CSI 17 Flashcards
When is laparoscopy used in assessment of an acute abdomen?
After the history, examination and investigations
What does the algorithm AIR stand for?
Appendicitis inflammatory response
For which groups of patients may acute abdominal pain present abnormally?
Immunocompromised (old) patients
Pregnant women
Why may acute abdominal problems present atypically in elderly patients?
They have more comorbidities
They have decreased immune function
Central and peripheral nervous systems are affected by ageing (peripheral nervous system decline may lead to altered perception of pain and temp)
Conditions like dementia may restrict their ability to communicate
Why may acute abdominal problems present atypically in pregnant patients?
It may be difficult to localise the pain
The baby displaces a lot of organs so pain may not be where expected for a certain organ
Obtaining radiographs has a risk
What are some common differentials of acute abdomen?
Intestinal obstruction Peritonitis secondary to infection Haemorrhage Ischaemia Contamination of GI contents
What is the most common cause of a GI obstruction?
Adhesions
What are other causes of GI obstruction?
Incarceration of hernia
Volvulus
Gallstones
Intussusception
What are causes of inflammation in the GI tract?
Cholecystitis Appendicitis Acute pancreatitis Diverticulitis UC/Chrohn's
What can perforation be a complication of?
Duodenal and gastric ulcers
What types of perforation result in oesophageal laceration and GI haemorrhage?
Oesophageal perforation (Boerhaave's syndorme) Mallory Weiss tear
What do you have to rule out in young women with an acute abdomen?
Ectopic pregnancy
What are risk factors and points in the history that indicate acute cholangitis?
History of pain
Worse after eating
High weight
What are risk factors and points in the history that indicate hernia?
Acute pain
Vomitting
High weight
What are risk factors and points in the history that indicate gastric ulcer?
Pain
Nausea and vomitting
Worse after eating
What commonly causes acute viral hepatitis?
Paracetamol overdose
What type of pain does biliary colic present with?
Colicky
Where is pain for biliary colic situated?
RUQ
What shows up on bloods for biliary colic?
Nothing
What happens in biliary colic?
Stone is stuck in duct and causes gallbladder muscle spasms which results in pain
How long does biliary colic last?
6 hours or less
What is biliary colic triggered by and why?
Fatty foods, when they are eaten there is cholecystokinin release which causes the gallbladder to contract
What type of pain does acute cholecystitis present with?
Severe and constant
Where is pain for acute cholecystitis situated?
RUQ
What sign is present with acute cholecystitis? Describe it
Murphy’s sign (hand is put under the right rib cage and the patient will complain of pain on inhalation, if the same is done on the left hand side the won’t complain of pain)
What will WCC and CRP be in someone with acute cholecystitis? Why?
Raised due to inflammation
What will temp be in someone with acute cholecystitis?
High
What cardiac sign may be present in someone with acute choelscystitis?
Tachycardia
What will LFTs be in someone with acute cholecystitis?
Normal, ALP may be raised
What will LFTs be in someone with ascending cholangitis?
Deranged
SGOT, bilirubin and ALP will be high
What triad is used to identify ascending cholangitis?
Charcot’s traid
What are the components of Charcot’s triad?
Fever, jaundice and abdominal pain
What happens to biliary outflow in ascending cholangitis?
There is outflow obstruction and infection
What sign asides from Murphy’s may patients with ascending cholangitis display?
Rigors
What is the primary imaging for RUQ pain?
Ultrasound
What are the 2 types of gallstones?
Cholesterol and pigment
What are most gallstones made of?
Cholesterol (70%)
What are pigment gallstones made of?
Bilirubin breakdown products (due to increased bile pigment production)
Why do pigment gallstones arise?
In conditions where theres high RBC breakdown or higher risk eg haemolytic anaemia
Why aren’t x rays useful in imaging for gallstones?
99% of the time stones don’t show up on them
What are some risk factors for gallstones?
Obesity Haemolytic anaemia Hyperlipidaemia Crohn's Female Pregnant Being on the OCP
Why does being on the OCP increase risk of gallstones?
There are higher levels of oestrogen which increases biliary production
Asides from risk factors, what else must you remember can cause gallstones?
Medications
What are the main complications of gallstones?
Gallstone ileus
Cancer of the gallbladder
What is cancer of the gallbladder called?
Cholangiocarcinoma
Where does pain radiate to in ascending cholangitis?
The back
How can you differentiate a stone that is causing acute pancreatitis?
Test for amylase and lipase, they will be high
Define ileus
A lack of peristalsis
Where does a gallstone become stuck to cause gallstone ileus?
Ileocaecal valve
What symptoms does small bowel obstruction cause?
Vomiting and severe pain
What happens over time before gallstone ileus can happen?
The gallbladder becomes inflammed, is eroded and a duodenal fistula forms to eventually allow impaction where the small bowel meets the large bowel
What is the surgical treatment for gallstones?
Laparoscopic cholecystectomy
What is needed to gain valid consent for surgery?
Capacity on the patient's behalf Knowledge of the procedure Explaining the diagnosis Explaining the treatment options Explain the purpose of the procedure Explain the risks
What are some general complications for any surgery?
Infection
Bleeding
Scarring
What are some systemic complications that can occur after a lap cole?
Bad reactions to anasthesia Hypoxia Clotting (DVTs and PE) Septicaemia Cutting a nerve Cutting the bowel Cutting the bile duct Cutting the vein or artery
What are long term complications of a lap cole?
Adhesions
Lack of healing
How will adhesions manifest clinically?
Intermittent bowel obstruction
Pain
What are the 2 main ways to classify surgical complications?
General vs specific
Early vs late
What are some specific complications of a lap coli?
Damage to surrounding organs eg liver
Bile duct injury
Risk of converting to an open procedure
What are early complications of a lap cole?
Wound infection
What are late complications of a lap cole?
Hernia
Scar not healing properly
What do most gallstones consist of?
Cholesterol
Bile pigments
Calcium salts
Glycoproteins
What do brown gallstones indicate?
Infection of the biliary tract
What do black gallstones indicate?
Calcium bilirubinate
What conditions is calcium bilirubinate found in?
Haemolytic anaemia
Ineffective haematopoiesis in cystic fibrosis
What are the 3 mechanisms of formation of cholesterol gall bladder stones?
Cholesterol supersaturation
Gallbladder hypomotility
Kinetic factors
How soluble is cholesterol?
Slightly soluble in aqueous media
Where is cholesterol made soluble?
In bile
When does precipitation of cholesterol occur?
When its solubility exceeds the cholesterol saturation index
At what ratio do cholesterol crystals occur?
Low phospholipid: cholesterol ratio
Also at low phospholipid and high bile conc
When are microcrystals flushed out?
During post prandial contractions of the gallbladder
In what patients is impaired motility seen?
Diabetics and rapid weight loss
What can increase lipid conc?
Decreased emptying of the gallbladder
What modulates formation of microcrystals?
Kinetic protein factors
What is a crystallisation promoting protein?
Mucin
