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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 abdominal pain
  • 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

how may abdominal pain present?

A
  • be located in any quadrant of the abdomen
  • be constant or colicky
  • 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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3
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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4
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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5
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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6
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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7
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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8
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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9
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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10
Q

what are some uncommon differentials for abdominal pain?

A

volvulus

intussusception

perforated duodenal ulcer

ovarian torsion

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11
Q

what are the commonest causes of acute abdomen?

A

nonspecific abdominal pain

renal colic

biliary colic

cholecystitis

appendicitis

diverticulitis

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12
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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13
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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14
Q

what is AST?

A

aspartate aminotransferase

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15
Q

where is AST made?

A

hepatocytes

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16
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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17
Q

when is AST most likely to be raised?

A

obstruction of the liver

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18
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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19
Q

what is biliary colic?

A
  • symptomatic cholelithiasis (gallstones)
  • least severe
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20
Q

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

A

choledocholithiasis

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21
Q

what is cholecystitis?

A

gallbladder inflammation

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22
Q

what is ascending cholangitis?

A
  • ascending bacterial infection of the biliary tree
  • caused by choleodocholithiasis
  • life threatening
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23
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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24
Q

explain how cholecystitis occurs

A

gallbladder inflammation (can have an infective cause)

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25
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 (!!)

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26
Q

how does biliary colic present in a physical examination?

A
  • constant, dull RUQ pain
  • often after eating
  • radiates to scapula
27
Q

how does cholecystitis present in a physical examination?

A
  • severe and constant RUQ and epigastric pain
  • radiates to scapula
  • fever,nausea and vomiting
  • Murphy’s sign
28
Q

how does ascending cholangitis present in a physical examination?

A
  • RUQ pain, jaundice and fever (Charcot triad)
  • Charcot triad, confusion and hypotension (Reynolds pentad)
  • hepatomegaly (enlarged liver)
29
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)
30
Q

how does cholecystitis present in a patient history?

A
  • can get nausea and vomiting
  • Murphy’s sign
  • mild temperature and tachycardia
31
Q

how does ascending cholangitis present in a patient history?

A
  • Charcot triad
    sepsis (!!) signs
  • pain
  • rigor and fever
  • tachycardia
  • hypotensive
32
Q

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

A
  • normal observations
  • normal LFTs + bilirubin
33
Q

what are the blood test results for someone with cholecystitis?

A
  • raised WCC and CRP
  • sometimes raised ALP
  • normal LFTs and bilirubin
34
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)

35
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

36
Q

what are the three main causes of gallstone formation?

A
  • bile contains too much cholesterol (supersaturation and nucleation)
  • bile contains too much bilirubin (supersaturation)
  • gallbladder does not empty correctly (hypomotility)
37
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

38
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

39
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

40
Q

what are the three types of gallstones?

A
  • cholesterol gallstones
  • pigment gallstones
  • mixed gallstones
41
Q

which is the most common type of gallstone?

A

cholesterol gallstone

42
Q

what are the features of cholesterol gallstones?

A
  • light yellow to dark green/brown
  • usually large
  • formed of cholesterol and other substances
  • linked to poor diet and obesity
43
Q

what are the features of pigment gallstones?

A
  • dark brown/black stones with too much bilirubin
  • formed of mainly bilirubin breakdown products
  • can be from excess bile pigment production OR haemolytic anaemia
44
Q

which gallstone type is linked to haemolytic anaemia?

A

pigment gallstone

45
Q

what are mixed gallstones?

A

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

46
Q

what are the risk factors for gallstones?

A 
female
> 40 years
obesity 
sedentary
high fat diet
hyperlipidemia
haemolytic anaemia
Crohn's disease
FHx of gallstones
47
Q

what is bile?

A

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

48
Q

how do gallstones arise?

A

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

49
Q

what affects the composition of gallstones?

A

age, diet, ethnicity

50
Q

what are the possible complications of gallstones?

A
  • biliary colic
  • acute cholecystitis
  • ascending cholangitis
  • 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)
51
Q

why are the majority of gallstones asymptomatic?

A

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

52
Q

when do gallstones most commonly become a problem?

A

when they obstruct flow through a duct

53
Q

what are three serious possible complications of gallstones?

A

jaundice
sepsis
cancer (in any structure w chronic inflammation)

54
Q

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

A

no symptoms = NO treatment

55
Q

how are symptomatic gallstones/acute cholelithiasis managed?

A

laparoscopic cholecystectomy (keyhole surgery to remove the gallbladder)

56
Q

what type of consent does every surgical procedure require?

A

written consent form

57
Q

what does valid consent require?

A
  • patients to have capacity (can be assessed when having a convo w the patient)
  • patient has to be well informed
  • decision must be voluntary and not coerced or forced
58
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

59
Q

list possible risks and complications of laparoscopic cholecystectomy

A

general (any operation)

  • wound infection
  • bleeding
  • post op pain
  • impaired scar healing
  • blood clots
  • death (from anaesthesia or perforating a vital structure)

specific
- damage to bile duct

60
Q

What are the four components of capacity?

A
  • understanding
  • weigh up information
  • retain information
  • communicate decision
61
Q

What is a common risk?

A

Affects more than 1 in 100 people

62
Q

Who can gain consent from a patient?

A

The person doing the procedure or someone who is very proficient in it

63
Q

What are the three types of consent?

A
  • written
  • verbal
  • implied
  • all three required

csi (phase 1b) (8 decks)

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