small intestine (breaks down sugar lactose which is found in diary products)

80
Q

symptoms of lactose intolerance

A

usually occur within 30 minutes after eating diary products
diarrhoea
crampy abdominal pains
bowel gas
bloating

81
Q

epidemiology of lactose intolerance

A

primary lactase deficiency is most common in adults of African, asian, hispanic o American Indian descent

secondary lactase deficiency can occur as a result of other conditions affecting the function of the small intestine including crohns and after a severe episode of gastroenteritis

82
Q

bile acid diarrhoea pathophysiology

A

bile acids are produced in the liver, stored in the gallbladder and secreted into the small intestine after meals

they are mostly reabsorbed in the ileum and returned to the liver in a cycle known as enterohepatic circulation

when they are not adequately reabsorbed, chronic diarrhoea along with bloating and cramping pain can result

83
Q

what is bile acid diarrhoea most commonly misdiagnosed as

A

irritable bowel syndrome with predominant diarrhoea

84
Q

epidemiology of bile salt diarrhoea

A

affected 1 in 100 people in the UK

85
Q

investigations for bile salt diarrhoea

A

SeHCAT scan- artificial bile is swallowed and an initial scan determines how much is present in the body

a further scan one week later shows how much of the original amount has been retained via enterohepatic circulation

86
Q

treatment for bile salt diarrhoea

A

low fat diet and bile acid sequestrants (drugs that bind to bile acids in the small intestine and prevent irritation of the colon)

87
Q

what is faecal calprotectin and what does it help distinguish between

A

is a biomarker of bowel inflammation

distinguishes between IBS (normal levels) and inflammatory bowel disease (elevated levels even if CRP is normal)

88
Q

anaemia may be seen in which 2 gastrointestinal diseases

A

coeliac
IBD

89
Q

what is toxic megacolon

A

extreme dilation of a segment of the diseased colon caused by paralysis of the colon

results in complete obstruction

90
Q

what on coeliac serology suggests coeliac disease

A

tissue transglutiamse antibody (tTGA)
endomysial antibody (EMA)

(are both antibodies formed in response to eating gluten)

91
Q

what biopsy may be done to confirm coeliac disease

A

duodenal biopsy

92
Q

what should be recommended as first line management for IBS

A

reduce caffeine (caffeine stimulates bowel motility)

reduce fizzy drinks (fizzy drinks exacerbate symptoms of bloating and bowel gas)

regular exercise (reduces stress and improves overall wellbeing)

loperamide

93
Q

what is loperamide

A

anti-motility drug
used first line with diarrhoea associated with IBS

opiate receptor agonist (binds to u) in the colon
decreases the smooth muscle tone in the intestinal wall
hardly crosses BBB so has no central effects

94
Q

what is a Low FODMAP diet

A

if general lifestyle and dietary advice does not help with IBS this can be recommended

fermentable olgiosaccharides
dissacharides
monosaccharides
polyols

(these are a group of carbohydrates that are incompletely digested and absorbed in the small intestine, have an osmotic effect, retaining water as they pass into the colon, they are then fermented which produces gas, extra gas and water can cause these unpleasant symptoms)

95
Q

examples of FODMAPs

A

fructose
lactose
sorbitol
fructans
galactans

(fruit is abundant so they are asked to limit fresh fruit consumption)

Semester 1 ( 3rd Year) (12 decks)

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