Colorectal Surgery JC053: Lower And Diffuse Abdominal Pain: RLQ Problems, Pelvic Inflammatory Disease, Peritonitis And Abdominal Emergencies Flashcards
Origin of abdominal pain
- Visceral pain
- stretching of hollow / solid organ (e.g. by distension, foreign body)
- **Dull + **Vaguely localised (∵ visceral pain fibre stimulated)
- location related to **embryonic origin of organ
—> Foregut (stomach, biliary tract, D1, D2): **Epigastric pain
—> Midgut (D2 to proximal 2/3 transverse colon): **Periumbilical pain
—> Hindgut (distal 1/3 transverse colon to rectum): **Hypogastric pain - Parietal pain
- irritation of pain fibres of **Parietal peritoneum (e.g. by inflammation, blood)
- **Sharp
- localised to ***Dermatome at site of stimulus
- e.g. Appendicitis
Describing the pain
- Location
- localised
- diffuse
- vague (fail / reluctant to describe location) - Onset
- sudden
- gradual - Severity
- mild
- excruciating - Character
- **colicky (pain / spasm resulting from contraction of hollow organ against an obstruction e.g. **Biliary tract, Ureter, Small / Large intestine)
- persistent
- dull / sharp - Duration
- Aggravating / Relieving factors
- Radiation / Shifting / Referred pain
- Symptoms associated with pain
***Location of pain
- RLQ (Colon, Appendix, Terminal ileum, Urogenital organs, Ovary, Hernia)
- **Acute appendicitis
- **Mesenteric adenitis
- **Caecal diverticulitis
- **Meckel’s diverticulitis
- ***Ureteric Colic
- Ruptured ectopic pregnancy
- Ovarian cyst torsion
- Ileitis
- Ca colon
- Inguinal / Femoral hernia
- Testicular pathology
- Cholecystitis (distended gallbladder) - LLQ
- **Sigmoid diverticulitis
- **Ca sigmoid
- Ureteric Colic
- Ruptured ectopic pregnancy
- Ovarian cyst torsion
- Inguinal / Femoral hernia
- Testicular pathology - Periumbilical pain
- **Small bowel IO
- **GE
- Early acute appendicitis
- **Bowel ischaemia
- IBS
- **Ruptured AAA
- ***Acute pancreatitis - Hypogastrium
- **Large bowel IO
- Cystitis
- **Pelvic inflammatory disease
- Urinary retention
Radiation / Shifting / Referred pain
Radiation:
- pain spread from one site to another
- e.g. ***Pancreatitis, Ruptured AAA —> Back
- e.g. Ureteric pathology —> Ipsilateral testicular region
- e.g. Testicular —> Ipsilateral loin region
Referred pain:
- pain felt at a site different from stimulus / pathology
- e.g. **Liver abscess —> right shoulder tip
- e.g. **Cholecystitis —> right scapula tip
Shifting pain:
- pain shifts from one site to another with time
- e.g. ***Acute appendicitis —> Periumbilical to RLQ
***Associated symptoms and History
- ***Vomiting, Diarrhoea
- GI pathology - Abdominal distension
- ***IO
- Peritonitis —> Paralytic ileus - Fever
- Infection - ***Dysuria, Haematuria
- Urogenital pathology - ***Rectal bleeding / Mucus
- Rectal pathology (benign / malignant) e.g. Colitis, Proctitis - ***Change of bowel habit
- Colorectal malignant / inflammation e.g. Colitis - Vaginal discharge
- Gynaecological pathology - Loss of appetite, Weight change
- Malignancies
- Benign: TB peritonitis, TB bowel - Family history
- Colorectal malignancies - Surgical history
- Appendectomy
- Abdominal surgery - Menstrual history
- Gynaecological pathology e.g. Cyclical?, Chance of pregnancy - Sexual history
Physical examination
- General
- Fever
- Vital signs: Temp, BP, Pulse, RR
- Hydration status - Abdomen
- **Distension (symmetrical / asymmetrical)
- **Tenderness, Guarding, Rebound tenderness (Peritoneal signs)
- **Mass (on deep palpation)
- **Bowel sound (hyperactive / hypoactive)
- Hernia (cough impulse)
- Scars - Rectal + Vaginal examination (+ Urine dipstix + External genitalia)
***Investigations
- Bedside tests
- **Urinalysis (Urine R/M: UTI, Microscopic RBC)
- **Pregnancy test - Blood tests
- CBC + D/C (e.g. **Leukocytosis in strangulation, ischaemic bowel, diverticulitis, acute appendicitis, peritonitis)
- LRFT
- Electrolytes
- **Amylase (acute pancreatitis)
- **ABG (bowel ischaemia: metabolic acidosis, vomiting: alkalosis)
- **VBG (lactate)
- Clotting profile (planning for invasive procedures)
- Type and screen (planning for invasive procedures) - Imaging
- Erect CXR (pneumoperitoneum / free gas under diaphragm: perforated viscus)
-
**Erect + Supine AXR
—> **free gas (pneumoperitoneum)
—> **dilated bowel (e.g. massive dilatation of colon)
—> **air-fluid levels
—> **evidence of strangulation:
——> thumb printing (large bowel wall thickening)
——> pneumatosis cystoides intestinalis (presence of multiple gas-filled cysts in submucosa / subserosa of the small intestine, signify necrotising enterocolitis, impending bowel perforation)
——> free peritoneal gas
—> **air in biliary tree - USG (pelvis)
- CT (more sensitive than AXR)
—> **level of obstruction (transition between dilated and collapsed loop)
—> lesions (tumour, foreign body)
—> **viability of bowel (by IV contrast) - Contrast studies
—> water soluble contrast
—> differentiate complete vs partial obstruction
—> Ba study: precipitate complete obstruction + barium peritonitis
—> therapeutic effect?
- Endoscopy
- Colonoscopy
- Upper endoscopy
Common causes of Lower abdominal pain
- Acute appendicitis
- Mesenteric adenitis
- Ureteric colic
- Diverticulitis
- Ileitis
- Meckel’s Diverticulum
- Torsion of testis
- Ectopic pregnancy
- Pelvic inflammatory disease
- Torsion / Ruptured ovarian cyst
- Large bowel obstruction
- Ischaemic bowel
- Acute appendicitis
- less common in elderly
S/S:
- Shifting pain: Periumbilical (visceral pain) —> RLQ (somatic pain)
- Localised tenderness + ***Guarding at McBurney’s point (1/3 from ASIS to umbilicus)
- N+V, Loss of appetite, Diarrhoea, Dysuria, Fever
- Gradual onset (within a few days)
- Flank pain (26% of appendix are retrocaecal), RUQ pain (4%) (SpC Revision)
- Rovsing’s sign, Psoas sign, Obturator sign (SpC Revision)
Investigations:
- AXR
—> Appendiceal faecalith / gas
—> Localised ileus
—> Blurred right psoas muscle
—> Free air
- CT scan:
—> Pericaecal inflammation, abscess
—> Periappendiceal phlegmon
—> Fluid collection, localised fat stranding
Diagnosis:
- **Clinical
- **Ultrasound + CT scan may be helpful (sensitivity at most 90%)
- Blood tests: ***Leukocytosis
Algorithm (SpC Revision):
- Clinical appendicitis —> Call surgeon
- Maybe appendicitis —> CT
- Unlikely appendicitis —> observe for 6-12 hours / re-examine after 12 hours
Treatment:
- Analgesia
- **Antibiotics (early uncomplicated case) (Tazocin: cover anaerobes, gram -ve, enterococci)
- **Appendicectomy (Laparoscopic vs Open)
- Mesenteric adenitis
- often misdiagnosed at Acute appendicitis
- usually in ***children
- Causative organisms: β-haemolytic Strept, E. coli, Strept viridans, Yersinia, Coxsackievirus, Rubeola virus, Adenovirus
S/S:
- **Sore throat + High fever (Recent)
- **Not much peritoneal sign
- Presence of ***enlarged LN at terminal ileum found during operation
Diagnosis:
- CT scan
- during Laparotomy / Laparoscopy for suspected acute appendicitis
- Ureteric colic
- Presence of stones in R/L Ureter
S/S:
- **True colic, Spastic, Severe, Gripping in nature
- starts at Loin —> **radiate to Groin
- ***RBC in urinalysis
Diagnosis:
- X-ray
- Plain CT abdomen
Treatment:
- Conservative
- Pain relief: majority of stones pass spontaneously
- Diverticulitis
Colonic diverticula: outpouchings of colon where mucosa herniate through muscular wall
- Diverticulitis: **microperforation
- usually at site where blood vessels penetrate bowel wall
- most common in **Sigmoid (Asians: more **right sided diverticula)
- 60% elderly over 80
- majority **asymptomatic
- Severity from **Diverticulitis —> **Localised diverticular abscess —> **Purulent peritonitis —> **Faecal peritonitis
S/S:
- Localised Fever, Tenderness, Guarding
- **Leukocytosis
- **Abscess formation, ***Peritonitis
- Change in bowel habits
- Urinary symptoms
- Tenesmus
- Paralytic ileus
- SBO
Diagnosis:
- CT scan (diagnosis + assess severity)
—> Mural thickening
—> Presence of diverticula
—> ***Collection with contrast enhancement (Peridiverticular abscess), free gas etc.
—> Pericolic fat stranding
—> Thickened bowel wall
Treatment (depend on severity):
- ***Antibiotics (Simple diverticulitis)
- Image-guided drainage (Localised diverticular abscess)
- Laparoscopy + Lavage (Purulent peritonitis)
- Laparotomy + Bowel resection (Faecal peritonitis)
- Ileitis
- Sometimes misdiagnosed with Acute appendicitis
- Incidental finding of ***inflamed terminal ileum during operation
Causes:
- **Crohn’s disease
- **TB
- ***Bacterial infection (e.g. Campylobacter, Yersinia, Salmonella)
- Radiation enteritis
- Meckel’s Diverticulum
- Remnant of omphalo-mesenteric (vitelline) duct
- Apex / Fibrous cord adherent to umbilicus
- May contain ***ectopic gastric / pancreatic mucosa (Meckel’s scan)
Rule of “2”:
- 2% population
- ***2 feet from ileocaecal valve
- 2 inch long
- presents at 2 yo
S/S:
- Bleeding, Perforation (Meckel’s diverticulitis), **Volvulus, **Intussusception
- ~ to Acute appendicitis
Diagnosis:
- CT scan
- Incidental finding during appendicectomy
Treatment:
- **Antibiotics
- **Diverticuloectomy / Small bowel resection
- Torsion of testis
Commonest age: ***10-15
S/S:
- Severe pain in testis and groin
- Preceded by vague abdominal pain
- Could radiate to ***loin
Examination:
- Tender + ***High lying tests
Treatment:
- **Surgical exploration +/- **Orchidopexy +/- ***Orchidectomy
DDx:
- ***Epididymo-orchitis
- Testicular tumour