case 12 - abdominal pain Flashcards
what is acute abdomen?
- 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
how may abdominal pain present?
- 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
how is a diagnostic work-up carried out for acute abdominal pain?
history, physical examination, imaging, and laboratory results
+ in some patients = digital laparascopy
which analgesic is used for acute abdominal pain?
opioid analgesia does not increase the risk of diagnosis/treatment decision error
what is important to remember about abdominal pain in older people, the immunocompromised and pregnant women?
often presents atypically so = delayed diagnosis of potentially life-threatening pathology
how is abdominal pain managed in older people?
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
how is abdominal pain managed in pregnant women?
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
how is abdominal pain managed in the immunocompromised?
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
what are some common differentials for abdominal pain?
adhesions
incarcerated/strangulated hernia
cholecystitis
perforated gastric ulcer
appendicitis
ectopic pregnancy
what are some uncommon differentials for abdominal pain?
volvulus
intussusception
perforated duodenal ulcer
ovarian torsion
what are the commonest causes of acute abdomen?
nonspecific abdominal pain
renal colic
biliary colic
cholecystitis
appendicitis
diverticulitis
how does the aetiology of acute abdomen vary according to age?
renal colic and appendicitis are more common in patients <60 years
gallbladder disease and diverticulitis are more common in older patients
what are the upper abdominal pain differential?
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)
what is AST?
aspartate aminotransferase
where is AST made?
hepatocytes
why is AST measured?
when hepatocytes are damaged, the AST enzyme is released from the cells and serum AST levels will be elevated
when is AST most likely to be raised?
obstruction of the liver
when is bilirubin most likely to be raised?
when there is an obstruction of the bile duct
biochemical marker of jaundice
released when RBCs breakdown
what is biliary colic?
- symptomatic cholelithiasis (gallstones)
- least severe
what is the term to describe when gallstones leave the gallbladder and enter the bile ducts?
choledocholithiasis
what is cholecystitis?
gallbladder inflammation
what is ascending cholangitis?
- ascending bacterial infection of the biliary tree
- caused by choleodocholithiasis
- life threatening
explain how biliary colic occurs
pain caused by gallbladder muscle spasms against a stone stuck in the cystic duct/neck of the gallbladder
(no inflammatory response)
explain how cholecystitis occurs
gallbladder inflammation (can have an infective cause)
explain how ascending cholangitis occurs
biliary outflow obstruction and infection = surgical emergency
gallstone (from liver or gallbladder) causes obstruction to biliary flow
high morbidity (!!)
how does biliary colic present in a physical examination?
- constant, dull RUQ pain
- often after eating
- radiates to scapula
how does cholecystitis present in a physical examination?
- severe and constant RUQ and epigastric pain
- radiates to scapula
- fever,nausea and vomiting
- Murphy’s sign
how does ascending cholangitis present in a physical examination?
- RUQ pain, jaundice and fever (Charcot triad)
- Charcot triad, confusion and hypotension (Reynolds pentad)
- hepatomegaly (enlarged liver)
how does biliary colic present in a patient history?
- 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)
how does cholecystitis present in a patient history?
- can get nausea and vomiting
- Murphy’s sign
- mild temperature and tachycardia
how does ascending cholangitis present in a patient history?
- Charcot triad
sepsis (!!) signs - pain
- rigor and fever
- tachycardia
- hypotensive
what are the blood test results for someone with biliary colic?
- normal observations
- normal LFTs + bilirubin
what are the blood test results for someone with cholecystitis?
- raised WCC and CRP
- sometimes raised ALP
- normal LFTs and bilirubin
what are the blood test results for someone with ascending cholangitis?
raised WBC count, CRP and ALP
raised bilirubin (jaundice - looking at skin only is unreliable)
what is Murphy’s sign?
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
what are the three main causes of gallstone formation?
- bile contains too much cholesterol (supersaturation and nucleation)
- bile contains too much bilirubin (supersaturation)
- gallbladder does not empty correctly (hypomotility)
why does excess cholesterol in the bile cause gallstone formation?
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
why does excess bilirubin in the bile cause gallstone formation?
too much bilirubin (blood disorders, liver cirrhosis, biliary tract infection)
excess contributes to gallstone formation
why does incomplete gallbladder emptying cause gallstone formation?
bile can become very concentrated if gallbladder does not empty properly or often enough = formation of gallstones
what are the three types of gallstones?
- cholesterol gallstones
- pigment gallstones
- mixed gallstones
which is the most common type of gallstone?
cholesterol gallstone
what are the features of cholesterol gallstones?
- light yellow to dark green/brown
- usually large
- formed of cholesterol and other substances
- linked to poor diet and obesity
what are the features of pigment gallstones?
- dark brown/black stones with too much bilirubin
- formed of mainly bilirubin breakdown products
- can be from excess bile pigment production OR haemolytic anaemia
which gallstone type is linked to haemolytic anaemia?
pigment gallstone
what are mixed gallstones?
combo of cholesterol, bile pigment and bile salts in the gallstone
what are the risk factors for gallstones?
female > 40 years obesity sedentary high fat diet hyperlipidemia haemolytic anaemia Crohn's disease FHx of gallstones
what is bile?
98% water with other dissolved substances (bile slats, bilirubin, cholesterol)
how do gallstones arise?
from the super saturation of bile = gives rise to diff sizes of galstones
what affects the composition of gallstones?
age, diet, ethnicity
what are the possible complications of gallstones?
- 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)
why are the majority of gallstones asymptomatic?
usually small + found within the gallbladder (not causing significant obstruction)
when do gallstones most commonly become a problem?
when they obstruct flow through a duct
what are three serious possible complications of gallstones?
jaundice
sepsis
cancer (in any structure w chronic inflammation)
what is the course of treatment if gallstones are discovered accidentally and the patient is asymptomatic?
no symptoms = NO treatment
how are symptomatic gallstones/acute cholelithiasis managed?
laparoscopic cholecystectomy (keyhole surgery to remove the gallbladder)
what type of consent does every surgical procedure require?
written consent form
what does valid consent require?
- 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
describe the process of informed decision making
explain diagnosis + prognosis
explain treatment options
describe procedure and logistics
explain purpose, risks, complications and benefits of procedure
give patient time to reflect
list possible risks and complications of laparoscopic cholecystectomy
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
What are the four components of capacity?
- understanding
- weigh up information
- retain information
- communicate decision
What is a common risk?
Affects more than 1 in 100 people
Who can gain consent from a patient?
The person doing the procedure or someone who is very proficient in it
What are the three types of consent?
- written
- verbal
- implied
- all three required
