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csi (phase 1b) > case 12 - abdominal pain > Flashcards

case 12 - abdominal pain Flashcards

1
Q

what is acute abdomen?

A

rapid onset of severe symptoms of abdominal pathology

may indicate a potentially life-threatening condition that requires urgent surgical intervention

a common reason for emergency department attendance

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2
Q

what are the clinical features of acute abdomen?

A

immediate assessment should distinguish patients with true acute abdomen that require urgent surgical intervention from patients who can initially be managed conservatively

access to an experienced surgeon reduces unnecessary admissions

patients with acute surgical pathology may deteriorate rapidly; patients with severe,
unremitting symptoms warrant thorough investigation and close monitoring

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3
Q

how may abdominal pain present?

A

be located in any quadrant of the abdomen

be intermittent, sharp or dull, achy, or piercing

radiate from a focal site

be accompanied by nausea and vomiting

be absent in older people, children, the immunocompromised, and in the last trimester of
pregnancy

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4
Q

how is a diagnostic work-up carried out for acute abdominal pain?

A

history, physical examination, imaging, and laboratory results

+ in some patients = digital laparascopy

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5
Q

which analgesic is used for acute abdominal pain?

A

opioid analgesia does not increase the risk of diagnosis/treatment decision error

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6
Q

what is important to remember about abdominal pain in older people, the immunocompromised and pregnant women?

A

often presents atypically so = delayed diagnosis of potentially life-threatening pathology

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7
Q

how is abdominal pain managed in older people?

A

comorbid conditions/medications may affect physiological response

are at higher risk for more severe disease due to decreased immune function

decreased CNS function can restrict an ability to communicate problems

decreased PNS function can alter perception of pain and temperature

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8
Q

how is abdominal pain managed in pregnant women?

A

many physical and physiological changes

enlarged uterus displaces and compresses intra-abdominal organs

laxity of the abdominal wall makes it difficult to localise pain and can blunt peritoneal signs

may have a mild physiological leukocytosis, so this finding is non-specific in pregnant
women presenting with an acute abdomen

high suspicion for intra-abdominal pathology = further studies are warranted e.g. additional laboratory testing, radiographic testing, serial physical examinations

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9
Q

how is abdominal pain managed in the immunocompromised?

A

altered inflammatory response

atypical symptoms and signs

abdominal pain is usually non-specific, and physical examination is often inconclusive

susceptible to opportunistic infections, e.g. cytomegalovirus colitis in AIDS patients

acute abdomen may occur as a result of immunosuppressive therapy

a lower threshold for hospital admission and cross-sectional imaging is required

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10
Q

what are some common differentials for abdominal pain?

A

adhesions

incarcerated/strangulated hernia

cholecystitis

perforated gastric ulcer

appendicitis

ectopic pregnancy

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11
Q

what are some uncommon differentials for abdominal pain?

A

volvulus

intussusception

perforated duodenal ulcer

ovarian torsion

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12
Q

what are the commonest causes of acute abdomen?

A

nonspecific abdominal pain

renal colic

biliary colic

cholecystitis

appendicitis

diverticulitis

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13
Q

how does the aetiology of acute abdomen vary according to age?

A

renal colic and appendicitis are more common in patients <60 years

gallbladder disease and diverticulitis are more common in older patients

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14
Q

what are the upper abdominal pain differential?

A

organ-based

  • heart
  • thorax/lungs
  • aorta

GI organs

  • pancreas
  • bile duct, gallbladder
  • stomach (peptic ulcers)
  • duodenum

systemic

  • DKA
  • addisonian crisis
  • electrolyte abnormalities
  • lead poisoning

other

  • gastroenteritis
  • pregnancy (women)
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15
Q

what is AST?

A

aspartate aminotransferase

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16
Q

where is AST made?

A

hepatocytes

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17
Q

why is AST measured?

A

when hepatocytes are damaged, the AST enzyme is released from the cells and serum AST levels will be elevated

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18
Q

when is AST most likely to be raised?

A

obstruction of the liver

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19
Q

when is bilirubin most likely to be raised?

A

when there is an obstruction of the bile duct

biochemical marker of jaundice

released when RBCs breakdown

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20
Q

what is biliary colic?

A

symptomatic cholelithiasis

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21
Q

what is the term to describe when gallstones that form leave the gallbladder and enter the bile ducts?

A

choledocholithiasis

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22
Q

what is cholecystitis?

A

gallbladder inflammation

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23
Q

what is ascending cholangitis?

A

bile duct inflammation

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24
Q

explain how biliary colic occurs

A

pain caused by gallbladder muscle spasms against a stone stuck in the cystic duct/neck of the gallbladder

(no inflammatory response)

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25
Q

explain how cholecystitis occurs

A

gallbladder inflammation (an have an infective cause)

26
Q

explain how ascending cholangitis occurs

A

biliary outflow obstruction and infection = surgical emergency

gallstone (from liver or gallbladder) causes obstruction to biliary flow

high morbidity (!!)

27
Q

how does biliary colic present in a physical examination?

A

constant, dull RUQ pain

28
Q

how does cholecystitis present in a physical examination?

A

severe and constant RUQ pain

epigastric pain

29
Q

how does ascending cholangitis present in a physical examination?

A

RUQ pain

30
Q

how does biliary colic present in a patient history?

A

symptoms last less than 6 hours

nausea and vomiting

pain likely to be constant (despite term colic)

NO JAUNDICE

stimulated by fatty foods (stimulates cholecystokinin release and therefore gallbladder contraction)

31
Q

how does cholecystitis present in a patient history?

A

can get nausea and vomiting

Murphy’s sign

mild temperature and tachycardia

32
Q

how does ascending cholangitis present in a patient history?

A

Charcot’s triad

  • jaundice
  • rigors and fever
  • RUQ pain

sepsis (!!) signs

  • pain
  • rigor and fever
  • tachycardia
  • hypotensive
33
Q

what are the blood test results for someone with biliary colic?

A

normal observations

normal LFTs + bilirubin

34
Q

what are the blood test results for someone with cholecystitis?

A

raised WBC count and CRP

sometimes raised ALP

normal LFTs and bilirubin

35
Q

what are the blood test results for someone with ascending cholangitis?

A

raised WBC count, CRP and ALP

raised bilirubin (jaundice - looking at skin only is unreliable)

36
Q

what is Murphy’s sign?

A

place hand on RUQ and ask patient to breathe in, liver and gallbladder move down and if INFLAMED, will press on hand and cause pain

check LUQ to ensure it is only in the RUQ

37
Q

what are the three main causes of gallstone formation?

A

bile contains too much cholesterol

bile contains too much bilirubin

gallbladder does not empty correctly

38
Q

why does excess cholesterol in the bile cause gallstone formation?

A

bile usually contains sufficient chemicals to completely dissolve the bile however when there is excess cholesterol, the bile chemicals are not sufficient for complete dissolving

= excess cholesterol may form into crystals and stones

39
Q

why does excess bilirubin in the bile cause gallstone formation?

A

too much bilirubin (blood disorders, liver cirrhosis, biliary tract infection)

excess contributes to gallstone formation

40
Q

why does incomplete gallbladder emptying cause gallstone formation?

A

bile can become very concentrated if gallbladder does not empty properly or often enough = formation of gallstones

41
Q

what are the three types of gallstones?

A

cholesterol gallstones
pigment gallstones
mixed gallstones

42
Q

which is the most common type of gallstone?

A

cholesterol gallstone

43
Q

what are cholesterol gallstones?

A

light yellow to dark green/brown

usually large

linked to poor diet and obesity

44
Q

what are cholesterol gallstones?

A

light yellow to dark green/brown

usually large

formed of cholesterol + other products

linked to poor diet and obesity

45
Q

what are pigment gallstones?

A

dark brown/black stones w too much bilirubin

formed of mainly bilirubin breakdown products

can be from excess bile pigment production OR haemolytic anaemia

46
Q

which gallstone type is linked to haemolytic anaemia?

A

haemolytic anaemia = excess bilirubin so pigment gallstone

47
Q

what are mixed gallstones?

A

combo of cholesterol and bile pigment and bile salts in the gallstone

48
Q

what are the risk factors for gallstones?

A

female

49
Q

what are the risk factors for gallstones?

A 
female
> 40 years
Native American/Hispanic/Mexican
overweight/obese
sedentary
high fat diet
high cholesterol diet (hyperlipidemia)
FHx of gallstones
50
Q

what is bile?

A

98% water with other dissolved substances (bile slats, bilirubin, cholesterol)

51
Q

how do gallstones arise?

A

from the super saturation of bile = gives rise to diff sizes of galstones

52
Q

what affects the composition of gallstones?

A

age, diet, ethnicity

53
Q

list possible complications of gallstones

A

biliary colic (gallstones in the neck of the gallbladder/hartman’s pouch/cystic duct)

acute cholecystitis (gallstones in the cystic duct)

ascending cholangitis (GS in the common bile duct)

gallstone pancreatitis (GS in the pancreatic duct)

gallstone ileus (really large GS in the duodenum causing small bowel obstruction)

gallbladder empyema

Mirizzi syndrome (extrinsic compression of the common hepatic duct from a GS in the cystic duct)

54
Q

why are the majority of gallstones asymptomatic?

A

usually small + found within the gallbladder (not causing significant obstruction)

55
Q

when do gallstones most commonly become a problem?

A

when they obstruct flow through a duct

56
Q

what are three serious possible complications of gallstones?

A

jaundice
sepsis
cancer (in any structure w chronic inflammation)

57
Q

what is the course of treatment if gallstones are discovered accidentally and the patient is asymptomatic?

A

no symptoms = NO treatment

58
Q

how are symptomatic gallstones/acute cholelithiasis managed?

A

laparoscopic cholecystectomy (keyhole surgery to remove the gallbladder)

59
Q

what type of consent does every surgical procedure require?

A

written consent form

60
Q

what does valid consent require?

A

patients to have capacity (can be assessed when having a convo w the patient)

61
Q

describe the process of informed decision making

A

explain diagnosis + prognosis

explain treatment options

describe procedure and logistics

explain purpose, risks, complications and benefits of procedure

give patient time to reflect

62
Q

list possible risks and complications of laparoscopic cholecystectomy

A

general (any operation)

  • wound infection
  • bleeding
  • post op pain
  • impaired scar healing

csi (phase 1b) (8 decks)

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