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Year 2 - CSI > CSI 5 - Abdominal pain > Flashcards

CSI 5 - Abdominal pain Flashcards

1
Q

What does the term acute abdomen refer to?

A

The rapid onset of severe symptoms of abdominal pathology

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2
Q

What is essential to diagnosis of acute abdomen?

A
  • a comprehensive history and thorough physical examination are essential
  • laboratory tests and imaging are used to support clinical assessment
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3
Q

What are the key components of the history? (3)

A
  • detailed evaluation of the pain (SOCRATES)
  • type and time of last meal/other oral intake (information required if surgery is indicated)
  • past medical and surgical history, medication use, and family history
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4
Q

What can the location of the pain identify?

A

The organ involved

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5
Q

What are some common locations of visceral pain? (5)

A
  • gallbladder (right hypochondriac)
  • stomach/pancreas (epigastric)
  • renal (flanks)
  • small bowel (umbilical)
  • colon/uterine (hypogastric)
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6
Q

What are some causes of pain that present suddenly and severe in onset? (3)

A
  • perforated ulcer
  • ruptured aortic aneurysm
  • ureteral colic (may be constant)
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7
Q

What are some causes of pain that present more colicky, crampy, and intermittent in nature? (4)

A
  • biliary colic
  • small bowel obstruction
  • ureteral colic (kidney stones)
  • colonic obstruction
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8
Q

What are some types of pain that present gradually or more progressively? (7)

A
  • cholecystitis
  • hepatitis
  • pancreatitis
  • diverticulitis
  • appendicitis
  • tubo-ovarian abscess
  • ectopic pregnancy
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9
Q

What may epigastric pain relate to? (6)

A
  • gastric ulcer/perforation (peptic/perforated ulcer)
  • pancreatitis
  • perforated oesophagus / oesophagitis
  • Mallory-Weiss tear
  • cholelithiasis (also considered)
  • myocardial infarction (also considered)
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10
Q

What may left upper quadrant pain relate to? (4)

A
  • splenic infarct/ruptured splenic artery aneurysm
  • pyelonephritis
  • kidney stones
  • perforation/malignancy of the colon
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11
Q

What may right upper quadrant pain relate to? (8 + 1)

A
  • cholelithiasis
  • cholecystitis
  • hepatitis
  • hepatic abscess
  • Fitz-Hugh Curtis syndrome
  • perforation/malignancy of the colon
  • pyelonephritis
  • kidney stones
  • (acute appendicitis in pregnant women due to displacement by enlarging uterus)
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12
Q

What may left lower quadrant pain relate to? (11)

A
  • sigmoid volvulus (typically older)
  • diverticulitis
  • Crohn’s disease
  • ulcerative colitis
  • kidney stones
  • gastrointestinal malignancy
  • psoas abscess
  • incarcerated/strangulated hernia
  • gynaecological concerns - ovarian torsion/cyst rupture, ectopic pregnancy, PID
  • situs inversus (less common)
  • midgut malrotation (less common)
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13
Q

What may right lower quadrant pain relate to? (6)

A
  • appendicitis
  • kidney stones
  • GI malignancy
  • psoas abscess
  • incarcerated/strangulated hernia
  • gynaecological concerns - ovarian torsion/cyst rupture, ectopic pregnancy, PID
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14
Q

What may periumbilical pain relate to? (4)

A
  • appendicitis (may radiate to right lower quadrant)
  • acute mesenteric ischaemia
  • leaking/ruptured abdominal aortic aneurysm
  • small bowel obstruction
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15
Q

What may persistent lateralised pain relate to? (4)

A
  • ascending/descending colon
  • kidney
  • gallbladder
  • ovary
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16
Q

What kind of pain may a perforated viscus cause?

A

Generalised pain

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17
Q

What do we ask about the onset and time course of the pain? (3)

A
  • time of onset?
  • sudden or gradual?
  • how is it changing over time?
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18
Q

What is sudden onset pain typical of? (7)

A
  • perforated ulcer
  • oesophageal tear/rupture
  • nephrolithiasis
  • biliary colic
  • acute cholecystitis
  • pancreatitis
  • appendicitis
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19
Q

What kind of pain does diverticulitis usually cause?

A

Persistent pain

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20
Q

What do previous instances of similar pain suggest?

A

A recurrent condition (e.g. cholecystitis, pancreatitis, diverticulitis), with increasing frequency and severity indicating disease progression

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21
Q

What do we ask about the character of the pain?

A

Elicit whether pain is intermittent, sharp, dull, achy or piercing

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22
Q

What does sharp, localised pain usually indicate?

A

Parietal peritoneum is irritated

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23
Q

What does dull, poorly localised pain felt in the midline usually indicate?

A

Visceral pain

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24
Q

What is the pain of kidney/ureteric stones like?

A

Characteristically severe, with the patient unable to find a comfortable position

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25
Q

What is the pain from adhesions and incarcerated/strangulated hernias like?

A

Intermittent and colicky

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26
Q

What is the pain of an abdominal aortic dissection like?

A

Severe, sharp, or tearing in the thorax or abdomen

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27
Q

What can the presence and pattern of radiation of pain suggest?

A

Potential aetiology

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28
Q

Where does the pain of renal colic frequently radiate?

A

From the flanks downwards into the groin (loin–>groin)

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29
Q

What can pain with radiation to the back indicate? (3)

A
  • pancreatitis
  • abdominal aortic dissection
  • ruptured AAA
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30
Q

What can right scapula pain indicate? (3)

A
  • gallbladder disease
  • liver disease
  • irritation of right hemidiaphragm (e.g. right lower lobe pneumonia)
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31
Q

What can left scapula pain indicate? (5)

A
  • cardiac disease
  • gastric disease
  • pancreatic disease
  • splenic disease
  • irritation of left hemidiaphragm
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32
Q

What can scrotal/testicular pain indicate? (2)

A
  • kidney stones
  • ureteral disease
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33
Q

What can pain associated with cholecystitis and cholelithiasis be exacerbated by?

A

Exacerbated by eating, especially fatty food

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34
Q

What can pain associated with appendicitis be exacerbated by?

A

Movement

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35
Q

What does pain made worse by food suggest?

A

Gastric ulcer

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36
Q

What does pain relieved by eating that worsens after a few hours suggest?

A

Duodenal ulcer

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37
Q

What does prior surgery increase the likelihood of?

A

Obstruction secondary to adhesions

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38
Q

What can cardiovascular disease predispose to?

A

Aortic aneurysm

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39
Q

What can atrial fibrillation predispose to?

A

Mesenteric ischaemia

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40
Q

What order should the physical examination of acute abdomen be performed in?

A
  • (measure vital signs: BP, temperature, pulse rate)
  • inspection - general assessment of how ill the patient appears
  • auscultation - chest and abdomen
  • percussion
  • palpation
  • other important examinations: rectal, pelvic, scrotal
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41
Q

What signs on inspection indicate haemorrhagic pancreatitis? (2)

A
  • Cullen’s sign - periumbilical discolouration
  • Grey-Turner’s sign - bruising of the flanks
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42
Q

When is rebound tenderness (or more generally examination evidence of peritoneal irritation) present?

A

Present not only in appendicitis and diverticulitis but with any condition where there is irritation of the parietal peritoneum

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43
Q

What is Murphy’s sign?

A

Right upper quadrant tenderness with arrest of inhalation during palpation - may be present with cholecystitis

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44
Q

What is often present in ectopic pregnancy?

A

Palpable adnexal mass with/without tenderness, and vaginal bleeding on speculum examination

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45
Q

What laboratory tests are done for all patients with acute abdomen? (4)

A
  • FBC
  • serum electrolytes panel
  • urinalysis
  • pregnancy test (all women of reproductive age)
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46
Q

What laboratory test finding is the hallmark of acute pancreatitis?

A

Significantly elevated serum lipase and amylase (more than 3x normal)

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47
Q

What imaging tests are done for acute abdomen? (7)

A
  • plain abdominal X-ray
  • erect chest X-ray (if perforation suspected)
  • CT of abdomen
  • ultrasound
  • MRI
  • fluoroscopy
  • endoscopy
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48
Q

What can epigastric pain indicate? (4)

A
  • oesophagitis
  • peptic ulcer
  • perforated ulcer
  • pancreatitis
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49
Q

What can right hypochondriac pain indicate? (6)

A
  • gallstones
  • cholangitis
  • hepatitis
  • liver abscess
  • cardiac causes
  • lung causes
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50
Q

What can left hypochondriac pain indicate? (3)

A
  • spleen abscess
  • acute splenomegaly
  • spleen rupture
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51
Q

What can umbilical pain indicate? (4)

A
  • appendicitis (early)
  • mesenteric lymphadenitis
  • Meckel diverticulitis
  • lymphomas
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52
Q

What can left/right lumbar pain indicate? (2)

A
  • ureteric colic
  • pyelonephritis
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53
Q

What can hypogastric pain indicate? (4)

A
  • testicular torsion
  • urinary retention
  • cystitis
  • placental abruption
54
Q

What can right iliac pain indicate? (6)

A
  • appendicitis
  • Crohn’s disease
  • caecum obstruction
  • ovarian cyst
  • ectopic pregnancy
  • hernias
55
Q

What can left iliac pain indicate? (5)

A
  • diverticulitis
  • ulcerative colitis
  • constipation
  • ovarian cyst
  • hernias
56
Q

What is the progression of gallstones like? (4)

A

(cholelithiasis) –> biliary colic –> acute cholecystitis –> choledocholithiasis –> ascending cholangitis

57
Q

What is biliary colic (from cholelithiasis)?

A

Gallstones stuck in cystic duct temporarily (so when CCK stimulates contraction of gallbladder post-prandially this causes pain) - usually resolves itself, no inflammation yet

58
Q

What are the features of biliary colic/cholelithiasis? (4)

A
  • epigastric, RUQ abdominal pain
  • steady pain
  • often after eating
  • radiates to scapula
59
Q

What is acute cholecystitis?

A

Gallstones stuck in cystic duct causes inflammation of the cystic duct and bile gets trapped in the gallbladder, inflammation +/- infection (phospholipase A secretion, prostaglandin release)

60
Q

What are the features of acute cholecystitis? (5)

A
  • severe epigastric, RUQ abdominal pain
  • radiates to scapula
  • fever, nausea, vomiting
  • positive Murphy sign (inspiratory pause)
  • emphysematous cholecystitis (diabetic elderly male) - due to inflammation, bacteria produce gas, collects in GB wall
61
Q

What is Murphy’s sign?

A
  • when palpating RUQ upon inhalation, gallbladder is felt
  • as gallbladder is inflamed and inhalation means diaphragm pushes both liver and gallbladder down
  • seen in acute cholecystitis
62
Q

What is choledocholithiasis?

A

Gallstone gets trapped in common bile duct (instead of cystic duct)

63
Q

What is ascending cholangitis?

A

Inflammation and infection of the biliary tree due to obstruction of bile flow - inflammation reaches CBD

64
Q

What are the features of ascending cholangitis? (4)

A
  • Charcot triad
  • Reynolds pentad
  • hepatomegaly
  • icterus (jaundice)
65
Q

What is Charcot’s triad?

A
  • abdominal pain (RUQ)
  • jaundice
  • fever
66
Q

What is Reynold’s pentad?

A
  • Charcot’s triad (abdominal pain, jaundice, fever)
  • confusion
  • hypotension
67
Q

What are the factors for gallstone formation? (3)

A
  • cholesterol supersaturation
  • gallbladder hypomotility
  • nucleation (kinetic factors)
68
Q

How does cholesterol supersaturation contribute to stone formation?

A
  • cholesterol only slightly soluble in aqueous media but soluble in bile through mixed micelles with bile salts and phospholipids, mainly phosphatidylcholine (lecithin)
  • supersaturation of cholesterol occurs when cholesterol concentration exceeds concentration at which it remains soluble
  • can result in formation of multilamellar vesicles that may then fuse and aggregate as solid cholesterol crystals
  • crystals can grow in size to form stones
69
Q

How does gallbladder hypomotility contribute to stone formation?

A
  • supersaturated bile often found in healthy individuals
  • assumed that microcrystals formed are effectively flushed from gallbladder during postprandial contractions
  • impaired gallbladder motility is commonly seen in several gallstone risk groups - diabetes mellitus, rapid weight loss
70
Q

How does nucleation (kinetic factors) contribute to stone formation?

A
  • formation of microcrystals in supersaturated bile is modulated by kinetic protein factors - promote crystallisation of cholesterol
  • in vitro studies using model bile systems have described several nucleation-inhibitory or nucleation-promoting proteins
  • mucin (glycoprotein mixture secreted by biliary epithelial cells) has consistently been defined as a nucleation-promoting protein in gallbladder sludge
71
Q

What is the composition of bile? (4)

A
  • water (97-98%)
  • bile salts (0.7%)
  • fats (0.5%) - cholesterol
  • bilirubin (0.2%)
72
Q

What are the three types of gallstones?

A
  • cholesterol stones (80-90%)
  • bilirubin stones (pigment stones)
  • mixed
73
Q

What are the risk factors for gallstones? (5)

A
  • obesity (increased cholesterol in bile –> C stones))
  • haemolytic anaemia (increased bilirubin supersaturation –> BR stones)
  • hyperlipidaemia (increased hepatic cholesterol secretion –> C stones)
  • Crohn’s disease (reduced bile acid absorption in terminal ileum –> supersaturation)
  • female sex (oestrogen associated with cholesterol metabolism –> C stones)
74
Q

What are the 5Fs (risk factors for stones?

A
  • female
  • fat
  • forty
  • fertile
  • fair
75
Q

Do gallstones show up on X-ray?

A

99% do not

76
Q

What are some complications of gallstones? (5)

A
  • gallstone pancreatitis (stuck in pancreatic duct = autodigestion, tissue damage, inflammation)
  • acute cholecystitis
  • gallstone ileus
  • biliary fistula
  • Mirizzi’s syndrome
77
Q

What is Mirizzi’s syndrome?

A
  • rare complication of gallstones
  • large gallstone gets stuck in cystic duct
  • compresses common hepatic duct externally
  • results in obstruction and jaundice
  • looks like cholangitis but gallstone is in cystic duct
78
Q

How do fistulas form?

A
  • stones cause inflammation, ulceration and damage
  • this penetrates the wall
  • inflammation comes into contact with underlying tissue
  • large hole called fistula appears between two tissues, and stone can leak through
79
Q

What is gallstone ileus?

A

Large stone passes down intestines (fistula) and becomes stuck in narrow ileocaecal valve –> pain, constipation, nausea and vomiting

80
Q

90% of the time that gallstones occur are they symptomatic or asymptomatic?

A

Asymptomatic

81
Q

What makes up valid consent? (3)

A
  • informed consent (what, risks+benefits, alternatives)
  • capacity (understand, retain, weigh up, communicate)
  • voluntary (no coercion)
82
Q

How can complications of a laparoscopic cholecystectomy be divided?

A
  • early complications
    • general
    • site-specific
  • delayed complications
    • general
    • site-specific
83
Q

What are the general early complications of a laparoscopic cholecystectomy? (3)

A
  • bleeding (excessive bleeding during or after surgery)
  • infection (e.g. surgical site infections)
  • DVT
84
Q

What are the site-specific early complications of a laparoscopic cholecystectomy? (2)

A
  • organ injury (damage to adjacent organs may occur during procedure)
  • adhesion formation (development of scar tissue between abdominal organs can lead to complications)
85
Q

What are the general delayed complications of a laparoscopic cholecystectomy? (2)

A
  • hernia (weakening of the abdominal wall through surgery can lead to hernias, where organs protrude through the incision site)
  • wound complications (issues with wound healing e.g. dehiscence or keloid formation)
86
Q

What are the site-specific delayed complications of a laparoscopic cholecystectomy? (2)

A
  • adhesive bowel obstruction (adhesions between organs can lead to bowel obstruction)
  • chronic pain (some patients experience persistent abdominal pain due to nerve damage or other factors related to surgery)
87
Q

Where does the gallbladder lie?

A

Right upper quadrant of the abdomen, affixed to the undersurface of the liver at the gallbladder fossa

88
Q

What does dysfunction in the physiology of the gallbladder most commonly result in?

A

Gallstones

89
Q

What do many gallbladder pathologies ultimately warrant?

A

Surgical intervention, and thus cholecystectomy (removal of gallbladder) is one of the most common surgical procedures

90
Q

Describe the drainage of bile produced by hepatocytes?

A
  • bile drained in the opposite direction of blood flow to the periphery of the lobule by small channels known as the Canals of Hering
  • they are lined by simple cuboidal epithelium
  • ultimately drain into the bile ductule of the portal triad –> drains into the bile duct
91
Q

What are the three layers of the gallbladder wall?

A
  • innermost mucosal layer - columnar epithelium with microvilli
  • lamina propria - smooth muscle
  • outer serosal layer
92
Q

What is the hepatic diverticulum?

A

Becomes the liver, extrahepatic biliary system and a portion of the pancreas

93
Q

Where does the common bile duct merge with the main pancreatic duct?

A

Ampulla of Vater in the pancreas

94
Q

What is the leading cause of pancreatitis?

A

Gallstone that becomes lodged in the ducts of the pancreas

95
Q

What does stimulation of the small intestine by fatty foods and proteins cause?

A

Gallbladder to empty bile into duodenum

96
Q

What is the function of the gallbladder?

A
  • store and concentrate bile, which is released into the duodenum during digestion
  • bile - alkaline fluid continuously produced by the liver, primary function is to aid in digestion and absorption of lipids as they are not soluble in water
97
Q

How is CCK released?

A
  • specialised enteroendocrine cells called I-cells located in duodenum and jejunum
  • I-cells stimulated by fatty acids and amino acids released from stomach –> CCK released
98
Q

What are the two main functions of CCK pertaining to the gallbladder?

A
  • stimulate smooth muscle of gallbladder to contract and release bile into biliary tree
  • simultaneously signal the muscular sphincter of Oddi to relax
99
Q

What stimulates release of bile into duodenum? (2)

A
  • meal –> CCK release from I-cells (hormonal)
  • meal –> ACh from vagus nerve (neural)
100
Q

What is the flow of bile after leaving the gallbladder?

A
  • flows down CBDs –> ampulla of Vater –> major duodenal papilla
  • flow through papilla controlled by opening and closing of sphincter of Oddi
  • not stimulated by CCK = gallbladder relaxes and fills with bile
101
Q

What does CCK do outside of the gallbladder?

A

Stimulates pancreatic secretions necessary for digestion and delays further emptying of stomach

102
Q

What inhibits release of CCK?

A

Somatostatin (turns off digestion)

103
Q

Bile acids in the liver are conjugated into what two amino acids which are now bile salts?

A

Glycine and taurine

104
Q

What nature of bile salts allows them to act as emulsifiers?

A
  • amphipathic nature
  • hydrophilic portions interact with water = soluble
    • negatively charged = repels from other bile salts and keeps lipids small and easy to digest
  • hydrophobic portions keep lipids contained in centre
105
Q

What colour is bilirubin?

A

Yellow

106
Q

What is unconjugated (indirect) bilirubin conjugated with in the liver?

A

Glucuronate via the enzyme UDP-glucuronosyltransferase

107
Q

What breakdown products of bile give urine and faeces their colour?

A
  • urobilin –> yellow urine
  • stercobilin –> brown faeces
108
Q

When bile cannot enter the duodenum, what happens?

A

Jaundice as there is a buildup of bilirubin which causes yellowing of skin, eyes and mucous membranes as well as alcoholic stools

109
Q

What is the initial choice to diagnose most disorders of gallbladder?

A

Abdominal ultrasound - non-invasive, effectively evaluate stones, sludge and signs of inflammation (stones, GB distension, GB wall thickening, pericholecystic fluid)

110
Q

Why is a CT done during an emergency department visit and why is it not always used?

A

Evaluates abdominal pain and is very accurate when diagnosing gallbladder disease but exposes the patient to radiation

111
Q

What is the most sensitive and specific diagnostic test to confirm cholecystitis?

A

Hepatobiliary iminodiacetic acid (HIDA) scan AKA cholescintigraphy - radionuclide scan where tracer given intravenously and taken up by hepatocytes

112
Q

An ejection fraction of what in the gallbladder is considered abnormal and indicative of functional gallbladder disease?

A

<35% (EF tested by administering CCK)

113
Q

If there is increased ALT, ALP and AST, what organ is obstructed by the gallstone?

A

Liver

114
Q

If there is increased lipase and amylase what organ is obstructed by the gallstone?

A

Pancreas

115
Q

In cholecystitis, what is the effect on gamma-glutaryltransferase?

A

Increased - found in both hepatocytes and epithelial cells of gallbladder

116
Q

What % of stones do cholesterol stones account for?

A

80%

117
Q

What kind of stones are pigmented stones divided into?

A

Brown and black stones (black composed of calcium bilirubinate and more likely to be seen on radiography)

118
Q

What are black and brown stones formed secondary to?

A
  • black stones secondary to haemolysis
  • brown stones secondary to infection
119
Q

What is the difference between cholelithiasis, biliary colic and choledocholithiasis?

A
  • cholelithiasis - gallstones in gallbladder
  • biliary colic - stone lodged in cystic duct
  • choledocholithiasis - gallstone lodged in common bile duct
120
Q

What is biliary colic characterised by?

A

RUQ pain in response to fatty meals as the lipids stimulate the secretion of CCK which causes painful contractions against the stone

121
Q

What is the difference in clinical findings between cholecystitis and biliary colic?

A

Acute cholecystitis has prolonged abdominal pain with associated fever and leukocytosis

122
Q

What increases the risk of cancer during cholecystitis?

A

Resultant scarring and calcification due to chronic cholecystitis

123
Q

What can acalculous cholecystitis (inflammation without stones) result from? (3 + 3)

A
  • infection
  • low perfusion
  • biliary stasis
  • (dehydration)
  • (TPN)
  • (vasculitis)
124
Q

How do somatostatin analogues e.g. octreotide increase the risk of gallstones forming?

A

Block release of CCK –> formation of biliary sludge and reduced gut motility

125
Q

How can fibrates lead to increased gallstone formation?

A

Block the rate-limiting enzyme 7-alpha-hydroxylase –> increased cholesterol and decreased bile production

126
Q

How can hormone replacement therapies containing oestrogen contribute to gallstone formation?

A

Oestrogen increases level of cholesterol –> cholesterol supersaturation

127
Q

What effect does bile acids sequestrants have on cholesterol levels in the body?

A

They prevent reabsorption of bile acids in the ileum and lead to lower cholesterol levels as the body is forced to use it as a substrate to produce new bile acids

128
Q

Once gallstones form, is the risk of developing symptomatic gallstone disease higher or lower in those with efficient gallbladder emptying?

A

Higher - more likely to be lodged in cystic duct or common bile duct and cause symptoms due to impeded flow etc

129
Q

How do we differentiate between biliary colic, acute cholecystitis and ascending cholangitis?

A
  • biliary colic: RUQ pain, no fever, no jaundice
  • acute cholecystitis: RUQ pain, fever, no jaundice
  • ascending cholangitis: RUQ pain, fever, jaundice (Charcot’s triad)
130
Q

How do you treat acute cholecystitis? (4)

A
  • analgesia and fluids
  • consider Abx
  • early/delayed cholecystectomy (mainly laparoscopic)
  • percutaneous cholecystostomy (if deemed unfit for surgery)

Year 2 - CSI (6 decks)

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