Central/Lower Abdominal Pain Flashcards
What features of an abdominal chest x-ray indicate bowel obstruction? (3)
Small bowel diameter > 3cm
Colon diameter > 6cm
Caecum diameter > 9cm
What structures give central abdominal pain? (5)
Medical causes (rarely - DKA, porphyria)
Intra-abdominal structures (midgut)
Retroperitoneal structures (pancreas, aorta, duodenum)
Abdominal wall (hernia, muscle, skin)
Referred pain (from back, base of lung, inferior heart)
[MIRAR]
What are possible differentials for continuous abdominal pain radiating to the back? (2)
Abdominal aortic aneurysm (AAA)
Pancreatitis
What are possible differentials for colicky abdominal pain that is now constant? (2)
Bowel obstruction with/without hernia
Irritable Bowel Syndrome
What are the possible differentials for colicky abdominal pain associated with diarrhoea? (2)
Gastroenteritis
Inflammatory Bowel Disease
What are the possible differentials for central abdominal pain that shifted to the right iliac fossa? (2)
Appendicitis
Rarely perforated Duodenal Ulcer
What are possible differentials of sudden severe pain radiating to the back, flank and/or groin? (2)
Abdominal aortic aneurysm (AAA) until proven otherwise
Renal colic
What is a possible differential of severe generalised pain with shoulder tip pain?
Diaphragm irritation by free fluid/blood within the abdomen
What symptoms can indicate the location of a colon malignancy? (2)
Change in bowel habits —> associated with left colon tumours
Anaemia —> associated with right colon tumours
What combination of signs suggest an infection or inflammation process in one organ? (3)
Pyrexia
Localised tenderness
Guarding
What is McBurney’s Point?
The classical point of maximum tenderness in appendicitis, corresponding to the position of the base of the appendix - one third of the way across the line between the anterior superior iliac spine and the umbilicus.
What is the most common cause of appendicitis?
Obstruction
What classical signs and symptoms are indicative of appendicitis? (4)
Fever
Right lower quadrant abdominal pain (at McBurney’s point)
Nausea and vomiting
Raised serum white blood cell count
What signs and symptoms indicate a ruptured appendix? (2)
Rebound tenderness (at McBurney’s point)
Abdominal guarding
What is involved in the standard treatment of appendicitis? (3)
Draining of abscesses if present
Appendectomy
Antibiotics
What symptoms can indicate retroperitoneal appendicitis? (2)
Lateral/lumbar pain
Ureter irritation
What symptoms can indicate intra-peritoneal appendicitis? (3)
-Pain localised to Right Iliac Fossa (RIF) as appendix tip irritates surrounding peritoneum
-Right hypochondrial pain if inflamed tip of appendix is subhepatic
-Diarrhoea due to irritation in patients with retro-ileal irritation
What is a hernia?
A protrusion of an organ through its containing wall and into a different cavity.
What are in the commonest abdominal wall hernias in order of frequency? (5)
Inguinal
Umbilical/ paraumbilical
Femoral
Incisional
Epigastric/midline
Describe the two types of inguinal hernia. (2)
-Direct: leading area of weakness is posterior wall of inguinal canal, where viscera herniate anteriorly through Hesselbach’s triangle and not into the scrotum.
-Indirect: leading area of weakness is the deep inguinal ring where intra-peritoneal contents herniate into the inguinal canal alongside the spermatic cord, and can exit the canal through the superficial inguinal ring and into the scrotum.
Where would a femoral hernia be located?
Below the inguinal ligament, inferior and lateral to the pubic tubercle.
What is a strangulated hernia?
A hernia where the ‘neck’ of the sac is quite tight, leading to blood supply to the herniated organ being cut off.
What is an incarcerated hernia?
A hernia where the contents are fixed in the sac with adhesion (the hernia is therefore irreducible).
What is an obstructed hernia?
A hernia where the bowel loop trapped within the sac causes bowel obstruction; with further oedema it can become strangulated.
What is the gold standard imaging for peritonitis of any cause?
CT scan
What is a sentinel loop?
A short segment of adynamic ileus (functional motor paralysis of digestive tract) close to an intra-abdominal inflammatory process.
How may the sentinel loop sign on an abdominal x-ray be helpful clinically?
It may aid in localising the source of inflammation.
What are three complications of an appendectomy that the patient would need to be counselled on?
-Conversion to open surgery
-Postoperative wound infection or intra-abdominal collection
-Bleeding
What part of the digestive system does ulcerative colitis affect?
Only the colon and rectum.
In what age group does inflammatory bowel disease (IBD) most commonly present?
Between ages of 15 and 40
Give five symptoms of inflammatory bowel disease (IBD).
Abdominal pain
Bloating
Bloody diarrhoea
Weight loss
Extreme tiredness
When during the menstrual cycle can irritable bowel syndrome (IBS) symptoms be worsened?
During the progesterone dominant premenstrual phase.
What are the common, whilst variable, symptoms of irritable bowel syndrome (IBS)? (7)
Diarrhoea
Constipation
Alternation between both of above
Abdominal pain
Diurnal bloating
Mucus in stool
Tiredness
What are diverticula?
Small bulges or pouches in the lining of the large intestine.
What is diverticulosis?
The presence of asymptomatic diverticula.
What is diverticulitis?
Infection or inflammation of the diverticula, causing severe pain (often in left lower quadrant), bloating, fever and bloody diarrhoea.
What is coeliac disease?
An autoimmune condition triggered by sensitivity to gluten; repeated exposure to gluten causes inflammation of the small intestine.
What skin rash is indicative of coeliac disease?
Dermatitis herpetiformis
What is faecal calprotectin?
A biomarker of bowel inflammation; the principle way to distinguish between irritable bowel syndrome (IBS has a normal faecal calprotectin) and inflammatory bowel disease (IBD has elevated faecal calprotectin).
What is involved in coeliac serology?
Blood tests for tissue transglutaminase antibody (tTGA) or endomysial antibody (EMA); these antibodies are formed in response to eating gluten in a patient with coeliac disease, and so a positive result is suggestive of coeliac disease and should prompt referral for consideration for a confirmatory duodenal biopsy.
What interventions should be recommended as first line management for irritable bowel syndrome with diarrhoea (IBS-D)? (4)
-Reducing caffeine intake
-Regular exercise
-Reducing intake of fizzy drinks
-Loperamide (an anti-motility drug used to treat diarrhoea associated with IBS).
What are the Rome-IV criteria for diagnosis of irritable bowel syndrome (IBS)?
Recurrent abdominal pain on average at least 1 day a week in the last 3 months, associated with two or more of the following criteria:
-related to defecation
-associated with a change in frequency of stool
-associated with a change in form (appearance) of stool
(Symptom onset must be at least 6 months prior to diagnosis)
What may be recommended for irritable bowel syndrome (IBS) if general dietary and lifestyle advice does not improve symptoms?
A low FODMAP diet may be recommended, under the supervision of a dietician.
