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CSI year 2 > Case 12 Abdominal pain > Flashcards

Case 12 Abdominal pain Flashcards

1
Q
  • What should Immediate assessment of the acute abdomen focus on?
A

Distinguishing patients with true acute abdomen that requires urgent surgical intervention from patients who can initially be managed conservatively

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2
Q

Which individuals can have acute abdomen without pain

A

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

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3
Q
  • What is the issue likely to be if there is severe epigastric pain?
  • What are some of the systemic causes of upper abdominal pain?
A

Myocardial infarction

Addisonian crisis
Diabetic ketoacidosis
Electrolyte insufficiencies

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4
Q
  • What is the pathophysiology behind biliary colic?
A

Gallstones stuck in the cystic duct temporarily so when CCK stimulates contraction of the gallbladder (post-prandial), after a fatty meal, this causes pain, No inflammation.

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5
Q
  • What is the pathophysiology behind cholecystitis?
A

Gallstones stuck in the cystic duct causes inflammation of the cystic duct and gallbladder and bile gets trapped in the gallbladder

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6
Q
  • What is the general pathophysiology behind cholangitis?
A

Inflammation and infection of the biliary tree due to obstruction of bile flow

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7
Q
  • Does biliary colic, cholecystitis and cholangitis have RUQ pain, fever, and jaundice?
A

BC- just pain
cholecystitis - pain and fever
cholangitis- all three (charcots triad). Jaundice as bilirubin not secreted from liver.

nausea and vomiting are present in BC and cholecystitis

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8
Q
  • What is Murphy’s sign?
A

When palpating the RUQ upon inhalation, the gallbladder is felt due to inflammation. inhalation diaphragm pushes it down. in acute cholecystitis

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9
Q
  • What are the Two types of gallstones?
A

pigment (bilirubin) gallstones
cholesterol gallstones (80%)

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10
Q
  • What are the 3 factors that encourage gallstone formation?
A

Cholesterol supersaturation

Gallbladder hypomotility possibly due to low or inactive CCK

Kinetic factors (nucleation) - promoting crystallisation of cholesterol

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11
Q
  • What are the risk factors for cholesterol stones?
A

Obesity - increased cholesterol in bile

Hyperlipidaemia - increased hepatic cholesterol secretion

Female gender - oestrogen is associated with the cholesterol metabolism

Female, fat , fertile, forty

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12
Q
  • What is a risk factor for bilirubin stones?
A

Haemolytic anaemia - increased bilirubin supersaturation

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13
Q
  • How does gallstone ileus occur?
A

Gallstone grows in size in the gallbladder

This then rubs against the wall of the gallbladder until it perforates through it mechanically into the small intestine

This forms a fistula between the small intestine and the fundus of the gallbladder

The gallstone then travels into the small intestine until it gets lodged in the ileocaecal valve

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14
Q
  • Complications of gallstones
A

galllstone pancreatitis
acute cholecystitis
causing billiary obstruction
gallstone illeus
billiary fistula
Mirizzis Syndrome
Bouveret syndrome

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15
Q
  • What are the general complications of a Laproscopic Cholecystectomy
A

Infection, bleeding, injury to other parts of abdomen, deep vein thrombosis

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16
Q

What are some of the specific complications of a laparoscopic cholecystectomy?

A

Diarrhoea, injury to bile duct

17
Q
  • What are brown pigment stones associated with?
A

Infections of the biliary tract

18
Q
  • What do black pigment stones consist of?
A

Calcium bilirubinate, often found in patients with haemolytic anaemia.

19
Q

What is bile composed of

A
  • Bile is composed of
    cholesterol, bilirubin, water, bile salts, phospholipids, and ions.
20
Q

What is the initial test of choice to diagnose most disorders of the gallbladder?

A

an abdominal ultrasound.

X-ray is less sensitive, as calcified gallstones are only seen on plain abdominal x-rays in about 10% of patients with cholelithiasis.

21
Q
  • What scan is done during an emergency department visit to evaluate abdominal pain.
A

CT scan

22
Q
  • What is choledocholithiasis?
A

Gallstone lodged in the common bile duct

23
Q
  • What do you need to do to gain consent for a procedure?
A

knowledge of procedure

explain diagnosis

treatment options

purpose of procedure

risks

24
Q
  • What happens in Mirizzi’s syndrome?
  • What happens in Bouveret syndrome?
A

Common hepatic duct obstruction caused by extrinsic compression from an enlarged impacted stone in the cystic duct

When the stone lodges in the upper part of the duodenum causing gastric outlet obstruction

25
Q

how is cholesterol made soluble

A

Cholesterol is made soluble in bile through mixed micelles with bile salts and phospholipids, mainly phosphatidylcholine (lecithin).

26
Q

how does supersaturation of cholesterol cause gallstones

A

Supersaturation of cholesterol occurs when the cholesterol concentration exceeds the concentration at which it remains soluble.

This can result in the formation of vesicles that may aggregate as solid cholesterol crystals to form stones.

27
Q

how does immobility of bile cause gallstone formation?

A

As supersaturated bile is found in healthy individuals, the microcrystals formed are effectively flushed from the gallbladder during postprandial contractions.

so impaired bile mobility would cause the crystals to be stuck and not flushed away

28
Q

how do Kinetic factors affect gallstone formation.

A

The formation of microcrystals in supersaturated bile is modulated by kinetic protein factors such as nucleation-promoting proteins.

Mucin is an example of a pro nucleating factor that promotes the crystallisation of bile.

29
Q

How is CCK released

A

Specialized enteroendocrine cells called I-cells are located in the duodenum and jejunum. When these cells are stimulated by fatty acids and amino acids released from the stomach, a peptide hormone called cholecystokinin (CCK) is released

30
Q
  • what are the two main functions of CCK pertaining to the gallbladder?
A

Its first function is to stimulate the smooth muscle of the gallbladder to contract and release bile into the biliary tree. The second function of CCK is to simultaneously signal the muscular sphincter of Oddi to relax.

31
Q
  • what is an example of teatment of gallbladder pathology apart from surgery
A

An example is bile acid sequestrants that prevent reabsorption of bile acids in the ileum and lead to lower cholesterol levels as the body is forced to use it as a substrate to produce new bile acids

32
Q

what are drugs that may increase the risk of gallstone formation ?

A

hormone replacement therapy containing estrogen causes increased levels of cholesterol.

Somatostatin analogs such as octreotide block the release of CCK and lead to the formation of biliary sludge.

Fibrates block the rate-limiting enzyme 7-alpha-hydroxylase causing increased cholesterol and decreased bile acid production.

33
Q
  • Upon auscultation, if you hear a tinkling sound, what is this a sign of?
  • Upon auscultation, if you hear no bowel sounds, what is this a sign of?
A

Early bowel obstruction

Later sign of obstruction or peritonitis

34
Q
  • Is it visceral or parietal pain that is well localised?
  • Is it visceral or parietal pain that is dull and achey?
A

Parietal

Visceral

35
Q
  • When bile cannot enter the duodenum, what happens?
A

Jaundice as there is a buildup of bilirubin which causes yellowing of skin, eyes and mucous membranes as well as alcoholic stools

36
Q
  • What is the most sensitive and specific diagnostic test to confirm cholecystitis?
A

Hepatobiliary iminodiacetic acid (HIDA) scan AKA cholescintigraphy

37
Q
  • What are the treatment options for acute cholecystitis?
A

Analgesia and fluids

Consider Abx

Early delayed cholecystectomy (laproscopic)

CSI year 2 (8 decks)

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